Creating Demand for Prescription
`Drugs: A Content Analysis of Television
`Direct-to-Consumer Advertising
`
`Dominick L. Frosch, PhD1,2
`Patrick M. Krueger, PhD3,4
`Robert C. Hornik, PhD2,5
`Peter F. Cronholm, MD, MSCE6
`Frances K. Barg, PhD6
`1Department of Medicine, University of
`California, Los Angeles, Los Angeles, Calif
`
`2Leonard Davis Institute of Health
`Economics, University of Pennsylvania,
`Philadelphia, Pa
`
`3School of Public Health, University of
`Texas Health Science Center at Houston,
`Houston, Tex
`
`4Population Research Center, University of
`Texas at Austin, Austin, Tex
`
`5Department of Medicine, University
`of Pennsylvania, Philadelphia, Pa
`
`6Annenberg School for Communication,
`University of Pennsylvania, Philadelphia, Pa
`
`5Department of Family Medicine & Com-
`munity Health, University of Pennsylvania,
`Philadelphia, Pa
`
`ABSTRACT
`PURPOSE American television viewers see as many as 16 hours of prescription
`drug advertisements (ads) each year, yet no research has examined how televi-
`sion ads attempt to infl uence consumers. This information is important, because
`ads may not meet their educational potential, possibly prompting consumers
`to request prescriptions that are clinically inappropriate or more expensive than
`equally effective alternatives.
`
`METHODS We coded ads shown during evening news and prime time hours for
`factual claims they make about the target condition, how they attempt to appeal
`to consumers, and how they portray the medication and lifestyle behaviors in the
`lives of ad characters.
`
`RESULTS Most ads (82%) made some factual claims and made rational argu-
`ments (86%) for product use, but few described condition causes (26%), risk
`factors (26%), or prevalence (25%). Emotional appeals were almost universal
`(95%). No ads mentioned lifestyle change as an alternative to products, though
`some (19%) portrayed it as an adjunct to medication. Some ads (18%) portrayed
`lifestyle changes as insuffi cient for controlling a condition. The ads often framed
`medication use in terms of losing (58%) and regaining control (85%) over some
`aspect of life and as engendering social approval (78%). Products were fre-
`quently (58%) portrayed as a medical breakthrough.
`
`CONCLUSIONS Despite claims that ads serve an educational purpose, they provide
`limited information about the causes of a disease or who may be at risk; they
`show characters that have lost control over their social, emotional, or physical lives
`without the medication; and they minimize the value of health promotion through
`lifestyle changes. The ads have limited educational value and may oversell the
`benefi ts of drugs in ways that might confl ict with promoting population health.
`
`Ann Fam Med 2007:5:6-13. DOI: 10.1370/afm.611.
`
`INTRODUCTION
`
`The United States and New Zealand are the only developed coun-
`
`tries that permit direct-to-consumer advertising (DTCA) of pre-
`scription drugs. Average American television viewers see as many
`as 16 hours of prescription drug advertisements (ads) per year, far exceed-
`ing the average time spent with a primary care physician.1 Since the Food
`and Drug Administration (FDA) relaxed DTCA regulations in 1997, a
`polarized debate around the practice has ensued.
`Opponents argue that ads mislead consumers and prompt requests for
`products that are unneeded or more expensive than other equally effective
`drugs or nonpharmacologic treatment options.2-4 Proponents counter that
`DTCA educates people about health conditions and available treatments
`and empowers them to become more active participants in their own care,
`thereby strengthening the health care system.5-7
`
`Confl icts of interest: none reported
`
`CORRESPONDING AUTHOR
`Dominick L. Frosch, PhD
`Department of Medicine
`University of California, Los Angeles
`911 Broxton Plaza
`Los Angeles, CA 90095-1736
`dfrosch@mednet.ucla.edu
`
`ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 5, NO. 1 ✦ JANUARY/FEBRUARY 2007
`
`6
`
`Page 1 of 8
`
`ACRUX DDS PTY LTD. et al.
`
`EXHIBIT 1615
`
`IPR Petition for
`
`U.S. Patent No. 7,214,506
`
`

`

`Creating Demand for Prescription
`Drugs: A Content Analysis of Television
`Direct-to-Consumer Advertising
`
`Dominick L. Frosch, PhD1,2
`Patrick M. Krueger, PhD3,4
`Robert C. Hornik, PhD2,5
`Peter F. Cronholm, MD, MSCE6
`Frances K. Barg, PhD6
`1Department of Medicine, University of
`California, Los Angeles, Los Angeles, Calif
`
`2Leonard Davis Institute of Health
`Economics, University of Pennsylvania,
`Philadelphia, Pa
`
`3School of Public Health, University of
`Texas Health Science Center at Houston,
`Houston, Tex
`
`4Population Research Center, University of
`Texas at Austin, Austin, Tex
`
`5Department of Medicine, University
`of Pennsylvania, Philadelphia, Pa
`
`6Annenberg School for Communication,
`University of Pennsylvania, Philadelphia, Pa
`
`5Department of Family Medicine & Com-
`munity Health, University of Pennsylvania,
`Philadelphia, Pa
`
`ABSTRACT
`PURPOSE American television viewers see as many as 16 hours of prescription
`drug advertisements (ads) each year, yet no research has examined how televi-
`sion ads attempt to infl uence consumers. This information is important, because
`ads may not meet their educational potential, possibly prompting consumers
`to request prescriptions that are clinically inappropriate or more expensive than
`equally effective alternatives.
`
`METHODS We coded ads shown during evening news and prime time hours for
`factual claims they make about the target condition, how they attempt to appeal
`to consumers, and how they portray the medication and lifestyle behaviors in the
`lives of ad characters.
`
`RESULTS Most ads (82%) made some factual claims and made rational argu-
`ments (86%) for product use, but few described condition causes (26%), risk
`factors (26%), or prevalence (25%). Emotional appeals were almost universal
`(95%). No ads mentioned lifestyle change as an alternative to products, though
`some (19%) portrayed it as an adjunct to medication. Some ads (18%) portrayed
`lifestyle changes as insuffi cient for controlling a condition. The ads often framed
`medication use in terms of losing (58%) and regaining control (85%) over some
`aspect of life and as engendering social approval (78%). Products were fre-
`quently (58%) portrayed as a medical breakthrough.
`
`CONCLUSIONS Despite claims that ads serve an educational purpose, they provide
`limited information about the causes of a disease or who may be at risk; they
`show characters that have lost control over their social, emotional, or physical lives
`without the medication; and they minimize the value of health promotion through
`lifestyle changes. The ads have limited educational value and may oversell the
`benefi ts of drugs in ways that might confl ict with promoting population health.
`
`Ann Fam Med 2007:5:6-13. DOI: 10.1370/afm.611.
`
`INTRODUCTION
`
`The United States and New Zealand are the only developed coun-
`
`tries that permit direct-to-consumer advertising (DTCA) of pre-
`scription drugs. Average American television viewers see as many
`as 16 hours of prescription drug advertisements (ads) per year, far exceed-
`ing the average time spent with a primary care physician.1 Since the Food
`and Drug Administration (FDA) relaxed DTCA regulations in 1997, a
`polarized debate around the practice has ensued.
`Opponents argue that ads mislead consumers and prompt requests for
`products that are unneeded or more expensive than other equally effective
`drugs or nonpharmacologic treatment options.2-4 Proponents counter that
`DTCA educates people about health conditions and available treatments
`and empowers them to become more active participants in their own care,
`thereby strengthening the health care system.5-7
`
`Confl icts of interest: none reported
`
`CORRESPONDING AUTHOR
`Dominick L. Frosch, PhD
`Department of Medicine
`University of California, Los Angeles
`911 Broxton Plaza
`Los Angeles, CA 90095-1736
`dfrosch@mednet.ucla.edu
`
`ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 5, NO. 1 ✦ JANUARY/FEBRUARY 2007
`
`6
`
`Page 1 of 8
`
`

`

`CR E AT ING DEM AND F OR PR ESCRIP T ION DRUGS
`
`Television advertising now comprises most of the
`consumer-directed prescription pharmaceutical mar-
`keting expenditures.8 Previous research has examined
`print ads,9-13 but unlike print ads, television ads com-
`bine visual imagery, music, and spoken words to create
`complex stories that may provide more information and
`appeal to a wider range of consumer emotions. To date,
`no one has analyzed systematically what television ads
`claim about health conditions, how they attempt to
`appeal to consumers, or how they portray the role of
`lifestyle behaviors and medication in achieving good
`health. These questions are critically important given
`evidence that DTCA prompts consumers to request
`prescriptions for advertised products from their physi-
`cians,14,15 and that many of those requests are fulfi lled
`despite being judged clinically inappropriate.16
`The goal of our study was to analyze the content
`of television DTCA messages to lay the foundation
`for future studies that examine the consequences of
`DTCA exposure. Little is known about how DTCA
`affects people’s health-related beliefs and behaviors
`beyond prescription requests, even though televi-
`sion pharmaceutical ads are among the most common
`forms of mediated health communication in the United
`States. Content analysis is a well-established method of
`inquiry for generating research questions and hypoth-
`eses for future experimental and observational studies
`that examine the effects of advertising on consumers’
`beliefs and behaviors.17,18
`
`METHODS
`Sampling Strategy
`We focused on ads that have the largest audiences,
`drawing a sample from peak television viewing times
`(prime time, 8:00-11:00 PM) and the evening news on
`channels with the most viewers (ABC, CBS, NBC, and
`Fox).1,19 We recorded programming for 4 consecutive
`weeks (June 30, 2004, to July 27, 2004), randomly
`selecting a different channel each day but never record-
`ing the same channel on 2 consecutive days. Each day
`of the week was represented for each network.
`The FDA regulations distinguish between product
`claim ads and reminder ads. Product claim ads must
`include the name and indication of the drug, as well
`as a major statement of product risks, and they must
`direct consumers to a detailed summary of product
`risks and benefi ts accessible through a toll-free tele-
`phone number, an Internet site, or a concurrent print
`ad. We limited our analysis to television ads, rather
`than Internet, print, or telephone sources, because tele-
`vision ads reach a wider audience, and people might
`seek further information only if the ads are suffi ciently
`compelling. Reminder ads are shorter and can mention
`
`the product name, but may not discuss indications, effi -
`cacy, or dosage recommendations.9-13,20 Our program-
`ming sample captured a total 103 ads comprising 31
`unique product claim ads and 7 unique reminder ads,
`which provided the basis for our analysis (Table 1).
`For each reminder ad we also had a corresponding
`product claim ad. We included reminder ads in our
`sample to describe how the messages and themes being
`communicated were affected by the shorter length of
`these ads. Our sample captured ads for 7 of the 10 top-
`selling prescription drugs in 2004.21
`
`Ad Coding
`We used 2 strategies to code the ads. First, to code
`the ads for the types of factual claims about the target
`condition (excluding product risk information) and the
`types of appeals to viewers, we drew on categories pre-
`viously developed for print ads.9,11 The specifi c factual
`claim categories we coded are shown in Table 2. Pro-
`ponents of DTCA have argued that ads serve in part to
`educate the public about diseases. Hence, our goal was
`to enumerate the frequency with which television ads
`made factual claims, regardless of the accuracy of this
`information. We drew on categories previously applied
`to print ads to code how the ads attempted to appeal to
`viewers with (1) rational appeals—providing informa-
`tion about product use, features, or comparison with
`similar products; (2) positive emotional appeals—evok-
`ing favorable affect, for example, by showing happiness;
`(3) negative emotional appeals—evoking negative affect
`by portraying fear, regret, or other negative emotions;
`(4) humor appeals—using puns, jokes, or satire; (5) fan-
`tasy appeals—depicting an unrealistic or surreal scene;
`(6) sex appeals—showing characters in an intimate
`encounter, scantily clad, or using provocative gestures;
`and (7) nostalgic appeals—using images from an earlier
`time, or black-and-white or sepia tone visuals.11
`Second, we developed inductive codes by approach-
`ing our sample with 2 research questions: (1) How do
`the ads portray the role of medication in the lives of
`characters? and (2) How do the ads portray the role of
`healthy lifestyle behavior in the lives of characters? We
`used grounded theory coding procedures to inductively
`develop common thematic categories and refi ne their
`defi nitions and properties.22,23 Because our study was
`descriptive and did not aim to produce a theory, we
`limited our use of grounded theory procedures to open
`and axial coding. Open coding refers to the analyti-
`cal process of examining, comparing, and categorizing
`qualitative data to develop thematic concepts. Axial
`coding involves coding similar data sequences to foster
`connections between emerging thematic concepts. Both
`coding procedures permit a thematic analysis of content
`data in mixed methods research projects.22-24 The fi rst
`
`ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 5, NO. 1 ✦ JANUARY/FEBRUARY 2007
`
`7
`
`Page 2 of 8
`
`

`

`CR E AT ING DEM AND F OR PR ESCRIP T ION DRUGS
`
`Table 1. Drug Advertisements Captured in Sample
`
`Brand name
`
`Generic Product Name
`
`Manufacturer
`
`Advertised Indication
`
`Actonel*
`Allegra*
`Ambien†
`Celebrex†
`Cialis†
`Crestor*
`Detrol LA*
`Enbrel*
`Fosamax*
`Lamisil*
`Levitra*
`Lipitor†
`Nexium*
`Diovan*‡
`Diovan HCT
`Lotrel
`Plavix*
`Prevacid†
`Procrit†
`Singulair*
`Valtrex†
`Zelnorm*
`Zocor*
`Zoloft*
`
`Risedronate
`Fexofenodine
`Zolpidem
`Celecoxib
`Tadalafi l
`Rosuvastatin
`Tolterodine
`Etanercept
`Alendronate
`Terbinafi ne
`Vardenafi l
`Atorvastatin
`Esomeprazole
`Valsartan
`Valsartan & HCT
`Amlodipine & Benazepril
`Clopidogrel
`Lansoprazole
`Epoetin Alfa
`Montelukast
`Valacyclovir
`Tegaserod
`Simvastatin
`Sertraline
`
`Procter & Gamble, Cincinnati, Ohio
`Aventis, Bridgewater, NJ
`Sanofi -Synthelabo, New York, NY
`Pfi zer, New York, NY
`Lilly ICOS, Indianapolis, Ind
`AstraZeneca, Wilmington, Del
`Pfi zer, New York, NY
`Immunex, Thousand Oaks, Calif
`Merck, Whitehouse Station, NJ
`Novartis, East Hanover, NJ
`Bayer, West Haven, Conn
`Pfi zer, New York, NY
`AstraZeneca, Wilmington, Del
`Novartis, East Hanover, NJ
`Novartis, East Hanover, NJ
`Novartis, East Hanover, NJ
`Bristol-Myers Squibb, Princeton, NJ
`TAP, Lake Forest, Ill
`Amgen, Thousand Oaks, Calif
`Merck, Whitehouse Station, NJ
`GlaxoSmithKline, Middlesex, UK
`Novartis, East Hanover, NJ
`Merck, Whitehouse Station, NJ
`Pfi zer, New York, NY
`
`Osteoporosis
`Allergy
`Insomnia
`Osteoarthritis, rheumatoid arthritis
`Erectile dysfunction
`Hypercholesterolemia
`Overactive bladder
`Rheumatoid arthritis
`Osteoporosis
`Onychomycosis
`Erectile dysfunction
`Hypercholesterolemia
`Gastroesophageal refl ux disease
`Hypertension
`Hypertension
`Hypertension
`Acute coronary syndrome
`Gastroesophageal refl ux disease
`Chemotherapy-related anemia
`Allergy
`Genital herpes
`Irritable bowel syndrome with constipation
`Hypercholesterolemia
`Depression, social anxiety disorder
`
`* Product claim advertisement only.
`† Product claim and reminder advertisement.
`‡ Advertisement promoted unnamed products that were identifi ed on corresponding Web site.
`
`author (DLF) led the analytical process in frequent con-
`sultation with the coauthors, a team whose disciplinary
`backgrounds included clinical psychology (DLF), soci-
`ology (PMK), communication (RCH), medicine (PFC)
`and anthropology (FKB). The authors discussed the
`thematic concepts that emerged when viewing a sample
`of the ads. The defi ning properties of the concepts
`were gradually refi ned to create specifi c coding catego-
`ries, whereupon 2 bachelor’s level research assistants
`were trained to code all of the ads independently.
`
`Coding Reliability and Frequency Presentation
`We had good aggregate interrater reliability for our
`coding categories, as indicated by κ values ranging
`from .76 to .88.25 Coding disagreements between the
`research assistants were resolved through consensus.
`We report weighted frequencies that refl ect the over-
`all prevalence of the codes among the ads captured in
`the programming we recorded. The weights equal the
`total number of times each of the 38 ads was captured
`in our sample (mean = 2.7, SD = 2.3, range 1-12).
`Thus, ads that were captured more often in our sample
`had a proportionately greater impact on the preva-
`lence of different coding categories. The unweighted
`
`data (not shown) refl ected similar frequencies and pat-
`terns of the codes.
`
`RESULTS
`Ad Length and Story Structure
`The average ad length was 44.9 seconds (SD 18.6 sec-
`onds, range 14-62 seconds); product claim ads (mean =
`51.8, SD 12.7) were signifi cantly longer than reminder
`ads (mean = 14.4, SD 0.5; Mann-Whitney U = 5.0; P
`<.001). We identifi ed 3 story structures for the ads.
`Almost one half (44.7%) of the ads showed characters
`before and after taking the product. A smaller propor-
`tion (39.5%) showed characters only after taking the
`product, and a minority showed characters only before
`taking the product (7.9%). Three ads (7.9%) did not
`use any characters or did not clearly depict whether
`characters had taken the product.
`
`Factual Claims About the Target Condition
`Because reminder ads cannot legally present factual
`information, we focused on product claim ads. Most of
`the ads made some factual claims about the target con-
`dition of the product, typically by mentioning condition
`
`ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 5, NO. 1 ✦ JANUARY/FEBRUARY 2007
`
`8
`
`Page 3 of 8
`
`

`

`CR E AT ING DEM AND F OR PR ESCRIP T ION DRUGS
`
`Table 2. Proportion of Advertisements That Present Factual
`Claims, Appeals, Lifestyle, and Medication Themes
`
`Categories of Content
`
`Weighted Percentages
`Product
`Reminder
`Claim Ads
`Ads
`
`All Ads
`
`symptoms (Table 2). More than one
`half the ads made a claim about the
`biological nature or mechanism of the
`disease, but only 26% made claims
`about risk factors or causes of the con-
`dition. Almost 25% made claims about
`the population prevalence of the con-
`dition, but among these ads, only 25%
`gave specifi c information (eg, 1 in 9).
`The remaining ads used vague terms,
`such as “millions.” Only 8% of the ads
`identifi ed specifi c subpopulations at
`increased risk of having the condition.
`Consistent with FDA regulations, all
`product claim ads, but none of the
`reminder ads, included information
`about major risks and side-effects.
`This information was always provided
`in the latter part of the ad, but never
`at the end, always leaving the fi nal
`frames for a promotional message.
`
`Factual claims*
`Any factual information (eg, symptoms)
`Biological nature or mechanism of disease
`Risk factors or cause of condition
`Prevalence of condition
`Subpopulation at risk of the condition
`Appeals
`Rational
`Positive emotional
`Negative emotional
`Humor
`Fantasy
`Sex
`Nostalgia
`Lifestyle portrayals
`Condition interferes with healthy or
`recreational activities
`Product enables healthy or recreational activities
`Lifestyle change is alternative to product use
`Lifestyle change is insuffi cient
`Lifestyle change is adjunct to product
`Medication portrayals
`Loss of control caused by condition
`Regaining control as result of product use
`Social approval as a result of product use
`Distress caused by condition
`Breakthrough
`Endurance increased as a result of product use
`Protection as a result of product use
`
`–
`–
`–
`–
`
`86.4
`95.1
`68.9
`32.0
`20.4
`5.8
`3.9
`
`26.2
`
`56.3
`0.0
`18.4
`19.4
`
`58.3
`85.4
`77.7
`47.6
`58.3
`17.5
`9.7
`
`82.0
`53.9
`25.8
`24.7
`7.9
`
`100.0
`94.4
`75.3
`36.0
`22.5
`4.5
`3.4
`
`30.3
`
`56.2
`0.0
`21.3
`22.5
`
`67.4
`88.8
`83.1
`53.9
`67.4
`12.4
`11.2
`
`–
`–
`–
`–
`
`0.0
`100.0
`28.6
`7.1
`7.1
`14.3
`7.1
`
` 0.0
`
`57.1
`0.0
`0.0
`0.0
`
`0.0
`64.3
`42.9
`7.1
`0.0
`50.0
`0.0
`
`Note: Total unweighted N = 38, product claim ads n = 31, reminder ads n = 7.
`
`* The Food and Drug Administration does not permit the presentation of factual information in
`reminder ads.
`
`Appeals
`Table 2 shows that all product claim
`ads used rational appeals, such as
`describing the product indication.
`Consistent with FDA regulations,
`reminder ads never used rational
`appeals. Almost 95% of product claim
`ads and 100% of the reminder ads
`used positive emotional appeals, often
`by depicting a happy character after
`taking a product. Sixty-nine percent
`of the ads used negative emotional
`appeals, such as showing a character
`in a fearful state before using the
`product. Almost one third of the ads
`used humor to appeal to viewers, sometimes by making
`fun of the character before taking the product.
`
`Lifestyle Portrayals
`Our inductive coding procedures identifi ed 5 themes
`related to lifestyle portrayals of the ad characters
`(Table 2). Twenty-six percent of the ads suggested that
`the target condition may interfere with healthy or rec-
`reational activities, and 56% of the ads suggested that
`the product enables healthy or recreational activities.
`We coded the physical activities portrayed in the ads,
`distinguishing among mild, moderate, and vigorous
`physical activity (results not tabled). More than one
`half of the ads (52.7%) showed the primary character
`engaging in some physical activity. Eighty percent of
`these ads showed characters engaging in moderate or
`vigorous physical activity.
`
`Several of the products advertised for our sample of
`ads target conditions (eg, hypercholesterolemia, insom-
`nia, hypertension) that have nonpharmacological treat-
`ment alternatives which involve behavior change. None
`of these ads explicitly mentioned behavior changes as
`an alternative to the product. More than 18% of the
`ads suggested that lifestyle change is insuffi cient to
`manage the condition, implying that using the product
`was a superior alternative. Nineteen percent of the ads
`suggested that lifestyle change may be an adjunct to
`using the product.
`
`Medication Portrayals
`We inductively identifi ed 7 themes related to medi-
`cation portrayals in the ads: (1) loss of control—the
`characters have lost control of some biological process,
`function, or ability as a result of their condition; (2)
`
`ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 5, NO. 1 ✦ JANUARY/FEBRUARY 2007
`
`9
`
`Page 4 of 8
`
`

`

`CR E AT ING DEM AND F OR PR ESCRIP T ION DRUGS
`
`regaining control—the characters have resumed con-
`trol of some biological process, function, or ability by
`using the advertised product; (3) social approval—the
`characters are viewed favorably by others because
`they used the product, or that people frequently use
`the product; (4) distress—the ad shows a character
`in physical, emotional, or social distress; (5) break-
`through—the ad suggests the product represents a
`breakthrough in medical science or progress in treating
`or curing a disease; (6) endurance—the ad suggests the
`product could increase endurance for some activity;
`and (7) protection—the ad suggests the product could
`protect individuals from some health risk.
`As shown in Table 2, many ads framed their prod-
`ucts around loss of control, which often had a pro-
`found detrimental effect on the character’s life. Further,
`most ads suggested that characters can regain control
`of lost functions or abilities by using the product. All
`ads that showed a loss of control subsequently showed
`regaining control through product use. Nearly 78%
`of the ads showed characters who received social
`approval for using and benefi ting from the product.
`Given the complexity of these themes, Table 3 displays
`selected examples of how the ads depicted loss of con-
`trol, regaining control, and subsequent social approval.
`More than 58% of the ads claimed that the adver-
`tised products represented a medical or scientifi c
`breakthrough, often in such statements as “[the prod-
`uct] goes beyond what you were previously taking,”
`“now you can…,” “… only [the product] can….” Smaller
`percentages of ads indicated that the product enhances
`endurance in some activity, such as being able to work,
`or protects against some health risk, such as blood
`clots or herpes outbreaks.
`
`Sample Television Ad
` The Supplemental Figure (which can be found online
`at http://www.annfammed.org/cgi/content/
`full/5/1/6/DC1) illustrates the application of the
`codes to an ad for rosuvastatin. The ad narrative
`provides a complete transcript of the spoken content,
`except for the statement of risks. For each frame, we
`note the codes we applied. Using black humor, the
`fi rst 2 frames show “Joe” running through the “Land
`of No,” a grim and deserted urban setting. Joe has lost
`control over his cholesterol, and the narrator suggests
`that lifestyle changes alone are not enough to keep
`him healthy. In the next 2 frames, Joe visits his doctor,
`who welcomes him approvingly and encourages him
`to take rosuvastatin. In the fi nal 2 frames, Joe leaves
`the doctor’s offi ce and enters into sunny suburbia,
`or the “Land of Success,” where his smiling neighbor
`waves as he walks home to enjoy a picnic with his
`smiling family.
`
` DISCUSSION
`We found that most product claim ads made some fac-
`tual claims about the target conditions, and more than
`one half made claims about the disease mechanisms.
`Even so, similar to print ads, television ads were often
`ambiguous about whether viewers might legitimately
`need the product.9 They offered limited information
`about risk factors, prevalence of the condition, or the
`subpopulations at greatest risk. By ambiguously defi n-
`ing who might need or benefi t from the products,
`DTCA implicitly focuses on convincing people that
`they may be at risk for a wide array of health condi-
`tions that product consumption might ameliorate,
`rather than providing education about who may truly
`benefi t from treatment. It has been suggested that
`DTCA contributes to the medicalization of what was
`previously considered part of the normal range of
`human experience.4
`All the product claim ads provided important infor-
`mation to viewers through rational arguments that
`detail either product use or the potential risks and ben-
`efi ts of the product use. The FDA limits the educational
`value of reminder ads, however, by prohibiting them
`from using rational appeals. Almost all ads used positive
`emotional appeals, and more than two thirds used nega-
`tive emotional appeals. Emotional appeals may prompt
`viewers to discount information about risks and benefi ts
`that is important when considering medication use,
`while they sway consumers in favor of a product.26 This
`approach may encourage viewers, some of whom may
`not be at risk of the condition, to seek treatment for
`clinically inappropriate reasons, such as fear, anticipated
`regret from not using the product, or expectations of
`happiness if they do use the product.
`We identifi ed several themes about the role of
`lifestyle in achieving and maintaining health. One
`quarter of the ads suggested that the target condi-
`tion interferes with healthy or recreational activities.
`Although 19% of ads mentioned that healthy behaviors
`could be useful in combination with the product, they
`never described behaviors as a reasonable alternative.
`Several ads for cholesterol-lowering drugs appeared
`to suggest that nonpharmacological approaches were
`almost futile. One ad for atorvastatin showed an ath-
`letic middle-aged woman coaching basketball while
`images and text noted that she had been coaching for
`25 years, ran 3 miles every day, and ate 50-calorie sal-
`ads for lunch. Then we learn that her total cholesterol
`level is 277 mg/dL. Viewers may interpret the ad to
`mean that the product can improve health if lifestyle
`change is unsuccessful, or possibly that healthy behav-
`iors are largely ineffective. In contrast, more than 56%
`of the ads showed the product enabling healthy or rec-
`reational activities. Thus, DTCA suggests that health
`
`ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 5, NO. 1 ✦ JANUARY/FEBRUARY 2007
`
`10
`
`Page 5 of 8
`
`

`

`CR E AT ING DEM AND F OR PR ESCRIP T ION DRUGS
`
`as well
`smile approvingly and bounce
`down. The other characters
`giggles, and bounces up and
`other characters, smiles,
`character interacts with the
`
`After taking Zoloft, the primary
`
`wrong, you can help make it right.”
`Zoloft, when you know more about what’s
`overcome those nervous anxious moments….
`ters as narration continues, “In time you could
`and jump up and down with the other charac-
`fades to white and begins to smile, giggle,
`across a synapse. The red character gradually
`tion shows neurotransmitter levels increasing
`symptoms of social anxiety disorder.” Anima-
`ance in the brain which may be related to
`can help. It works to correct a chemical imbal-
`Narration states, “Zoloft prescription medicine
`
`background
`with Rio de Janeiro in the
`kiss and hug in the surf
`dance, sail, bike, and fi nally
`primary character. They
`smiles and laughs with the
`
`The male romantic partner
`
`that’s the way it should be.”
`year.” She concludes, “My days are mine, and
`fact, I’ve been outbreak-free for almost a
`helps reduce the number of outbreaks. In
`found out about Valtrex. Just 1 pill a day
`mock saying, “So I talked to my doctor and
`The camera returns to her sitting in the ham-
`
`in the family meal (Ad 2)
`wife and begins participating
`serving dish, he smiles at his
`As the husband/father takes the
`
`rst time in the ad (Ad 1)
`ing with her family for the
`orange juice, she begins talk-
`
`fi
`
`As the wife/mother takes the
`
`activities
`ing their enjoyable vacation
`their father and photograph-
`The children are laughing with
`
`beverages
`host, and offer a toast with
`selves at the hands of their
`
`Guests are enjoying them-
`
`Coworkers are interested in the
`
`photographer’s activities
`
`The father happily receives a serving dish from
`
`his wife and says, “I’ll take that.” (Ad 2)
`
`The mother raises her glass for more orange
`
`juice and says, “I’ll take that.” (Ad 1)
`
`And healing is such a great feeling.”
`importantly, it also heals acid refl ux erosions.
`Nexium not only gets rid of heartburn, more
`healing purple pill. For many, one prescription
`
`The narrator states, “Next time, Nexium, the
`
`Ad shows the vacationing man with his children
`
`in a boat, visiting waterfalls, being cheerful
`
`ously serving food and socializing
`guests in a backyard barbecue, simultane-
`Ad shows the basketball referee entertaining
`
`professional task
`coworker, followed by a stern focus on her
`rapher at work in the studio, smiling at her
`refreshed, not groggy.” Ad shows the photog-
`fast and stay asleep longer. So you wake up
`in America. Ambien helps you fall asleep
`Ambien, the number 1 prescribed sleep aid
`ration continues, “To help you sleep there’s
`waking up refreshed next morning, as nar-
`Ad shows a new character going to bed and
`
`this way.”
`that you’re the only one whoever feels
`and races. So you stay back. You worry
`and don’t know why. Your heart thumps
`ers are judging you. You’re embarrassed
`of being criticized, or imagine that oth-
`being very nervous? Maybe you’re scared
`states “You know that feeling of suddenly
`white, are dancing and talking. Narration
`isolated. Other characters, depicted in
`appears unhappy, uncomfortable, and
`
`The main character enters a party and
`
`The character sits in a hammock and states,
`
`the screen and disappear
`of the week scroll across the bottom of
`like it took days out of my life.” The days
`as her voice narrates, “Each outbreak felt
`the beach with a male romantic partner,
`sle.” The next scene shows her sitting on
`“Living with genital herpes can be a has-
`
`frown (Ad 2)
`man’s plate. His face turns from smile to
`wife pours it onto a slice of meat on the
`
`Gravy transforms into thumbtacks as the
`
`wide with distress (Ad 1)
`briefl y raises the glass, and her eyes grow
`pours it into the woman’s glass. She
`and steaming green acid as the husband
`Orange juice transforms into bubbling
`engaged in animated conversation.
`is served. Other family members are
`ner table with a large family, as food
`
`Both ads show characters at the din-
`
`settings
`fortable in social
`Ability to feel com-
`
`Red egglike cartoon
`
`character
`
`Sertraline
`
`ters, and vacation
`romantic encoun-
`
`Ability to enjoy
`
`Y