Selling Sickness: How Drug Ads Changed Health Care
David Couper went to his doctor after watching a small green creature jump up and down on the nail of an infected toe.
For Anne Nissan, a 17-year-old in Prescott, Ariz., the image that stayed with her was of a party. Women were on a roof in a city, pimple-free and laughing, utterly unbothered by the cramps that immobilized her once a month.
And then there is Samantha Saveri, a transportation planner in Baltimore. She remembers bunnies and the promise of digestive regularity.
Three different people in three different places were all driven to contact their doctors after watching an ad for a prescription medication on television. Each walked into a doctor's office with a specific request, and walked out with a prescription for exactly the medication he or she desired.
The Rise Of Prescription Drugs In America
Prescription drug spending is the third most expensive cost in our health care system. And spending seems to grow larger every year. Just last year, the average American got 12 prescriptions a year, as compared with 1992, when Americans got an average of seven prescriptions. In a decade and a half, the use of prescription medication went up 71 percent. This has added about $180 billion to our medical spending.
While there are more medicines on the market today than in 1992, researchers estimate that around 20 percent of the $180 billion increase has absolutely nothing to do with the number of medications available, or increases in the cost of that medication.
To understand this change, one place to look is Wilder, Vt. There, in a tasteful housing complex on the side of a mountain, is the home of Joe Davis.
Davis is retired now, but in his speech and manner it's easy to hear the breezy salesmanship that made him so successful. Davis was an adman: "I was trained — or I was toilet-trained as we like to say — in packaged goods," Davis says. "General Foods, Procter & Gamble — that kind of thing."
Until the 1980s, the kind of people who sold stuff like packaged goods were completely different from the kind of people who sold stuff like prescription drugs. In those days, drugs ads were for doctors, not the public. They were designed by people who worked at these small, technically minded medical advertising companies and targeted this small, technically minded audience.
"Nobody had ever thought that these drugs should be or could be advertised to the patients. It was just outside of people's brains," Davis says. "They thought that only doctors could understand the products. They're technical products. They're scientific products."
But it was more than that. There was a fear — shared by doctors and drug companies alike — that advertising drugs directly to consumers could be harmful. Both the drug companies and the doctors worried that even though consumers couldn't really evaluate whether or not a drug was appropriate, they might become convinced by an ad, and pressure their doctor to prescribe it.
Not only might doctors end up passing out inappropriate medications, but also, drug ads could disrupt the doctor-patient relationship — a relationship that, at the time, was mostly a one-way street. Davis tells this story about his own mother, a sophisticated woman whom he found fumbling with a bottle of pills one day. When he asked what she was taking:
" 'Well,' she said, 'I take a yellow pill, a green pill and a white pill.' I said, 'That's great. What are they for?' "
His mother had no idea what they were for, Davis says. All she knew was that her doctor had told her to take them.
"It was very passive from the patient standpoint," Davis says. "The patient just took whatever orders were given by the doctor."
An Advertising Revolution
It used to work like this: Doctors decided what to prescribe. Drug companies — through medical advertisers — tried to influence doctors. Patients did what they were told.
The only problem, says Davis, was that the system wasn't working out for the drug companies. For them, the system was much too slow.
Because doctors exclusively held the keys to the kingdom, drug companies spent enormous amounts of time and money trying to get their attention. To give you a sense, the average doctor got around 3,000 pieces of mail a year from the drug industry, and to break through this noise often took years.
And so Davis, who had previously only sold packaged goods, approached William Castagnoli, the then-president of a large medical advertising company. The two came up with a solution: They would advertise directly to the patient. They'd get the patient to go in and ask the doctor for the drug. "Pull the drug through the system," Davis says with a certain amount of glee.
There was only one small problem with this solution: It was almost impossible to do.
In the early 1980s, FDA regulations required that drug ads include both the name of a drug and its purpose, as well as information about all the side effects. But side-effect information often took two or three magazine pages of mouse print to catalog, and this wouldn't do for a major television campaign. As Castagnoli says, "We couldn't scroll the whole disclosure information over the television screen — OK?"
But then, in 1986, while designing an ad for a new allergy medication called Seldane, Davis hit on a way around the fine print. He checked with the Food and Drug Administration to see if it would be OK.
"We didn't give the drug's name, Seldane," he says. "All we said was: 'Your doctor now has treatment which won't make you drowsy. See your doctor.' "
This was one of the very first national direct-to-consumer television ad campaigns. The results were nothing short of astounding. Before the ads, Davis says, Seldane made about $34 million in sales a year, which at the time was considered pretty good.
"Our goal was maybe to get this drug up to $100 million in sales. But we went through $100 million," Davis says. "And we said, 'Holy smokes.' And then it went through $300 million. Then $400 million. Then $500 million. $600 [million]! It was unbelievable. We were flabbergasted. And eventually it went to $800 million."
Pharmaceutical companies took note.
Today, drug companies spend $4 billion a year on ads to consumers. In 1997, the FDA rules governing pharmaceutical advertising changed, and now companies can name both the drug and what it's for, while only naming the most significant potential side effects. Then, the number of ads really exploded. The Nielsen Co. estimates that there's an average of 80 drug ads every hour of every day on American television. And those ads clearly produce results:
"Something like a third of consumers who've seen a drug ad have talked to their doctor about it," says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.
"About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored."
Whether the increase in the number of prescription drugs taken is good or bad for patient health is an open question. There's evidence on both sides. What's not up for debate is this: By taking their case to patients instead of doctors, drug companies increased the amount of money we spend on medicine in America.
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STEVE INSKEEP, host:
It's MORNING EDITION from NPR News. Good morning. I'm Steve Inskeep.
If you bought prescription drugs recently, consider this: Medication is the third most expensive item in our health care system. It's about 10 percent of what we spend overall on health care, and it was about half that much 30 years ago.
Today, NPR's Alix Spiegel looks at one thing that's been driving this change: television advertising.
ALIX SPIEGEL: Anne Nissan is a 17-year-old student who lives in Prescott, Arizona. David Couper is 49, a career counselor based in L.A. And then there's Samantha Saveri. She's 26, works in Baltimore, Maryland, a transportation planner. Three very different people in three very different places whose stories all begin the same way: with a couch and a television.
Ms. SAMANTHA SAVERI (Transportation Planner): I remember sitting on the couch.
Mr. DAVID COUPER (Career Counselor): We were watching "Jeopardy."
Ms. ANNE NISSAN (Student): On my sofa, probably a rerun of "House."
SPIEGEL: So there they are, in Arizona and California, in Maryland, enjoying a small moment away from school and work and life. And then out of the darkness, at a slightly increased volume, comes the message.
Ms. SAVERI: The commercial begins with a yellow and green landscape.
Mr. COUPER: A little creature who sort of jumps up and down, kind of vaguely evil.
Ms. NISSAN: It looks like it was a party setting up on a rooftop, you know, a big city type of thing.
Ms. SAVERI: And the narrator started talking about symptoms that some people struggle with, including constipation, diarrhea.
Mr. COUPER: Fungus.
Ms. NISSAN: PMS and the cramps and everything.
Mr. COUPER: And then it says you can take this drug and everything will be fine.
SPIEGEL: You see, David had been struggling with this infection on his toe, Anne had terrible cramps and Samantha found herself rushing to the bathroom at odd times. Then suddenly, right in front of them, the answer.
Mr. COUPER: It stuck in my mind.
Ms. NISSAN: That's exactly what I need.
Ms. SAVERI: I think it made me feel hopeful.
SPIEGEL: There was just one more thing that Anne and David and Samantha needed to do, one more hurdle between them and salvation. To solve their problem, they needed a prescription.
Mr. COUPER: So then I went to my doctor.
Ms. NISSAN: And then we just went to my doctor.
Ms. SAVERI: So I made an appointment with my doctor, just basically said look, I really want to try this.
Ms. NISSAN: I brought up the name of the medication.
Mr. COUPER: This wonder drug.
Ms. NISSAN: And do you think it would work for me? If so, you know, hit me up. Hit me up. Hit me up.
(Soundbite of laughter)
SPIEGEL: Today, the average American gets 12 prescriptions a year. In 1992, we got, on average, seven prescriptions a year. That's a 58 percent increase, which costs American society about 180 billion more dollars. [POST-BROADCAST CORRECTION: The actual increase was 71 percent.]
Now there are more medicines on the market today than there were in 1992, but researchers think that around 20 percent of that $180 billion increase has absolutely nothing to do with the number of medications available or the cost of that medication. What does it have to do with? Direct-to-consumer advertising.
Mr. JOE DAVIS: Hey, my name is Joe Davis, and we're in Vermont - Wilder, Vermont. I used to be wild, and now I'm wilder.
SPIEGEL: Joe Davis is retired now, but in his speech and manner, it's easy to hear the breezy salesmanship that made him so successful. Davis, you see, was an adman.
Mr. DAVIS: I was trained - or I was toilet-trained, as we like to say - in packaged goods: General Foods, Procter and Gamble - this kind of thing.
SPIEGEL: Now as a mystery, here, for context: until very recently, the 1980s and '90s, the kind of people who sold stuff like packaged goods were really different from the kind of people who sold stuff like prescription drugs. Drug ads were designed by people who worked at these small, technically minded medical advertising companies, companies that only targeted this small, technically minded audience. Drug ads, said Davis, were for doctors.
Mr. DAVIS: Nobody had ever thought that these drugs should be or could be or would be advertised to the consumer or the patient because they thought only doctors could understand the products. They're technical products.
SPIEGEL: But really, it was more than that. There was this fear shared by doctors and drug companies alike that advertising drugs directly to consumers could be harmful, because though consumers couldn't really evaluate whether or not a drug was appropriate, they might become convinced by an ad, and then pressure their doctor to prescribe it.
Also, it might disrupt the doctor-patient relationship. See, at the time, the doctor-patient relationship was mostly a one-way street. Joe Davis tells this story about his own mother, a sophisticated woman who Davis found fumbling with a bottle of pills one day. Davis says he asked what she was taking.
Mr. DAVIS: Well, she said, I take a yellow pill, a green pill and a white pill. I said that's great. What are they for? Well, I - she said, I don't know. Why do take them? Well, the doctor told me to take them. So it was very passive from the patient's standpoint.
SPIEGEL: So doctors decided what to prescribe and drug companies, through medical advertisers, tried to influence doctors. But, says Davis, the system wasn't working out well for the drug companies.
Mr. DAVIS: The whole problem with this system is - the whole problem is that it's very slow.
SPIEGEL: Even though drug companies spent an enormous amount of time and money trying to change the prescribing behavior of doctors, that process often took years. And because of patents, the amount of time companies had to make money off their products was limited. And so Joe Davis, the man from packaged goods, contacted this guy name William Castagnoli, then-president of one of the larger medical advertising companies, and the two came up with a solution.
Mr. DAVIS: Why not talk to the patient and have the patient go in and ask the doctor for the drug and pull it through the system?
SPIEGEL: The problem was this was almost impossible to do. At the time, the early '80s, FDA regulations required that when drug ads included both the name of a drug and its purpose, side effect information must also be included. But side-effect information could take mountains of mouse print to catalog. Here's Castagnoli.
Mr. WILLIAM CASTAGNOLI: In the newspapers it would take up a whole page.
SPIEGEL: But, says Castagnoli, there was almost no way to make it work on television.
Mr. CASTAGNOLI: Because we couldn't scroll the whole disclosure information over the television screen — okay?
SPIEGEL: But then in 1986, while designing an ad for a new allergy medication called Seldane, Davis finally hit on a way around the regulations. After checking to make sure the FDA wouldn't object, here's what they did…
Mr. DAVIS: We didn't give the drug's name, Seldane. All we said was: Your doctor now has treatments that won't make you drowsy. See your doctor.
SPIEGEL: This was one of the very first national direct-to-consumer television ad campaigns and the results were nothing short of astounding. Davis says before the ads Seldane sold about $34 million a year, which was actually considered pretty good.
Mr. DAVIS: Our goal was maybe to get this drug up to $100 million in sales. But we went through $100 million and we said holy smokes. And then it went through $300 million and then it went through $500 million - 600 million. It was unbelievable. We were flabbergasted. And eventually it went to 800 million.
SPIEGEL: Pharmaceutical companies clearly took note. Today, drug companies spend $4 billion a year on ads to consumers. The regulations now permit TV drug ads to name both the drug and what it's for, as long as major risks are disclosed. And the Nielsen Company estimates there's an average of 80 drug ads every hour of every day on American television.
Julie Donohue is a professor of public health at the University of Pittsburgh and she says those ads clearly produce results.
Professor JULIE DONOHUE (University of Pittsburgh): Something like a third of consumers who've seen a drug ad have talked to their doctor about it. About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored.
SPIEGEL: Now, whether the increase in the number of prescription drugs taken is good or bad for patient health is an open question. There's evidence on both sides. What's not up for debate is this: By taking their case to patients instead of doctors, drug companies increase the amount of money that Americans spend on medicine.
Alix Spiegel, NPR News, Washington. Transcript provided by NPR, Copyright National Public Radio.
