The Patient Was…

Direct-to-Consumer (DTC) advertising of prescription drugs is big, really big, business. It is estimated that expenditures on pharmaceutical advertising to non-professional consumers in calendar-year 2025 were about 10 billion U.S. dollars, with the majority of that money going to television advertising. The largest expenditure for a single drug was about 440 million dollars.

My feelings about DTC pharmaceutical advertising have changed significantly over many years. Although DTC drug advertising in its present form began in 1997, I was thinking about the idea several years before that. As a physician, and medical director of a large pharmaceutical advertising agency, I thought that all the parties involved would benefit: patients, physicians, drug companies, television networks. Patients would be more informed, physicians would have better conversations with patients and their families, and drug companies and television networks would profit. Win-win-win-win.

To pursue the idea, I organized a lunch with the President of my advertising agency and a close friend of mine who was Vice-President of a major television network. They both were interested in the idea of drug advertising directly to consumers, but both were wary of all the possible pitfalls, including legal issues. Each luncheon guest suggested that the other take the lead in exploring the notion and initiating activity around it, with a promise to support it once it “had legs” (remember these were advertising and media folks).

Since neither one was willing to take the lead, and stick his and his organization’s neck out, nothing came of it at the time. Of course, once the idea took hold some years later, both organizations were active participants and were part of the “win” column.

To this day, the idea of DTC pharmaceutical advertising is very controversial. Notably, only two countries allow it in its present form: The U. S. and New Zealand.

Supporters claim that patients are more informed about their conditions and available treatment options. And they get access to newer therapies earlier. Physicians have more information to share with patients and families, and can have more fruitful conversations, leading to better patient outcomes.

Critics, on the other hand, claim that overall costs of drugs go up, patients may misunderstand some of the material provided, misleading information can be dangerous, unnecessary prescribing may occur, and the doctor-patient relationship may be strained because of disagreements provoked by advertising content.

There have been attempts by some groups to curb or even outright ban DTC advertising of prescription medications. In each instance, the courts have deemed it protected commercial speech. There are, however, regulations that govern it. The FDA is now paying closer attention to every aspect of what consumers are exposed to. And pharmaceutical companies have so-called Review Committees, comprised of representatives from medical, legal, marketing and regulatory divisions, that review all material developed and distributed by the organization. I personally was a member of the Review Committee of both major pharma companies where I served as a Medical Director.

Having early been a proponent of DTC pharmaceutical advertising, I now find more fault than benefit with it. While the concept is still admirable, the actuality, in my view, is problematic.

Do costs go up as a result of advertising? It’s hard to deny that they do. If you spend millions of dollars promoting a product, those dollars have to drive usage, sales, and profits. And they do. The reasoning is simple: If DTC advertising wasn’t profitable, they wouldn’t do it. I’ve nothing against corporate profitability, but one must acknowledge that overall costs to the consumer, to insurers, and ultimately to society do increase.

Misleading information, or frankly misinformation, is a bigger problem. There are claims made in some advertisements that are not entirely factual. Benefits of a drug may be stated in such a way as to make the effects sound better than actual data support. A claim of efficacy may suggest broader benefits than are warranted.

The handling of side effects is perhaps the most egregious problem with DTC advertising. Every drug, with no exceptions, has some downside. Even water, if given as a treatment, can be given in excess and cause serious injury. When TV advertising was first under development, companies realized that there was simply no way to include all side effects in a 30–second or one-minute commercial. The solution, approved by regulatory authorities, was to have all side effects available in a print version that consumers could access in a magazine or other printed source. Who does that?

The side effect issue is a serious one for companies and regulators. There is the concept of “fair balance,” in an ad which is often misunderstood. Many people think it means that the ad must give equal time to alternative treatments. But no, it means something else. “Fair balance” refers to equal time and emphasis given to side effects of a drug as to benefits. Have you noticed how that often plays out in a television ad for a drug?

When the benefits of the drug are shown, there is usually lively music, people are having a great time, families are bonding, there is activity, everything is just great! When the side effects are discussed, there is often distracting music, the speaker’s voice is a little more staccato, there is a more monotonic quality, fewer pauses and variation in tone and pitch, and there may still be happy scenes on the screen. To me, this isn’t fair balance and tends to minimize the potential risks of a drug. As a physician, it disturbs me.

The patient – doctor relationship is a sacred one. The entire blog ThePatientWas.com revolves around this. DTC advertising of prescription drugs has, in many instances, altered this. Much of the precious, and now increasingly limited, time for discussion between patient and physician is taken up by discussions generated by things patients have heard, or thought they heard, in a television ad. Often, it’s irrelevant to their problem. Sometimes, the advertised drug is ill-advised for the particular patient; in fact, the drug may be contraindicated with other medications they require. Yet, the matter has to be discussed, perhaps at the expense of other, more important information.

The time and effort expended by physicians in dealing with patients who come armed with advertising-generated ideas and queries should not be underestimated. Some physicians give in and, if the drug in question isn’t a recognized danger to the patient, they will prescribe it. Might it be actually beneficial, and something the physician should have thought of themselves? Yes, but more often it’s an unnecessary addition to the patient’s drug regimen, or it simply replaces an older, less expensive, but equally effective medication. Studies attempting to quantify the impact of patients’ requests for specific drugs show a significant increase of physician prescribing of the requested drug.

To sum up my view on DTC advertising of prescription drugs, the negatives outweigh the positives. There are better ways to educate patients and to improve the conversations and relations between them and their physicians.