As David Impey, consultant for BigBear Communications points out, the environments for direct to consumer advertising (DTCA) in Europe and in the United States are very different.
Whereas in the US pharma companies have been allowed to engage in DTCA activities under fairly strict guidelines, most DTCA is forbidden in the EU. In fact, the United States and New Zealand are the only countries in the world where pharma companies are allowed to mention their brand names in public media forums. In his presentation to eyeforpharma’s Pharma Marketing Congress in October 2007, Impey addressed this challenge: how can EU pharma companies legally and ethically enjoy the advantages of DTCA – even in markets where these activities have to be carefully executed – while avoiding the very real, negative consequences of marketing to consumers?
So, what’s so great about DTCA?
Does advertising that targets consumers directly actually work? Yes, says Impey, it really does. DTCA gets brand names directly in front of patients and makes patients feel more connected with the normally giant, faceless, mysterious pharma companies. DTCA also involves patients more in their own treatment choices. Somewhere between 2% and 7% of patients who see a direct-to-consumer ad will end up requesting and receiving a prescription for the drug advertised.
And DTCA pays. In the US, drug spending rose by $42.7 billion from 1993 to 1998. Just ten brands – the ten mostly vigorously promoted brands – accounted for fully 22% of that increase, and 50% of the increase in 2000 came from just 50 highly promoted brands. From 1999 to 2000, the total increase in pharma sales totaled more than $20 billion; nearly half of that growth (47.8%) came from the highly advertised 50 brands, and the other half (52.2%) from nearly 10,000 medicines less vigorously promoted or not promoted at all. A study of 64 drugs found a median increase of $2.20 in sales for every dollar spent in direct to consumer advertising. Clearly, DTCA has a profound affect on sales.
What’s not so great?
As Impey says, all of these exciting returns come at a cost, however. There is considerable criticism out there about DTCA. One criticism is that the drugs being advertised are the new, exciting blockbuster drugs, not the “old and cheap” medicines, and the “new” drugs being touted are seldom more than expensive replacements for older, cheaper generics.
Drug ads on TV especially, according to critics, are incomplete in their information, sometimes to the point of being misleading. The ads are too emotional, they discount or minimize the impact of living a healthy lifestyle, they skew the doctor-patient relationship, and they only appear to be enabling patients to make an informed decision. Loss of industry reputation due to DTCA may nullify the advantages of greater brand exposure.
And DTCA costs money. A lot of money. In 2005, pharma companies spent $4.2 billion on DTCA, $1.9 billion on television commercials alone.
Additionally, says Impey, patients don’t really understand the information they’re given. A 2002 consumer survey by the FDA revealed that 41% of patients read none of the summary, compared to 10% of patients who read it all. And 55% of patients said the information was “hard” or “very hard” to understand. In TV advertising, information is given too quickly; patients are often unable to understand the rapid-fire delineation of possible side effects as they go rattling past.
Visible, costly advertising frequently results in collateral damage to a pharma company’s reputation. An American Enterprise Institute study in 2002 claimed that 70% of consumers “mistrust advertising claims in general.” Such advertising feeds the opinion that if companies have so much money to spend on costly television commercials, then perhaps they could reduce the prices of their products a little.
DTCA in an EU context
In most European states, healthcare is almost entirely funded by the government. This means that it is in the state’s best interest to keep costs low and limit access to healthcare resources. As a result, DTCA, with its concomitant increase in prescriptions, is utterly incompatible with the budgetary and political objectives of most EU governments. As Impey points out, in times of budgetary crisis, the easiest target for cuts is the “profligate, cash-rich drug companies.”
So, Impey asks, what can be done? Or, what can be done under very rigid controls without risk of damage to reputation? The rule for most EU countries is that any information given to patients must be the same as that given to the health care professionals, and it can only be given with the consent of the HCPs. Therefore it is vitally important to get doctors on board.
Getting into the Flomax
As an example of what can be done, Impey offers up the Flomax 30 Project. In 1998, Flomax (tamsulosin) was introduced to the market as a treatment for Benign Prostatic Hyperplasia (BPH). It was the sixth alpha-blocker on the market but was differentiated by being an alpha A1 receptor. It offered relief from symptoms with few or no side effects.
Some of the key issues identified by the pharma company behind the product were that GPs had little knowledge of the product, and thus their confidence in prescribing it was “rock bottom.” Doctors were concerned that they might miss prostate cancer cases, and out of their fear and lack of knowledge, they tended to follow local hospital prescribing practices. Not surprisingly, the problem was compounded by patients being unwilling to come forward with their symptoms.
After the initial launch phase, Flomax did well. But the pharma company thought the drug could do even better. They devised a strategy that would increase sales by using DTCA techniques, while never crossing the very firm line the UK government had set to regulate such marketing practices. They selected 12 hospital catchment areas, chosen for either Flomax’s existing market leadership in the area or where the drug had the highest new patient share (i.e. incoming patients were more likely to be prescribed Flomax than a competitor).
The company would launch a disease-specific (not brand-specific) marketing campaign to educate the public. To that end, they established a Men’s Health Matters organization with free phone numbers where people could get advice from a nurse or request educational materials such as booklets or audiotapes.
The strategy in action
Once the target hospitals were selected, the pharma company got agreements to set up a Prostate Assessment Center (PAC). At the PAC, men with symptoms received a definitive diagnosis that separated BPH sufferers from those with other health concerns. Throughout, the pharma company provided support, whether it was supplying money, nurses or equipment. Local media supplied PR opportunities to promote the Prostate Assessment Center. Success, says Impey, relied on the sales force. Each rep had his or her own catchment area to manage, signaling the pharma company when it was time to enter the next phase of operations.
The next step was to involve local doctors. Meetings with consultants were arranged (with CME accreditation, when possible), and doctors were provided with support materials for their waiting rooms. Doctors were trained to recognize the symptoms and encouraged to send patients presenting with lower urinary tract symptoms to the PAC. Bringing doctors into the loop well in advance of the general public, says Impey, removed barriers to treatment and minimized the risk of resentment.
Finally, the general public was included. A disease awareness program helped make potential patients familiar with symptoms and reassured sufferers that treatment was both simple and available. The goal was to prevent unnecessary worry and educate men that the symptoms didn’t inevitably point to cancer. In keeping with UK regulations, never was the brand name Flomax mentioned – not in the posters, not in the media, not in the reading materials in doctors’ waiting rooms. The focus was entirely on recognizing and seeking appropriate treatment for the condition. Branding, Impey says, was reserved for the doctors.
Because budgets for each catchment area were set in advance and careful track was kept of expenses, the pharma company was able to get accurate ROI numbers. Before the program began, the average cash market share of the 12 pilot areas was between 20% and 25%. Within six months of rollout, average market share was at least 35% and usually around 40%. The scheme was so successful that it was expanded from 12 areas to 25 and then to 50; at its peak, actual sales of Flomax were £55 million in an £80 million market.
Lessons learned
While some pharma companies in Europe may look longingly at the more permissive advertising climate of the US, Impey believes the US system is far from perfect. It’s too simplistic, he says; it’s far better to increase sales in a way that brings greater benefit to medicine and enhanced reputation to the pharma industry. DTCA in the US has been very effective in boosting sales of particular brands, but it has “created significant resentment against the industry.” Non-branded case studies such as Flomax 30 have also proven to significantly benefit brand sales, along the way providing real benefits to patients, doctors and communities as well.
Author: Shannon Perry, journalist, eyeforpharma
