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Direct-to-consumer advertising (DTCA), linked to inappropriate medication use and higher health care expenditures, is the fastest growing form of pharmaceutical marketing. DTCA is legal only in the United States and New Zealand. However, the advent of online interactive social media “Web 2.0” technologies—that is, eDTCA 2.0—may circumvent DTCA legal proscriptions.
The purpose of this study was to assess the prevalence of DTCA of leading pharmaceutical company presence and drug product marketing in online interactive social media technologies (eDTCA 2.0).
We conducted a descriptive study of the prevalence of eDTCA 2.0 marketing in the top 10 global pharmaceutical corporations and 10 highest grossing drugs of 2009.
All pharmaceutical companies reviewed (10/10, 100%) have a presence in eDTCA 2.0 on Facebook, Twitter/Friendster, sponsored blogs, and really simple syndication (RSS) feeds. In addition, 80% (8/10) have dedicated YouTube channels, and 80% (8/10) developed health care communication-related mobile applications. For reviewed drugs, 90% (9/10) have dedicated websites, 70% (7/10) have dedicated Facebook pages, 90% (9/10) have health communications-related Twitter and Friendster traffic, and 80% (8/10) have DTCA television advertisements on YouTube. We also found 90% (9/10) of these drugs had a
Pharmaceutical companies use eDTCA 2.0 to market themselves and their top-selling drugs. eDTCA 2.0 is also used by illicit online drug sellers. Regulators worldwide must take into account the current eDTCA 2.0 presence when attempting to reach policy and safety goals.
Pharmaceutical direct-to-consumer advertising (DTCA) is legal only in the United States and New Zealand among industrialized countries [
With the Internet’s rapid development, users have migrated from passive information sources, using read-only “Web 1.0” technology, to interactive, dynamic, and custom-built relationships, using “Web 2.0” technologies [
With DTCA public health concerns, lack of specific US regulation, global DTCA legal prohibition, and the Internet’s extensive reach via social networking and other Web 2.0 technologies, we assessed global pharmaceutical company eDTCA 2.0 presence for potential marketing. Here, the focus was the corporate presence in eDTCA 2.0 social media for potential marketing, rather than the accuracy of DTCA claims, which has been found problematic elsewhere [
We identified the 10 largest pharmaceutical companies and the top 10 grossing medicines worldwide in 2009 using IMS Health sales data, which tracks revenue by company and product [
Google searches were run to identify their eDTCA 2.0 presence. Important to note is that eDTCA 2.0 presence contains a mix of DTCA categories, including reminder advertisements that only contain information about a disease or condition and recommend health care provider consultation; help-seeking advertisements that include product name and therapeutic claims; and product-claim advertisements that only provide the product name [
Dedicated corporate social media sites were defined as manufacturer-hosted websites launching multiple company social media marketing tools, including Facebook and Twitter or Friendster. Facebook is the leading social network interactive service connecting 500 million users [
In assessing eDTCA 2.0 prevalence for drugs, searches were conducted to determine whether each specific product had a dedicated website, product-specific Facebook pages, user-generated Twitter/Friendster postings, and YouTube-available DTCA. Dedicated product pages were identified as manufacturer websites that solely marketed the product. A corporate Facebook page where the profile was identified by product name and description was defined as a product-specific Facebook page. In determining whether products were the subject of Twitter/Friendster postings, all postings uploaded by all users that discussed health-related communications were reviewed for drug-specific discussions. YouTube-available DTCA was identified as any generated viewable video content upload of video-broadcasted DTCA relating to the specific drug. eDTCA 2.0 for drug products also includes a mix of DTCA types; however, the predominant category in this space is product-claim advertisements, which identify the product and the therapeutic claim along with safety and efficacy information.
Searches were conducted from September 2010 to December 2010 using the Google search engine. The search strategy for identifying dedicated social media marketing tools used by pharmaceutical companies included the following key word searches. For dedicated manufacturer-hosted social media sites the identified corporation name and the term “social media” were used for the search (eg, “Pfizer+social media”). For specific social media tools used by pharmaceutical companies, we used social media tool links from the identified manufacturer’s hosted social media website results and key word searches consisting of the identified corporation name and the social media tool type (eg, “Pfizer+Facebook”). In assessing eDTCA 2.0 presence for drug products, searches for dedicated product websites used the identified drug name and the key word “official website” (eg, “Lipitor+official website”). For product-specific social media tools we used the identified drug name and the social media tool type (eg, “Lipitor+Facebook”).
Top 10 pharmaceutical companies by sales and eDTCA 2.0a presence
Company | Dedicated social |
Facebook page | Twitter/Friendster | Sponsored |
YouTube channel | Mobile |
Pfizer | Yes | Yes | Yes | Yes | Yes | Yes |
Merck & Co. | No | Yes | Yes | Yes | No | Yes |
Novartis | No | Yes | Yes | Yes | Yes | Yes |
Sanofi-Aventis | Yes | Yes | Yes | Yes | Yes | Yes |
GlaxoSmithKline | No | Yes | Yes | Yes | Yes | Yes |
AstraZeneca | Yes | Yes | Yes | Yes | Yes | Yes |
Roche | Yes | Yes | Yes | Yes | Yes | Yes |
Johnson & Johnson | No | Yes | Yes | Yes | Yes | Yes |
Eli Lilly | No | Yes | Yes | Yes | No | No |
Abbott | No | Yes | Yes | Yes | Yes | No |
a Direct-to-consumer advertising developed for interactive social media “Web 2.0” technologies.
b Really simple syndication.
Top 10 grossing drugs and eDTCA 2.0a presence
Drug | Dedicated product |
Facebook page | Twitter/Friendster | YouTube | eDTCA 2.0 online |
Lipitor | Yes | Yes | Yes | Yes | Yes |
Plavix | Yes | No | Yes | Yes | Yes |
Nexium | Yes | Yes | Yes | Yes | Yes |
Seretide | Yes | No | Yes | Yes | Yes |
Seroquel | Yes | Yes | Yes | Yes | Yes |
Enbrel | Yes | Yes | Yes | Yes | No |
Remicade | Yes | Yes | Yes | No | No |
Crestor | Yes | Yes | Yes | Yes | Yes |
Zyprexa | No (taken down) | No | Yes | No | Yes |
Humira | Yes | Yes | No | Yes | No |
a Direct-to-consumer advertising developed for interactive social media “Web 2.0” technologies.
During searches for drug-specific, corporate eDTCA 2.0 presence, we also observed an unexpected finding: use of eDTCA 2.0 pharmaceutical marketing by illicit online pharmacies. Illicit online pharmacies are websites or links to websites identified as marketing the sale of drug products without a prescription [
Top 20 drugs by global sales and eDTCA 2.0a link to illegal online drug sellers
Drug | Facebook page link | Twitter/Friendster link |
Lipitor | Yes | Yes |
Ablify | Yes | Yes |
Advair Diskus | No | Yes |
Cymbalta | Yes | Yes |
Cialis | Yes | Yes |
Lyrica | No | No |
Plavix | Yes | Yes |
Symbicort | No | Yes |
Ambien CR | Yes | Yes |
Crestor | No | Yes |
Viagra | Yes | Yes |
Pristiq | Yes | Yes |
Flomax | No | Yes |
Chantix | No | Yes |
Yaz | Yes | Yes |
Enbrel | No | No |
Celebrex | Yes | Yes |
Boniva | No | No |
Spiriva | No | No |
Caduet | Yes | Yes |
a Direct-to-consumer advertising developed for interactive social media “Web 2.0” technologies.
The Internet’s global expanse has led to significant patient use. The National Center for Health Statistics reported 51% of adults searched for health information on the Internet from January to June 2009 [
Pharmaceutical companies appear to agree, adapting and engaging eDTCA 2.0 technologies to promote themselves and their highest grossing drugs. With near universal adoption of the most popular social media marketing represented by Facebook, Twitter/Friendster, and RSS feeds and blogs, companies are firmly committed to eDTCA 2.0. As well, 80% of firms with YouTube-dedicated channels and mobile health applications indicate they are also investing in other eDTCA 2.0 tools, such as multimedia formats with videos and health communications-related software.
However, these results indicate that eDTCA 2.0 marketing may not be limited to where DTCA is permitted by law. eDTCA 2.0 sites such as GlaxoSmithKline’s blog site and AstraZeneca’s community Facebook page indicate they are “intended for US residents/customers only,” but appear to offer no access restrictions to non-US users [
Estimates of 2009 total online DTCA spending (including eDTCA 2.0) are between US $117 million and $1 billion. Although these figures appear lower than traditional DTCA expenditures, these figures may both underestimate [
For public health policymakers and patients, the Internet’s escalating use is of concern. First, pharmaceutical manufacturers’ eDTCA 2.0 development and presence may set back even further FDA efforts to effectively regulate DTCA [
This may serve as a stark warning for public health policy, given earlier work that concluded that prohibited television-based US DTCA transmitted to Canada increased prescriptions for tegaserod by 42% after it began—a drug that was later withdrawn from US and Canadian markets due to safety concerns [
In addition, assessments of online drug advertisements show suspect quality and overemphasis of potential benefits [
Prevalence of safety issues for top 20 products advertised direct to consumers, 2009
Drug | Safety warninga |
Lipitor | Subject to recall; other safety notification |
Ablify | Black box warning; subject to recall |
Advair Diskus | Black box warning |
Cymbalta | Black box warning |
Cialis | Other safety notification |
Lyrica | None |
Plavix | Black box warning; subject to recall; other safety notification |
Symbicort | Black box warning; other safety notification |
Ambien CR | Other safety notification |
Crestor | Other safety notification |
Viagra | Other safety notification |
Pristiq | Black box warning; other safety notification |
Flomax | Other safety notification |
Chantix | Black box warning |
Yaz | Black box warning; other safety notification |
Enbrel | Black box warning; subject to recall; other safety notification |
Celebrex | Black box warning |
Boniva | Other safety notification |
Spiriva | Subject to recall |
Caduet | None |
a “Other safety warnings” include voluntary recalls, counterfeit warnings, warnings on contraindications, warnings about combining with other drugs, and other US Food and Drug Administration-issued alerts.
Adding even more public health risks and worries is the discovery that rogue online pharmacies are already entrenched in eDTCA 2.0. The presence of illegal online pharmacies using interactive social media to sell illicit products is of great worry [
Indeed, illegal online pharmacies have succeeded in selling tainted or fake drugs globally [
Such illicit presence and online purchasing of drugs are rife with patient risks. Counterfeit, diverted, and unregulated drugs are sold by these illegal vendors causing patient harm [
The combination of eDTCA 2.0 presence by drug companies and by illicit drug sellers creates even greater patient risks than each alone, and a more urgent imperative for public action [
Regulatory priority for eDTCA 2.0 is needed for other reasons. The relatively overstated benefits associated with traditional DTCA [
Given limited recognition and inadequate regulation of eDTCA 2.0, and difficulty instituting a global ban due to US legal considerations [
In preventing eDTCA 2.0 illegal export, similar to disease outbreak surveillance and control, the United States should take an active role in ensuring that eDTCA 2.0 originating from US-based companies or information technology infrastructure is not transmitted across its borders [
To do this, the United States should require marketers, pharmaceutical manufacturers, Web content providers (such as Internet service providers and registrars), and social media sites to engage in active surveillance and block foreign internet protocol (IP) address holders or users from viewing eDTCA 2.0 content. Such efforts would be analogous to prior activities between a joint task force between the FDA and Federal Trade Commission to combat illegal Web activity involving the sale of fraudulent H1N1 supplements [
Another key component is clear eDTCA 2.0 sponsorship identification. Patients must be appraised about online sources, including financial underwriting, of eDTCA 2.0 content [
Lack of marketing transparency is not new, with inappropriate pharmaceutical financial funding leading to US reform [
There are potential benefits of eDTCA 2.0, similar to those identified for traditional DTCA, including motivating discussion between patients and providers, increasing patient education, and encouraging patients to seek treatment [
Finally, regulatory efforts should provide specific manufacturer guidance as to eDTCA 2.0 limits. Although the FDA has not issued guidelines, it has held hearings discussing risk-versus-benefit reporting, manufacturer liability, and social media roles in DTCA, and announced plans to issue some guidance on the topic [
This study has several limitations. Results are descriptive and only provide a snapshot of the current state of eDTCA 2.0. The online environment is in constant flux, and findings may not reflect changes in marketing trends.
Advertising spending is likely only a rough indicator of social media presence and DTCA use. DTCA expenditures were not stratified specifically for eDTCA 2.0, since these figures are not readily available. Further, risks associated with DTCA may not be directly analogous to eDTCA 2.0 regarding product and patient safety, and can vary based on media and content.
Further, we examined only global sales revenue of the top 10 firms and products, not regional or country variations in spending or firms outside of these high sales markets. These sales data are also difficult to validate. Examination of smaller grossing firms and drugs could show different prevalence due to marketing spending limits and differing promotion strategies. We also did not validate whether sites advertising illegal online drug sales fill orders without prescriptions, since purchasing drugs over the Internet for nonmedically appropriate reasons for a fictitious patient creates legal and ethical concerns.
As well, we examined high-volume social media sites based only on popularity, but did not validate the actual number of impressions or volume of traffic on these sites. Smaller, less-visited sites may be used more by illicit drug sellers and consumers that may lead to underreporting of prevalence. Indeed, we found many social media sites of different content and origin promoting illegal online pharmacies.
Overall, DTCA globalization through eDTCA 2.0 by both drug companies and illegal online pharmacies is a global public health challenge. Licit and illicit entities have embraced the evolution in eDTCA 2.0, leaving regulatory efforts languishing. The new consumer is one that is global and connected online, a profile that precisely fits the patient/consumer of eDTCA 2.0 [
None declared
direct-to-consumer advertising
direct-to-consumer advertising developed for interactive social media “Web 2.0” technologies
US Food and Drug Administration
Internet protocol
really simple syndication
Verified Internet Pharmacy Practice Sites