Tasked with research and development, pharmaceutical companies aid in the worldwide prevention and treatment of illness and disease; these companies encounter fierce competition and (usually) work within the bounds of government regulations [1]. Pharmaceutical companies set aside a portion of their budgets for research and development but over time the amount spent on direct-to-consumer marketing has surpassed research and development [2]. Direct-to-consumer pharmaceutical marketing refers to the promotion of prescription medications to consumers as patients, instead of targeting only doctors [3]. Previous research purports that direct-to-consumer marketing is effective [4,5], especially in encouraging consumers to ask their doctors about specific medications. A survey by the Kaiser Family Foundation shows that after talking to their physician about a medicine they saw advertised, about 44% of patients who requested the advertised medication were ultimately prescribed this medication [6]. However, patient trust in the pharmaceutical industry is extremely low—only 58% of Americans trust pharmaceutical companies [7]. This poses a challenge for pharmaceutical companies and their direct-to-consumer marketing efforts.

Health care marketers are beginning to use the term patient influencer to refer to those who promote pharmaceutical medications and/or medical devices, allowing companies to “leverage the patient experience and expertise in the design, development and promotion of their products and services” [8]. Due to consumers’ negative perceptions of pharmaceutical companies, it makes sense that new tactics are being used to establish and improve relationships with consumers. A recent report by eMarketer noted that consumer response is highest when messages are delivered from social media influencers compared to brand-owned channels; further, content from influencers is more effective at meeting communication goals [9]. Pharmaceutical marketers’ entry into social media in general, and influencer marketing in particular, presents both opportunities and challenges relevant to the various stakeholders involved. Little published research is available in this area, despite the pharmaceutical industry’s increasing use of patient influencers. There are different forms of patient influence, and each involves patients in a different way. The purpose of this viewpoint paper then is to simply raise awareness of influencer marketing by pharmaceutical companies and generate research and debate on the use of influencers in health care.

The following sections of this paper will explore the concepts of expert patients, patient advocates, and digital opinion leaders. Expert patients are far removed from pharmaceutical companies; they exert influence on other patients via online health communities [10,11]. A patient advocate is also active online, but they influence other patients via their social media presence and raise awareness about a particular disease or illness [12,13]. Some patient advocates are directly involved in promoting pharmaceutical products. Some health care professionals are also digital opinion leaders whose influence is due to their active social media presence along with a reputation for being a leader in their field [14,15]. Table 1 summarizes these key concepts. Together, these different groups hold the potential to involve and influence patients in health and medical decision-making.

Shared decision-making in health care requires collaboration between patients and physicians; in reality, however, there are many obstacles to patients collaborating with physicians, including technology barriers, health literacy levels, and access to health insurance [16]. Physicians’ time is also constrained; a recent survey reported that 51% of physicians spend 9-16 minutes with patients [17], which could have an impact on health outcomes [18-20]. Patients then often turn to the internet and social media to fill the gaps in the health care system.

Online communities can be a source of health information and peer empowerment for patients. Online communities are social platforms where “people come together to get and give information or support, or learn or to find company” [21]. A study of an online community for patients with arthritis found that members developed expertise in disease self-management in part by modeling behaviors that were discussed in the community [22]. By sharing disease experience, patients are able to “crowdsource” answers to their current situation, and “see” the outcome of different strategies through the shared user-generated content [23]. A study by Fox, Ward, and O’Rourke [24] found evidence to suggest that online communities result in the development of expert patients. The researchers found that active participants ultimately became expert patients in the online community; they shared information within the community and received valuable support from other patients. Although these patients became experts, their expertise was limited to the biomedical model that supports pharmaceutical interventions. They did not become experts in a wide range of approaches to weight loss [24]. Despite this limitation, the authors suggest that informed patients are in turn informed consumers who are engaging directly with providers on health technologies as opposed to only indirectly through a medical professional.

Research found that patients often join online communities in search of information about disease treatment options, including pharmaceutical medications [25-27]. For instance, a recent content analysis (N=1960) of 4 online health communities found that medication (N=568) is one of the most popular topics discussed by members [28]; medication adherence is discussed in terms of the presence of disease symptoms, and members share their experiences with specific medications, focusing on the specific barriers to adherence (eg, cost, side effects) [29]. The number of online health communities has rapidly increased as more patients desire to access alternate sources of information as well as connect with other patients with the same illness or disease [30,31]. Although previous research notes that online health education programs about chronic disease self-management positively impact participants’ health outcomes [32,33], scant research studies the health effects of online peer-to-peer communities and the influence of user-generated content on health attitudes and behaviors.

Recent marketing efforts by pharmaceutical companies have focused on digital advertising and engagement tactics to connect with patients and build relationships [34]. In fact, pharmaceutical companies are using digital data analytics to formulate target audience profiles and direct-to-consumer marketing strategies that take a holistic approach and consider patients’ overall lifestyle preferences and their well-being, not only the disease diagnosis [35]. This new focus describes pharmaceutical companies’ efforts in relationship marketing, using social platforms to speak with patients and learn about their preferences [36]. Relationship marketing draws from the practice of public relations and attempts to foster customer loyalty and long-term retention.

The pop culture term influencer refers to a brand’s commercialization of the relationship between an influential social media user and his or her followers [37]. Social media influencers can be defined as “third-party users of social media who have achieved micro-celebrity status in the form of large followings on social media platforms and who have a position of influence on their audience” [38]. From a strategic communication perspective, social media influencers are actors who influence “organizational stakeholders through content production, content distribution, interaction, and personal appearance on the social web” [39]. The relationship between an influencer and his or her followers is fundamental to a brand’s success because it should drive positive word-of-mouth and purchase intentions [40]. eMarketer reported that more than two-thirds of North American retailers use some form of influencer marketing [41]. Brands are not just selling products but entire lifestyles, employing social media influencers to build trust through authentic, curated content. Followers perceive influencers as being knowledgeable experts on specific topics, with relevant sources for information and support for their opinions and behaviors [42].

Influencers may or may not have demographics and psychographics that are similar to those of the consumer, but they are similar to the consumer in that they share a common interest in the topic of the group [43]. Influencers are chosen to represent a brand for a number of reasons, including industry popularity [44], quality of social media content [45], experience with brand partnerships [46], and audience demographics [47]. Choosing an influencer is part of a larger marketing strategy that usually supports campaign goals and broader communication objectives [48].

In direct-to-consumer pharmaceutical marketing, it can be risky for brands to activate paid social media influencers for a number of reasons: navigating Food and Drug Administration (FDA) and Federal Trade Commission (FTC) regulations, concerns about authenticity, and managing consumer engagement [49-52]. Kim Kardashian’s endorsement of Diclegis, a medication to treat morning sickness, is a prime example of the risks inherent in celebrity influencers partnering with pharmaceutical companies. In 2015, Kardashian and Duchesnay, the drug manufacturer, were found to have violated FDA regulations by not properly disclosing the risks and side effects of the drug in Kardashian’s Instagram post about how the drug helped her combat morning sickness during her pregnancy [53,54]. Rather than continuing to pursue partnerships with celebrity influencers, pharmaceutical marketers have instead turned to health and medical opinion leaders as well as patient advocates. Typically, patient advocates are active on social media, tend to raise awareness of illness and disease, and are considered micro- or nano-influencers. These types of influencers typically have a smaller number of followers but cultivate more targeted communities, generating higher engagement rates and building stronger relationships with stakeholders than celebrity influencers [55]. Pharmaceutical brands are beginning to opt for micro- and nano-influencers who have very specific audiences that may be primed for health messaging. A recent article in Vox described the value of patients to pharmaceutical marketers in building brands [56]. Lived experience is something that patients have in common with each other, and cannot be replicated; thus, patient influencers are simply commercializing their lived health experience. Patient influencers used in this way attempt to create an emotional linkage with followers by sharing strategic and curated pieces of their illness and disease experience.

According to a recent comprehensive review of medical marketing expenditures in the United States, pharmaceutical companies spend nearly 70% of their promotional budgets marketing to health care professionals, or just over US $20 billion in 2016 [57]. These marketing activities include prescriber detailing, free samples, direct physician payments, and disease education. A substantial portion of the direct payments goes toward sponsoring key opinion leaders [58]. Physicians have long been influencing other physicians by giving keynote speeches and lectures at educational events and serving as product champions or product endorsers for pharmaceutical companies [59]. The industry now also recruits physicians who are digital opinion leaders; that is, health care professionals with an active social media presence who are seen as leaders among their peers, but who might have different characteristics than traditional key opinion leaders [58]. Pharmaceutical marketers are beginning to use the term influencer to describe this type of opinion leader. Online marketing services like Klear compile lists of the top physician influencers across social media platforms [60].

Noticeably absent from the literature is the role advertising and marketing agencies play in relationship marketing and the use of influencers to promote pharmaceutical brands. Patient advocates self-select to engage in pharmaceutical marketing efforts and are supplied with promotional collateral to share with their followers so that their persuasive messaging stays within the boundaries of disease awareness—the type of direct-to-consumer advertising permitted by regulating government agencies. However, little is published about this phenomenon. Sites like WEGO Health are actively recruiting patients as social media influencers or patient advocates so as to connect pharmaceutical companies and other health and medical brands with patients to commercialize their lived disease experience [8].