One difference between Canadian and American health care is that the US government allows research-based drug makers to advertise the benefits of their medicines to patients, but the Canadian government outlaws this freedom of speech. Unfortunately, the Canadian Medical Association Journal (the Canadian equivalent of the Journal of the American Medical Association) has encouraged Canada’s government to maintain this restriction. The grounds are pretty unconvincing: A survey of physicians and patients in both countries, which was reported in a recent issue of the journal, shows that patients who request advertised drugs from their doctors are much more likely to receive prescriptions than patients who do not. This is unsurprising. We would hardly expect drug makers to advertise their medicines unless the expense was associated with increased sales.
Unfortunately, the journal’s contributors suggest that pharmaceutical advertising increases the cost of prescription drugs, encourages people to buy “lifestyle” drugs for baldness or sexual dysfunction, and lures patients into taking medicines without understanding the risks. None of these accusations are supported.
According to the survey, patients who requested advertised drugs received them in 86 percent of cases, whereas patients who did not request drugs only received prescriptions in 26 percent of cases. However, the survey also showed that patients who request non-advertised drugs receive prescriptions in 74 percent of cases. So, while advertising explains some increase in patients’ requests for prescriptions, it is quite minor relative to other, unexplained, reasons why patients request prescriptions.
Furthermore, for prescriptions written without patients’ requests, the doctors considered only 12 percent to be “possibly” or “unlikely” to be appropriate (as opposed to “likely”). For prescriptions for requested, advertised drugs, the rate of ambivalence was 50 percent. However, the rate of ambivalence for prescriptions for requested, non-advertised drugs was 39 percent, so we have the same problem as above. Although advertising increased ambiguity somewhat, the big jump occurred when a prescription was requested for other reasons.
Furthermore, we do not know many “possibly” or “unlikely” prescriptions would have caused negative outcomes. We would expect any increase in prescription volume to include some prescriptions that have negative consequences. The real issue is whether the increase in “good” prescriptions is greater than the increase in “bad” prescriptions.
This is likely the case. The Food and Drug Administration recently completed a survey of 500 American physicians. In 91 percent of cases, they said that patients did not try to influence the treatment in a way that would have been harmful.
As well, although thousands of prescription medicines are sold in the US, only 50 accounted for 95 percent of all advertising spending in 2000, and the top ten accounted for 41 percent of spending. Viagra®, was the only one of the top ten that could be described as a “lifestyle” drug. The other nine treated cholesterol, obesity, stomach ulcers, depression, arthritis, or allergies. Propecia®, for baldness, was ranked 41st with less than one percent of total pharmaceutical ad spending.
If we compare spending on pharmaceutical advertising in 2001 with overall spending on prescriptions in the US, the numbers imply that a $49 prescription would “contain” advertising costs of one dollar – hardly a big deal. However, even this analysis is overly simplistic. Advertising enhances competition by increasing awareness of different products. It is expensive for patients to learn about different products, and advertising reduces these costs. The better-informed patients are about alternative therapies, the more leverage they have over individual suppliers. Furthermore, many drugs that are advertised are for conditions that are under diagnosed and under treated.
Unfortunately for Canadians, about half of Canada’s prescription spending is government spending. This presents a conflict of interest when regulating pharmaceutical advertising. If rules preventing advertising keep patients ignorant of different medicines, they will be less likely to demand better access to newer drugs that have superior outcomes. For government agents trying to manage growing healthcare spending, this creates a powerful and perverse incentive.
American patients are fortunate to have diverse sources of information about medicines, not just what their governments want them to know. Advertising is one of those sources. Americans should be wary of losing access to this information as the federal and state governments increasingly control what’s in their medicine cabinets.