Health Care Marketing Plans

Recognizing Misleading Pharmaceutical Marketing Online

Julian De Freitas, BA, Brian A. Falls, MD, Omar S. Haque, MD, PhD, and Harold J. Bursztajn, MD

In light of decision-making psychology, this article details how drug marketing operates across established and novel web domains and identifies some common misleading trends and influences on prescribing and patient-initiated medication requests. The Internet has allowed pharmaceutical marketing to become more salient than ever before. Although the Internet’s growth has improved the dissemination of pharmaceutical information, it has also led to the increased influence of misleading pharmaceutical marketing. Such mismarketing is of concern, especially in psychiatry, since psychotropics generate considerable revenue for drug companies. In a climate of resource-limited drug regulation and time-strapped physicians, we recommend improving both independent monitoring and consumer awareness of Internet-enabled, potentially misleading, pharmaceutical marketing influences.

J Am Acad Psychiatry Law 42:219 –25, 2014

Although the Internet has existed for a few decades, its widespread use is a relatively recent phenomenon. Internet use in general, and specifically with regard to health information, has increased enormously over a short period.1 By 2003, nearly two-thirds of Ameri- can adults had gone online, and nearly two-thirds of these adults had searched for health information at least once in the previous year.2 The growth of online information services and patient forums can be seen as an encouraging development. These resources facilitate an unprecedented support network for mil- lions of patients and provide invaluable health infor- mation to otherwise isolated communities. Physi- cians also find them useful.3 At the same time, concerns continue to surround the many new ways in

which the Internet has increasingly permitted phar- maceutical companies to bypass traditional safe- guards in the doctor-patient relationship by market- ing products directly to consumers.4 Consumers include patients as well as their prescribing physi- cians, since, to be sold, a prescription must be deemed necessary by a doctor and desired by a pa- tient. Pharmaceutical companies therefore seek to influence both physicians and patients through pro- vider-directed and direct-to-consumer marketing, respectively. The majority of these marketing efforts are provider-directed, although both marketing types effectively sell medications.5

Although direct-to-consumer marketing is not re- stricted to the Internet, as a medium the Internet introduces its own host of intricacies, since it oper- ates within a different time frame and architecture than other communications media. Unlike other means of transmission, the Internet allows for instant contact regardless of geographical distance, location, or accuracy of the information conveyed. Further- more, its structure is not specified by any particular design, but is the self-organized product of a combi- nation of technological capabilities and human needs. Its fluid and ever-evolving nature allows for the invention of new and often unpredictable do- mains and applications, many of which have been effectively used by the pharmaceutical industry,

Mr. De Frietas is a Research Candidate in Experimental Psychology, Department of Experimental Psychology, Oxford University, Oxford, UK. Dr. Falls is a member of the Program in Psychiatry and the Law and a Clinical Fellow in Psychiatry, Department of Psychiatry, Har- vard Medical School, Department of Psychiatry, VA Boston Health- care System, Boston, MA. Dr. Haque is a member of the Program in Psychiatry and the Law, Harvard Medical School, Department of Psy- chiatry at the Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Cambridge, MA, and a Resident, Department of Psychiatry and Human Behavior, Brown University, Providence, RI. Dr. Bursztajn is Associate Clinical Professor and Co-Founder, Program in Psychiatry and the Law Harvard Medical School Depart- ment of Psychiatry, Beth Israel Deaconess Medical Center and the Massachusetts Mental Health Center, Cambridge, MA. Address for correspondence: Harold J. Bursztajn, 96 Larchwood Drive, Cam- bridge, MA 02138. E-mail: harold_bursztajn@hms. harvard.edu.

Disclosures of financial or other potential conflicts of interest: None.

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R E G U L A R A R T I C L E

such as tracking a user’s browsing history to tailor banner advertisements specifically to that user.6

The global nature of the Internet also defies re- strictions on direct-to-consumer marketing im- posed by all countries except the United States and New Zealand.7 As a result, nearly any user world- wide can encounter unregulated and unmonitored pharmaceutical marketing online. Clearly, such efforts are not simply repurposed print or broad- cast media campaigns.

Misleading Pharmaceutical Marketing

When should influencing health care consumers (an integral objective of pharmaceutical marketing) be characterized as misleading? Although pharma- ceutical marketing is sometimes construed as con- ventional,8 the exceptionality of drug promotion lies in its unique consequences for both patient health and the health care system generally as well as in the nature of the patient-physician contract it can under- mine. Even conventional marketing techniques are highly problematic within a medical context, since they may have detrimental downstream effects on a patient’s health and trust in medical care. Inaccura- cies, imbalances, failures to meet accepted scientific standards, and other misleading aspects of drug mar- keting can lead to increased health care costs (when patients are persuaded to buy new drugs instead of cheaper alternatives, including nonpharmaceutical treatments), injury or death (when patients are en- couraged to buy drugs for which there are safer alter- natives or for purposes not fully approved),9 and eroded patient trust in the reliability of health care (when patients believe that physicians with conflicts of interest are explicitly or implicitly placing their own financial interests above the best standard of care for their patients).8 Since patients have the right to the most objective scientific treatments, and since physicians take a professional oath to meet this stan- dard of care, marketing that jeopardizes the objectiv- ity (or even perceived objectivity) of this care consti- tutes mismarketing.

Finally, much work in psychology, social science, and medical ethics (for reviews, see Refs. 8, 10) has shown that it is not only impaired patients who are influenced by misleading pharmaceutical marketing, but also the public more generally.8,11–13

Conflicts of Interest in Online Pharmaceutical Marketing

Given that the pharmaceutical industry is for profit, it not only has an interest in maximizing health but also a separate and often conflicting inter- est in expanding the number of prescriptions written for its products. Pharmaceutical companies therefore continue to search for new and creative ways to max- imize revenue, with more investment in online drug marketing; spending on Internet advertising alone is projected to rise by $830 million over the next three years.14 In principle, this behavior is regulated by the Fair Balance requirement of the U.S. Food and Drug Administration (FDA), which states that drug mar- keting must not be false or misleading and must in- clude drug risks presented in a balanced manner.15

Yet some pharmaceutical manufacturers have repeat- edly admitted to failing to meet this requirement and on several occasions have pleaded guilty to illegal marketing. Instances of pharmaceutical mismarket- ing are cause for special concern in psychiatry, since psychotropic medications are major revenue genera- tors for drug companies. In 2010, four psychotropics were among the top 20 of all prescribed drugs in the United States,16 and 5 were among the top 20 in sales revenue.17 Regardless of the financial incentives that pharmaceutical companies have to market their products, medicine’s primary ethics-based interest is to ensure the maximal health and well-being of pa- tients.18 Whenever this aim is jeopardized, it is the first priority of the health care profession to undo the circumstances that endanger it.

Online Domains of Pharmaceutical Mismarketing

We will now discuss how some of the most com- mon formats of online pharmaceutical marketing can be exploited to bias physicians and patients, how the design of these promotions should be improved to be less misleading, and the common presenta- tional trends and ethics principles that emerge from this kind of marketing. Some of these cases have been addressed by the FDA, but others have not. That some patterns of mismarketing continue uninter- rupted could indicate that they are so novel that the FDA has not yet fully considered or noticed them. If the agency is indeed aware of these occurrences and presentations, it may simply lack sufficient staff to regulate them.

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Search Engines

Quick and easy to use, search engines are often the first portal of inquiry for clinical information. How- ever, most users do not look beyond the first two pages of search results.19 Whereas 81 percent of phy- sicians use search engines to answer a clinical ques- tion, more than half end their search at the first web page viewed.20 The importance of the first page that opens in the search result is underscored by studies showing that medical searches of this kind are rarely just exploratory; rather, two-thirds of patients21 and three-fourths of physicians who go online are looking for a specific medication by name.20 Some drug com- panies use search engine optimization techniques,22

and their advertisements frequent the top of such inquiries, especially if the search is conducted with the medication’s name.20 Among doctors who use search engines, 92 percent click on a link at the top of the first results page.20 Since website objectivity is not a crucial factor in most nonmedically related searches, there is typically little reason for users to doubt the importance and usefulness of search results in these instances. The pharmaceutical industry, however, has a clear incentive to profit through its sites, and so the objectivity of these sites cannot be assumed. When health is at stake, it is important that users be presented first and foremost with sources completely free of bias or potential for bias. It may be helpful to introduce fuller disclosure of website sources at the search result level, as this could inform advertisers of which links users click from the search results page.

In 2009, the FDA warned 14 major drug compa- nies that their search engine advertisements were misleading.23 The companies had not included suf- ficient information online regarding medication risks. Companies often feature these risks in small print at the bottom of a webpage, in small textboxes that sometimes require the viewer to scroll to read them, or two or more clicks away. In 2010, Google took what appears to have been a self-initiated step toward improving the credibility of medication searches when it altered the order of nonadvertise- ment search results displayed. Since these changes, the first official link in a medication search is the medication’s National Institutes of Health (NIH) online address (URL), which provides detailed, un- biased drug information, including side effects. This improvement, though commendable, has not altered the display order for medical condition search re-

sults, some of which promote the prescription and use of specific medication brands. For example, al- though only four of the top 50 Google and Yahoo search results for schizophrenia in a 2008 study led overtly to drug company websites, more than half of all the sites had identifiable commercial funding.24

A nearly identical study found similar results when PTSD was the search term.25 The 75 percent of web- searching doctors who are looking for information on a particular medical problem21 can unknowingly be exposed to prescription-promoting information presented by pharmaceutical companies.

Drug Company Websites

Since one-third of physicians’ and many of pa- tients’ search terms are branded medication names,20

it is important to consider the influence of drug com- pany websites, which may mislead viewers as any other form of marketing can. A recent meta-analysis of pharmaceutical company-funded mental health web sites found that their content leaned signifi- cantly more toward biogenetic causes and medical treatments (as opposed to psychosocial causes and treatments) than that of their financially indepen- dent counterparts.26 Drug websites’ structures and layouts influence users’ perceptions of website cred- ibility.27 Pharmaceutical companies often display prominent photographs, fonts, and graphics on their product pages. By contrast, important safety infor- mation is sometimes hidden in plain view, thereby satisfying the FDA’s Fair Balance requirement while still being hardly noticeable. On several occasions the FDA has sent warning letters to companies that have failed to include drug risk information, have in- cluded this information but placed it a few mouse clicks away, or have recommended their drugs for unapproved uses.28 Even if companies adequately communicate drug risks through words, they may still convey biased messages via photos, videos, and other graphics, all of which may be more attention grabbing (e.g., because of their placement and dy- namic character). Although such Internet practices are commonplace in conventional marketing, they may quickly become problematic in a medical con- text. Visual presentations of this kind can be used to convey salient, emotionally appealing messages that illustrate and sometimes magnify drug benefits, but seldom drug side effects or alternative treatments (even when the visuals accompany drug risk and treatment information). For instance, a user whose

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attention is drawn to moving images of smiling, ener- getic beneficiaries of a medication’s therapeutic effects may not notice the small print detailing side effects and contraindications. Such misleading portrayals may soften the impact of drug risk information or distract online users from that information altogether.

Some pharmaceutical companies also use so-called unbranded websites to provide information about diseases that can be treated with medications that they manufacture. Often, they do so without reveal- ing their sponsorship of these sites.29 In 2010 the FDA warned pharmaceutical giant Novartis about its sponsorship of three distinct websites that provided information on different types of cancer. All three sites, disguised as informational, promoted Gleevec (a Novartis product) for unapproved uses and dos- ages while underplaying the drug’s risks.30 One site was falsely portrayed as “independently operated and not managed by” Novartis. The site repeatedly en- dorsed Gleevec as a treatment option, but identified no other drugs in the same class. Despite the FDA’s warnings, consumers continue to want access to these promotional sites.31 This preference may indi- cate a lack of public awareness regarding the influen- tial nature of these sites, or the extent to which phy- sicians and patients depend on such information for rapid relief from the uncertainty that may compound their distress.

One benefit of the Internet as a marketing me- dium, in contrast with print and other media, is that its content may always be modified and its presenta- tion quickly and easily improved to be less mislead- ing. Particularly under the vigilance of the FDA, there have been noticeable steps toward fair balance in company websites and links. That said, the edit- able nature of the Internet is a double-edged sword: in the time it takes for the FDA to correct one inac- curacy, new problems may appear elsewhere, espe- cially whenever companies market their drugs under multiple domain names.

E-mail Lists, Blogs, and Wikis

Domains that promote discussion among typi- cally anonymous individuals, such as e-mail lists, blogs, and wikis, relieve authors of many of the usual constraints on communication, such as disclosures of conflicts of interest and other reputational infor- mation. Even when e-mail lists require conflict-of- interest disclosures, such rules can be ignored. In the extreme, these domains can host fraudulent testimoni-

als from avatars, who may be employed to deceive, working within what are perceived to be trusted infor- mation channels among patients and caregivers. There has been little research into the magnitude of these ad- verse impacts on care giving, presumably because of the confidential nature of many of these services.

Wikipedia and other user-edited consensus re- sources, helpful as they can be when information is disseminated responsibly, present unique challenges to informed decision-making, since anyone online (including pharmaceutical companies) can contrib- ute to the content of these sites. Although some of these websites have policies strongly discouraging page editing by parties carrying conflicts of inter- est,32 there are no measures currently in place to prevent such editing. Moreover, although Wikipedia encourages conflict-of-interest disclosures,32 there is no way of ensuring that user-editors comply. In fact, none of the major medically related wikis (Ganfyd, AskDrWiki, Medcyclopedia, WikiDoc, and Medpe- dia) address conflicts of interest. Although the extent to which pharmaceutical companies have edited wiki content is unknown, it has been discovered that at least some Wikipedia entries are written by corpora- tions, including pharmaceutical companies.33 Em- ployees of the pharmaceutical giant AstraZeneca and of the global health care company Abbott, for exam- ple, reportedly used company computers to delete negative information about drugs they sell, promot- ing a unilaterally positive view of their products.33

Manufacturers may also promote their medications on wiki pages featuring conditions that their prod- ucts treat. These promotions may even be toward conditions for which their products are not FDA approved. Such misleading practices may contribute to persistent misunderstandings concerning the ap- propriate use and dosage of medications, undermin- ing the autonomy of informed decision-making.

Health Information Services

Health information services, geared mainly to- ward medical professionals, often promote pharma- ceutical interests while appearing to be objective sources of clinical knowledge. For example, in its first e-mail to subscribers the service MDLinx calls itself “the only way to stay on top of the medical litera- ture.” The service also e-mails pharmaceutical adver- tisements presented as newsletter updates, but claims to avoid pharmaceutical representative influence by “putting you in command of the representative’s

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visit,” meaning that subscribers choose which of the virtual, soliciting pharmaceutical representatives is allowed to disseminate product information to them. However, framing the interaction this way may in- troduce an illusion of control,34 exploiting the hu- man tendency to underestimate the probability of negative outcomes in situations over which one has perceived control. Consequently, otherwise cautious subscribers are more likely to believe that they have little incentive to safeguard against manipulation, and little disincentive to engage in risky interactions with representatives.

Yet regardless of patients’ or physicians’ beliefs, pharmaceutical representatives have an incentive to engage in selective disclosure or to oversimplify study results to maximize sales. Furthermore, direct inter- actions with representatives do not facilitate expo- sure to the full range of drugs available on the market. Rather, these interactions typically favor brand- name drugs over generics, since manufacturers of the latter have fewer resources to devote to drug service funding. Finally, subtle framing techniques sur- rounding so-called e-mail updates that feature phar- maceutical advertisements can divert attention from the primary problem with these presentations: they may influence physicians to select drugs that are most marketed over those that are most effective. A recent investigation exemplified information-processing and decision-making tensions of this kind: the health information service WebMD admitted to connec- tions with Eli Lilly and other drug and device com- panies.35 The New York Times described the website as “permeated with pseudomedicine and subtle mis- information,” framing “health information commer- cially, using the meretricious voice of a pharmaceu- tical rep.”35 In short, health information services may sometimes facilitate the very kind of marketing in- fluence that they claim is absent.

Conclusion

In this article, we have explored how misleading pharmaceutical marketing on the Internet can exist within and morph across different web domains. Specifically, we examined the domains of search en- gines, drug company websites, e-mail lists, blogs and wikis, and health information services. In analyzing these domains, we found techniques of mismarket- ing that were both largely domain specific (e.g., de- leting negative drug information on medical wikis, using search engine optimization techniques, and de-

ploying avatars) and domain general (e.g., failing to reveal financial conflicts of interest, hiding drug risks in plain view, and displaying salient visuals that con- flict with drug information provided).

These observations are important because pa- tients, physicians, and various organizations increas- ingly use the Internet to convey and search for health information. We argue that online mismarketing is a serious legal and ethics-related problem with specific indicators and that it occurs across many of the do- mains in which health information is distributed. Since each of these domains features its own host of idiosyncrasies, future research should investigate whether the best solutions should be domain specific or whether a more general solution is preferable. Most likely, the optimal solution will operate at both levels. Although some solutions to offline forms of pharmaceutical mismarketing have previously dem- onstrated minor success,11 innovative strategies may be needed in order to implement similar solutions within online contexts. Furthermore, if we are to weed out both overt and covert forms of misleading marketing, then solutions should be both strict and clear to all involved.

We think our work is best viewed as a case study of how influential mismarketing within pharmaceutical drug promotions can occur across online contexts. The domains discussed here were chosen because they appear to be among the most commonly used today. However, these are by no means an exhaustive list, and some currently popular domains include so- cial networks (e.g., Facebook), social news and enter- tainment websites (e.g., Reddit), image (e.g., Flickr) and video-hosting websites (e.g., YouTube), and mo- bile health software (e.g., Epocrates). Future research should also investigate pharmaceutical marketing within these domains to assess the extent to which such marketing could be characterized as misleading.

Although solutions to online pharmaceutical mis- marketing are beyond the scope of this article, some promising methods for implementing solutions may already be available, such as independent surveillance and evaluation systems. For example, the FDA’s sur- veillance system, the Truthful Prescription Drug Marketing and Promotion Program (aka the Bad Ad Program), relies on prescribers and the general public to identify and report pharmaceutical misinforma- tion. However, the FDA has found that the program is costly and appears to be underutilized among doc- tors and the public, with only 239 reports filed in the

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program’s first eight months.36 As another example, The Swedish nongovernmental website evaluation organization, Health on the Net Foundation (HON), administers a seal of approval (called the HONcode) to web sources it considers to be objec- tive, of high quality, and transparent.32 Nevertheless, HONcode-certified sites are checked only periodi- cally (starting one year after they receive the approval seal) or after the foundation’s monitoring services have detected a consumer complaint or technical malfunction.37

Although these systems are not perfect, they may be a step in the right direction. For now, the most effective solution could be simply to raise awareness, such as through more academic publications on this subject or greater incorporation of this information into continuing medical education courses and elec- tronic health alerts.

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