Phoebe Gu, Kylie A Williams, Parisa Aslani, Betty B Chaar - jppr

Phoebe Gu, BPharm, Pharmacy Student, Kylie A Williams, BPharm, DHP, PhD,
Senior Lecturer in Pharmacy Practice, Parisa Aslani, BPharm (Hons), MSc,
PhD, GradCert Ed Stud (Higher Ed), Associate Professor in Pharmacy Practice,
Betty B Chaar, BPharm, MHLaw, PhD, Lecturer in Pharmacy Practice, Faculty
of Pharmacy, The University of Sydney, Sydney, New South Wales
Address for correspondence: Dr Betty Chaar, Faculty of Pharmacy, The
University of Sydney, Sydney NSW 2006, Australia.
E-mail: betty.chaar@sydney.edu.au
196
RESEARCH
Direct–to–Consumer Advertising of Prescription
Medicines on the Internet:
An Australian Consumer Perspective
Phoebe Gu, Kylie A Williams, Parisa Aslani, Betty B Chaar
ABSTRACT
Background: In Australia there are strict regulations in place
to protect the consumer from direct–to–consumer advertising
(DTCA) of prescription medicines. However, the degree of
infallibility of these restrictions is unclear.
Aim: To investigate the DTCA encountered by Australian
consumers when searching the Internet for common health- or
medicine-related questions.
Method: 2 health topics, weight loss and impotence, were
chosen and explored from 2 perspectives – the health condition
and a commonly used medicine (brand name). Key words were
chosen to simulate the language and search style of a consumer.
The first 10 hits from each search were evaluated using the
validated DISCERN scale, and a descriptive report of each web
site was conducted with a specific focus on evidence for DTCA.
Results: Of the 70 web sites visited, 10 sites originating from
the USA or New Zealand exhibited DTCA. The scale and
intensity of DTCA varied between search topics and strategies
and ranged in appearance from simple, pictorial advertising to
subtle forms of persuasive language. DTCA of some
pharmaceuticals was often hidden within disease awareness
campaigns, ePharmacy web pages and online communities.
Conclusion: Australian consumers are exposed to DTCA of
prescription medicines on the Internet. Clearly, DTCA
restrictions in Australia are not infallible. Australian policy
makers in the interests of public health must take measures to
address the gaps.
J Pharm Pract Res 2011; 41: 196-202.
INTRODUCTION
Direct–to–consumer advertising (DTCA) refers to
promotional material on therapeutic goods presented to
the general public. The WHO defines medicine promotion
as: ‘all informational and persuasive activities by
manufacturers and distributors, the effect of which is to
induce the prescription, supply, purchase and/or use of
medicinal drugs’. 1,2 Direct–to–consumer advertising
includes, but is not limited to, advertisements on
television and radio, in print media and on the Internet.
Currently, DTCA of prescription medicines in Englishspeaking
nations is legal only in the USA and New
Zealand. In Australia, the advertising of prescription
medicines is prohibited by the Therapeutic Goods Act
1989, and restricted to over–the–counter medicines and
herbal or complementary preparations. 3 For certain over–
the–counter medicines, DTCA may be disallowed if
perceived to affect the Australian population adversely,
such as the weight loss product Xenical (orlistat). 3,4
Medicines Australia, the professional body
representing pharmaceutical companies in Australia, has
a Code of Conduct to ensure that companies do not
override the prohibitions. 5 However, with the increased
use of the Internet for seeking medicine and health
information, these regulations and codes have little
jurisdiction over what is published on the World Wide
Web by non-Australian web sites. 6,7
Direct–to–consumer advertising of prescription
medicines has always been a controversial issue in public
health care. In addition to stimulating product sales,
advocates of DTCA claim that through raising awareness,
DTCA may improve adherence to therapy and alert
consumers to medical advances. Proponents of
pharmaceutical DTCA believe that consumers have a
right to autonomy in deciding what kind of medicinal
product is appropriate for them. 8
Conversely, opponents of DTCA have grave
concerns for the safety of consumers. They claim that
there is an inherent danger in marketing pharmaceuticals
(that require expert knowledge to prescribe and dispense)
to the general public, as marketing with DTCA could be
misleading or encourage consumers to use inappropriate
products. 1,4 They also claim that the marketing tactics
used often confuse patients into believing the promotional
material is unbiased education. 9 Direct–to–consumer
advertising of prescription medicines may also increase
the demand for more expensive medicines when a less
expensive, equally or more effective treatment option is
available. 4,9,10
One contentious issue resides with the selective
information presented to consumers in DTCA. Royne et
al. 11 demonstrated that the inclusion of information on
precautions and negative effects of an advertised product
impaired recall and involvement of the consumer. Direct–
to–consumer advertising of prescription medicines has
often been found to contain little, if any, warnings on
adverse effects of the advertised medicines. Additionally,
Reast et al. 8 reported that DTCA can result in patients
self-diagnosing and feeling dissatisfied or disappointed
when physicians refuse their request for a prescription
medicine.
Direct–to–consumer advertising of prescription
medicines is an attractive marketing strategy aimed at
promoting loyalty to a brand product and creating
demand, and plays an important role in the financial
viability of pharmaceutical companies. With increased
Internet access and utility, there is a growing concern
that Australian pharmaceutical DTCA regulations are
being sidestepped. 4 There has been no research into
DTCA encountered on the Internet by a consumer
seeking health-related information from a DTCArestricted
country such as Australia.
Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011.

The aim of this study was to investigate the DTCA
encountered by Australian consumers when searching
the Internet for health- or medicine-related questions.
METHOD
To explore the scope of DTCA that consumers may be
exposed to on the Internet, a number of web searches
were conducted following common consumer searching
behaviour. 7 Two common health topics that consumers
may feel uncomfortable discussing with their health
professionals and for which they may seek information
on the Internet, were chosen, i.e. erectile dysfunction
and weight loss. Each topic was explored from two
perspectives, the health condition and a popular medicine
used to treat the health condition. The medicines searched
for on the Internet were one prescription medicine (Viagra)
and one over–the–counter medicine (Xenical). Direct–
to–consumer advertising for Xenical, an over–the–
counter medicine, is prohibited in Australia. 3
Search Strategy
Key words and single search terms were adapted from
the literature to emulate the language and style of a
consumer. Searches were conducted from 20 January to
6 February 2009. The search engine Google was used to
conduct the searches as it is the most widely utilised
consumer search engine .
For the topic ‘weight loss’ the following search terms
were used:
• ‘weight loss’ (health condition approach);
• ‘weight loss’ (health condition approach, advanced
search);
• ‘weight loss treatment’ link provided by the search
engine (health condition approach, advanced
search); and
• ‘Xenical’ (brand name approach).
For the topic ‘erectile dysfunction’ the following
search terms were used:
• ‘impotence’ (health condition approach);
• ‘impotence treatment’ link provided by the search
engine (health condition approach, advanced
search); and
• ‘Viagra’ (brand name approach).
According to the literature, consumers tend to select
the first ten hits of their search. 7 Therefore, the first ten
hits from each of the searches (including sponsored links)
were explored for evidence of DTCA using a standardised
data collection checklist. All relevant pages of each search
result were visited. All forms of advertising and provision
of information on any pharmaceutical, or lack thereof,
were included in the analysis, such as:
• visual advertisements (e.g. pop-up, images or motion
pictures of medicines or brand names);
• use of persuasive language (subjective and emotive);
• incomplete or non-evidence based information (e.g.
lack of precautions and description of adverse
effects); and
• external links and articles which promote the sale of
a product.
Evaluation Tools
Data Collection Checklist
A purpose-designed data collection checklist was used
to gather the following information for each web site
visited: URL address; name of web site; date of visit;
origin of the web site; author(s) and sponsors of the
web site; and credibility marked by presence of either
references or quality seals. A descriptive report of each
web site visited was generated, with a specific focus on
evidence for DTCA.
DISCERN Scale
The DISCERN scale was used to evaluate the quality of
health-related information provided on each web site. 1,12
The DISCERN scale is a validated tool used to assess
the quality of written health treatment information,
including that found on the Internet. 13 The scale assesses
criteria such as sources of information, dates of
references, accuracy and style of presentation. Scoring
ranges from 1 to 5, with a score of 5 representing the
point at which a web site fulfils all quality criteria. To
ensure objectivity, the web sites were cross-validated
by three researchers and an average DISCERN value
was reported.
RESULTS
Seventy web sites were visited, i.e. 10 web sites for each
search. Some of these web sites were duplications, as
would be expected from a search based on a consumer
perspective. When conducting the searches using
Google, the search engine defaulted to the Australian
version . However, of the 70 web
sites visited, 33 originated from the USA, 36 were
Australian and one was from New Zealand. Ten web
sites contained DTCA, nine of which were from the USA
and one from New Zealand. This highlighted the ease
with which consumers can be exposed to non-Australian
web sites containing pharmaceutical DTCA.
Weight Loss
Direct–to–consumer advertising infiltrated all four
‘weight loss’ searches (Tables 1 to 3). The first ten results
of the first and second searches for ‘weight loss’ returned
identical results. Of the first ten results for the search
term ‘weight loss’, the first three web sites were
sponsored. The two non-sponsored web sites – WebMD
and About.com – contained DTCA. WebMD contained
visual advertisements for the antidepressant Cymbalta,
which were labelled advertisements. About.com
contained sponsored links and captions advertising
weight loss medicines. These were external links which
varied each time the web page was visited. Different
sponsored links would appear from time to time, and the
DTCA appeared sporadically.
In the advanced search, three web sites were
sponsored links and identical to the previous search. Of
the remaining seven web sites, one (MedicineNet.com)
contained evident DTCA in the form of visual advertising
for Cymbalta similar to that found in the previous search.
The targeted search term ‘Xenical’ returned three
sponsored links all of which were ePharmacies. Six of the
ten web sites contained evidence of DTCA. Two official
Xenical web sites (USA and NZ) contained persuasive
language reassuring consumers that Xenical was the
correct choice: ‘You have just taken the first step towards
a new, healthier, slimmer YOU!’ The information on
precautions, warnings and side effects was limited. For
example, the New Zealand Xenical web site contained
only one paragraph on adverse effects that was
embedded in a page of frequently asked questions. It
offered no precautions on the use of Xenical except for a
link to the consumer medicine information leaflet.
Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011. 197

Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011.
198
The types of Xenical DTCA encountered included
animated advertisements, flash banners across the page,
an online community post, and advertisements for other
medicines (e.g. Lexapro, Cymbalta, Lipitor) appearing
sporadically via external links. All of the web sites
contained information or made reference to weight loss
medicines.
Erectile Dysfunction
In the search for information about erectile dysfunction,
30 web sites were found and visited (Tables 4 to 6). The
search terms ‘impotence’ and the advanced search
‘impotence treatment’ yielded little evidence of DTCA.
Most web sites contained unbiased information on
prescription medicines.
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200
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The targeted search term ‘Viagra’ returned no
sponsored links but one web site contained evident
DTCA. This was an ePharmacy using persuasive
language and claiming Viagra to be a wonder drug.
DISCUSSION
Although Australia is a DTCA-restricted country,
consumers are not exempt from exposure to advertising
of pharmaceutical products, including prescription
medicines, on the Internet. This study exposed many
examples of varying nuances of marketing of prescription
and over–the–counter medicines accessed on the
Internet in simple health-related searches.
Xenical and Viagra were often marketed via web sites
promoting disease awareness, ePharmacies and online
communities. Furthermore, topics, such as weight loss,
attracted more DTCA than others. Nine web sites
containing DTCA for the topic ‘weight loss’ and one
web site containing DTCA for erectile dysfunction were
found. This may be attributed to the fact that Viagra, a
globally well known product, is less in need of investment
on Internet DTCA.
A comparison of different search perspectives
demonstrated that DTCA was more prominent in searches
conducted from a medicine perspective than from a
health condition perspective. In ‘weight loss’ health
condition related searches, two out of ten web sites
contained DTCA. However, the search using Xenical
returned six web sites containing DTCA. Similarly, the
search for erectile dysfunction resulted in DTCA for
Viagra. Possibly because the treatment options for a
particular health condition may not always involve a
medicine.
Importantly, this study also highlighted the effect of
the variability between the origins of the web sites
accessed on the Internet by Australian consumers. In
five out of seven Internet searches conducted, more than
half of the web sites accessed were from the USA and all
of the web sites with evident DTCA originated from the
USA or New Zealand. Australian consumers can easily
access DTCA-infiltrated web sites originating from
countries where DTCA is less regulated or unrestricted.
This finding is supported by with the literature, which
has described the inability of current legislation to
regulate the content of the Internet. 4
The DTCA identified in this study was in various
forms – strong pictorials to subtle linguistics. In some
instances, DTCA was easily distinguished from unbiased
information on web sites with labels such as
‘advertisement’ or ‘sponsored by’, while other web sites
weaved marketing strategies into health information and
appearing to be provided for the benefit of consumers.
In such instances, it may be difficult for consumers to
determine the nature or quality of the information.
The DISCERN scale was an useful indicator of the
quality of the information on the web sites. However, as
the scale does not assess marketing material, the web
sites that were rated highly on the DISCERN scale, did
not necessarily exclude DTCA of medicines. Therefore,
consumers accessing quality information on the Internet
may still be exposed to DTCA of prescription or other
medicines.
We also found that consumers are exposed to
various advertising strategies that although do not
strictly fit the definition of DTCA, yet promote medicinal
products. For example, the Advanced Medical Institute
web site provided quality information on erectile
dysfunction, with only one treatment option listed – its
own nasal delivery technology. Although no trade or
drug name was included, the information was biased and
could be confusing for consumers.
Interestingly, the search for Xenical resulted in three
web sites that were Australian ePharmacies. A number of
online communities also had users posting links to non-
Australian ePharmacies. This not only facilitated easy
access to the product but was also a subtle means by
which Australian consumers familiarise with the drug
names and are continually exposed to elements of
marketing.
These observations demonstrated the relative ease
with which Australian consumers can access web sites
infiltrated with DTCA of medicines. However, we
acknowledge that the Internet, a dynamic media, renders
precise replication of the study difficult. Longitudinal
investigations undertaken at regular intervals and on
various disease states and medicines may be beneficial.
This infiltration is not unique to Australia, Liang et
al. 14 have highlighted that this phenomenon occurs
worldwide and ‘transcends geopolitical borders’. Liang
et al. 14 raised concerns about a plethora of issues and
implications related to online DTCA of prescription
medicines and suggested there is ‘particular concern in
a regulatory vacuum and in areas of limited knowledge
of online DTCA’. A number of strategies have been
proposed to address these issues: ‘One approach could
be to require marketers, companies, web content
providers, and social media sites to actively survey and
block foreign Internet protocol addresses from online
DTCA content, specifically Facebook and Twitter pages.
Public–private partnerships to develop filtering software
can be part of this effort, which may be shared globally.
Furthermore, the public should be informed about online
DTCA sources. This sponsored marketing should be
disclosed, taking into account social network vagaries
including short–entry limitations and correction of user–
generated content that makes unverified, negative, or
clinically inappropriate comments, as well as reporting
of potential adverse events’. 15,16
To date, it appears that none of these remedial
suggestions have been implemented, but it is obvious
that attention has been drawn to the concerns associated
with online DTCA of prescription medicines worldwide.
Therefore, it is not surprising that despite Australian
regulations prohibiting DTCA of prescription medicines,
the policy is not infallible. This study did not analyse
the content of the DTCA of the prescription medicines
observed, but to highlight the existence of a gap, and in
an age of phenomenal technological advances that gap
is bound to expand and DTCA of medicines inevitably
will filter through to more Australians as pharmaceutical
companies explore such legal loopholes for wider
promotion of their products. It is imperative that policy
makers in Australia address the issue of opportunistic
appearances of DTCA of prescription medicines on the
Internet.
Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011. 201

A study of this nature has some limitations. Dynamic
changes occur swiftly in the technologically advanced
world of the Internet. Since this study was conducted,
changes may have occurred to the web sites, the
medications and the nature of the promotions. This study
can be viewed as a snapshot description at a certain
point in time, but this does not lessen the value or
accuracy of the overall findings and that DTCA filters
through to consumers in Australia via the Internet.
In conclusion, Australian consumers are exposed to
advertising of prescription medicines on the Internet.
Clearly, DTCA restrictions in Australia are not infallible.
Australian policy makers in the interests of public health
must take measures to address the gaps.
Competing interests: None declared
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Received: 14 October 2010
Revisions requested after external review: 31 January 2011
Revised version received: 3 March 2011
Accepted for publication: 3 July 2011
202
This activity has been accredited
for 1 hour of Group 2 CPD activity
(or 2 CPD credits) suitable for
inclusion in an individual
pharmacist’s CPD plan, if online
questions are completed and
submitted. No: S2011/66
Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011.