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ISBN 1-84544-855-3 ISSN 0736-3761

Volume 22 Number 7 2005

Journal of

Consumer
Marketing
Pharmaceutical marketing
Guest Editor: Ross Mullner

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Journal of Consumer Marketing
Volume 22, Number 7, 2005
ISSN 0736-3761

Pharmaceutical marketing
Guest Editor
Ross Mullner

Contents
362 Access this journal online 404 Global marketing of lifesaving drugs:
an analogical model
363 Editorial Oswald A. Mascarenhas, Ram Kesavan
364 Introduction and Michael Bernacchi

Misplaced marketing 412 Does DTC mean direct to court?

365 For the drugs we need Donna J. Cunningham and Rajesh Iyer
Herbert Jack Rotfeld 421 Pharmaceutical marketing on the
369 Direct-to-consumer prescription internet: marketing techniques and
drug advertising: a study of customer profile
consumer attitudes and behavioral Calin Gurau
intentions 429 Direct-to-consumer advertising of
Tanuja Singh and Donnavieve Smith prescription drugs: help or
379 Direct-to-consumer advertising and hindrance to the publics health?
young consumers: building brand Greg Finlayson and Ross Mullner
value 432 Herbal product claims: boundaries
Erin E. Baca, Juan Holguin Jr and of marketing and science
Andreas W. Stratemeyer Stephanie Y. Crawford and
388 Understanding the dynamics of the Catherine Leventis
pharmaceutical market using a 437 Executive summary
social marketing framework
David Holdford 442 Book reviews
397 Direct-to-consumer prescription 447 Computer currency
drug advertising: concerns and Edited by Dennis A. Pitta
evidence on consumers benefit
449 Internet currency
Jaeun Shin and Sangho Moon
Edited by Dennis A. Pitta
451 Note from the publisher

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Editorial
Today, pharmaceutical companies are increasing their
marketing budgets to advertise directly to the consumer.
This spiraling effort has begun to attract the attention of both
consumer advocacy groups, as well as the federal government
(in the USA), in terms of taking a closer look at the effects of
such advertising efforts. In July of 2005, the US Senate
Majority leader asked pharmaceutical marketers to voluntarily
stop their direct-to-consumer advertising during a drugs first
two years on the market. The ability for a pharmaceutical
company to affect both the physician (who can prescribe a
specific drug) and a consumer (who can request that they
receive a prescription for a certain drug) has virtually affected
the traditional model of marketing communications, which
has been used for many years. In addition, products that are
not regulated by the United States Food And Drug
Administration (FDA) are also gaining popularity, in terms
of being advertised directly to the consumer.
There is no doubt that pharmaceutical companies have
discovered that appealing directly to the consumer, and by-
passing the traditional doctor-patient relationship, has
become a very effective tool. The pharmaceutical companies
have been able to create a heightened awareness among
consumers, as it concerns the introduction of new drugs, and
have observed how consumers have the ability to literally
create strong market demand a for these new prescription
drugs. It will be interesting to observe how this new model of
marketing communications will play out.
Singh and Smith have tried to determine whether direct-to-
consumer drug advertising influences consumers behavioral
intentions. They indicate that while consumers generally have
favorable perceptions of prescription drug advertising, their
behavioral intentions are influenced by a heightened
awareness of specific branded drugs. Consumer motivation
to request drugs may be impacted by several factors.
Baca, Holguin and Stratemeyer have shown that
demographics influence attitudes and interest in direct-to-
consumer advertising, and those younger consumers interest,
and propensity to seek additional information for themselves
and family members, increases as a result of this type of
advertising.
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Holdford describes the affordable drugs movement and
presents a social marketing framework to place major
developments within a meaningful theoretical context. The
author also provides referenced descriptions and examples of
forces causing change within the pharmaceutical market. He
also classifies forces into six conditions influencing successful
social movements.
Shin and Moon provide an overview of the economic and
clinical impacts of direct-to-consumer advertising on both the
consumer and physician. Their findings recognizes direct-to-
consumer advertising as a positive force for public health and
at the same time identifies its potential negative effects on the
economic and clinical aspects of the health care markets.
Mascarenhas, Kesavan and Bernacchi apply the concept of
analogical reasoning (paying attention to select features of
(marketing) information, discerning patterns in it, and
applying said patterns to present market challenges) to the
current situation in the pharmaceutical industry. The authors
posit that challenging pharmaceutical companies to explore
new innovations in reengineering and redesigning their
products and services so that developing nations that need
them the most can afford them is of the utmost importance.
Cunningham and Iyer have examined the current
controversy in the direct-to-consumer advertising arena, and
have created an intricate road map of recommendations of
how to prevent this concept from coming to mean, direct-to-
court for the pharmaceutical industry.
Calin Gurau investigates the perceived advantages and risks
associated with online pharmaceutical transactions. From this
research, the author proposes specific segmentation of
consumers into four main categories.
Finlayson and Mullner review the issues regarding the
direct-to-consumer advertising that have been identified in
the literature from the perspective of consumers, consumer
groups, physicians, the medical profession and the
pharmaceutical industry.
Crawford and Leventis explore the boundaries in marketing
and science with respect to labeled claims of herbal products
and other dietary supplements. They report that the need for
consumer choice, meaningful information and free-market
access to dietary supplements must be balanced with the
demands for truth-in-advertising and consumer protection
from unreliable claims and adverse health events.
Included in this issue, you will also find our other sections
of interest to you the reader Misplaced marketing, Book
reviews and Computer currency.
Richard C. Leventhal

Introduction
About the Guest Editor
Dr Ross Mullner is Associate Professor in the Division of Health Policy
and Administration at the School of Public Health, University of Illinois
at Chicago. He is also Adjunct Associate Professor in the Department of
Pharmacy Administration at the University of Illinois College of
Pharmacy. His research interests include health care marketing, health
services research, and the history and future of medicine and public
health. Dr Mullner has written six books and over 100 journal articles on
various aspects of health care. He has served on the editorial boards of
several journals including Health Services Research, and Inquiry. He is
currently the Associate Editor of the Journal of Medical Systems. Dr
Mullner received his doctoral degree and two masters degrees from the
University of Illinois.
Pharmaceutical marketing
In 2004, pharmaceutical companies in the USA spent more
than $10 billion on marketing activities. Of the total, $7
billion was spent on one-on-one marketing to physicians by
company sales representatives, and more than $3 billion
dollars was spent on marketing to the general public through
television and newspaper direct-to-consumer advertising.
Many politicians, public policy makers, and the general
public are beginning to seriously question the need for these
large marketing expenditures. Physicians are beginning to
restrict the number of drug company sales representatives
they see, and the general public seems to be saturated from
the many drug advertisements they are exposed to each day.
Some are beginning to feel the nations pharmaceutical
companies are becoming more concerned with marketing
than scientific research.
Those who oppose these marketing efforts argue that
pharmaceutical companies aggressively market only the latest
and most expensive drugs, even though other older drugs may
be more effective, safer, and much less costly. They argue
these marketing efforts greatly increase both the private- and
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364
public-sector expenditures for prescription drugs. For
example, the price of prescription drugs has dramatically
risen in the last several years, and the price of drugs is rising at
a faster rate than the general rate of inflation for health care.
They also argue the pricing policies of the pharmaceutical
companies are inappropriate and socially irresponsible. For
example, prescription drugs are sold at much lower prices in
Canada and Mexico than they are in the USA. And millions
of US citizens are forced to purchase their drugs from these
countries to lower their medical costs. The pharmaceutical
companies have also been accused of keeping the prices of
their HIV/AIDS drugs artificially high, forcing many
developing countries experiencing the devastating AIDS
pandemic to either go without the drugs or to produce their
own HIV drugs at a fraction of the cost.
In sharp contrast, those who favor these marketing efforts
argue that the pharmaceutical companies are conducting
huge, privately funded, highly visible and effective public
health education campaigns. They argue these marketing
efforts raise the general publics awareness of important
medical conditions, motivates the public to take action, and
helps them to better and more effectively communicate with
physicians and other health professionals. They also argue
many people who seek care because of their marketing efforts
are frequently diagnosed with medical conditions different
from those that were advertised. And many of these
conditions such as diabetes, hypertension, and heart disease
are discovered earlier when they can be more effectively
treated. Lastly, they argue that the pharmaceutical companies
are responding to the publics concerns by adopting a
voluntary code of conduct that will ensure better dialogue
between patients and physicians.
The purpose of this special issue is to address some of the
complex and controversial issues posed by pharmaceutical
marketing. Specifically, articles in this issue will address the
impact of direct-to-consumer advertising of drugs, the
marketing of drugs over the internet, pharmaceutical
companies marketing policies, and the marketing of herbal
products, which are not regulated by the United States Food
and Drug Administration (FDA). Hopefully, this issue will
provide many new insights into the benefits and pitfalls of
pharmaceutical marketing.
Ross Mullner
 Misplaced marketing

For the drugs we need

Herbert Jack Rotfeld
Auburn University, Auburn, Alabama, USA

Abstract
Purpose To delineate confusions and uncertainties of the issues surrounding those criticisms. Critics assert that all marketing of medical products is
abusive, while actual impacts are disputed.
Design/methodology/approach Pulling from past commentaries on pharmaceutical marketing and current criticisms of the practice, to indicate
areas of confusion.
Findings The ills of pharmaceutical marketing are not as great as critics presume, but the practices are not as positive as the companies might wish
to assert. With uncertainty on the actual impact of specific practices, the companies are engaging in a certain degree of warfare via ever-increasing
budgets of sometimes-questionable value.
Practical implications Puts criticisms of pharmaceutical marketing in context.
Originality/value Perspectives for understanding pharmaceutical marketing.

Keywords Pharmaceuticals industry, Drugs, Brand names

Paper type Viewpoint

Regardless of the consumer protection problem described in
our term papers, the students in our 1975 graduate marketing
and society course mentioned consumer information as a
major part of the solution. Misprescribed pharmaceuticals,
deceptive loan terms, fraudulent car repairs and many other
consumer problems would be solved, we often said, if the
businesses were required to provide consumers with more
detailed and accurate information. Our instructor, Mary
Gardiner Jones, had recently completed her service as a
member of the Federal Trade Commission, and while she
generally agreed with us, I will always remember her lament
after one too many presentations on this theme: I dont want
to be required to be my own expert pharmacist, mechanic,
accountant or doctor. She was a lawyer by education and
that, she said, was difficult enough.
Over five decades ago, the US Government changed the
relationships among doctors, patients, and pharmacists.
Initially, prescriptions were a doctors recommendation of a
potentially useful drug, but patients did not need the doctors
permission to make a purchase and pharmacists could also
make recommendations. The 1951 Durham-Humphrey
Amendment defined the kinds of drugs that cannot be
safely used without medical supervision and restricted their
sale to prescription by a licensed practitioner. In theory, with
The Emerald Research Register for this journal is available at
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The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0736-3761.htm
Journal of Consumer Marketing
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[DOI 10.1108/07363760510631093]
all the new drugs just starting to come out at that time,
patients would be forced to have the rational and informed
expertise of a doctor involved in their drug-purchasing
decisions.
Advertising information or influence
The doctors are the experts, or so we like to believe. And with
the medical doctors as the decision makers, for many years
the pharmaceutical industry exclusively focused their brand-
name promotional practices on physicians. Even with the
more recent advent of direct-to-consumer (DTC) advertising,
the companies sales representatives still have regular and
expensive contacts with physicians, spending large sums of
money per year promoting brand name drugs by giving
doctors various gifts, travel subsidies, and free meals in
addition to the arguably more educational, though potentially
biased, sponsored teachings and symposia.
The total annual advertising and other promotional
spending by US pharmaceutical companies has grown into
the billions of dollars, or as some industry critics like to say,
well over a thousand dollars per physician per year. And to the
critics, that huge sum alone is the basis for asserting a huge
and improper influence on prescribing decisions. Some rare
doctors refuse any gifts from the drug companies of any kind
in an effort to remain free of the taint of being bought.
Skeptical patients given a brand name prescription look for
coffee mugs with that same name around the front office as
potential proof that the brands company salesperson had
recently paid the doctor a visit and generated the direction to
buy an expensive product.
It is hard to tell just what influence specific promotional
efforts might have on the doctors who honestly assert they
have patients interests as their prime concern. No one wants
to believe that a patient will be prescribed new anti-depressant

365
 For the drugs we need
Herbert Jack Rotfeld
or antihistamine just because the doctor has a pen with that
name written on it. To some extent, it is possible that even the
drug companies question the sales value of the plethora of
special gifts and advertising specialty products with a brand
name printed on the side. At the same time, however, the
drug manufacturers must feel the competitive pressure to
provide the same sales support as is done at the competing
companies. In a competitive industry, there must be a degree
of advertising dollar combat, with the different companies
trying to maintain a financial share of advertising voice.
It still must be admitted that like any other consumer-
purchased product from cars to house paint, the physician
decision-makers primary source of product information is
provided by the manufacturers. Some critics of the
pharmaceutical industry assert that the companies abuse
this information power and intentionally desire to mislead
medical people. Regardless of whether there is intentional
malfeasance, one study found that a significant number of
statements from the sale representatives contradicted
information readily available to them, and that the
physicians generally failed to recognize the inaccuracies
(Ziegler et al., 1995). While our personal doctors might
claim that they derive their information only from research
articles, there exists persistent evidence that they may be
misled about a brands value apart from the scientific data on
the matter (e.g. Avorn et al., 1982).
Even the medical practitioners do not always know or
understand all the information they have available. Research
repeatedly finds that once a company starts selling a drug to
assist a certain condition, the number of people diagnosed
with the problem increases by several times the original rate.
Patients must at least wonder about the medical decision
when their new prescription is pre-printed on the doctors
note pad (Wazana, 2000).
Questions of brand value
When new pharmaceutical products are first introduced, the
primary marketing goal is to generate awareness of a
previously-unavailable potential treatment for medical
problems. Yet the longer-term desire would be to generate a
degree of brand awareness and even brand loyalty among
doctors and their patients that extends beyond the time of
patent protection to when generic substitutes are available.
Such brand loyalty exists for many categories of products,
including non-prescription over-the-counter (OTC) drugs B
i.e. many consumers pay a premium price for Aleve or
Sudafed instead of the chemically identical generic naproxen
sodium or pseudophedrine hydrochloride B So it is logical for
a pharmaceutical manufacturer to desire such loyalty to their
brand names after the patent expires.
Yet even where such loyalty might have a potential to exist,
it is discouraged by state laws that encourage pharmacists to
substitute the cheaper generic products for prescriptions. In
addition, insurance companies have taken brand names, any
brand names, as a surrogate indicator of medical profligate
spending, and in the process, they also make it more costly for
people to use any and all newly developed drugs. Even if is a
new product without an available generic version, many
frustrated patients discover that their medical coverage either
refuses to pay for brand name drugs or requires a higher co-
366
Journal of Consumer Marketing
Volume 22 Number 7 2005 365 368
payment for coverage of brands than for generic products. In
theory, when a doctor recommends a brand name, the patient
must decide if the specific brand is worth the higher cost. In
practice, the patient is forced to pay for a unique treatment
that is still under patent protection.
The possible solution that some would like to see at some
future time is a designation as all pharmaceutical brand names
as unnecessary, or, at least, not serving the needs of doctors or
their patients. In those nations that require dispensing of
generic forms of prescriptions whenever they are available,
this is the de facto outcome.
At a more basic level, there is some question as to whether
the medical system is served by brand names for any
prescription drug product whose patent has expired. Some
people retain an unrealistic faith in the power of brand name
drugs, but the Food and Drug Association (FDA) repeatedly
assures the public that any functional benefit is virtually non-
existent. Generic drug manufacturers are subjected to the
same standards as their brand name counterparts. But despite
these repeated assurances from the government agency
charged with regulating the efficacy and purity of
prescription drugs, some patients and even doctors retain
faith in the brand names.
Logically, the FDA could ban the use of all brand names for
pharmaceutical drugs. When a new drug first comes on the
market, the pharmaceutical company has a patent. No one
else can make it without their permission and they can charge
whatever mark-up is deemed necessary, or rather, whatever
the market will tolerate. They do not need a brand name to do
this. And once the patent expires, they have competition from
what are now identical products. The new products brand
name might have had an initial value to make it easier for
consumers to recall the name in direct-to-consumer television
commercials, but once the product becomes generic, maybe
the former brand name could become generic, too.
Of course, no company would ever tolerate such a change
in regulations, especially since brand names have a carryover
value after the initial patent expiration. Higher dose or time
release variations of the product can give new extended life to
a brand name, as can new approvals of the original drug in
combination with other products. There are also a growing
number of prescription brand names that find extended life as
the product gains new approval for OTC sales. Without
prescribing laws or insurance payments encouraging generic
substitutions, potential brand loyalty acquires new strength
with consumer purchases.
Over-informed consumers
New Zealand and the USA might be on the leading edge of
what could be an international trend as consumers are
expected to play a bigger role in their drug decisions as the
two nations allow direct to consumers (DTC) advertising for
various prescription drugs. Reportedly the physicians in the
two countries are skeptical to outright opposed to the
practice, and despite similar survey responses from UK
physicians, there is pressure to start allowing the practice in
UK and the greater European Community (Reast et al.,
2004). The a priori presumed benefits and potential problems
have been debated ad infinitum in the news media (for a
 For the drugs we need
Herbert Jack Rotfeld
summary, see Auton, 2004), yet one detailed large-scale
consumer study on actual impacts concluded that:
The reality of DTCs effect on consumer behavior and doctor-patient
relationship [in the USA] is more benign than its detractors fear and less
specifically influential on product sales than many pharmaceutical brand
managers would hope (White et al., 2004, p. 65).
In theory, consumers are well informed by the new conduit of
information. While the main promotional pages of the
advertising have many appeals to consumer emotions (Main
et al., 2004), the print versions are filled with the same page of
print-heavy data on indications, contraindications and
precautions found in medical journal advertisements, and
the television voiceovers and superimposed print disclaimers
themselves provide enough warnings of side effects to make
the audience members nauseous. This additional regulatory-
required information is the same materials required in the
advertising to the expert audience of physicians; if the front
makes a emotional sales appeal, the extra two data pages
provide all the information needed for an informed rational
decision. While there would exist serious doubts that the
typical consumer, or any non-expert layperson, would read
the data.
A secondary effect of requiring the technical prescribing
data in all DTC advertising is that there are fewer such
messages. When a prescription drug changes to OTC status,
the data pages are no longer required. With the advertising
purchases now able to be a single page instead of three, an
extensive study of magazine advertising in one product
category found a near-immediate tripling of the number of
advertisements for the brand when the former DTC
prescription product became OTC (Avery et al., 2005).
Such an effect of limiting pharmaceutical advertising could be
an unspoken regulatory intent of the data requirements,
though there does not exist any proof that rule-writers at the
FDA considered this as a goal. But it is clearly an effect.
Yet you have to wonder about just what impact all this DTC
advertising must have or what the companies hope to
accomplish. The products are often brands under exclusive
patent rights, so the company is trying to establish strong and
broad demand while they still have an exclusive product. And
since the ads often make emotional appeals, people are
encouraged to rush to doctors for what could be minor non-
medical concerns. Not every case of depression, sleep loss, or
lowered sex drive should be treated by expensive drugs. Even
highly educated medical students tend to spot each new
disease studied in their own bodies, and freshman psychology
students tend to suddenly find all sorts of neurotic difficulties
in themselves or their friends, so these DTC ads can readily
play on consumers uncertainty about their own health.
Food and Drug Administrations officials repeatedly insist
that, at least in their view, the medical practitioners are still
gatekeepers on the drug purchases. Unfortunately, with the
increasingly competitive environment of patient services and
medical care, many doctors concentrate on patient
satisfaction, satisfying the medical customers short-term
perceived needs even when the therapeutic solution is not so
simple. A patient comes to the office wanting a cure or
something that looks like a cure, and even without DTC
advertising the physicians can make prescriptions that are, at
best, useless.
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Journal of Consumer Marketing
Volume 22 Number 7 2005 365 368
A sizable percentage of patients would probably respond
negatively if their physician refused to prescribe the DTC
drug the consumer thinks will solve the problem (Bell et al.,
1999). Physicians must feel the pressure (Spurgeon, 2000),
and a possibly misplaced marketing orientation insists that the
customers needs be satisfied. It would be unrealistic to think
that many doctors would not give the requested drug, even
when the advertised brand might not be the physicians first
choice for treatment, or even when the patient might be better
off not taking any drug at all.
Meanwhile at the advertising spending war
Columnists in the advertising trade magazines have
questioned the value of DTC advertising. While it might
generate some consumer knowledge or inquiries of a newly
introduced product, there does not seem to be any long-term
effects on brand demand by consumers. In the wake of a
scandal over the hidden dangers of a heavily promoted
branded pain reliever, the introduction of a different new
product included a promise by the company to refrain from
any consumer-oriented advertising for one year. It is hard to
believe that a company would so quickly give up a
promotional tool if it felt it was important for long-term
consumer awareness and prescription sales, so it is possible
that the company also questioned the actual value of
expenditures on consumer advertising. The new scandal-
tied criticisms of DTC advertising gave the company an easy
way out of expensive spending on a practice of questionable
value.
But then, there are so many variables in prescription
decisions, every decision on promotional spending is filled
with uncertainty, and valid questions exist of each specific
practices pragmatic utility. In a highly competitive business,
with a short shelf-life on a prescription brand name, each
pharmaceutical manufacturer is encouraged to maintain a
loud and strong spending voice. Advertising and promotional
spending almost becomes an arms race of sorts, with spending
on marketing increasing as fast as successes in research and
development on new products. In turn, the expensive
marketing becomes are added target for blame in the high
costs of drugs.
References
Auton, F. (2004), The advertising of pharmaceuticals direct
to consumers: a critical review of the literature and debate,
International Journal of Advertising, Vol. 23 No. 1, pp. 5-52.
Avery, R., Kenkel, D., Lillard, D. and Mathios, A. (2005),
Regulating advertisements: the case of smoking cessation
products, unpublished presentation to the 2005 American
Council on Consumer Interests National Conference,
Columbus, OH, April 6-9.
Avorn, J., Chen, M. and Hartley, R. (1982), Scientific versus
commercial sources of influence on the prescribing behavior
of physicians, The American Journal of Medicine, Vol. 73,
July, pp. 4-8.
Bell, R.A., Wilkes, M.S. and Kravitz, R.L. (1999),
Advertisement-induced prescription drug requests:
patients anticipated reactions to a physician who refuses,
The Journal of Family Practice, Vol. 48, June, pp. 446-52.
 For the drugs we need
Herbert Jack Rotfeld
Main, K.J., Argo, J.J. and Huhmann, B.A. (2004),
Pharmaceutical advertising in the USA: information or
influence?, International Journal of Advertising, Vol. 23
No. 1, pp. 119-42.
Reast, J.D., Palihawadana, D. and Spickett-Jones, G. (2004),
UK Physicians attitudes towards direct-to-consumer
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review, International Journal of Advertising, Vol. 23 No. 2,
pp. 229-51.
Spurgeon, D. (2000), Doctors feel the pressure from direct
to consumer advertising, The Western Journal of Medicine,
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Wazana, A. (2000), Physicians and the pharmaceutical
industry: is a gift ever just a gift?, Journal of the American
Medical Association, Vol. 283, 12 January, pp. 373-80.
White, H.J., Draves, L.P., Soong, R. and Moore, C. (2004),
Ask your doctor! Measuring the effect of direct-to-
consumer communications in the worlds largest healthcare
market, International Journal of Advertising, Vol. 23 No. 1,
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Ziegler, M.G., Lew, P. and Singer, B.C. (1995), The
accuracy of drug information from pharmaceutical sales
representatives, Journal of the American Medical Association,
Vol. 273 26 April, pp. 1296-8.
 Direct-to-consumer prescription drug
advertising: a study of consumer attitudes and
behavioral intentions
Tanuja Singh and Donnavieve Smith
Department of Marketing, Northern Illinois University, DeKalb, Illinois, USA

Abstract
Purpose To determine whether direct-to-consumer prescription drug advertising influences consumers behavioral intentions.
Design/methodology/approach Gathered data from 288 respondents using a pencil and paper mail survey. Respondents were asked about their
knowledge and behavior regarding prescription drugs.
Findings Indicated that while consumers generally have favorable perceptions of prescription drug advertising, their behavioral intentions are
nevertheless influenced by a heightened awareness of specific branded drugs. Consumers feel empowered by the information provided in direct-to-
consumer advertising and they are concerned about governmental attempts to regulate prescription drug advertising.
Research limitations/implications Data was collected from a relatively homogenous sample with respect to ethnicity. Future research efforts could
include respondents from diverse ethnic backgrounds and could incorporate questions regarding respondents actual behaviors with respect to branded
prescription drug medications.
Practical implications Useful information for researchers, public policy makers and prescription drug manufacturers. Results suggest that consumer
motivation to request branded drugs may be impacted by factors related to the quality of advertisements, trust in their physician, and personal
competence. Consumer interest in advertised drugs may also depend on the strength of the relationship that they have with their physician.
Originality/value This research fills an identified gap in the literature. While researchers have examined consumers general perceptions of direct-to-
consumer prescription drug advertising, little research has been done on the link between consumer perceptions and behavioral intentions.

Keywords Advertising, Promotional methods, Consumer behaviour, Pharmaceutical products, Medical prescriptions

Paper type Research paper

An executive summary for managers and executive
readers can be found at the end of this issue.
Introduction
Depression elicits Prozac, high cholesterol has made Lipitor
a familiar name and hay fever sufferers are all familiar with
Claritin(Schroff, 2003). A once mysterious industry has now
opened its doors to American consumers and prescription
drug advertising has become a billion dollar business. From
the multimillion-dollar Super Bowl ads to the repetitive spots
that are shown during primetime sitcoms, advertising for
branded prescription drugs abounds. Overall, the advent of
prescription drug advertising has added an entirely new
dimension to the role of consumers in the decision making
process for prescription medications and consumers are now
more informed than ever before (Smith, 1998).
In order to increase brand awareness for prescription
medication, drug manufacturers spent $15.7 billion on
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The current issue and full text archive of this journal is available at
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Journal of Consumer Marketing
22/7 (2005) 369 378
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631101]
promotions in 2001, of which $2.5 billion went to mass
media advertising. Prescription drug advertising, often
referred to as direct-to-consumer (DTC) advertising, has
increased at an annual rate of 13-20 percent since 1997. Thus
far, there have been mixed findings regarding the overall
financial impact of DTC advertising on the pharmaceutical
industry. While there is some evidence that suggests a direct
and positive correlation between mass media advertising and
drug manufacturers earnings (Findlay, 2002; Anderson,
2003), the relationship between adverting expenditures and
the success of specific brands is not clear. Clearly, drug
manufacturers place a great deal of faith in DTC ads and the
impact that they can have on consumers decision to adopt
advertised brands, but the exact nature of that impact remains
controversial. While a recent study reports that for every 10
percent increase in DTC advertising, there is a 1 percent
increase in drug sales (Kaiser Family Foundation, 2003),
there is also evidence that DTC advertising often serves to
increase the size of a market for a specific class of drugs, but
not necessarily the market share for a particular brand
(Krisanits, 2003).
Researchers have examined DTC advertising from various
viewpoints. Some have focused on the governmental rulings
that have paved the way for DTC advertising (Dukes et al.,
2001) and the case law that deals with drug manufacturers
responsibility to warn consumers about the side effects of
prescription medication. Other researchers have recently
addressed the efficacy of DTC advertising as an educational
tool. While some claim that there is little rationale for direct-
to-consumer advertising of prescription drugs (Lexchin and

369
 Direct-to-consumer prescription drug advertising
Tanuja Singh and Donnavieve Smith
Mintzes, 2002, p. 194), others suggest that DTC advertising
benefits not only health-care organizations, but also
physicians as well as patients (Calfee, 2002).
Researchers (Wilkes et al., 2000) have also examined
consumers attitudes towards DTC advertising and the
actions that consumers have taken in response to DTC ads.
However, research has not investigated how consumers self -
perceptions or perceptions of their relationship with their
primary physician might impact their decision-making for
DTC advertised drugs. Further, while all of these studies have
established that DTC advertising is a topic worthy of further
investigation, there has not been any research done on the
individual and relational variables that might influence the
behavioral intentions of consumers during their medical
decision making processes. Furthermore, researchers have not
investigated whether these behavioral intentions might be
detrimental to the doctor-patient relationship.
The debate between industry advocates and public policy
advocates is often rancorous in so far as DTC advertising is
concerned. Industry advocates obviously argue that there are
numerous merits to DTC advertising. They contend that it is
primarily an educational tool for the consumer. Conversely,
public policy advocates point to the inherent dangers of such
advertising and suggest that the effects of too little knowledge
may in fact be harmful to the consumer.
This study was designed to provide some insights into
consumers thinking and decision making processes as they
respond to DTC advertising in the current marketplace. In
particular, the study attempted to answer the following
questions:
.
How do consumers view DTC advertising in general?
.
Does DTC advertising cause consumers to engage in
specific behaviors or behavioral intentions (e.g., asking a
primary care provider for more information about a drug
that they have been exposed to or asking a physician to
prescribe a particular advertised drug)?
.
Does DTC advertising empower consumers and if so,
what are the outcomes of this perceived empowerment?
Background
History of direct-to-consumer advertising
Despite its origins in the sixteenth century, direct marketing
of pharmaceutical products to consumers is a relatively recent
phenomenon (Dukes et al., 2001). Prior to the 1980s,
prescription drug manufacturers primarily marketed branded
drugs to physicians in an effort to avoid disrupting the
intricate, and often delicate, relationship that existed between
doctors and patients (Dukes et al., 2001; Ausness, 2002).
Between 1983 and 1985 the FDA requested a voluntary
moratorium on DTC advertising noting that there was a lack
of previous court rulings on the issue. Around 1985 the ban
was lifted and the courts reached a compromise by declaring
that DTC ads were to be subjected to the same regulations
that had previously guided pharmaceutical drug advertising to
physicians. Consumers were to be protected through full
disclosure and drug manufacturers would be required to
provide a brief summary of the product in the form of
package insert.
As a result of industry pressure, and after considerable
debate and deliberation, the FDA relaxed its rules in 1997
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Volume 22 Number 7 2005 369 378
and for the first time, manufacturers were allowed to provide
the name of the drug and the conditions that were associated
with its use. At the same time, the FDA relaxed the guidelines
concerning the information regarding the inclusion of product
risk information. With the relaxed guidelines, drug
manufacturers would only be required to mention the most
critical information basically those risks that would be
common for the general population. In addition, drug
manufacturers were also required to open up the lines of
communication with their consumers. Consequently, drug
manufacturers started providing consumers with information
on request via toll-free numbers, the Internet, print
advertising and similar means (Wilkes et al., 2000). By
1999, the final guidance on DTC advertising was issued and
DTC ads had gone mainstream with drug manufacturers
using a broad spectrum of promotional devices for
prescription drugs including the back of ATM receipts,
bank statements, and airline luggage labels (Reast et al.,
2004).
The debate over DTC advertising
While the pharmaceutical industry was once enveloped in a
shroud of mystery, consumers now have more information at
their disposal than ever before. On the surface it appears that
consumers might appreciate the opportunity to become more
involved in their medical care and it also seems apparent that
drug manufacturers should benefit from the provision of
information in the form of DTC ads. However, there have
been growing concerns about the necessity of DTC ads and
their true benefits. Proponents and opponents of direct-to-
consumer advertising have established their rhetoric and have
staked out their positions (Dukes et al., 2001, p. 2). While
many arguments have been advanced regarding the legitimacy
of DTC advertising, the central question revolves around
whether or not DTC advertising is truly beneficial to
consumers and if so, how?
Drug industry advocates point to the educational value of
advertising directly to consumers and assert that consumers
are now able to manage their health issues more effectively
because of the information they garner from DTC ads.
Supporters also point to the criticality of time, noting that
there has traditionally been a time lag in the communication
between pharmaceutical companies and doctors/patients; that
doctors would often hear about medical advances and new
medicines well after the information was needed. Supporters
assert that DTC advertising bridges this information gap by
informing consumers and physicians about new and
promising advances in the medical field to treat particular
conditions (Calfee, 2002).
Opponents of DTC advertising disagree with these
assertions and charge that FDAs decision to allow DTC
advertising of prescription drugs has created or will create
numerous problems (Elliott, 2002). Some lament the
changing doctor-patient relationship, while others decry the
viewing of patients as consumers (Reast et al., 2004). These
detractors argue that DTC ads might create a false sense of
empowerment for the average consumer who does not have
the ability or background to effectively evaluate the claims
associated with the advertised drug (Wilkes et al., 2000). For
these consumers, the complexity of information presented in
DTC advertisements may prove to be too difficult to
 Direct-to-consumer prescription drug advertising
Tanuja Singh and Donnavieve Smith
understand and interpret. Opponents also contend that DTC
advertising might result in self-diagnosis of assumed
medical conditions by the consumers, leading to
unnecessary and perhaps even dangerous uses of
prescription drugs (Chandra and Holt, 1999).
Opponents are also skeptical about the incremental value of
information provided about new drugs. Citing data from
numerous studies, Lexchin and Mintzes (2002, p. 194) note
that a very small percentage of new medications are truly
breakthrough advances that provide substantial
improvements over existing therapies. In fact, they claim
that drug companies are motivated more by profits than they
are by informing consumers about better or safer drugs that
offer significant advances over existing treatments. It has also
been suggested that the drive to increase profits could
eventually become a detriment to drug manufacturers.
Opponents believe that DTC advertising has little
educational merit and that most prescription drug
advertising only serves to meet the financial motives of drug
manufacturers. Some feel that DTC advertising might
eventually increase the costs of prescription medication as
consumers demand branded drugs to treat their medical
conditions and abandon the less expensive, generic versions of
the drugs that might be equally effective.
Overall, DTC advertising offers several fruitful avenues for
continuing research. From a consumer context, it is
important that researchers empirically assess the impact of
DTC advertising on consumer decision making regarding
medical treatment. This exploration should focus on
consumers acquisition of product knowledge, the formation
of consumer attitudes towards individual brands and/or
classes of prescription medication and the behavioral outcome
after exposure to DTC ads. For example, it would be
instructive to evaluate whether DTC advertising has changed
the manner in which consumers acquire, view and utilize
medical information. If consumers have become more
attentive to their own medical needs and have taken steps to
discuss their medical questions with a medical practitioner,
then DTC ads would foster positive behavior change.
However, if consumers resort to self-diagnosis after
exposure to DTC ads, have pressured their physicians to
provide unnecessary prescriptions, or have resisted competent
medical advice, then DTC ads would be contributing to
negative and potentially dangerous behavior changes.
Theoretical foundations
Attitude-behavior research
Generally, advertisers have assumed that consumers attitudes
towards a brand directly affect the choice of that particular
brand. While it is not possible to review the vast domain of
attitude research in this paper, the earlier foundational
theories in attitude research would lead one to assume that
consumers behavioral intentions could be reflective of their
attitudes towards advertising, as well as attitudes towards a
certain branded product. In other words, it could be argued
that if consumers have positive attitudes towards DTC
advertising, they are more likely to adopt the specific
advertised brand and vice-versa (Ajzen and Fishbein, 1977).
More recent research has shown that attitude towards an ad
or a brand may not always be indicative of a consumers final
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Volume 22 Number 7 2005 369 378
choice in decision making; in fact, in some cases consumers
intentions and final brand choice may not necessarily be
related at all (Biehal et al., 1992). Research also suggests that
the relationship between consumer attitudes and behavioral
intentions might be more complex than originally believed
(Biehal et al., 1992; Burton and Lichtenstein, 1988). As such,
consumers may develop a preference for a particular brand or
product even when they do not have very favorable attitudes
towards the advertisements for these products particularly in
situations where consumers perceive greater risk levels (Biehal
et al., 1992).
Various studies point to consumers lack of faith in drug
manufacturers and their perceptions regarding prescription
drugs as belonging to a risk-laden product category. A recent
survey indicated 57 percent of Americans do not trust
corporate executives to give them honest information, with an
overwhelming number of respondents expressing negative
views about drug manufacturers in particular (Schroff, 2003).
Additionally, a Harris poll reported that the number of
respondents who felt that drug manufacturers do a good job
of serving consumers dropped by 20 percent between 1997 to
2002. These statistics suggest that consumers may not be as
receptive to DTC advertising as drug manufacturers would
like and as consumer advocates fear. Therefore, it seems that
while consumers may have negative perceptions of DTC
advertising and/or drug manufacturers, they are still willing to
inquire about and request specific branded drugs that they
have come to know about as a result of DTC advertising.
Overall, one could argue that DTC advertising has created
at least some value for the consumer (Shankland, 2003).
Proponents of DTC advertising suggest that as patients
become increasingly more involved in decisions that relate to
their medical conditions, DTC advertising enables them to be
not just better informed about their medical options, but it
also provides a level of control over their medical choices
(Eagle and Kitchen, 2002). Supporters of DTC advertising
also claim that while the rise in DTC advertising might create
some discomfort for the physician, it empowers the patient as
it seeks to change the previously paternalistic approach that
governed the doctor-patient relationship. Drug manufacturers
of course invest a great amount of time and effort into DTC
advertising by spending millions of dollars on commercials
and other promotional tools that purport to reach a large
current and potential consumer population. These changes in
the DTC promotional environment have at least partially
contributed to millions of people actually inquiring about
particular drugs by name and 25 percent of these requests
resulting in the physician prescribing the requested brand
(Shankland, 2003).
Our research explores the relationship between consumers
views of DTC advertising and the resulting behavior or
behavioral intention. We suggest that consumers may have a
paradoxical relationship with DTC advertising in that the
factors that facilitate consumer attitudes toward DTC
advertising may differ from the factors that facilitate
consumers behavioral intentions (e.g. propensity to ask
their medical provider about a drug or a disease) or actual
behaviors (e.g. actually seeking information from their
physician about a particular drug), interest and/or adoption
of DTC advertised drugs. Whether a patient would ask his or
her physician about a specific prescription drug is likely to be
 Direct-to-consumer prescription drug advertising
Tanuja Singh and Donnavieve Smith
function of several variables including such things as whether
the consumer perceives him/herself to be competent to
evaluate the claims, the quality of DTC advertising and the
value of the information contained in the ad. Therefore, we
suggest the following hypothesis:
H1. Consumers willingness to consult his/her physician
about an advertised prescription medication will be a
function of the perceived information value in the
DTC ad, the quality of the DTC ad, and a consumers
perceived competence.
While DTC advertising has become commonplace, the
terminology used in majority of the ads can be difficult for
the average consumer to comprehend. Studies have found
that 97 percent of prescription drug literature is too difficult
for the average adult to digest (Smith, 1998). As a result,
consumers are turning to others in their personal
environments to assess the credibility of information that
they receive via DTC ads; consumers are asking their friends,
families, and/or their co-workers about specific branded drugs
(Smith, 1998). Most important, consumers are turning to
their physicians to confirm or dispel specific claims made via
DTC advertising (Alleyne, 2002; Wilkes et al., 2000).
Research also suggests that doctors themselves have varied
perspectives on the value of DTC advertising (Coney, 2002).
While medical opinion in the USA was initially quite favorable
towards DTC advertising, recent data seems to suggest
growing skepticism and negative attitudes towards such
advertising (Reast et al., 2004). Similarly, other researchers
have found that of the physicians surveyed in a study, only 15
percent had a positive view of DTC ads, 33 percent were
neutral, and 52 percent disapproved of the practice (Yuan and
Duckwitz, 2002).
As consumers become better informed regarding various
drugs that are available to treat specific illnesses, their
decision to insist on a specific brand will most often be a
function of the type of relationship that they have with their
primary physician. Generally, most physicians would be more
likely to prescribe a brand name prescription medication that
had been requested by a patient, when the patient had either
failed to respond to or tolerate another form of treatment
(Yuan and Duckwitz, 2002). Moreover, it has been suggested
that doctors will prescribe a DTC advertised drug because it
is indeed the best treatment available for that specific
condition (Shankland, 2003) irrespective of patients
requests fostered by DTC advertisements. Conversely,
doctors offer many reasons why they might refuse patients
requests such as potential drug interaction and the availability
of better treatment alternatives.
If the patient-physician relationship is good, one would
expect that there is a lot of informational exchange taking
place in the physicians offices between the consumer and the
medical service provider. At the crux of these conversations
lies the patients trust in his/her physicians ability to create
the most effective treatment plan. Therefore, if a patient views
his/her physician as the primary source of medical
information, there will be a higher level of trust in the
relationship. On the other hand, if consumers feel that they
are competent and knowledgeable about their medical needs,
they might discount their physicians advice. Finally, if
consumers believe that the information in the DTC ad is
valuable to them, they would tend to rely less on their
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Volume 22 Number 7 2005 369 378
physicians judgment and could seek alternative sources of
information.
Accordingly, we advance the following hypothesis:
H2. Consumers willingness to trust their physicians
judgment regarding an advertised drug will be a
function of whom they view as the primary source of
medical information, their personal perceived personal
competence, and value of information contained in
DTC ads.
Consumer empowerment/freedom of choice
Advocates of DTC advertising contend that the advent of
DTC advertising has given consumers an opportunity that
they have never had before. They claim that consumers can
take an active role in the treatment of their medical conditions
via the knowledge they acquire from DTC advertising.
Industry advocates claim that consumers now have increased
choice in their medical decisions, which obviously is
beneficial. Research dealing with empowerment can provide
the backdrop against which the issue of increased choice can
be evaluated. Some researchers believe that increased choice
and information availability provide consumers with increased
level of control in their decision making environment.
Consequently, it is assumed that a sense of empowerment
will always be viewed by consumers as a benefit since
increased control allows consumer to get a better match
between their needs and market offerings (Kreps, 1979).
Based on this argument, it could be said that a sense of
empowerment about their medical decisions would be viewed
positively by consumers and welcomed.
However, other researchers question the generalization that
consumers always view increased choice as a benefit (Wathieu
et al., 2002, p. 298). Instead, these researchers believe that
providing consumers with more control may be a mixed
blessing, potentially leading to a less compelling choice or a
less satisfactory outcome. In fact, some studies have found
that when consumers are provided with fewer alternatives,
they often feel more satisfied with the decision they make
(Iyengar and Leppar, 2000). This view would compel one to
argue that DTC advertising may not always contribute to the
consumers sense of empowerment. Wathieu et al. (2002)
contend that it is not merely the size of the choice set that
matters in a decision environment, but it also depends on
whether or not consumers have the ability to specify and
adjust the choice context. Clearly medical decisions are
considerably more demanding, risky and complex than many
average everyday, ordinary decisions consumers make.
Therefore, consumer empowerment may not be as simple as
having more choice but rather would be determined by a kind
of trade-off between the benefits and costs associated with the
ensuing empowerment. Thus, we propose the following
hypothesis:
H3. Consumers perceived empowerment as a result of
DTC advertising is a function of perceived benefits
and perceived costs of DTC advertising.
Some of these ideas are rooted in the theory of choice
(Steiner, 1970) used by social scientists to explain the
perception of freedom of choice, and may have some
bearing on consumers perceptions of DTC advertising. The
 Direct-to-consumer prescription drug advertising Journal of Consumer Marketing
Tanuja Singh and Donnavieve Smith Volume 22 Number 7 2005 369 378

theory of choice argues that there are two aspects to choice Table I Sample demographics
decision control and outcome control. It can be argued that
Percentage
the DTC prescription drug advertising might give consumers
the perception of freedom of choice and decision control as Age
they feel that their medical decisions reflect their own Under 21-30 13.2
judgments and personal preferences rather than those of their 31-40 19.4
physician. This sense of empowerment or freedom of choice 41-50 22.6
could prompt consumers to oppose any regulatory actions 51-60 17.7
that might limit their access to prescription medication Over 69 27.1
information. If consumers perceive that they have been
Gender
liberated by the advent of DTC advertising, any attempt
Female 58
that threatens to limit communication between information
Male 42
providers (i.e. drug manufacturers) and consumers could be
viewed as a threat to consumers freedom of choice. This Education
leads us to the following hypothesis: Less than high school 3.1
H4. The higher the degree of felt empowerment and the Finished high school 17.4
more the perceived benefits, the more negative the Two-year college 14.2
attitude toward governmental regulation of DTC ads. Some four year college 16.7
Completed four-year college or university 28.8
Completed Masters degree or equivalent 15.6
PhD or other advanced degree 4.2
Methodology
Income
Survey design and sample description No answer 6.6
A paper and pencil survey was developed after a review of the Less than $20,000 5.6
extant literature in the area. A pilot test suggested minor $20,001-$40,000 20.8
modifications in the wording of some statements to improve $40,001-$60,000 18.8
communicability. The revised survey was further tested for $60,001-$80,000 16.7
face and content validity by scholars working in the area of $80,001-$100,000 13.2
survey design. Overall, the survey contained thirty-five $100,001-$130,000 11.8
statements anchored from strongly disagree to strongly $130,001-$150,000 3.1
agree, eight questions addressing consumer knowledge and More than $150,000 3.5
behavior regarding prescription drugs and seven standard
demographic questions, resulting in a total of 50 questions. A Marital status
mailing list of adult respondents (aged 21 or above) residing Married 68.4
in a large mid-western region of the USA was leased from a Single 22.3
commercial list provider. The survey was mailed to 2,500 Living together 2.8
randomly selected addresses from this list. It included a Other 6.6
standard statement regarding the confidentiality of consumer Political affiliation
data and an offer to participate in a drawing for $100. Democrats 29.5
A total of 288 usable responses were received in the allowed Republican 33.0
time-frame. After taking into account the 64 surveys which Independent 14.2
were returned undelivered, the response rate is approximately None 18.0
12 percent. The sample consisted of approximately 58 Other 7.30
percent of women and 42 percent men. The subject pool was
quite diverse in terms of income, education, and age but
relatively homogenous in terms of its ethnic background with
the majority of the respondents being Caucasian completely safe drugs (there is no such requirement) and
(approximately 89 percent). About 90 percent of the about 13 percent believed that companies can only advertise
respondents considered themselves to be healthy and 94 safe drugs. Only about 58 percent of the respondents correctly
percent reported having health insurance which covered noted that the statement, companies cannot advertise those
prescription drugs at least to some extent. Table I describes prescription drugs which might have serious side effects, is
the demographic information for the sample. false. About 40 percent of the respondents had asked their
physician about a particular drug after seeing an ad and about
Consumer beliefs and opinions about DTC advertising 15 percent reported being motivated to inquire about a
Approximately 66 percent of the respondents reported that condition they believed that they might have, after watching a
they pay some attention to prescription drug ads. DTC ad. A total of 17 percent had requested a particular
Interestingly, 63 percent of the respondents did not know brand of drug after seeing an ad; in about 58 percent of these
whether DTC prescription drug ads require government instances, the physician prescribed the requested brand.
approval (they do not) and 14 percent erroneously believed There was a near unanimous agreement among
that some government agency approves these ads. Almost 37 respondents that DTC prescription drug advertising has
percent did not know if companies can only advertise increased significantly in recent years. A majority of

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 Direct-to-consumer prescription drug advertising
Tanuja Singh and Donnavieve Smith
respondents (more than 73 percent) viewed DTC advertising
as nothing more than savvy marketing (mean value 3:97)
and there was a statistically significant difference between
men and women (mean values 4.13 versus 3.84; t 2:429,
two-tailed significance 0:017) in terms of how they
responded to this statement. Respondents with advanced
degrees were much more skeptical of DTC advertising
relative to others in the group. For example, the mean
agreement level with the statement about DTC advertising
being nothing more than savvy marketing was 4.33 for
respondents having a Ph.D. or an equivalent degree, which
was significantly higher than those with a Masters degree
(mean value 3:76; t-value 1.989; two-tailed
significance 0:050). However, there were no systematic
differences among respondents as a function of political
ideology, age, or income in so far as this statement was
concerned.
In general, consumers did not believe that they had become
more knowledgeable about their medical needs as a results of
DTC advertising (mean value 2:44) but, agreed somewhat
that DTC advertising empowers people (mean value 3:22)
by giving them more say in their own medical decisions.
Interestingly, people aged 40 years or less felt significantly
more empowered than those over 40. For example, the mean
value for the statement that DTC advertising empowers
people was 3.41 for people aged 31-40 years whereas it was
3.03 for people older than 60 (p , 0:05, t 2:072)
About 65 percent of the consumers believed that the
average consumer does not have the competence to evaluate
claims made in a prescription drug ad and 58 percent
indicated that they did not trust DTC ads. Interestingly, more
than 80 percent disagreed that consumers are better informed
as a result of DTC advertising. However, only about 46
percent of the respondents agreed that they were personally
opposed to DTC prescription drug advertising and only 42
percent supported the idea of banning DTC advertising of
prescription drugs. At the same time, Democrats, more than
Republicans, agreed that they would personally support
stricter regulations on DTC advertising (mean values 3:54
versus 3.21; t 2:146, two-tailed significance 0:033).
There were no other systematically significant differences as
a function of gender, income, and education. Governments
role in approving and controlling DTC ads was supported by
only 31 percent of the respondents but, an equal number of
respondents were indifferent to the idea. About 37 percent of
the respondents supported the idea that DTC advertising
should be controlled by the government.
Factor analysis and hypotheses testing
A principal components analysis with a varimax rotation
resulted in a six-factor solution (Eigenvalues above 1.00) with
62 percent of variance explained. A variance extracted of 60
percent or more is considered satisfactory in the social
sciences, particularly in exploratory research (Hair et al.,
1998). The six factors generally reflected the following
dimensions of consumer attitudes towards DTC advertising:
information value of DTC ads, perceived quality of DTC ads,
consumer competence, views about information complexity of
DTC ads, views about the primary source of medical
information, and beliefs about the outcome of DTC
advertising. Most factor loadings were above 0.50 and
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Journal of Consumer Marketing
Volume 22 Number 7 2005 369 378
significant indicating a relatively clean factor structure. The
first factor, which contained 12 items, extracted the highest
amount of variance (23 percent) and the last factor, which
contained two items, extracted the least amount of variance
(4.7 percent).
Factor scores were used as independent variables in
subsequent regression analyses to test hypotheses H1 and
H2. For H1, the dependent variable was the mean of the item
that asked whether DTC advertising would prompt the
respondents to inquire about a branded drug that they saw
advertised to treat a medical condition that respondents
believed they had. This dependent variable (DV1) was labeled
DOCADVICE and the mean value for this item is 3.54 on a
five-point Likert-type scale ranging from strongly disagree (1)
to strongly agree (5), indicating a general agreement with this
statement. The first regression with the dependent variable
DOCADVICE resulted in three independent variables being
significant predictors of DV1. These comprised of
information value (factor 1), perceived quality of DTC ads
(factor 2) and perceived consumer competence (factor 3).
Tables II and III present the results of the regression analysis.
As shown, the F-value for the model is 44.799 with a p-value
of , 0.005 and an adjusted R2 of 0.313. Thus, views about
the information value of DTC advertising, quality concerns
regarding these ads and respondents views of their own
perceived competence were significantly related to their
behavioral intentions regarding seeking information from
their physician about a particular drug that they saw
advertised. Therefore, hypothesis, H1 is supported.
As shown in Tables II and III, information value is
positively related to the propensity to ask ones physician
about a branded drug, along with the quality of information
contained in the ad and how competent the consumer feels to
evaluate the claims contained in the ad. Quality of
information contained in the ad and consumer competence
are negatively correlated with the criterion variable suggesting
that the more competent the consumer feels about being able
to evaluate the claims and the higher the perceived quality of
information contained in the DTC ad, the less likely he/she is
to inquire about particular prescription drugs and seek advice
from his/her physician. It is pertinent to note the relative
Table II Seeking advice from the physician (dependent variable:
DOCADVICE)
Independent variable Standardized Beta t-value p-value
Information value 0.532 10.897 0.000
Perceived quality of DTC ads 2 0.151 23.086 0.002
Perceived Personal Competence 2 0.121 22.474 0.014
Note: Adjusted R 2 0.313
Table III
Model Sums of squares df Mean square F Significance
Regression 90.325 3 30.108 44.799 0.000
Residual 191.544 285 0.672
Total 281.869 288
Note: Adjusted R 2 0.313
 Direct-to-consumer prescription drug advertising
Tanuja Singh and Donnavieve Smith
importance of the first independent variable information
value, as evidenced by the high standardized beta in the
equation. It is the most significant predictor of consumers
behavioral intentions. The other two, perceived quality of
DTC ads and perceived competence, while important,
explain lower incremental amounts of variance in the
equation.
For hypothesis H2, the dependent variable is the mean of
the item that asked the respondents whether they would
respect their physicians judgment if he/she turned down their
request to prescribe an advertised drug that the respondent
had requested. This dependent variable (DV2) was labeled
MEDDEC. The mean values for this dependent variables is
3.90 on a five-point Likert-scale ranging from strongly
disagree (1) to strongly agree (5), indicating a general
agreement with this statement.
The second regression with the dependent variable
MEDDEC resulted in two variables being significant
predictors of DV2. These comprised of respondents views
about the primary source of medical information (factor 5)
and information value of DTC advertising (factor 1). Tables
IV and V show the results of the regression analysis. As
shown, the F-value for the model is 41.548 with a p-value of
, 0.005 and an adjusted R2 of 0.220. Thus, consumers
willingness to respect their physicians judgment about a
medical condition was significantly related to whether his/her
physician was the primary source of medical information and
information value of DTC advertising. In this model, the
higher standardized beta is associated with respondents
primary source of medical information. Information value is
negatively correlated with the dependent variable whereas
views about the primary source of medical information are
positively correlated. In essence, the higher the perceived
information value of an ad, the less the willingness of the
consumer to go along with the physicians judgment. On the
other hand, if the physician is the primary source of medical
information, this translates into a higher level of trust in his/
her judgment. Thus, hypothesis H2 is supported.
To tests hypotheses H3 and H4, multi-item measures were
used: perceived cost and perceived benefits of DTC
Table IV Impact on medical decision (dependent variable: MEDDEC)
Standardized
Independent variable Beta t-value p-value
Views about primary source of
medical information 0.434 8.338 0.000
Information value 2 0.192 23.685 0.002
Note: Adjusted R 2 0.220
Table V
Model Sums of squares df Mean square F Significance
Regression 22.974 2 30.108 41.548 0.000
Residual 158.143 286 0.672
Total 204.090 288
Note: Adjusted R 2 0.220
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Journal of Consumer Marketing
Volume 22 Number 7 2005 369 378
advertising were measured using three items each
(Cronbachs alpha 0:7028 and 0.6662 respectively). The
two dependent variables were: perceived empowerment which
was labeled EMPOWER (DV3) and attitude towards
governmental regulation of DTC ads, which was labeled
REGULATE (DV4). Mean value for DV1 on a scale ranging
from strongly disagree (1) to strongly agree (5) is 3.22
suggesting that the respondents agree that DTC advertising
empowers people. Mean value for DV4 is 3.16 on the same
strongly disagree (1) to strongly agree (5) scale suggesting that
in general, there is some support for governmental regulation
of DTC advertising.
Tables VI and VII present the results of the regression
analysis with the dependent variable Empower. The model
is significant with an F-value of 68.838, p , 0:005 and an
adjusted R2 of 0.320. The model suggests that empowerment
is positively related to the perceived benefits of DTC
advertising and negatively related to the perceived costs of
such advertising. In essence, mere information and
information availability do not empower the consumer.
Instead it appears that consumers make a trade-off between
the perceived benefits of DTC advertising versus the costs
they believe are associated with such advertising. As such, H3
is supported.
Finally, Tables VIII and IX present the results of the
regression analysis with the dependent variable Regulate.
As shown, the model is significant with an F-value of 16.659,
p , 0:005, and an adjusted R2 of 0.098.
Both empowerment and perceived benefits are negatively
related to consumers willingness to support government
regulation of DTC advertising. Thus, the more empowered
the consumers feel the less amenable they are to support
regulatory interference in their medical information seeking
environment. However, despite the statistical significance of
these results, one must interpret these results with caution
due to the low adjusted R2. In effect, while H4 appears to have
been supported, these results should be validated using
another study to ensure the strength of the relationships in the
equation.
Table VI Perception of empowerment (dependent variable:
EMPOWER)
Standardized
Independent variable Beta t-value p-value
Perceived benefits of DTC advertising 0.445 7.793 0.000
Perceived costs of DTC advertising 20.193 23.374 0.001
Note: Adjusted R 2=0.320
Table VII
Model Sums of squares df Mean square F Significance
Regression 98.548 2 49.274 68.838 0.000
Residual 204.718 286 0.716
Total 303.266 288
Note: Adjusted R 2 0.320
 Direct-to-consumer prescription drug advertising
Tanuja Singh and Donnavieve Smith
Table VIII Feelings about government regulation (dependent variable:
REGULATE)
Standardized
Independent variable Beta t-value p-value
Perceived benefits of DTC advertising 20.213 23.186 0.002
Level of perceived empowerment 20.153 22.293 0.023
Note: Adjusted R 2 0.098
Table IX
Model Sums of squares df Mean square F Significance
Regression 24.828 2 12.414 16.659 0.000
Residual 213.15 286 0.745
Total 237.943 288
Discussion and implications
Overall, the advent of DTC advertising presents a wealth of
interesting dichotomies and valuable insights regarding
consumer perceptions. Our findings reveal that although
consumers are motivated to ask their primary care physicians
about drugs promoted through DTC advertising, they are not
particularly knowledgeable about DTC advertisements. In
particular, our findings show that consumers are not
particularly knowledgeable about prescription drugs or the
laws that govern DTC advertising, even though they claim
that DTC advertising has increased their overall awareness of
prescription drugs. It could very well be that while consumers
have become more aware of the brands mentioned in DTC
ads, they are not necessarily more educated about the benefits
and risks associated with advertised brands. Specifically,
consumers know that DTC drug ads abound; however,
consumers may not fully understand the message in DTC
ads, nor do they trust in drug manufacturers to provide them
with accurate information. This disparity may exist because
consumers are not comfortable with the format in which
drugs are advertised, they do not feel competent to evaluate
the claims made in such advertising, and they are not aware of
the various avenues to get more information.
As consumers become savvier and as drug manufacturers
seek to establish profitability for their specific brands,
researchers and practitioners will need to examine the types
of ads that most impact the development of favorable
attitudes towards DTC advertised drugs. Currently, many of
the ads for DTC drugs feature consumers who are active and
thriving in their day-to-day lives with little mention of the
drugs connection to the alleviation of specific symptoms
related to the individuals given condition. Perhaps,
consumers are in need of more information regarding the
drugs specific impact on the condition and their long term
benefits and effects. Currently, many of the ads are
ambiguous and it seems that drug manufacturers have left it
to the physicians to fill in the blanks regarding the actual
benefits of their respective products. However, as we move
into an era of consumer empowerment, we should expect that
consumers will be demanding more of the drug
manufacturers and their brands. These changing demands
could mean that drug manufacturers may have to take the
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Journal of Consumer Marketing
Volume 22 Number 7 2005 369 378
extra steps needed to ensure that consumers make the
connection between their drug and alleviation of specific
medical conditions.
Behavioral intentions are positively influenced by DTC
advertising in that consumers are asking their physicians
about DTC advertised drugs and are more likely to ask about
a specific brand, however, our findings also suggest that
consumers willingness to take action is dependent on a
number of variables. Consumer action after exposure to DTC
ads is not only a function of the effectiveness of DTC ads, but
also a function of their perceptions of their own personal
competence, the value of information in the ads, and the
overall quality of DTC advertisements.
While some researchers and practitioners have noted that
consumers might shop around until they find a doctor that is
willing to issue a prescription for a specific brand, our findings
suggest that this shopping around will stem more from the
level of trust that consumer places in his/her doctor and the
relationship that exists between the consumer and his/her
physician. However, our research also suggests that the
quality of the DTC ads may have some bearing on consumers
willingness to seek a DTC advertised drug from another
physician. In other words, if consumers do not have a strong
relationship with their primary care physicians but find the
information in a DTC ad to be useful and informative, they
may be more likely to seek the brand from an another
physician.
This reasoning highlights the way in which the physician-
patient relationship has evolved with the onset of DTC
advertising. Where consumers once felt entrapped in their
relationships with their physicians, the acquisition of
information regarding branded drugs has given consumers
more power than ever before. Interestingly enough, our
findings suggest that mere empowerment may not be enough
to ensure consumer satisfaction with DTC advertising, nor
might it be enough to facilitate consumer acceptance of and/
or trust in drug manufacturers. While drug manufacturers
have assumed that merely providing consumers with more
information would ensure consumer trust and acceptance,
researchers have found that increased choice alternatives do
not necessarily lead to increased satisfaction (Wathieu et al.,
2002).
In order for consumers to truly be satisfied with DTC
advertisements, they must become more knowledgeable about
the products and their efficacy. Patients face a daunting task.
True empowerment demands the truth . . . (Friedwald,
2000). As it stands, there seems to be a gap between
consumer awareness and the real truth about DTC
advertised brands. While consumers/patients do have more
information available to them because of DTC advertising,
they may not necessarily be able to effectively evaluate the
costs and benefits of the given options. As such, our findings
highlight the need for increased focus and attention on the
manner and context in which branded drugs are advertised.
On the surface it seems that advertising broad-based benefit
would be attractive to consumers; however, there is no
guarantee that consumers are able to differentiate these
benefits from those offered by competing drug manufacturers
or other nutritional supplements (Wealleans, 2003). Typically
DTC advertisements show a stream of indistinguishable
communication in which execution cliches abound-walking
 Direct-to-consumer prescription drug advertising
Tanuja Singh and Donnavieve Smith
the dog, playing with grandchildren, painting, cooking, etc.
(Wealleans, 2003, p. 98). Our findings suggest that it may not
be enough to merely mention a brand name and to show that
the consumer is able to engage in an active lifestyle despite
his/her medical condition.
Further, as noted by practitioners, the traditional consumer
goods product marketing model may not be the best option
for the marketing of DTC branded drugs. Marketers must
thoroughly understand the psychology of the consumer and
his/her beliefs about a particular drug category before
formulating an ad campaign (Schroff, 2003). While
consumer goods manufacturers have relied on brand
associations to build brand loyalty, drug manufacturers must
create a distinct format for the successful advertisement of
branded drugs. With consumer goods, it may be enough to
merely get consumers to be familiar with a particular brand
name; however, with branded prescription drugs there are
many other factors to consider such as the patients disease
history, their physicians medical training, possible generic
substitutions and the amount of co-pay that the patient may
have to contribute (Shankland, 2003). As such, consumers
may need to receive information about branded drugs that
reaches beyond the scope of hearing the brand name repeated
time and time again, and drug manufacturers must determine
the best method to convey this information. Thus, drug
manufacturers must address whether would be advantageous
for them to modify the way in which DTC advertising is
created and disseminated.
At the present time, drug manufacturers have been
successful in terms of getting more information to the
public and opening up lines of communication with their
consumers. Next, drug companies must determine what type
of relationship they want to have with consumers. DTC
advertising has been successful in making the consumer aware
of various medical conditions and increasing the recognition
of branded drugs (Alleyne, 2002; Krisanits, 2003; Smith,
1998; Wilkes et al., 2000). With the flattening out of DTC
advertising spending (Shankland, 2003), it seems that DTC
advertising is at a major crossroads and drug manufactures
will have to make some critical decisions regarding the future
of prescription drug advertising to consumers.
Future research
This research addressed attitude and behavioral change issues
from the consumers perspective. To have a better
understanding of how DTC advertising affects the
physician-patient dyad, it would be useful to evaluate what
physicians feel about the efficacy of such advertising for their
patients. Since DTC advertising is here to stay, it might also
be useful to get the physicians perspectives on what type of
information should be incorporated into DTC advertising by
the drug companies so that the consumers can use it more
effectively and benefit from the information provided in the
ad.
Another rich avenue would be to address the impact of
ethnicity and/or other individual differences on consumers
response to DTC advertising. For example, it is well known
that African-Americans lag behind their Caucasian
counterparts in terms of access to quality healthcare and
knowledge about medical issues; evaluating the efficacy of
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Journal of Consumer Marketing
Volume 22 Number 7 2005 369 378
DTC advertising for this population may be of tremendous
value in assessing whether it can bridge the knowledge gap
that has existed for decades. The National Medical
Association, the nations oldest and largest African-
American medical association, recently released findings
from a survey of 900 black physicians in which they found
resounding support for DTC advertisements, particularly for
African-American patients (Alleyne, 2002). These physicians
noted that DTC advertisements encourage dialogue between
doctors and patients and it increases the likelihood of doctors
visits, both of which have been fairly difficult issues for
African-American patients. Similarly evaluating perceptual
differences regarding the value and efficacy of DTC
advertising among other sub-cultures (e.g. Hispanic-
Americans, Asian-Americans, etc.) might also be useful to
assess whether cultural variables play a role in medical
decision making, and whether DTC prescription drug
advertising might be used to encourage information seeking
among these sub-groups.
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 Direct-to-consumer advertising and young
consumers: building brand value
Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer
Department of Marketing and Management, College of Business Administration, The University of Texas at El Paso,
El Paso, Texas, USA

Abstract
Purpose Direct-to-consumer advertising (DTCA) is a pervasive element in society today. Consumers have responded accordingly by becoming more
knowledgeable, developing specific perceptions and attitudes toward DTCA. The purpose of this article is to examine direct-to-consumer prescription
drug advertising issues among younger adults as both consumers and caregivers to determine whether companies are, or should be, taking advantage
of building brand value through DTCA.
Design/methodology/approach A sample of 225 young adults answered questionnaires to measure the effects of DTCA. The questionnaire was
based on a study by the National Consumers League and only the items that were most central to the current study were utilized and/or modified to
measure the following key variables: age; current health status; prescription drug use; attitudes toward DTCA; interest in DTCA; DTCA recall; and
inclination to seek additional information.
Findings The findings show that demographics influence attitudes and interest in DTCA, as well as younger consumers interest and propensity to
seek additional information for themselves and family members. Details of the statistical analysis of the study are given.
Originality/value The implications of the findings for pharmaceutical marketers, health care advisors, and academic researchers are discussed in the
paper.

Keywords Advertising, Brand identity, Young adults, Pharmaceuticals industry, Prescription medicines

Paper type Research paper

An executive summary for managers and executive
readers can be found at the end of this issue.
While advertising expenditures continue to grow every year in
the USA, marketers, executives, policy makers, academics,
and the general public continue to debate its merit (Macias
and Lewis, 2003). Although personal selling, sales promotion,
publicity, and public relations are important elements of
promotional activities within the marketing mix, advertising is
likely the most visible and noticeable component (Coulter
et al., 2001). This is clearly exemplified in the pharmaceutical
industry where expenditures on promotions have grown from
$2.64 billion in 2002 to $3.2 billion in 2003 (Slaughter,
2004). There is little doubt that the average American has
seen an increasing number of advertisements from
pharmaceutical firms (Findlay, 2001). For example, for
heavily advertised brands, increases in consumer awareness
levels have ranged from 40 to 75 percent over previous years
for drugs such as Viagra, Allegra, Lipitor, and Zoloft
(Slaughter, 2004). Additionally, Parker and Pettijohn (2003)
suggest that information regarding DTCA for pharmaceutical
products will continue to grow as the baby-boomer generation
continues to age. In 2003, the Food and Drug Administration
The Emerald Research Register for this journal is available at
www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0736-3761.htm
Journal of Consumer Marketing
22/7 (2005) 379 387
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631110]
(FDA) identified the benefits of direct-to-consumer
advertising (DTCA) as, creating increased levels of
awareness, involvement, compliance, reach, and client-
patient interaction (Food and Drug Administration, 2004).
As a result, medical patients are recognized as an evolving
market segment in terms of influence. Further noted by
Mintzes et al. (2002, p. 279) Patient requests for medicines
are a powerful driver of prescribing decisions.
To capture this fast growing and profitable market, direct-
to-consumer advertising (DTCA) has flourished with
expenditures in the billions for some of the largest
pharmaceutical firms. Promotional activities for
pharmaceutical products is approaching that of the largest
Fortune 500 firms products with Advertising Age (2004) listing
promotion expenditures for Pfizer at $2.57 billion,
GlaxoSmithKline at $1.55 billion, and Merck at $1.16
billion. These expenditures rank Pfizer, GlaxoSmithKline,
and Merck as the 4th, 12th, and 19th largest Fortune 500
advertisers respectively in the USA for 2002. With such large
investments in promotional activities by pharmaceutical firms,
consumers appear to be responding to DTCA.
Extant literature has suggested that consumers in general
have positive attitudes toward advertising and feel that DTCA
is a valuable source of information regarding various products
and services (for examples, see Perri and Nelson, 1987; Perri
and Dickson, 1988; Everett, 1991; Williams and Hensel,
1995; Shavitt et al., 1998; Paul et al., 2002). However,
because prescription drug DTCA is relatively new, having
only been legal since 1985 and only used extensively after
1997 when the FDA relaxed the standards for DTCA (Macias
and Lewis, 2003), questions remain regarding the
effectiveness of the advertisements for this segment of the
industry. Thus, what is not known is how effectively these
advertising campaigns achieve the goals of the firm in

379
 Direct-to-consumer advertising and young consumers
Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer
reaching consumers as well as which advertising theories are
most appropriate for measuring the effectiveness of DTCA.
Therefore, given that researchers have only recently examined
the effectiveness and the related impact of DTCA by
pharmaceutical firms and that empirical research on this
subject is still emerging (Menon et al., 2004), this research is
exploratory in nature.
Although skepticism remains regarding whether DTCA
truly educates the consumer and thus begins to establish
brand loyalty or whether DTCA merely contributes to rising
drug costs, drug companies are discovering what packaged-
goods companies and other consumer markets have known
for years: Nothing is more powerful than building consumer
brand loyalty, (Marx, 1996, p. 56). To build brand loyalty,
companies have to focus on building value for their brand
(Moore et al., 2002). According to Rutledge:
The brand is your customers belief in what you stand for as a company. The
brand is what allows you to charge a little more or merit a larger market share
than the companies selling no-name products. That little bit more
translates into future incremental cash flow. The present value of this stream
of future-incremental-cash-flow is brand equity. Building brand equity is the
only way I know to create long-term value for shareholders (Rutledge, 1998,
p. 154).
The result of building or increasing product brand value
translates into increased sales and increased value for the
company. For example, after Merck invested approximately
$145 million into the advertisement of Vioxx, a product for
arthritis and joint pain, sales increased more than 300 percent
to over $1.5 billion (Bittar, 2001). Interbrands 2004 report, a
well-respected private brand consulting firm in the UK,
identified Coca-Cola as the worlds most valuable brand,
possessing a brand value of $67.4 billion (BBC News, 2004);
this figure represents about 68 percent of the total market
value of the firm, supporting the idea that brand names add
value to firms. Kirmani (1990) suggests that consumers use
their impressions of advertising costs as an indication of brand
quality. While the effects of DTCA have been investigated,
unanswered questions remain, such as; Who is responding to
DTCA? What is motivating the consumer to request a specific
drug? And finally, what are consumer attitudes toward
DTCA?
Questions such as these are important given the enormous
costs that firms, specifically pharmaceutical firms, invest in
bringing products to market and the subsequent costs of
promotional activities. While various efforts have been made
to understand the effects of direct-to-consumer prescription
drug advertising in terms of consumers interest, attitudes,
and propensity to seek additional information (Hoek et al.,
2004), the majority of the research has focused on older
consumers or current users of prescription drugs. This study
adds to the extant literature by empirically determining what
effects, if any, DTCA has on younger adults as consumers and
caregivers in terms of interest and attitudes as well as
propensity to seek additional information. Specifically, we
seek to extend past research by examining this demographic
relationship to determine whether pharmaceutical companies
are taking advantage of building brand value through DTCA.
Background
Direct-to-consumer advertising research
Drug companies recognize the value of DTCA, allocating a
total of $2.5 billion to media campaigns during the year 2000
including television, print, radio, billboards, and other forms
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Journal of Consumer Marketing
Volume 22 Number 7 2005 379 387
of media and promotional activities. It is reasonable to
conclude that pharmaceutical firms believe that increased
levels of media and sales promotion spending is directly
related to establishing and maintaining strong brand equity
(Herremans et al., 2000). Additionally, DTCA is being placed
within a multitude of media so that the actual audience ranges
from young adults to senior consumers with much of this
advertising placed in primetime television and national
magazines that appeal to a broad-based audience. Thus,
exploring the likelihood of specific demographic groups, or
younger consumers, and responses to DTCA is an important
research topic (Pinto et al., 1998).
The majority of the literature on DTCA has focused on
consumer attitudes, propensity to seek information, and
comprehension of DTCA among older adults (Maddox,
1999; Menon et al., 2004). Overall, the literature suggests that
consumers have an awareness of and carry a positive attitude
toward DTCA (Perri and Nelson, 1987; Everett, 1991;
Williams and Hensel, 1995); thus far, however, the vast
majority of research efforts focused primarily on consumers
age 35 and older. Studies have focused on older consumers
because it is assumed they are the primary users of
prescription drug medications (Williams and Hensel, 1995;
NCL, 2003). However, the National Consumers League
(2003) conducted a study regarding the effectiveness and
attitude toward DTCA of prescription drugs, and in general,
their findings reveal that attitudes toward DTCA were
positive across a broad range of age groups. Variances in
findings across these studies were found among different age
groups with regard to interest level and DTCA. Overall, the
NCL (2003) study did not investigate specifics regarding
younger consumers and DTCA. Thus, it is suggested that
factors such as interest level varies based on the age of the
consumer.
The phenomenon of younger people paying attention to
DTCA may seem somewhat perplexing. Burak and Damico
(1999) found 35.9 percent of 18-24 year olds were familiar
with the prescription allergy medication Allegra. Although
intuitive, older consumers typically need more medication
and are therefore more likely to be interested in DTCA;
however, many prescription drugs such as allergy medications
are targeted to a broad age group. Coupled with the aging of
the population, a trend involving the growing numbers of
caregivers, typically younger consumers, has been a topic of
discussion.
Caregiving refers to individuals who undertake everything
from the primary caregiving role itself to support for older
relatives (Dellmann-Jenkins et al., 2000). The activities
surrounding caregivers involve assistance with searching for
information to help with illnesses which includes reviewing
DTCA. A study by Prevention Magazine (2004) found that
caregivers are more likely than other consumers to pay
attention and respond to DTCA. Of the population of
caregivers sampled in this study, 29 percent were in the 18-34
age group, which was the largest proportion in relation to the
other age categories (Slaughter, 2004). The categories
identified for caregivers (specifically, whom they are
responsible for) include everything from children to
grandparents. Another study found that of the individuals
under the age of 40, one-quarter to one-third of this
population is identified as caregivers of someone in their
family (Dellmann-Jenkins et al., 2000). Additionally, the same
study found that younger consumers (one in four) obtain
 Direct-to-consumer advertising and young consumers
Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer
information from DTCA for someone else to whom they are
giving care. The overarching theme is that younger consumers
are becoming increasingly more aware and knowledgeable
about DTCA. It seems younger consumers (as responsible
caregivers) want to provide information to assist in making an
informed decision.
Given that prescription drug manufacturers are spending in
excess of one billion dollars per year in marketing their
products directly to consumers, it appears logical to assume
that a variety of individuals (both target audience members
and caregivers) are going to be exposed to, recall more, and
have a higher level of interest in prescription drug advertising.
Advertising of pharmaceutical drugs is influential in
encouraging consumers to seek additional information for
these products (Williams and Hensel, 1995; Hoek et al.,
2004). As awareness and interest expands for DTCA, the
consumer base is also expanding from users of prescription
drugs to those caring for someone with health conditions
requiring a prescription drug. Thus, higher recall and interest
in DTCA and an increased motivation by consumers to
obtain more information may cause pharmaceutical
companies to re-think the concept of building brand value.
Brand value and direct-to-consumer advertising
Marketing experts generally agree that there is a strong link
between advertising and building value for a brand (Cobb-
Walgren et al., 1995). Miller and Berry (1998, p. 82) note,
established brands are stronger and more robust than many
suspected. Brand value goes beyond brand awareness to
include favorable attitudes toward the brand (Moore et al.,
2002). Building brand equity is related to the degree of brand
recognition, the strength of consumers mental and emotional
associations, as well as perceived brand quality (Aaker, 1996).
When brands are positioned correctly, consumers feel strong
ties toward them (Cobb-Walgren et al., 1995).
Pharmaceutical advertisers have a unique opportunity to
position their brands through promoting desirable and
positive benefits of their products. By expanding the target
audience, firms can help develop strong consumer beliefs
about product benefits and brand value through
pharmaceutical drug advertising and integrate the branding
strategy throughout the organization (Dunn and Davis,
2003); this approach may be critical to achieving overall
success with the brand. Although pharmaceutical companies
are utilizing a combination of promotional activities to add
value to their brands, the majority of their brand value is being
built through advertising (Kirmani, 1990; Cobb-Walgren
et al., 1995; Miller and Berry, 1998; Herremans et al., 2000;
Coulter et al., 2001).
Because consumers cannot purchase certain medications
without a prescription, pharmaceutical companies who utilize
DTCA are trying to encourage some other behavioral
response such as seeking additional information (Williams
and Hensel, 1995). Eliciting positive attitudes and increased
interest in DTCA is an important goal for pharmaceutical
companies in order to move consumers closer to actual
purchase by encouraging them to seek additional information
about their product(s). The attempt to position a brand name
in the consumers evoked set allows companies to build
familiarity with the brand (Cobb-Walgren et al., 1995);
establishing familiarity with the brand name and conveying
favorable images for the brand can be translated into
acceptance and preference for the brand (Bogart and
Lehman, 1973). In turn, this awareness should result in
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purchase request or some other positive behavioral response
(Cobb-Walgren et al., 1995; Miller and Berry, 1998).
The awareness and attitudes toward DTCA among older
adults are particularly important to pharmaceutical
companies because older adults tend to be heavy users of
advertised drugs (Perri and Nelson, 1987; Williams and
Hensel, 1995). However, younger consumers may be equally
important to pharmaceutical companies because they often
become caregivers of older adults and as this segment ages,
they may also become users of pharmaceutical drugs.
Furthermore, pharmaceutical companies should look at
younger consumers as caregivers and future consumers for
their brand as firms may be able to move those they care for
along the path to purchase by encouraging younger
consumers to seek additional information for others or
themselves (Williams and Hensel, 1995). The path to
purchase was first proposed by Lavidge and Steiner (1961)
as a seven-step process, labeled the Hierarchy of effects
model and suggested that the buying process is not a single
event, but rather composed of a series of steps that a
consumer goes through that ultimately leads to a purchase.
Hierarchy of effects model
The framework proposed by Lavidge and Steiner (1961), as
well as the numerous variants proposed over the last 40 years,
can be traced back to Lewis (1898), and the AIDA model
consisting of four separate attributes:
(1) attention;
(2) interest;
(3) desire; and
(4) action.
In this model, researchers noted that advertising can be an
important factor in creating awareness for a product or service
(Moore et al., 2002; Parker and Pettijohn, 2003). This is
particularly important for pharmaceutical companies because
consumers have limited outlets in which to gather information
about various healthcare options (Roth, 2003). The
framework is a suitable model to help gain an
understanding of the effects of DTCA (Vakratsas and
Ambler, 1999; Menon et al., 2004), and for this study, the
impact on different segments of the market. Therefore, it
could be suggested that without awareness, other marketing
objectives are not likely to be achieved (Roth, 2003).
Lavidge and Steiner (1961) suggest that different
advertisements or campaigns can be focused at different
steps in the seven-step buyer process. For example, the
authors posit that firms, when bringing a new product to
market, should focus their advertising primarily during the
first steps of the process. The primary goal of the advertiser in
this scenario should be to make potential customers aware of
the new product and inform them of the products benefits
and features. However, because consumers are not the final
authority in regards to the purchase of prescription drugs, it is
difficult to assess the actual path to purchase (Menon et al.,
2004). Therefore, this study will not examine the final
conditions and determinants that lead consumers to purchase
a pharmaceutical drug. Rather, this study will investigate
whether consumers, specifically young consumers, pay
attention to DTCA by reviewing their attitudes, interest,
and recall of pharmaceutical advertising.
 Direct-to-consumer advertising and young consumers
Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer
Research hypotheses
While age may impact the degree to which consumers have
favorable attitudes and interest in DTCA, two other variables
are suggested to impact attitudes and interest, including
health status and prescription drug use as well as an
additional variable, concern for family members condition,
is expected to impact interest in DTCA (see Figure 1).
To accomplish the stated objectives of this study, several
research hypotheses are proposed. First, research has shown
that older consumers are more likely to be users of
prescription drugs and are more likely to have favorable
attitudes toward DTCA (Williams and Hensel, 1995; Menon
et al., 2004). Research has indicated that overall consumers
feel DTCA is a useful source of information (Perri and
Nelson, 1987; Everett, 1991; Williams and Hensel, 1995;
Roth, 2003). What is currently unknown is the attitudes of
younger consumers toward DTCA. It is unclear whether
consumers who do not currently suffer from any acute
medical conditions will or will not pay particular attention to
DTCA. Younger consumers are less likely to have these sorts
of chronic medical conditions. Thus, it can be expected that
younger consumers attitudes may vary from older
consumers attitudes toward DTCA. Since consumers thus
far have been found to hold favorable attitudes toward
DTCA, it is expected:
H1. Older consumers will have more positive attitudes
toward DTCA than younger consumers.
Because of the multitude of media outlets chosen for DTCA,
it is difficult to ascertain whether older consumers would have
more interest in DTCA than younger consumers. Younger
consumers have been found to display interest in DTCA
(NCL, 2003). Pollay and Mittal (1993) and Shavitt et al.
(1998) suggest that consumers use advertising for information
about brands and product availability, and further posit that
younger consumers think of advertising as an informational
source for products in general more than older audiences do.
Generation Y consumers have been found to be just as likely
as Generation X, Baby Boomers, and Matures to recall
pharmaceutical advertisements (Slaughter, 2004). Therefore,
it can be expected that younger consumers would be just as
likely as older consumers to have an interest in DTCA, which
leads to the following hypothesis:
H2. Younger consumers are as likely as older consumers to
express interest in DTCA.
Figure 1
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Volume 22 Number 7 2005 379 387
Previous studies have hypothesized expected relationships
between health status and attitudes toward DTCA (Williams
and Hensel, 1995), as well as health status and interest in
DTCA among older consumers (NCL, 2003). These findings
suggest that there is a propensity for those in poor health to
have more favorable attitudes toward, and be more interested
in, DTCA. Based on these results, there is no reason to expect
that younger consumers would not respond similarly. Thus
the following hypotheses are proposed:
H3. Health status will directly affect the interest in and
attitudes toward DTCA among younger consumers.
H3a. Younger consumers in average or poor health will be
more likely than younger consumers in good health to
have an interest in DTCA.
H3b. Younger consumers in average or poor health will be
more likely than younger consumers in good health to
have favorable attitudes toward DTCA.
There has been little empirical research on the relationship
between ad recall and interest in DTCA. In a study
conducted by the NCL (2003), a positive relationship was
indicated between ad recall and interest in DTCA among
older consumers (i.e. over 35 years of age). Based on their
findings and the belief that younger consumers are similar to
older consumers regarding their interest in DTCA, the
following hypothesis is proposed:
H4. There is a positive relationship between interest in
DTCA and recall among younger consumers.
It is also reasonable to assume that those younger consumers
currently taking prescription drugs would have positive
attitudes toward and interest in DTCA. Although Williams
and Hensel (1995) did not find a significant relationship
between older consumers current drug use and their attitudes
toward DTCA, the NCL (2003) study found a positive
relationship between prescription drug use among older
consumers with regard to attitude and interest in DTCA. As
previously noted, there is an expectation that younger
consumers and older consumers respond similarly to
DTCA, thus the following hypotheses are proposed:
H5a. There is a positive relationship between prescription
drug use and attitude toward DTCA among younger
consumers.
H5b. There is a positive relationship between prescription
drug use and interest in DTCA among younger
consumers.
Because DTCA has been identified as an important source of
information overall for consumers (Perri and Nelson, 1987;
Everett, 1991; Williams and Hensel, 1995; Roth, 2003), it is
expected that a positive relationship exists between attitudes
toward DTCA and an inclination to seek additional
information among younger consumers. Additionally,
Williams and Hensel (1995) found that those consumers
with more favorable attitudes toward DTCA were more
inclined to seek additional information from a pharmacist
and/or a friend. This leads to the following hypothesis:
H6. There is a positive relationship between attitudes
toward DTCA and inclination to seek additional
information among younger consumers.
Similarly, because pharmaceutical companies are trying to
move consumers closer to an actual purchase by encouraging
them to seek additional information, the AIDA model
suggests that favorable attitudes and increased interest in
 Direct-to-consumer advertising and young consumers
Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer
DTCA are related to consumers inclination to seek
additional information (Parker and Pettijohn, 2003). Perri
and Nelson (1987) point out that a majority of consumers
would likely ask their doctor about a product that they had
seen advertised, and consumers with an interest in advertising
will use this information to help guide their decision making
(Shavitt et al., 1998; Handlin et al., 2003). As noted earlier,
the NCL (2003) found that younger consumers display an
interest in DTCA. Therefore, the following hypothesis is
proposed:
H7. There is a positive relationship between interest in
DTCA and inclination to seek additional information
among younger consumers.
Finally, it is expected that younger consumers may express
more interest in DTCA when a family member has an
unresolved health condition. Little research has addressed the
relationship between younger consumers caregiving activities
in terms of interest in DTCA. These caregiving activities may
be heightened when younger consumers become concerned
about a family member who suffers from a condition
illustrated in a DTCA. Younger consumers have been found
to exhibit a more active caregiving role with the emergence of
a trend among young adult children and grandchildren
serving as caregivers to elderly relatives (Dellmann-Jenkins
et al., 2000). Thus, the following hypothesis is proposed:
H8. There is a positive relationship between concern for a
family member and interest in DTCA among younger
consumers.
Methodology
Research instrument and subjects
The questionnaire was obtained from the National
Consumers League (NCL, 2003) and only the items that
were most central to this study were utilized and/or modified
to measure the following key variables: age; current health
status; prescription drug use; attitudes toward DTCA;
interest in DTCA; DTCA recall; and inclination to seek
additional information.
Questionnaires were administered to 225 undergraduate
students enrolled in a major university in the southwest USA.
The mean as well as the median age for the undergraduate
population is 25. Students were given the questionnaires
during their classes but were not forewarned of the study in
order to ensure there were no biases toward the topic.
Responses from 20 participants were deemed unusable,
resulting in a total of 205 usable questionnaires.
Measurement
Participants were asked to provide information on their
current health status through a slightly modified version of an
item developed for the NCL (2003) study. The item consisted
of six categories and was modified from Would you consider
yourself . . . to the following question: Overall, how would
you rate your current heath? Choices in the NCL (2003)
study included:
.
generally healthy;
.
in good health, but have some chronic conditions;
. not in very good health;
.
in poor health; and
.
do not know.
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Volume 22 Number 7 2005 379 387
The choices in the current study included:
.
good health;
.
average health; and
.
poor health.
The original NCL (2003) instrument may have been biased
toward older consumers as the choices appeared skewed
toward a negative assessment rather than a positive
assessment of current health status. The modified version
for this study reflected a more realistic assessment of health
assessment by a younger population.
Prescription drug use, ad recall, and interest were measured
with questions taken from the survey obtained through the
NCL (2003). Respondents were asked to report their use of
prescription medication for pain over the previous year.
Specifically, the question asked, In the past year, have you
used a prescription medicine for pain? Choices included:
Yes, currently use; Yes, have used in the past year; and, No,
have not used in the past year. The questions for ad recall and
interest were, respectively, In the past 12 months, have you
seen or heard any advertising for medications that you can
only get with a prescription? and Were any of these
prescription drug advertisements for a condition that was of
particular interest to you? Respondents were simply asked to
respond to each question: Yes; or No. Additionally, to
measure degree of information search, respondents were
asked: Thinking about a prescription drug advertisement
you saw or heard that interested you, what did you do after
seeing or hearing that advertisement? Did you seek more
information? Respondents simply answered: Yes; or No.
Attitudes toward DTCA of prescription medications was
measured using ten items developed by the NCL (2003) in
order to assess the multiple facets of attitude toward DTCA.
Overall, the scale contained both positive and negative
statements regarding DTC pharmaceutical advertising. The
scale consisted of ten, five-point Likert-type statements
anchored by strongly disagree and strongly agree. Only one
item, the second question, was modified for better
understanding, with provide information replacing de-
stigmatize. It was deemed that the rest of the questions
appeared clear and straightforward so additional modifications
were not necessary. All items for this scale are shown below:
(1) Advertisements describe the side effects and/or risks of
medications so that you understand them.
(2) Advertisements provide information about the
conditions that may have gone untreated due to
patient embarrassment.
(3) Advertisements help you when you want to talk to your
doctor about a condition that you think you might have.
(4) Advertisements encourage people to ask for drugs they
do not need or cannot take.
(5) Advertisements just help pharmaceutical companies sell
their drugs.
(6) Advertisements are largely responsible for the increased
cost of prescription drugs.
(7) Advertisements for medicines should only be in medical
magazines for doctors.
(8) Advertisements remind people to take their medicines
or refill their prescriptions.
(9) Advertisements are confusing.
(10) Advertisements make you feel good about the
medicines you are already taking.
Items 4, 5, 6, 7 and 9 are reverse coded.
 Direct-to-consumer advertising and young consumers
Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer
The NCL (2003) study did not report reliability for the
attitude scale. Therefore, the ten-item attitude scale was
subjected to an exploratory R-type factor analysis to test
convergent validity. The data is appropriate for factor analysis
with an overall measure of sampling adequacy (MSA) of
0.841 (Hair et al., 1998). Factors were extracted using
principal components estimation with a varimax rotation,
which revealed three factors. Factor loadings ranged from
0.463 to 0.844. According to Hair et al. (1998), factor
loadings of 0.40 or greater are considered important. The
percentage of variance explained by the three-factor solution
was 53.1 percent. Factor one included items 4, 5, 6, 7, and 9,
which are negative statements related to attitudes toward
DTCA in general and exhibited factor loadings of 0.463,
0.605, 0.722, 0.749, and 0.564 respectively. Factor two
included items 1, 2, and 3, which include positive statements
related to attitudes toward information regarding DTCA and
exhibited factor loadings of 0.844, 0.822, and 0.516
respectively. Factor three included items 8 and 10, which
include positive statements, related to attitudes toward
DTCA prescription medicines specifically and produced
factor loadings of 0.735 and 0.771 respectively.
Reliability levels were assessed among the three factors,
with a 0:62 for factor one, a 0:66 for factor two, and
a 0:64 for factor three. A commonly used threshold for
acceptable reliability is a coefficient alpha of 0.70, although
this is not an absolute standard and may decrease to 0.60 in
exploratory research (Hair et al., 1998). All items were
retained for further analysis. The scale as a whole showed an
adequate level of reliability, a 0:68. In summary, the ten-
item, three dimensional attitude scale developed by NCL
(2003) showed sufficient internal consistency across all
dimensions and proved to be reliable measure of attitudes
toward DTCA for the present study. For the attitude scale,
the dependent measure was calculated by averaging overall
across the scale to assess each variable.
The final part of the instrument contained demographic
measures of age, education, and income. Based on the median
age of 25 years, the sample was split into two categories based
on their responses. The first category represented younger
consumers (25 years or younger) while the second category
represented older consumers (26 years or older).
Results
H1 predicts that there is a positive relationship between age
and attitudes toward DTCA and was supported (p , 0:05) as
the ANOVA shows, attitude toward DTCA was significantly
related to age (F-value 5.520, p , 0:020). Mean differences
were examined to test if the relationship was in the expected
direction. As expected, younger consumers (25 or less) hold
less positive attitudes toward pharmaceutical advertising with
a mean score of 3.0236 than older consumers, with a mean
score of 3.1688.
H2 examined the relationship between younger consumers
and interest in DTCA. A correlation revealed no significant
relationship (r 20:024, p 0:733) between younger
consumers and interest in DTCA. Based on these results
H2 was not supported.
H3 was tested in a one-way MANOVA with health status
used as the independent variable. The analysis shows that the
set of dependent variables (interest and attitudes) was
significantly related to health status (Wilks l4;392 0:918,
p , 0:05). Given the positive MANOVA findings for the main
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Journal of Consumer Marketing
Volume 22 Number 7 2005 379 387
effects, follow-up univariate ANOVAs and Tukey-HSD paired
comparisons were performed on each interest and attitude
measure (Hair et al., 1998). Health status was significantly
related to attitude and interest (H3a and H3b) across the three
categories of health status (p , 0:05). Therefore, H3, H3a,
and H3b were all supported. MANOVA and ANOVA results
are summarized in Table I.
Pairwise comparisons of each dependent variable on health
status is displayed in Table II. These results further revealed
that the differences between the groups were as hypothesized.
Those in poor health had higher interest levels (with a lower
mean indicating higher interest levels). Although significant
overall (p , 0:05), the mean score for good health was higher
that the mean score for average health in relation to attitude
toward DTCA. In terms of attitudes, it seems those in good
and average health have similar views toward DTCA, with
those in average health with slightly less positive attitudes than
those in good health.
H4 predicted a positive relationship between interest in
DTCA and recall. A one-way ANOVA was utilized to test the
significance of the variables. Interest in DTCA was
significantly related to recall (p , 0:001). Younger
consumers who indicated interest in DTCA were able to
recall more pharmaceutical ads (F-value 42.274,
p , 0:000). Given these results, H4 was supported.
The hypothesized positive relationships were examined
between attitude toward DTCA and prescription drug use
(H5a); and interest in DTCA and prescription drug use (H5b)
among younger consumers. ANOVAs were utilized to test
both hypotheses and the relationship between attitude and
prescription drug use was marginally significant, p , 0:10 (F-
value 3.551, p , 0:061), and the relationship between
interest and prescription drug use and was not supported
(F-value 0.012, p , 0:912). Further, the results of these
tests revealed that prescription drug use has a marginally
significant positive effect on younger consumers attitudes.
Prescription drug use does not, however, relate significantly
with interest in DTCA. Therefore, H5a was partially
supported and H5b was not supported.
To test H6 and H7, which predict that there is a positive
relationship between attitudes toward and interest in DTCA
and inclination to seek additional information, univariate
ANOVAs were utilized. H6 was not statistically significant, (F-
value 0.920, p , 0:538). However, H7 was statistically
significant, (F-value 7.521, p , 0:007), with interest in
DTCA being a significant predictor of younger consumers
propensity to seek additional information regarding
pharmaceutical drugs. Therefore, H6 was not supported
and H7 was supported.
The hypothesized positive relationship was examined
between concern for family member and interest in DTCA
(H8). Univariate ANOVA was utilized to test the hypothesis
and the relationship between concern for family member and
interest in DTCA among younger consumers was statistically
significant, p , 0:0001 (F-value 21.978, p , 0:000). As
expected, younger consumers who are concerned about a
family member is a significant predictor of interest in DTCA.
Discussion
This study examines the relationship between DTCA and
young consumers attitudes, interest and inclination to seek
out additional information regarding pharmaceutical drugs.
Overall, the results of this study confirm and extend previous
 Direct-to-consumer advertising and young consumers Journal of Consumer Marketing
Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer Volume 22 Number 7 2005 379 387

Table I Health status and attitudes toward DTCA

MANOVA Results ANOVA Results
Independent variable Dependent variable Wilks Lambda F df P < F df P <
0.918 4.306 (4, 392) 0002
Health status Interest 5.210 (2, 197) 0.006 *
Attitudes 3.427 (2, 197) 0.034 *
Note: * Significant at the 0.05 level

Table II Pairwise comparisons between health status and DTCA outcomes

Dependent variable Health status Meana Mean difference Std. error Sig.
Attitude toward DTCA Good Health 3.041
Average health 20.138 0.064 0.033 *
Average health 3.179
Poor health 0.379 0.198 0.057 * *
Poor health 2.800
Good health 20.241 0.195 0.218
Interest in DTCA Good health 1.722
Average health 0.169 0.090 0.062
Average health 1.603
Poor health 0.603 0.278 0.031 *
Poor health 1.000
Good health 20.772 0.273 0.005 *
Notes: a Lower score indicates higher interest and attitudes toward DTCA; * Significant at the 0.05 level; * * Significant at the 0.10 level

research by developing and empirically testing these
relationships and the findings support the role of age in the
relationship between attitudes and interest in DTCA.
Attitudes of younger consumers toward DTCA were related
to age, health status, and prescription drug use. Moreover,
younger consumers attitudes toward DTCA were not related
to recall of DTCA or inclination to seek additional
information. This research also demonstrated that younger
consumers were just as likely to have an interest in DTCA.
However, this interest was not related to inclination to seek
out additional information which implies that younger
consumers are paying attention, moving through the initial
stages of the AIDA model, but have not progressed to the
desired stage of the model.
These results are of importance because both attitude and
interest can serve as important indicators of the attractiveness
of DTCA advertisements for younger consumers. These
results indicate that younger consumers are aware of
pharmaceutical products and are taking a participative role
in DTCA. Additionally, relationships were established
between health status, ad recall, and prescription drug use
among younger consumers with regard to interest in DTCA.
Our study of younger consumers was partially consistent
with the research of Williams and Hensel (1995) which found
DTCA to elicit positive attitudes among older consumers.
Thus, this study supports previous findings and suggests a
generally positive attitude toward DTCA existing across
different age groups. While the relationship between younger
consumers and older consumers with regard to attitude
toward DTCA was not as strong as previous findings, younger
consumer attitudes are still an important component of
DTCA as both future consumers and caregivers. This is
particularly clear as our study found a significant relationship
with younger consumers attitudes toward DTCA.
Research done by Williams and Hensel (1995) found that a
negative relationship existed between health status and
attitudes toward DTCA, and our results in examining the
same relationship revealed the same relationship among
young consumers. Thus, as health status decreases, attitudes
and interest in DTCA increases. Williams and Hensel (1995)
further suggested that the theory of selective attention
explains this relationship. Consumers, in general, pay
attention to advertising which is meaningful and relevant in
different situations. Since younger consumers overall are
exhibiting positive attitudes toward advertising, this finding
would imply that further research is warranted to examine the
precise relationship between perceived health status of
younger consumers and attitudes toward DTCA.
Managerial implications
In general, pharmaceutical marketers, health care advisors,
and academic researchers should note the strongest
relationships within this study concerned interest in DTCA.
This implies that DTCA is influential in attracting attention
from not only older consumers, but also younger, and more
importantly, future consumers. This finding is important not
only because younger consumers are undertaking care-giving
roles, but also as the younger population group begins to age,
they become a stronger customer base for the wide range of
pharmaceutical products. With increases in purchasing power
over time, these consumers will already posses a heightened
awareness of various products and brand names associated
with pharmaceuticals. Similarly, as products move through
their patent cycle to become over-the-counter (OTC e.g.

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Erin E. Baca, Juan Holguin Jr and Andreas W. Stratemeyer
Claritin, Claritin-D) or generic drugs, younger consumers will
be more familiar with the brand names of these medications.
As such, it is important for pharmaceutical marketers to
educate and provide access to information to build brand
value with younger consumers. Researchers and managers
should recognize that the attitude formation process clearly
begins with younger consumers who are not necessarily
current users of prescription drugs but will be in the future
and as caregivers may have influence over current users.
In contrast, interest in DTCA and relationships between ad
recall, health status, and prescription drug use were all
significantly related. The relationship between ad recall and
interest in DTCA is also positive for younger consumers such
that the greater the ad recall, the greater the interest in the
advertised product. This finding is interesting and merits
further exploration of this relationship by pharmaceutical
marketers since this confirms earlier results found with older
consumers, but younger consumers have not been identified
as primary users of pharmaceutical drugs. This provides a
unique opportunity because younger consumers are taking an
interest in DTCA, and pharmaceutical marketers can channel
their efforts toward building their brand by creating an
awareness of pharmaceutical drugs in new market segments.
Firms that take advantage of building their brand should
likely benefit in a couple of different ways. First, firms should
be able to reach this audience and establish a market for
products that are currently unknown to this segment but
could be appropriate at a future date. Second, establishing the
brand name is an important means to reach consumers who
care for and attend to older family members. With consumers
entering their senior years, it is reasonable to assume that
while the current market consists of these consumers, a
secondary target would be the care-givers. Information and
branding learned through DTCA would be valuable in
establishing the firms brand with this secondary target
audience for top of mind awareness. Through communication
and influence, caregivers can be more informed with the daily
decisions that face the older population.
Limitations and directions for future research
Despite some potentially important implications of this study,
there are some limitations. While the sample for the study
consisted of a convenience sample, this approach provided a
relatively good basis for comparison among younger
consumers. Future studies should assess generalizability of
the results to younger consumers across a larger geographical
area. Furthermore, despite efforts to insure reliability, it
should also be noted that the measures for attitudes toward
DTCA utilized in this study were those developed by the
NCL (2003) study. The measures obtained through the NCL
(2003) study, particularly the assessment of attitudes toward
DTCA, only provided acceptable reliabilities and would need
improvement in the measures for DTCA. Although the NCL
study included a large population group, the strength of
various items within the dimensions associated with attitude
were not clear and merit attention before utilizing the
measures in subsequent studies. Therefore, pharmaceutical
marketers and researchers should coordinate their efforts and
take a careful look at the measurement and formation of
attitudes by consumers toward DTCA.
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Journal of Consumer Marketing
Volume 22 Number 7 2005 379 387
Conclusion
This research has added an important component to extant
literature concerning attitudes, recall, and an intention to seek
additional information regarding DTCA from target market
segments and younger consumers. Despite certain limitations,
our results also add to understanding the multidimensional
nature of DTCA. A significant amount of DTCA targets
older adult consumers because they tend to be heavy
consumers of prescription medications (Everett, 1991;
Williams and Hensel, 1995; Menon et al., 2004). However,
DTCA is found across a multitude of media outlets geared
toward a broad audience base.
Therefore, examining younger population segments are
important for understanding how potential consumers are
moved along the path to purchase in an effort to build value
for the brand. In particular, investigating younger consumers
further establishes the impact of DTCA on both caregivers
and potential users instead of limiting the audience to current
users of pharmaceutical drugs (Shufeldt et al., 1998). Younger
consumers are just as likely as older consumers to receive drug
information through mass media. Furthermore, the emphasis
of building brand value among younger consumers with
regard to DTCA should be further extended to ensure young
consumers attitudes and interest in DTCA is positive.
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 Understanding the dynamics of the
pharmaceutical market using a social
marketing framework
David Holdford
Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA

Abstract
Purpose The objectives of this paper are to describe the affordable drugs movement and present a social marketing framework to place major
developments within a meaningful theoretical context.
Design/methodology/approach Specific examples are used to illustrate the framework and its utility in understanding the complexities of the
pharmaceutical market. Methods to research the dynamics of the market are also presented.
Findings Provides referenced descriptions and examples of forces causing change within the pharmaceutical market. Classifies forces into six
conditions influencing successful social movements: structural conduciveness, structural strains, growth of generalized beliefs, precipitating events,
mobilization for action, and utilization of social control by opponents. Suggests social research methodologies to study the conditions in greater depth.
Research limitations/implications This is a descriptive framework that has not been validated for its use in the pharmaceutical market.
Practical implications Offers a useful framework for academics, managers, students, and individuals to classify and study developments in the
pharmaceutical industry.
Originality/value This paper provides an overview of major forces within the pharmaceutical market and offers direction for those who wish to
explore it in greater detail.

Keywords Pharmaceuticals industry, Social marketing, Economics

Paper type General review

An executive summary for managers and executive
readers can be found at the end of this issue.
The pharmaceutical marketplace is facing major pressures
from a broad range of dynamic and powerful forces. Major
healthcare legislation such as the Medicare Prescription Drug,
Improvement Act of 2003, widespread criticisms of
pharmaceutical industry marketing, increasing consumer
involvement in health care, calls to improve FDA oversight
of the pharmaceutical industry, and demands for more
affordable drugs are forcing society to re-examine the way that
pharmaceuticals are developed, distributed, and financed
within the USA. To understand the impact and potential
consequences of these forces, it is helpful to place them within
some meaningful theoretical context.
Social marketing has been presented as a framework for
analyzing social change (Kotler, 1971). Social marketing is a
process for influencing social ideas and behaviors based on the
premise that social causes can be marketed like any product.
Founded on the fields of sociology, psychology, and
marketing, it best known for its utility in promoting socially
desirable behaviors such as recycling, seat belt use, family
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The current issue and full text archive of this journal is available at
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Journal of Consumer Marketing
22/7 (2005) 388 396
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631129]
planning, and AIDs prevention. It can also be used to study
and influence major social movements such as consumerism,
conservatism, and many other isms (Fox and Kotler, 1980).
Social movements are defined as relatively persistent,
organized efforts by large numbers of people to effect social
change. The study of social movements attempts to
understand their success or failure with the intention of
predicting their consequences and influencing their course.
Social movements studied in health care include the
movements toward self-care, (Schiller and Levin, 1983)
health care reform (Hoffman, 2003), and insurance reform
(Atim, 1999). It has been suggested that social movements
would benefit from marketing thinking and planning (Kotler,
1971). It has also been proposed that a social movement
framework can help in understanding the dynamics of the
pharmaceutical market (Wells and Banaszak-Holl, 2000).
There is currently an organized movement by individuals
and groups to change how the pharmaceutical marketplace
provides safe, effective, and affordable medicine. This
movement is not new. It has been around since the
beginning of the modern pharmaceutical industry,
periodically intensifying and diminishing throughout the
years. Revitalized in recent years, movement supporters
assert that the current pharmaceutical system is broken and
major changes are necessary (Angell, 2004; Avorn, 2004;
Goozner, 2004) They allege that the pharmaceutical industry
makes excessive profits by taking advantage of perverse
incentives in a market where consumers rely on third parties
(i.e. physicians) to choose drugs for them and prescription
drug insurance coverage (often provided by employers or the
government) to shield consumers from the full cost of paying
for those drugs. The distorted economics of the market
therefore permits the industry to succeed by marketing new,

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 Understanding the dynamics of the pharmaceutical market
David Holdford
expensive drugs that are often no better than cheaper
alternatives currently on the market. Those high priced drugs
are supported by tax incentives and Federal investment in
research and development. Furthermore, promotional efforts
by drug companies encourage inappropriate prescribing by
physicians, incorrect drug use and unreasonable expectations
by patients, and wasteful expenditures on drugs and other
health care. Drug price comparisons between what Americans
and citizens of other developed countries are presented as
further proof of problems with the market.
In defending themselves, the pharmaceutical industry
counters that money spent on drugs brings tremendous
value to Americans. They contend that drug costs are a small,
affordable portion of the health care dollar. Drugs are cost
effective, because they reduce and prevent hospitalizations,
doctors office visits, nursing home stays, and emergency
room visits. Furthermore, they assert that billions of dollars in
revenues received by the industry are reinvested into research
and development of new therapies that will save millions of
lives and prevent untold suffering. They insist that if change is
needed, it should strengthen the patent system on new
medications, ensure the freedom to inform and educate the
public and health care professionals, and reduce government
regulation. Any remedies proposed by opponents that restrict
financial incentives to innovate, reduce educational and
promotional efforts, or add to regulatory costs will only result
in negative, unintended consequences.
Opposition to the pharmaceutical industry occurs for
several philosophical and practical reasons. One is the belief
that it is unethical for any industry to profit from the suffering
of others and that the market should not be used to distribute
health care. Another is concern about the overuse of drugs to
solve the ills of individuals and society. There is also the real
concern that drug expenditures are becoming unaffordable.
This paper will focus on the struggle to control the costs of
prescription drugs. Specifically, it will deal with the effort of
individuals and groups to improve the way we pay for and
finance drug development and manufacturing, distribution,
prescribing, and medication use. Labeled the affordable
drugs movement, it will be studied using a social marketing
framework. Opposition to the movement will be considered to
come primarily from members of Pharmaceutical Research
and Manufacturers of America (PhRMA), a trade association
that represents all major pharmaceutical manufacturers. This
paper does not contend that PhRMA is against affordable
drugs just that PhRMA is opposed to many of the
movements proposed strategies for achieving affordability. In
fact, PhRMA resists most efforts to challenge the status quo
when it comes to promoting affordable drug initiatives
(Murray, 2004).
This paper will be organized in the following way. First, it
will describe how social movements develop and sustain
themselves using illustrations from the pharmaceutical
market. Then it will list social marketing strategies
employed by the industry to interrupt or divert change
efforts of the affordable drugs movement. Finally, a discussion
will present ways that the affordable drugs movement
framework can help understand and research the changing
pharmaceutical market.
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Volume 22 Number 7 2005 388 396
Factors associated with social movement success
The sociology literature identifies six factors associated with
successful social movements (Table I) (McAdam et al., 1988)
These factors are the conditions and stresses affecting society,
public perceptions that reform is needed and agencies to
support it, the presence of precipitating events to trigger
change, and the techniques used by opposing parties to
support or hinder change.
Structural conduciveness
The first factor, structural conduciveness, describes the broad
social conditions necessary for collective behavior (McAdam
et al., 1988). Structural conduciveness refers to the degree to
which an environment encourages conflicts between groups.
The aging US population is an example. It is a broad social
condition increasing the need for drugs. As the population
ages, demand for pharmaceuticals to treat chronic diseases
increases. A related social condition leading to conflict is the
publics demand for the newest, high priced drugs. Fueled by
profit expectations of shareholders and the increasing
complexity of drug development and research, prices for
some drugs, such as the cancer drug Erbitux, can cost
$10,000 per month or more (Nishad, 2004). Consequently,
drug spending has been increasing at double digit percentage
rates up to $179.2 billion in 2003 (Smith et al., 2005). The
global marketplace is another cause of conflict because it
permits consumers to compare the cost paid for drugs in the
USA with the relatively low prices paid by the rest of the
world. Discord is further fanned when rising drug
expenditures exacerbate governmental deficits, since state
and Federal governments are some of the largest purchasers of
prescription drugs. The Federal debt limit will soon exceed
eight trillion dollars, without considering the demands for
Social Security and Medicare reforms or spending for the
military (Wall Street Journal, 2004). Even the Medicare
Prescription Drug, Improvement Act of 2003 has exacerbated
Federal budgetary concerns about drug affordability with
program cost estimates rising from an original $400 billion to
$720 billion over ten years (Lueck, 2005). All of these
structural issues increase conflicts between providers, payers,
politicians, employers, consumers, and patients and enhance
the demand for change.
Structural strains
A related factor stimulating social movements is the existence
of structural strains which are defined by sociologists as
stresses existing within a social system that lead to discontent
(McAdam et al., 1988). These strains are caused by events or
situations within society that lead to the perception of a
problem.
Two major structural strains causing discontent with drug
affordability are the increased requirements in patient cost-
sharing by health plans and the impending retirement of baby
boomers. Increased patient cost-sharing causes dissatisfaction
because it forces patients to share the pain of high drug costs.
In the past, employer-paid private drug insurance plans
covered most or all of employee drug costs as a way of
attracting and keeping employees in a competitive job market.
Now, rising drug costs have forced employers to pass some of
those costs on to employees through increased prescription
drug co-payments and coinsurance. Some employers are even
dropping drug insurance altogether. Consequently, more
 Understanding the dynamics of the pharmaceutical market Journal of Consumer Marketing
David Holdford Volume 22 Number 7 2005 388 396

Table I Conditions influencing successful social movements

Condition
Structural conduciveness
Structural strains
Growth of generalized beliefs
Precipitating events
Mobilization for action
Utilization of social control by
opponents to movement
Description
Broad social conditions necessary for collective behavior and
conflicting interests
Stresses existing within a social system that lead to open
discontent
Growing and spreading perception that current conditions are
unacceptable
Events that trigger the desire for action
Marshaling of resources to change the status quo
Use of social influence techniques to control individuals or
groups
Examples
Increasing drug expenditures, Federal budget deficits
Increased cost-sharing, retirement of baby boomers
Polling data, content and direction of media coverage
Thalidomide disaster, recession
Proposals for legislation, protests
Public relations, co-opting opponents

people are feeling the pinch of rising drug costs. This strain is
exacerbated by the fact that baby boomers are now facing
retirement. Baby boomers are a large and activist cohort of
current and potential prescription drug users who are
expected to demand drugs not just to treat illnesses but
improve lifestyle. There is also concern that many boomers
have not saved enough to adequately fund their retirement.
Increased cost sharing and the aging of baby boomers will
cause significant strains on the US health care system.
Today, industry opponents have had some success
monopolizing the media to portray it in a negative light
through the publication of studies, polls, anecdotal reports,
articles, and books. Several books critical of the
pharmaceutical industry have been published (Abramson,
2004; Angell, 2004; Avorn, 2004; Goozner, 2004; Jerome
Kassirer, 2004). Public media have also given extensive
coverage to politicians, consumer groups, academics, policy
analysts and others with grievances against the industry.

Growth of generalized beliefs Canalization

The conduciveness of structural conditions in society and its
resulting stresses can help shape public opinion that current
conditions are undesirable. When public opinion coalesces
into common generalized beliefs of social events and stresses,
it can lead to a call for change. Public opinion is influenced by
many sources mass media, personal experience, and word-
of-mouth discussions between individuals. Movements that
control public generalized beliefs and public discourse can
dictate the direction and perceived viability of change.
Lanzarfeld and Merton argue three conditions are
necessary to control social discussion: monopolization (i.e.
control of mass media), canalization (i.e. presence of general
attitudes supporting change), and supplementation (i.e.
word-of-mouth discussions that supplement messages in the
media and help spread general attitudes) (Lazarfeld and
Merton, 1949). When these three conditions favor one side
over another, public dialogue can degenerate into propaganda
promoting a favored viewpoint.
Monopolization
Social movements that monopolize traditional media (e.g.
newspapers, television) and non-traditional media (e.g.
internet) can present their viewpoint in a way that
effectively obstructs any counter-arguments of opposing
viewpoints. Monopolization is very difficult to do in a free
society with freedom of speech and the press. Nevertheless, it
does sometimes happen. In 1993, when President Clinton
attempted to implement a major reform of the health care
system, media coverage turned so negative against the
pharmaceutical industry that major legislation to overhaul
the pharmaceutical market almost passed (Ostrowski, 1994).
If the proposed plan had been simpler and less confusing,
public discourse would have led to major changes in the
pharmaceutical market. Instead, squabbles among supporters
of change let PhRMA and other powerful interest groups
effectively challenge the legislation (Hoffman, 2003).
Public acceptance of propaganda by either side of the
affordable drugs debate is facilitated by the publics prevailing
attitudes (i.e. canalization) (Lazarfeld and Merton, 1949).
Polling data indicate little support for drug companies.
Opinion surveys rank public perceptions of drug companies
down with cigarette companies (Time, 2004) Polls
consistently and strongly indicate that the public believes
drug prices are too high with as many as 87 per cent thinking
drug prices to be unreasonably high or somewhat high
(Harris Interactive, 2004a). A total of 60 per cent of
Americans express support for drug price controls (Harris
Interactive, 2004a), 81 percent believe that drug prices are a
greater burden in the USA compared to Canada (Harris
Interactive, 2004b), and 84 per cent support drug
importation from Canada (Harris Interactive, 2004c). The
one positive finding for PhRMA is that most Americans feel
that drug costs are not a difficult problem at the moment with
75 percent indicating that they have little difficulty paying for
drugs (Harris Interactive, 2004d).
Supplementation
Supplementation of media coverage and public opinion
through word-of-mouth (WOM) sets the final condition for
developing a generalized belief that change is needed
(Lazarfeld and Merton, 1949) WOM consists of non-
commercial discussions of products and ideas between
friends, peers, acquaintances, and family members. They
are considered more credible than commercial forms of
communication but more difficult to control due their
spontaneity and randomness. WOM discussions about drug
prices may occur between individuals, friends, and family
members who experience hardships in paying for drugs. Even
individuals with full prescription drug coverage may complain
about the high price of drugs if their uninsured parents are
forced to pay a large portion of their discretionary income for
prescription drugs. Despite the difficulty influencing WOM,

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David Holdford
social movements try to facilitate discussions through
grassroots organizing of protests and other forms of activism.
Precipitating events
Social movements can be paralyzed even when a dissatisfied
public demands change if there exist significant barriers to
action (Kotler, 1972). Movements often need some
precipitating factor or event that sparks action. Precipitating
events may be spontaneous or provoked by agencies such as
the American Association of Retired Persons (AARP). Over
the years, most major drug legislation has occurred because
some precipitating event turned public sentiment against drug
companies. The Federal Food and Drugs Act of 1906, Food,
Drug, and Cosmetic Act of 1938, Durham Humphrey
Amendment of 1951, and the Kefauver Harris Amendments
of 1962 all occurred because events turned public opinion
against the prevailing practices of the pharmaceutical
industry. Precipitating events can be a single, major episode
or a series of smaller incidents that incrementally ratchet up
the pressure for change.
Single events such as the thalidomide tragedy have initiated
most major legislation governing the pharmaceutical industry.
Thalidomide was a sedative and anti-nauseant drug used by
pregnant women in Europe in the early 1960s. At the time,
the Food and Drug Administration (FDA) resisted putting
the drug on the US market. When reports started to appear in
Europe of thousands of infants with grotesque birth defects
born to pregnant mothers who had been taking the drug,
support blossomed for the previously languishing Kefauver-
Harris Amendments to the Federal Food, Drug, and
Cosmetic Act. This legislation required pharmaceutical
companies to prove that their drugs were effective prior to
marketing. Without the precipitating thalidomide tragedy, the
legislation likely would not have passed.
In contrast, the Medicare Prescription Drug, Improvement
Act of 2003 resulted from a series of precipitating events.
Organizations such as the AARP provoked politicians to act
with a series of media events (e.g. busloads of seniors crossing
the border to buy Canadian drugs) and drug price studies
illustrating the high cost of prescription drugs for seniors.
State and local governments demanded relief on drug costs
from the Federal government. The re-election strategy
adopted by President George W. Bush and Republican
congressional victories also contributed to the passing of a
drug bill that was pushed through Congress by a small voting
margin.
Current events have weakened the credibility and public
confidence in the industry and increased the pressure for
reform. Some pharmaceutical companies have run into
trouble with their marketing practices (Angell, 2004;
Lenzer, 2004). Warner Lambert plead guilty to illegal and
fraudulent promotion of unapproved uses for the drug
Neurontin and paid fines of more than $430 million (FDA
Consumer, 2004). Links between the widely used and
marketed COX-2 arthritis drugs with heart attacks and
strokes have lead to calls for changes in FDA oversight.
Concerns over cholesterol lowering agents, attention deficit
therapies, antidepressants, and other drugs have the further
undermined confidence in the pharmaceutical industry.
Mobilization for action
Public opinion will only translate into social movement when
conditions mobilize action. Action requires direction
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Volume 22 Number 7 2005 388 396
(knowledge of how and where a person might go to act)
and mechanism (the existence of an agency that enables the
person to act) (Weibe, 1951). Direction provides an outlet for
movement supporters to act on their beliefs. Mechanism
provides a way to gather like-minded individuals and
coordinate their actions. AARP is a mechanism used by
seniors to contribute money, participate in protests, write
letters to legislators, and organize voter drives. Without the
AARP, many seniors would need to find other ways to remain
engaged in the seniors movement.
A major impediment to the affordable drugs movement is
that there are not many outlets for opponents to express their
dissatisfaction. Individuals who want to push for affordable
drugs have few organizations that promote affordable drugs.
Indeed, the lack of grass roots activities has been cited as a
reason for some of the past failures of health care social
movements (Hoffman, 2003).
Social control techniques
The progress of social movements depends, in large part, on
the reaction of those opposing them. Opponents who
effectively exert social control techniques can deflect
negative public opinion and undercut the arguments of
social movements. Social control techniques are defined as
social strategies used to influence individuals or groups
(McAdam et al., 1988). Social control borrows heavily from
social marketing. Several strategies used by the
pharmaceutical industry are described below.
Manage the publics image
Drug companies are aware that they have image problems
(Ostrowski, 1993, 1994). They have responded with public
relations campaigns that attempt to present a consistent and
coherent message (Tsao, 2004). The message is that drug
companies need money to innovate, high profits to pay for the
risk of research, marketing to educate people about complex
therapies, me-too drugs to meet the individual needs of
patients, and less regulation to reduce the costs of making
drugs. In addition, industry emphasizes how they provide free
and low cost drugs to needy patients and save lives. A good
public image helps when implementing some of the other
social control techniques.
Influence the evaluation process
Social movements operate on the premise that objective
assessments of a situation lead to the conclusion that change
is needed. Opponents to movements attempt to influence this
evaluation process so their viewpoints are represented. In
health care, evaluations of drug affordability are conducted on
multiple levels and by many players. Public policy relating to
prescription drugs is made at the international (e.g. World
Health Organization, World Trade Organization), national
(e.g. FDA, FTC), state (e.g. board of pharmacy), and local
levels (e.g. public health department). The pharmaceutical
industry attempts to influence discussion at all levels in their
lobbying and advocacy. To illustrate, pharmaceutical
companies spent $93 million in 2000 lobbying Congress,
the White House, and other federal agencies. (USA Today,
2004) State and local lobbying totals are substantial too but
harder to come by given the differences in state and local
reporting requirements. At the health system and hospital
levels, pharmaceutical companies heavily lobby medical
directors, pharmacy directors, formulary committee
 Understanding the dynamics of the pharmaceutical market
David Holdford
members, and individual physicians to present their
perspectives in decision-making forums.
Influence the agenda
A related tactic is to influence the agenda of decision makers
in a way that benefits drug companies. Industry often argues
that opponents focus on the wrong issues. They counter that
affordability is not a question of high drug prices, drug
company profits, nor marketing clout. Instead, the real issues
are the needs to permit the marketplace to decide what drugs
will succeed or fail, reduce legislation that prevents
innovations from getting to patients, and reward the risks of
investors with profits. Indeed, marketers would likely argue
against the label affordability movement used in this paper
in favor of an industry friendlier tag such as the drug
regulation burden movement.
Build coalitions and alliances
Opponents of social movements frequently build coalitions
and alliances to give them allies to lobby for their cause and
influence public opinion (Joanna, 2002; Sibyl, 2000).
Pharmaceutical companies often develop coalitions with
consumer and disease advocacy groups to work together
toward common goals and associate themselves with good
causes (Herxheimer, 2003). Relationships with disease
advocacy and public health groups are especially important
given these groups own potent lobbying efforts $12 million
for Federal politicians and officials in 2000 (Landers and
Sehgal, 2004). Industry often contributes to the lobbying
efforts of advocacy groups by funding those with similar goals.
Some advocacy groups are accused of being so closely
attached to industry that they are little more than front-
groups used to conduct stealth-lobbying campaigns
(Moynihan, 2003). Although they profess their
independence, advocacy groups openly work with industry
to influence legislation (Joanna, 2002).
Co-opting opponents
Co-opting occurs when one converts an opponent into a
supporter. Co-opting can be accomplished in a variety of
ways. One is to place a supporter in an opposition group. This
might be done by encouraging a supporter to serve on a
regulatory agency that is blocking a pharmaceutical industry
initiative. Another strategy might be to co-opt potential
opponents with consulting fees or other financial incentives.
In fact, financial relationships between clinical researchers
and drug companies are a serious concern among many
(Bodenheimer, 2000a). Co-opting can also occur when
opponents find areas of common interest and work together.
This occurred when pharmaceutical companies found that
AIDS activist groups, vocal critics of drug pricing policies,
could be used to pressure politicians to support funding for
expensive AIDS treatments.
Cultivate opinion leaders
Cultivating key opinion leaders (KOLs) is a major strategy
used by pharmaceutical companies to influence public and
private discussions about drugs (Angell, 2004; Avorn, 2004;
Jackson, 2001). Industry develops relationships with KOLs in
medicine, academia, public policy, and government to spread
key talking points about the value presented by drugs. KOLs
are physicians and other individuals whose opinions have
greater influence due to their position, expertise, and/or
connections (Holdford, 2004).
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Volume 22 Number 7 2005 388 396
Drug companies spend a large portion of their marketing
budget on KOLs. For the average physician, drug companies
spend an estimated $8,000 to $13,000 every year in
promotional expenses (Wazana, 2000). For opinion leaders,
the amount is significantly more. Opinion leaders are wooed
with dinners, trips, and consultant contracts. Influential
physicians in some key practice settings annually receive
hundreds of thousand of dollars worth of drug samples (Wolf
et al., 1998). Physicians who are willing to write editorials
supporting industry interests receive monetary compensation
(Brennan, 1994). Drug company support of KOLs influences
information provided in continuing medical education
(Relman, 2001) and medical publications (Lexchin et al.,
2003).
The effectiveness of the pharmaceutical industry in using
social control techniques is illustrated by the fact that few
changes opposed by industry have occurred over the years
despite widespread negative public opinions about drug
companies (Time, 2004). In effect, the pharmaceutical
industry has been able to use social control to divide and
disarm opposition in the community (Dukes, 2002).
Proposed changes
The fundamental structural issues affecting drug expenditures
(e.g. aging population, government budget deficits) will
continue to pressure the status quo (Moran, 2000). There is
also a belief that the current structure of the health care
system is a major part of the problem (Newhouse, 2004;
Nichols et al., 2004). Therefore, some change is likely to
occur although the exact form is still undetermined. Proposed
changes associated with improving drug affordability fall into
three types: regulating industry, increasing competition, or
making better purchases with our drug dollars.
Regulating industry
Most regulatory solutions for making drugs more affordable
focus on having the Government control the price of drugs
(Maynard and Bloor, 2003) The Government can accomplish
this directly by restricting the prices charged by companies or
indirectly by restricting the amount of drug revenue that can
go to profits. Direct price controls in European countries
work by having some governmental agency establish a price
ceiling for which a drug can be sold or reimbursed through an
insurance program. Prices are typically set based on charges
for comparable drugs in other markets within or outside of the
country. Prices are controlled through the establishment of a
national drug formulary that permits the government to
negotiate drug prices and influence prescribing (Huskamp
et al., 2003) An indirect mechanism of price control used in
the UK attempts to regulate pharmaceutical company profits.
Profit controls are problematic because they do not halt drug
price increases and encourage inefficiency in drug
development (Maynard and Bloor, 2003).
There is significant resistance to price controls by the
pharmaceutical industry and public policy experts (Calfee,
2001). One reason is that experience in other countries
indicates price controls alone do not stop drug price increases
(Menon, 2001). All industrial countries face rising drug
expenditures despite a broad range of price controls. Another
reason for opposition is that it is not clear what unintended
consequences price controls may have on innovation and long
term health care costs (Maynard and Bloor, 2003). If price
 Understanding the dynamics of the pharmaceutical market
David Holdford
controls choke off the pharmaceutical innovations coming
onto the market, any savings might come at a high cost. Price
controls also invite meddling by politicians who may try to
pick up political points by interfering with their
implementation and administration (Frank, 2003;
Newhouse, 2004). Finally, price controls fly in the face of
free market advocates who argue for private markets to
regulate health care costs and encourage pharmaceutical
innovation (Bush, 2004).
Increasing competition
Despite the resistance to governmental price controls, there
are growing feelings that reliance on the market alone is not
the solution (Nichols et al., 2004). Under the current patent
system for drugs, abusive pricing practices by industry can
occur unless patented medications are made to compete
against generic and therapeutic alternatives (Newhouse,
2004). Consequently, efforts have been made to increase
market competition by enhancing drug choices. One
proposed strategy is to weaken patent laws to allow cheaper
generic drugs to more quickly enter the market. The problem
with this strategy is that it reduces incentives to develop
therapeutic innovations (Eisenberg, 2001). An alternative
solution is to permit substitution of lower priced,
therapeutically similar drugs for more expensive ones.
Patents would still be in place but low priced substitutes
could be switched for higher priced drugs, regardless of
whether they differ chemically, if they achieve the same
medical outcomes. The argued advantage of this therapeutic
substitution is that it permits competition between
therapeutic equals (i.e. me-too drugs) but still gives a
competitive advantage in the market for drugs that achieve
unique therapeutic benefits.
Importation of low priced drugs from Canada and other
countries has also been suggested as a way of increasing price
competition. In fact, the new Medicare Drug Legislation
permits importation, if the Food and Drug Administration
(FDA) demonstrates that it can be done safely (something the
FDA has been unwilling to do). Nevertheless, some states
encourage their citizens to shop for Canadian drugs.
Minnesota, Illinois, New Hampshire, Wisconsin and other
states direct citizens to purchase at state-approved Canada
Internet pharmacy web sites. It is believed that some form of
legalized drug importation is inevitable, if no major
unforeseen roadblock occurs (i.e. deaths due to counterfeit
drugs) (Jill, 2004). The benefits of doing so, however, are
expected to be modest (1 percent decrease in total drug
expenditures) (Congressional Budget Office, 2004).
Make better purchases
Demands to regulate drug companies are based on the
assumption that industry is the problem for high drug
expenditures, while calls to increase competition assume that
the market needs to be fixed. However, the problems of drug
affordability could be resolved simply if better purchases are
made at the payer, physician, or patient levels. If more
discipline and rationality were encouraged in the process of
drug selection and reimbursement, greater value could be
achieved with health care dollars spent. Current mechanisms
for purchasing drugs encourage industry to increase
marketing, charge higher prices for new drugs, and promote
utilization (Newhouse, 2004). None of these things are bad if
they increase the development and use of necessary drugs.
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Volume 22 Number 7 2005 388 396
The problem is that the health care market chooses and pays
for many drugs that are unnecessary, overpriced, and
inappropriate. Drugs could be made more affordable if
payers, prescribers, and patients made better choices.
Improve prescribing
Physicians are responsible for most health care utilization
choices, so the health care system should facilitate cost-
effective prescribing. Managed health care had argued that
drug costs can be controlled through the use of drug
formulary systems that restrict physician prescribing and
insurance coverage to a limited list of essential, cost-effective
drugs (i.e. formulary). Formularies are enforced with the use
of management tools such as drug utilization review,
restricted provider networks, therapeutic and generic
substitution, provider benchmarking, and patient cost-
sharing. To get on the formulary, drug companies are forced
to offer their drugs at lower prices or be excluded from
insurance coverage.
However, evidence of the effectiveness of managed care is
still limited (Bodenheimer, 2000b; Carroll, 2002; Schulman
et al., 1996). Despite the spread of managed care coverage,
plans still see double digit increases in drug expenditures. One
reason is that many of the tools in the formulary toolbox are
rarely utilized (Carroll, 2002). Reasons include public
opposition to restrictions on drug therapies, lack of
integration between health care providers, and patient
demand for the newest pharmaceuticals. In addition,
managed care can be profitable under the current ineffective
cost control system because most excess drug costs can be
passed on to payers (Moran, 2000).
Even the Federal Government, the largest single purchaser
of prescription drugs, is unwilling to utilize some tools to
control drug costs. Critics of the Medicare Prescription Drug
Program complain that the Federal government is expressly
prohibited from negotiating lower drug prices with
manufacturers. Instead, negotiations on drug prices will be
made by the individual drug plan providers (e.g. pharmacy
benefit managers) to avoid governmental price controls.
Rightly or wrongly, this restriction takes away one of Federal
Governments most potent cost management tools. State and
Federal governmental politics have also hamstrung the ability
of pharmacy benefit managers and other non-governmental
purchasers to control drug costs with numerous rules,
regulations, and laws that reduce their ability to restrict
payment on drugs (e.g. birth control), restrict provider
networks (e.g. any willing provider laws), and integrate
services (e.g. antitrust laws).
Involve patients in their drug choices
The difficulty in implementing cost control strategies has lead
managed care providers to share the risk of pharmaceutical
costs with patients through consumer-driven health care.
Consumer-driven healthcare is a broad term for strategies
designed to empower patients to choose their own health care
and share the risks of their costs. Elements of consumer-
driven plans include choice of different healthcare options,
medical savings and flexible spending accounts, and cost-
sharing through co-payments, coinsurance, deductibles, and
reimbursement caps. The goal is to make patients take greater
responsibility for their drug and health care decisions.
Although cynics might describe consumer-driven healthcare
as just another way of saying consumers pay more for
 Understanding the dynamics of the pharmaceutical market
David Holdford
healthcare (Kleinke, 2004), it is a cost control strategy that is
becoming increasingly important.
Focus on value in making drug choices
The current environment of medical research and evidence-
based medicine results in the conclusion that more medicine
is better (Kleinke, 2004). This means that even if the most
effective drug is chosen for every patient who needs it,
pharmaceuticals expenditures will continue to spin out of
control unless cost is also factored into the choice. Some
argue that payments for drugs should be structured around
consideration of value rather than price (Kleinke, 2004;
Chernew et al., 2004). That means that payers need to be able
to refuse to cover drugs that are not cost-effective (where the
cost exceeds the benefit received) (Newhouse, 2004). If
patients want to pay for any extra marginal benefit associated
with an uncovered drug, they should be expected to pay for all
or part of the cost of drugs depending on their impact on
health outcomes (Fendrick et al., 2001; Morgan et al., 2004).
Methodological and practical issues still exist with the
assessment of drug cost effectiveness. For instance, few head-
to-head comparisons of competing drugs occur in clinical
trials making direct cost effectiveness comparisons difficult.
Another issue is that cost-effectiveness analysis requires
transparency in data, analytical methods, and conclusions
along with transparent rules before it can be widely applied in
the design of pharmacy benefits (Kleinke, 2004). The
problem with transparency is that it opens up methods to
immediate criticism by opponents that can be exploited by
savvy pharmaceutical marketers. KOLs can be solicited to
attack the methods or results in order to water-down the
pharmacoeconomic decision-making process.
Managerial implications
Issues relating to the affordability of drugs are complex and
multifaceted. The descriptive framework presented in this
paper can be used as a tool to place developments in the
pharmaceutical marketplace into a meaningful context.
Conditions listed in Table I describe variables that can be
studied to understand the swirl of conflicting information
about pharmaceuticals. The two conditions of structural
conduciveness and structural are useful but stable
characteristics of the broad market environment. Therefore,
their value lies in providing groundwork for understanding the
other four, more dynamic conditions of the framework. The
remaining four conditions from Table I can be studied to
monitor major trends and events that impact the
pharmaceutical market.
Social research methodologies can permit researchers to
understand the growth, direction, and character of
generalized beliefs by the public about drug affordability.
Public opinions about drug affordability are being monitored
through polls conducted by media such as the Wall Street
Journal, but most are static cross-sectional studies that do not
provide much depth about public feelings. More extensive,
longitudinal studies of public opinions would provide greater
understanding of changes in attitudes over time. Opinion
leaders can also be interviewed about their feelings on major
issues such as that demonstrated in the community tracking
study. This study conducts periodic interviews of households,
physicians, and health system leaders in 60 communities and
recently found greater support for government intervention in
health care (Nichols et al., 2004). Content analyses of media
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Volume 22 Number 7 2005 388 396
reporting and publications can also be conducted to examine
issues and trends identified as important by the media.
Case studies can explore the direct and indirect significance
of major events in the pharmaceutical market. Case studies
can describe and explain unique or interesting events such as
the implementation of the Medicare Prescription Drug,
Improvement Act of 2003. For instance, it is not clear at the
moment whether the Act will increase or decrease pressure for
change. Although it was meant to solve the problem of
affordable drugs for seniors, many details and consequences
of the Act are unclear. If seniors judge it favorably, and it
slows the rise of inappropriate drug expenditures, pressure on
the pharmaceutical market will be relieved. If things go badly,
however, renewed calls for price controls and other dramatic
solutions will intensify.
Content analysis of the media can be used to explore
resources mobilized by governmental, political, consumer,
business, and professional agencies. It has been used to
understand how agencies in the consumer movement
mobilized resources to promote their agenda (Smith and
Bloom, 1989). In a similar manner, content analysis can be
used to examine issues advanced by the movement, the types
of groups and individuals promoting change, and the form
and direction of the change advanced over time.
Finally, researchers can study the changing social control
strategies used by industry to resist change. The evolving
effectiveness of techniques can be instructive. For example,
there is growing resistance to the acceptance of drug company
money by individuals and groups. One group called No Free
Lunch advocates the elimination of pharmaceutical
promotion from medical education, practice, and research
(No Free Lunch, 2005) If physicians, educators, and
researchers widely adopt the solutions proposed by No Free
Lunch, the influence of drug companies in resisting change
will be diminished.
Conclusion
The only certainty in the pharmaceutical market is that
change will occur. It will either happen when public demands
for change overpower the ability of the pharmaceutical
industry to resist it or when industry decides that change is in
its best interests. In other words, industry can be proactive in
their support of change, or they can wait and let others
decide. The economics of the pharmaceutical market are
unlikely to spontaneously improve it, so systematic research
should be conducted to understand its dynamics. The paper
presents a framework for doing so.
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 Understanding the dynamics of the
pharmaceutical market using a social
marketing framework
David Holdford
Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA

Abstract
Purpose The objectives of this paper are to describe the affordable drugs movement and present a social marketing framework to place major
developments within a meaningful theoretical context.
Design/methodology/approach Specific examples are used to illustrate the framework and its utility in understanding the complexities of the
pharmaceutical market. Methods to research the dynamics of the market are also presented.
Findings Provides referenced descriptions and examples of forces causing change within the pharmaceutical market. Classifies forces into six
conditions influencing successful social movements: structural conduciveness, structural strains, growth of generalized beliefs, precipitating events,
mobilization for action, and utilization of social control by opponents. Suggests social research methodologies to study the conditions in greater depth.
Research limitations/implications This is a descriptive framework that has not been validated for its use in the pharmaceutical market.
Practical implications Offers a useful framework for academics, managers, students, and individuals to classify and study developments in the
pharmaceutical industry.
Originality/value This paper provides an overview of major forces within the pharmaceutical market and offers direction for those who wish to
explore it in greater detail.

Keywords Pharmaceuticals industry, Social marketing, Economics

Paper type General review

An executive summary for managers and executive
readers can be found at the end of this issue.
The pharmaceutical marketplace is facing major pressures
from a broad range of dynamic and powerful forces. Major
healthcare legislation such as the Medicare Prescription Drug,
Improvement Act of 2003, widespread criticisms of
pharmaceutical industry marketing, increasing consumer
involvement in health care, calls to improve FDA oversight
of the pharmaceutical industry, and demands for more
affordable drugs are forcing society to re-examine the way that
pharmaceuticals are developed, distributed, and financed
within the USA. To understand the impact and potential
consequences of these forces, it is helpful to place them within
some meaningful theoretical context.
Social marketing has been presented as a framework for
analyzing social change (Kotler, 1971). Social marketing is a
process for influencing social ideas and behaviors based on the
premise that social causes can be marketed like any product.
Founded on the fields of sociology, psychology, and
marketing, it best known for its utility in promoting socially
desirable behaviors such as recycling, seat belt use, family
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www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
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Journal of Consumer Marketing
22/7 (2005) 388 396
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631129]
planning, and AIDs prevention. It can also be used to study
and influence major social movements such as consumerism,
conservatism, and many other isms (Fox and Kotler, 1980).
Social movements are defined as relatively persistent,
organized efforts by large numbers of people to effect social
change. The study of social movements attempts to
understand their success or failure with the intention of
predicting their consequences and influencing their course.
Social movements studied in health care include the
movements toward self-care, (Schiller and Levin, 1983)
health care reform (Hoffman, 2003), and insurance reform
(Atim, 1999). It has been suggested that social movements
would benefit from marketing thinking and planning (Kotler,
1971). It has also been proposed that a social movement
framework can help in understanding the dynamics of the
pharmaceutical market (Wells and Banaszak-Holl, 2000).
There is currently an organized movement by individuals
and groups to change how the pharmaceutical marketplace
provides safe, effective, and affordable medicine. This
movement is not new. It has been around since the
beginning of the modern pharmaceutical industry,
periodically intensifying and diminishing throughout the
years. Revitalized in recent years, movement supporters
assert that the current pharmaceutical system is broken and
major changes are necessary (Angell, 2004; Avorn, 2004;
Goozner, 2004) They allege that the pharmaceutical industry
makes excessive profits by taking advantage of perverse
incentives in a market where consumers rely on third parties
(i.e. physicians) to choose drugs for them and prescription
drug insurance coverage (often provided by employers or the
government) to shield consumers from the full cost of paying
for those drugs. The distorted economics of the market
therefore permits the industry to succeed by marketing new,

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 Understanding the dynamics of the pharmaceutical market
David Holdford
expensive drugs that are often no better than cheaper
alternatives currently on the market. Those high priced drugs
are supported by tax incentives and Federal investment in
research and development. Furthermore, promotional efforts
by drug companies encourage inappropriate prescribing by
physicians, incorrect drug use and unreasonable expectations
by patients, and wasteful expenditures on drugs and other
health care. Drug price comparisons between what Americans
and citizens of other developed countries are presented as
further proof of problems with the market.
In defending themselves, the pharmaceutical industry
counters that money spent on drugs brings tremendous
value to Americans. They contend that drug costs are a small,
affordable portion of the health care dollar. Drugs are cost
effective, because they reduce and prevent hospitalizations,
doctors office visits, nursing home stays, and emergency
room visits. Furthermore, they assert that billions of dollars in
revenues received by the industry are reinvested into research
and development of new therapies that will save millions of
lives and prevent untold suffering. They insist that if change is
needed, it should strengthen the patent system on new
medications, ensure the freedom to inform and educate the
public and health care professionals, and reduce government
regulation. Any remedies proposed by opponents that restrict
financial incentives to innovate, reduce educational and
promotional efforts, or add to regulatory costs will only result
in negative, unintended consequences.
Opposition to the pharmaceutical industry occurs for
several philosophical and practical reasons. One is the belief
that it is unethical for any industry to profit from the suffering
of others and that the market should not be used to distribute
health care. Another is concern about the overuse of drugs to
solve the ills of individuals and society. There is also the real
concern that drug expenditures are becoming unaffordable.
This paper will focus on the struggle to control the costs of
prescription drugs. Specifically, it will deal with the effort of
individuals and groups to improve the way we pay for and
finance drug development and manufacturing, distribution,
prescribing, and medication use. Labeled the affordable
drugs movement, it will be studied using a social marketing
framework. Opposition to the movement will be considered to
come primarily from members of Pharmaceutical Research
and Manufacturers of America (PhRMA), a trade association
that represents all major pharmaceutical manufacturers. This
paper does not contend that PhRMA is against affordable
drugs just that PhRMA is opposed to many of the
movements proposed strategies for achieving affordability. In
fact, PhRMA resists most efforts to challenge the status quo
when it comes to promoting affordable drug initiatives
(Murray, 2004).
This paper will be organized in the following way. First, it
will describe how social movements develop and sustain
themselves using illustrations from the pharmaceutical
market. Then it will list social marketing strategies
employed by the industry to interrupt or divert change
efforts of the affordable drugs movement. Finally, a discussion
will present ways that the affordable drugs movement
framework can help understand and research the changing
pharmaceutical market.
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Factors associated with social movement success
The sociology literature identifies six factors associated with
successful social movements (Table I) (McAdam et al., 1988)
These factors are the conditions and stresses affecting society,
public perceptions that reform is needed and agencies to
support it, the presence of precipitating events to trigger
change, and the techniques used by opposing parties to
support or hinder change.
Structural conduciveness
The first factor, structural conduciveness, describes the broad
social conditions necessary for collective behavior (McAdam
et al., 1988). Structural conduciveness refers to the degree to
which an environment encourages conflicts between groups.
The aging US population is an example. It is a broad social
condition increasing the need for drugs. As the population
ages, demand for pharmaceuticals to treat chronic diseases
increases. A related social condition leading to conflict is the
publics demand for the newest, high priced drugs. Fueled by
profit expectations of shareholders and the increasing
complexity of drug development and research, prices for
some drugs, such as the cancer drug Erbitux, can cost
$10,000 per month or more (Nishad, 2004). Consequently,
drug spending has been increasing at double digit percentage
rates up to $179.2 billion in 2003 (Smith et al., 2005). The
global marketplace is another cause of conflict because it
permits consumers to compare the cost paid for drugs in the
USA with the relatively low prices paid by the rest of the
world. Discord is further fanned when rising drug
expenditures exacerbate governmental deficits, since state
and Federal governments are some of the largest purchasers of
prescription drugs. The Federal debt limit will soon exceed
eight trillion dollars, without considering the demands for
Social Security and Medicare reforms or spending for the
military (Wall Street Journal, 2004). Even the Medicare
Prescription Drug, Improvement Act of 2003 has exacerbated
Federal budgetary concerns about drug affordability with
program cost estimates rising from an original $400 billion to
$720 billion over ten years (Lueck, 2005). All of these
structural issues increase conflicts between providers, payers,
politicians, employers, consumers, and patients and enhance
the demand for change.
Structural strains
A related factor stimulating social movements is the existence
of structural strains which are defined by sociologists as
stresses existing within a social system that lead to discontent
(McAdam et al., 1988). These strains are caused by events or
situations within society that lead to the perception of a
problem.
Two major structural strains causing discontent with drug
affordability are the increased requirements in patient cost-
sharing by health plans and the impending retirement of baby
boomers. Increased patient cost-sharing causes dissatisfaction
because it forces patients to share the pain of high drug costs.
In the past, employer-paid private drug insurance plans
covered most or all of employee drug costs as a way of
attracting and keeping employees in a competitive job market.
Now, rising drug costs have forced employers to pass some of
those costs on to employees through increased prescription
drug co-payments and coinsurance. Some employers are even
dropping drug insurance altogether. Consequently, more
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David Holdford Volume 22 Number 7 2005 388 396

Table I Conditions influencing successful social movements

Condition
Structural conduciveness
Structural strains
Growth of generalized beliefs
Precipitating events
Mobilization for action
Utilization of social control by
opponents to movement
Description
Broad social conditions necessary for collective behavior and
conflicting interests
Stresses existing within a social system that lead to open
discontent
Growing and spreading perception that current conditions are
unacceptable
Events that trigger the desire for action
Marshaling of resources to change the status quo
Use of social influence techniques to control individuals or
groups
Examples
Increasing drug expenditures, Federal budget deficits
Increased cost-sharing, retirement of baby boomers
Polling data, content and direction of media coverage
Thalidomide disaster, recession
Proposals for legislation, protests
Public relations, co-opting opponents

people are feeling the pinch of rising drug costs. This strain is
exacerbated by the fact that baby boomers are now facing
retirement. Baby boomers are a large and activist cohort of
current and potential prescription drug users who are
expected to demand drugs not just to treat illnesses but
improve lifestyle. There is also concern that many boomers
have not saved enough to adequately fund their retirement.
Increased cost sharing and the aging of baby boomers will
cause significant strains on the US health care system.
Today, industry opponents have had some success
monopolizing the media to portray it in a negative light
through the publication of studies, polls, anecdotal reports,
articles, and books. Several books critical of the
pharmaceutical industry have been published (Abramson,
2004; Angell, 2004; Avorn, 2004; Goozner, 2004; Jerome
Kassirer, 2004). Public media have also given extensive
coverage to politicians, consumer groups, academics, policy
analysts and others with grievances against the industry.

Growth of generalized beliefs Canalization

The conduciveness of structural conditions in society and its
resulting stresses can help shape public opinion that current
conditions are undesirable. When public opinion coalesces
into common generalized beliefs of social events and stresses,
it can lead to a call for change. Public opinion is influenced by
many sources mass media, personal experience, and word-
of-mouth discussions between individuals. Movements that
control public generalized beliefs and public discourse can
dictate the direction and perceived viability of change.
Lanzarfeld and Merton argue three conditions are
necessary to control social discussion: monopolization (i.e.
control of mass media), canalization (i.e. presence of general
attitudes supporting change), and supplementation (i.e.
word-of-mouth discussions that supplement messages in the
media and help spread general attitudes) (Lazarfeld and
Merton, 1949). When these three conditions favor one side
over another, public dialogue can degenerate into propaganda
promoting a favored viewpoint.
Monopolization
Social movements that monopolize traditional media (e.g.
newspapers, television) and non-traditional media (e.g.
internet) can present their viewpoint in a way that
effectively obstructs any counter-arguments of opposing
viewpoints. Monopolization is very difficult to do in a free
society with freedom of speech and the press. Nevertheless, it
does sometimes happen. In 1993, when President Clinton
attempted to implement a major reform of the health care
system, media coverage turned so negative against the
pharmaceutical industry that major legislation to overhaul
the pharmaceutical market almost passed (Ostrowski, 1994).
If the proposed plan had been simpler and less confusing,
public discourse would have led to major changes in the
pharmaceutical market. Instead, squabbles among supporters
of change let PhRMA and other powerful interest groups
effectively challenge the legislation (Hoffman, 2003).
Public acceptance of propaganda by either side of the
affordable drugs debate is facilitated by the publics prevailing
attitudes (i.e. canalization) (Lazarfeld and Merton, 1949).
Polling data indicate little support for drug companies.
Opinion surveys rank public perceptions of drug companies
down with cigarette companies (Time, 2004) Polls
consistently and strongly indicate that the public believes
drug prices are too high with as many as 87 per cent thinking
drug prices to be unreasonably high or somewhat high
(Harris Interactive, 2004a). A total of 60 per cent of
Americans express support for drug price controls (Harris
Interactive, 2004a), 81 percent believe that drug prices are a
greater burden in the USA compared to Canada (Harris
Interactive, 2004b), and 84 per cent support drug
importation from Canada (Harris Interactive, 2004c). The
one positive finding for PhRMA is that most Americans feel
that drug costs are not a difficult problem at the moment with
75 percent indicating that they have little difficulty paying for
drugs (Harris Interactive, 2004d).
Supplementation
Supplementation of media coverage and public opinion
through word-of-mouth (WOM) sets the final condition for
developing a generalized belief that change is needed
(Lazarfeld and Merton, 1949) WOM consists of non-
commercial discussions of products and ideas between
friends, peers, acquaintances, and family members. They
are considered more credible than commercial forms of
communication but more difficult to control due their
spontaneity and randomness. WOM discussions about drug
prices may occur between individuals, friends, and family
members who experience hardships in paying for drugs. Even
individuals with full prescription drug coverage may complain
about the high price of drugs if their uninsured parents are
forced to pay a large portion of their discretionary income for
prescription drugs. Despite the difficulty influencing WOM,

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David Holdford
social movements try to facilitate discussions through
grassroots organizing of protests and other forms of activism.
Precipitating events
Social movements can be paralyzed even when a dissatisfied
public demands change if there exist significant barriers to
action (Kotler, 1972). Movements often need some
precipitating factor or event that sparks action. Precipitating
events may be spontaneous or provoked by agencies such as
the American Association of Retired Persons (AARP). Over
the years, most major drug legislation has occurred because
some precipitating event turned public sentiment against drug
companies. The Federal Food and Drugs Act of 1906, Food,
Drug, and Cosmetic Act of 1938, Durham Humphrey
Amendment of 1951, and the Kefauver Harris Amendments
of 1962 all occurred because events turned public opinion
against the prevailing practices of the pharmaceutical
industry. Precipitating events can be a single, major episode
or a series of smaller incidents that incrementally ratchet up
the pressure for change.
Single events such as the thalidomide tragedy have initiated
most major legislation governing the pharmaceutical industry.
Thalidomide was a sedative and anti-nauseant drug used by
pregnant women in Europe in the early 1960s. At the time,
the Food and Drug Administration (FDA) resisted putting
the drug on the US market. When reports started to appear in
Europe of thousands of infants with grotesque birth defects
born to pregnant mothers who had been taking the drug,
support blossomed for the previously languishing Kefauver-
Harris Amendments to the Federal Food, Drug, and
Cosmetic Act. This legislation required pharmaceutical
companies to prove that their drugs were effective prior to
marketing. Without the precipitating thalidomide tragedy, the
legislation likely would not have passed.
In contrast, the Medicare Prescription Drug, Improvement
Act of 2003 resulted from a series of precipitating events.
Organizations such as the AARP provoked politicians to act
with a series of media events (e.g. busloads of seniors crossing
the border to buy Canadian drugs) and drug price studies
illustrating the high cost of prescription drugs for seniors.
State and local governments demanded relief on drug costs
from the Federal government. The re-election strategy
adopted by President George W. Bush and Republican
congressional victories also contributed to the passing of a
drug bill that was pushed through Congress by a small voting
margin.
Current events have weakened the credibility and public
confidence in the industry and increased the pressure for
reform. Some pharmaceutical companies have run into
trouble with their marketing practices (Angell, 2004;
Lenzer, 2004). Warner Lambert plead guilty to illegal and
fraudulent promotion of unapproved uses for the drug
Neurontin and paid fines of more than $430 million (FDA
Consumer, 2004). Links between the widely used and
marketed COX-2 arthritis drugs with heart attacks and
strokes have lead to calls for changes in FDA oversight.
Concerns over cholesterol lowering agents, attention deficit
therapies, antidepressants, and other drugs have the further
undermined confidence in the pharmaceutical industry.
Mobilization for action
Public opinion will only translate into social movement when
conditions mobilize action. Action requires direction
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(knowledge of how and where a person might go to act)
and mechanism (the existence of an agency that enables the
person to act) (Weibe, 1951). Direction provides an outlet for
movement supporters to act on their beliefs. Mechanism
provides a way to gather like-minded individuals and
coordinate their actions. AARP is a mechanism used by
seniors to contribute money, participate in protests, write
letters to legislators, and organize voter drives. Without the
AARP, many seniors would need to find other ways to remain
engaged in the seniors movement.
A major impediment to the affordable drugs movement is
that there are not many outlets for opponents to express their
dissatisfaction. Individuals who want to push for affordable
drugs have few organizations that promote affordable drugs.
Indeed, the lack of grass roots activities has been cited as a
reason for some of the past failures of health care social
movements (Hoffman, 2003).
Social control techniques
The progress of social movements depends, in large part, on
the reaction of those opposing them. Opponents who
effectively exert social control techniques can deflect
negative public opinion and undercut the arguments of
social movements. Social control techniques are defined as
social strategies used to influence individuals or groups
(McAdam et al., 1988). Social control borrows heavily from
social marketing. Several strategies used by the
pharmaceutical industry are described below.
Manage the publics image
Drug companies are aware that they have image problems
(Ostrowski, 1993, 1994). They have responded with public
relations campaigns that attempt to present a consistent and
coherent message (Tsao, 2004). The message is that drug
companies need money to innovate, high profits to pay for the
risk of research, marketing to educate people about complex
therapies, me-too drugs to meet the individual needs of
patients, and less regulation to reduce the costs of making
drugs. In addition, industry emphasizes how they provide free
and low cost drugs to needy patients and save lives. A good
public image helps when implementing some of the other
social control techniques.
Influence the evaluation process
Social movements operate on the premise that objective
assessments of a situation lead to the conclusion that change
is needed. Opponents to movements attempt to influence this
evaluation process so their viewpoints are represented. In
health care, evaluations of drug affordability are conducted on
multiple levels and by many players. Public policy relating to
prescription drugs is made at the international (e.g. World
Health Organization, World Trade Organization), national
(e.g. FDA, FTC), state (e.g. board of pharmacy), and local
levels (e.g. public health department). The pharmaceutical
industry attempts to influence discussion at all levels in their
lobbying and advocacy. To illustrate, pharmaceutical
companies spent $93 million in 2000 lobbying Congress,
the White House, and other federal agencies. (USA Today,
2004) State and local lobbying totals are substantial too but
harder to come by given the differences in state and local
reporting requirements. At the health system and hospital
levels, pharmaceutical companies heavily lobby medical
directors, pharmacy directors, formulary committee
 Understanding the dynamics of the pharmaceutical market
David Holdford
members, and individual physicians to present their
perspectives in decision-making forums.
Influence the agenda
A related tactic is to influence the agenda of decision makers
in a way that benefits drug companies. Industry often argues
that opponents focus on the wrong issues. They counter that
affordability is not a question of high drug prices, drug
company profits, nor marketing clout. Instead, the real issues
are the needs to permit the marketplace to decide what drugs
will succeed or fail, reduce legislation that prevents
innovations from getting to patients, and reward the risks of
investors with profits. Indeed, marketers would likely argue
against the label affordability movement used in this paper
in favor of an industry friendlier tag such as the drug
regulation burden movement.
Build coalitions and alliances
Opponents of social movements frequently build coalitions
and alliances to give them allies to lobby for their cause and
influence public opinion (Joanna, 2002; Sibyl, 2000).
Pharmaceutical companies often develop coalitions with
consumer and disease advocacy groups to work together
toward common goals and associate themselves with good
causes (Herxheimer, 2003). Relationships with disease
advocacy and public health groups are especially important
given these groups own potent lobbying efforts $12 million
for Federal politicians and officials in 2000 (Landers and
Sehgal, 2004). Industry often contributes to the lobbying
efforts of advocacy groups by funding those with similar goals.
Some advocacy groups are accused of being so closely
attached to industry that they are little more than front-
groups used to conduct stealth-lobbying campaigns
(Moynihan, 2003). Although they profess their
independence, advocacy groups openly work with industry
to influence legislation (Joanna, 2002).
Co-opting opponents
Co-opting occurs when one converts an opponent into a
supporter. Co-opting can be accomplished in a variety of
ways. One is to place a supporter in an opposition group. This
might be done by encouraging a supporter to serve on a
regulatory agency that is blocking a pharmaceutical industry
initiative. Another strategy might be to co-opt potential
opponents with consulting fees or other financial incentives.
In fact, financial relationships between clinical researchers
and drug companies are a serious concern among many
(Bodenheimer, 2000a). Co-opting can also occur when
opponents find areas of common interest and work together.
This occurred when pharmaceutical companies found that
AIDS activist groups, vocal critics of drug pricing policies,
could be used to pressure politicians to support funding for
expensive AIDS treatments.
Cultivate opinion leaders
Cultivating key opinion leaders (KOLs) is a major strategy
used by pharmaceutical companies to influence public and
private discussions about drugs (Angell, 2004; Avorn, 2004;
Jackson, 2001). Industry develops relationships with KOLs in
medicine, academia, public policy, and government to spread
key talking points about the value presented by drugs. KOLs
are physicians and other individuals whose opinions have
greater influence due to their position, expertise, and/or
connections (Holdford, 2004).
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Drug companies spend a large portion of their marketing
budget on KOLs. For the average physician, drug companies
spend an estimated $8,000 to $13,000 every year in
promotional expenses (Wazana, 2000). For opinion leaders,
the amount is significantly more. Opinion leaders are wooed
with dinners, trips, and consultant contracts. Influential
physicians in some key practice settings annually receive
hundreds of thousand of dollars worth of drug samples (Wolf
et al., 1998). Physicians who are willing to write editorials
supporting industry interests receive monetary compensation
(Brennan, 1994). Drug company support of KOLs influences
information provided in continuing medical education
(Relman, 2001) and medical publications (Lexchin et al.,
2003).
The effectiveness of the pharmaceutical industry in using
social control techniques is illustrated by the fact that few
changes opposed by industry have occurred over the years
despite widespread negative public opinions about drug
companies (Time, 2004). In effect, the pharmaceutical
industry has been able to use social control to divide and
disarm opposition in the community (Dukes, 2002).
Proposed changes
The fundamental structural issues affecting drug expenditures
(e.g. aging population, government budget deficits) will
continue to pressure the status quo (Moran, 2000). There is
also a belief that the current structure of the health care
system is a major part of the problem (Newhouse, 2004;
Nichols et al., 2004). Therefore, some change is likely to
occur although the exact form is still undetermined. Proposed
changes associated with improving drug affordability fall into
three types: regulating industry, increasing competition, or
making better purchases with our drug dollars.
Regulating industry
Most regulatory solutions for making drugs more affordable
focus on having the Government control the price of drugs
(Maynard and Bloor, 2003) The Government can accomplish
this directly by restricting the prices charged by companies or
indirectly by restricting the amount of drug revenue that can
go to profits. Direct price controls in European countries
work by having some governmental agency establish a price
ceiling for which a drug can be sold or reimbursed through an
insurance program. Prices are typically set based on charges
for comparable drugs in other markets within or outside of the
country. Prices are controlled through the establishment of a
national drug formulary that permits the government to
negotiate drug prices and influence prescribing (Huskamp
et al., 2003) An indirect mechanism of price control used in
the UK attempts to regulate pharmaceutical company profits.
Profit controls are problematic because they do not halt drug
price increases and encourage inefficiency in drug
development (Maynard and Bloor, 2003).
There is significant resistance to price controls by the
pharmaceutical industry and public policy experts (Calfee,
2001). One reason is that experience in other countries
indicates price controls alone do not stop drug price increases
(Menon, 2001). All industrial countries face rising drug
expenditures despite a broad range of price controls. Another
reason for opposition is that it is not clear what unintended
consequences price controls may have on innovation and long
term health care costs (Maynard and Bloor, 2003). If price
 Understanding the dynamics of the pharmaceutical market
David Holdford
controls choke off the pharmaceutical innovations coming
onto the market, any savings might come at a high cost. Price
controls also invite meddling by politicians who may try to
pick up political points by interfering with their
implementation and administration (Frank, 2003;
Newhouse, 2004). Finally, price controls fly in the face of
free market advocates who argue for private markets to
regulate health care costs and encourage pharmaceutical
innovation (Bush, 2004).
Increasing competition
Despite the resistance to governmental price controls, there
are growing feelings that reliance on the market alone is not
the solution (Nichols et al., 2004). Under the current patent
system for drugs, abusive pricing practices by industry can
occur unless patented medications are made to compete
against generic and therapeutic alternatives (Newhouse,
2004). Consequently, efforts have been made to increase
market competition by enhancing drug choices. One
proposed strategy is to weaken patent laws to allow cheaper
generic drugs to more quickly enter the market. The problem
with this strategy is that it reduces incentives to develop
therapeutic innovations (Eisenberg, 2001). An alternative
solution is to permit substitution of lower priced,
therapeutically similar drugs for more expensive ones.
Patents would still be in place but low priced substitutes
could be switched for higher priced drugs, regardless of
whether they differ chemically, if they achieve the same
medical outcomes. The argued advantage of this therapeutic
substitution is that it permits competition between
therapeutic equals (i.e. me-too drugs) but still gives a
competitive advantage in the market for drugs that achieve
unique therapeutic benefits.
Importation of low priced drugs from Canada and other
countries has also been suggested as a way of increasing price
competition. In fact, the new Medicare Drug Legislation
permits importation, if the Food and Drug Administration
(FDA) demonstrates that it can be done safely (something the
FDA has been unwilling to do). Nevertheless, some states
encourage their citizens to shop for Canadian drugs.
Minnesota, Illinois, New Hampshire, Wisconsin and other
states direct citizens to purchase at state-approved Canada
Internet pharmacy web sites. It is believed that some form of
legalized drug importation is inevitable, if no major
unforeseen roadblock occurs (i.e. deaths due to counterfeit
drugs) (Jill, 2004). The benefits of doing so, however, are
expected to be modest (1 percent decrease in total drug
expenditures) (Congressional Budget Office, 2004).
Make better purchases
Demands to regulate drug companies are based on the
assumption that industry is the problem for high drug
expenditures, while calls to increase competition assume that
the market needs to be fixed. However, the problems of drug
affordability could be resolved simply if better purchases are
made at the payer, physician, or patient levels. If more
discipline and rationality were encouraged in the process of
drug selection and reimbursement, greater value could be
achieved with health care dollars spent. Current mechanisms
for purchasing drugs encourage industry to increase
marketing, charge higher prices for new drugs, and promote
utilization (Newhouse, 2004). None of these things are bad if
they increase the development and use of necessary drugs.
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Volume 22 Number 7 2005 388 396
The problem is that the health care market chooses and pays
for many drugs that are unnecessary, overpriced, and
inappropriate. Drugs could be made more affordable if
payers, prescribers, and patients made better choices.
Improve prescribing
Physicians are responsible for most health care utilization
choices, so the health care system should facilitate cost-
effective prescribing. Managed health care had argued that
drug costs can be controlled through the use of drug
formulary systems that restrict physician prescribing and
insurance coverage to a limited list of essential, cost-effective
drugs (i.e. formulary). Formularies are enforced with the use
of management tools such as drug utilization review,
restricted provider networks, therapeutic and generic
substitution, provider benchmarking, and patient cost-
sharing. To get on the formulary, drug companies are forced
to offer their drugs at lower prices or be excluded from
insurance coverage.
However, evidence of the effectiveness of managed care is
still limited (Bodenheimer, 2000b; Carroll, 2002; Schulman
et al., 1996). Despite the spread of managed care coverage,
plans still see double digit increases in drug expenditures. One
reason is that many of the tools in the formulary toolbox are
rarely utilized (Carroll, 2002). Reasons include public
opposition to restrictions on drug therapies, lack of
integration between health care providers, and patient
demand for the newest pharmaceuticals. In addition,
managed care can be profitable under the current ineffective
cost control system because most excess drug costs can be
passed on to payers (Moran, 2000).
Even the Federal Government, the largest single purchaser
of prescription drugs, is unwilling to utilize some tools to
control drug costs. Critics of the Medicare Prescription Drug
Program complain that the Federal government is expressly
prohibited from negotiating lower drug prices with
manufacturers. Instead, negotiations on drug prices will be
made by the individual drug plan providers (e.g. pharmacy
benefit managers) to avoid governmental price controls.
Rightly or wrongly, this restriction takes away one of Federal
Governments most potent cost management tools. State and
Federal governmental politics have also hamstrung the ability
of pharmacy benefit managers and other non-governmental
purchasers to control drug costs with numerous rules,
regulations, and laws that reduce their ability to restrict
payment on drugs (e.g. birth control), restrict provider
networks (e.g. any willing provider laws), and integrate
services (e.g. antitrust laws).
Involve patients in their drug choices
The difficulty in implementing cost control strategies has lead
managed care providers to share the risk of pharmaceutical
costs with patients through consumer-driven health care.
Consumer-driven healthcare is a broad term for strategies
designed to empower patients to choose their own health care
and share the risks of their costs. Elements of consumer-
driven plans include choice of different healthcare options,
medical savings and flexible spending accounts, and cost-
sharing through co-payments, coinsurance, deductibles, and
reimbursement caps. The goal is to make patients take greater
responsibility for their drug and health care decisions.
Although cynics might describe consumer-driven healthcare
as just another way of saying consumers pay more for
 Understanding the dynamics of the pharmaceutical market
David Holdford
healthcare (Kleinke, 2004), it is a cost control strategy that is
becoming increasingly important.
Focus on value in making drug choices
The current environment of medical research and evidence-
based medicine results in the conclusion that more medicine
is better (Kleinke, 2004). This means that even if the most
effective drug is chosen for every patient who needs it,
pharmaceuticals expenditures will continue to spin out of
control unless cost is also factored into the choice. Some
argue that payments for drugs should be structured around
consideration of value rather than price (Kleinke, 2004;
Chernew et al., 2004). That means that payers need to be able
to refuse to cover drugs that are not cost-effective (where the
cost exceeds the benefit received) (Newhouse, 2004). If
patients want to pay for any extra marginal benefit associated
with an uncovered drug, they should be expected to pay for all
or part of the cost of drugs depending on their impact on
health outcomes (Fendrick et al., 2001; Morgan et al., 2004).
Methodological and practical issues still exist with the
assessment of drug cost effectiveness. For instance, few head-
to-head comparisons of competing drugs occur in clinical
trials making direct cost effectiveness comparisons difficult.
Another issue is that cost-effectiveness analysis requires
transparency in data, analytical methods, and conclusions
along with transparent rules before it can be widely applied in
the design of pharmacy benefits (Kleinke, 2004). The
problem with transparency is that it opens up methods to
immediate criticism by opponents that can be exploited by
savvy pharmaceutical marketers. KOLs can be solicited to
attack the methods or results in order to water-down the
pharmacoeconomic decision-making process.
Managerial implications
Issues relating to the affordability of drugs are complex and
multifaceted. The descriptive framework presented in this
paper can be used as a tool to place developments in the
pharmaceutical marketplace into a meaningful context.
Conditions listed in Table I describe variables that can be
studied to understand the swirl of conflicting information
about pharmaceuticals. The two conditions of structural
conduciveness and structural are useful but stable
characteristics of the broad market environment. Therefore,
their value lies in providing groundwork for understanding the
other four, more dynamic conditions of the framework. The
remaining four conditions from Table I can be studied to
monitor major trends and events that impact the
pharmaceutical market.
Social research methodologies can permit researchers to
understand the growth, direction, and character of
generalized beliefs by the public about drug affordability.
Public opinions about drug affordability are being monitored
through polls conducted by media such as the Wall Street
Journal, but most are static cross-sectional studies that do not
provide much depth about public feelings. More extensive,
longitudinal studies of public opinions would provide greater
understanding of changes in attitudes over time. Opinion
leaders can also be interviewed about their feelings on major
issues such as that demonstrated in the community tracking
study. This study conducts periodic interviews of households,
physicians, and health system leaders in 60 communities and
recently found greater support for government intervention in
health care (Nichols et al., 2004). Content analyses of media
394
Journal of Consumer Marketing
Volume 22 Number 7 2005 388 396
reporting and publications can also be conducted to examine
issues and trends identified as important by the media.
Case studies can explore the direct and indirect significance
of major events in the pharmaceutical market. Case studies
can describe and explain unique or interesting events such as
the implementation of the Medicare Prescription Drug,
Improvement Act of 2003. For instance, it is not clear at the
moment whether the Act will increase or decrease pressure for
change. Although it was meant to solve the problem of
affordable drugs for seniors, many details and consequences
of the Act are unclear. If seniors judge it favorably, and it
slows the rise of inappropriate drug expenditures, pressure on
the pharmaceutical market will be relieved. If things go badly,
however, renewed calls for price controls and other dramatic
solutions will intensify.
Content analysis of the media can be used to explore
resources mobilized by governmental, political, consumer,
business, and professional agencies. It has been used to
understand how agencies in the consumer movement
mobilized resources to promote their agenda (Smith and
Bloom, 1989). In a similar manner, content analysis can be
used to examine issues advanced by the movement, the types
of groups and individuals promoting change, and the form
and direction of the change advanced over time.
Finally, researchers can study the changing social control
strategies used by industry to resist change. The evolving
effectiveness of techniques can be instructive. For example,
there is growing resistance to the acceptance of drug company
money by individuals and groups. One group called No Free
Lunch advocates the elimination of pharmaceutical
promotion from medical education, practice, and research
(No Free Lunch, 2005) If physicians, educators, and
researchers widely adopt the solutions proposed by No Free
Lunch, the influence of drug companies in resisting change
will be diminished.
Conclusion
The only certainty in the pharmaceutical market is that
change will occur. It will either happen when public demands
for change overpower the ability of the pharmaceutical
industry to resist it or when industry decides that change is in
its best interests. In other words, industry can be proactive in
their support of change, or they can wait and let others
decide. The economics of the pharmaceutical market are
unlikely to spontaneously improve it, so systematic research
should be conducted to understand its dynamics. The paper
presents a framework for doing so.
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 Direct-to-consumer prescription drug
advertising: concerns and evidence on
consumers benefit
Jaeun Shin
KDI School of Public Policy and Management, Seoul, South Korea, and
Sangho Moon
SungKyunKwan University, Seoul, South Korea

Abstract
Purpose The purpose of this study is to provide an overview of the economic and clinical impacts of direct-to-consumer (DTC) advertising on
consumers and physicians.
Design/methodology/approach Controversy around the benefits and concerns associated with DTC advertising are summarized. The sources are
sorted based on their position toward DTC promotions: defending or opposing. Two recent works by Woloshin et al. and by Weisseman et al. are
discussed in depth to provide the empirical evidence for the impacts of DTC promotions.
Findings Notwithstanding many concerns against DTC advertising, evidence-based papers report that both consumers and physicians are potentially
benefited from it. Consumers rate the health-related information contained in DTC advertising as important. Physicians do not feel that they are
pressured to prescribe inappropriate medications driven by DTC advertising. Physicians perceive improved communication and education among DTCA-
influenced patients. However, consumers tend to overestimate drug effectiveness when the ads vaguely convey the benefit information and
subsequently, seek unnecessary treatments. DTC advertising needs to be required to demonstrate the benefit information using actual data. This will
help consumers avoid overuse of drugs.
Originality/value This paper recognizes DTC advertising as a positive force for the public health and at the same time identifies its potential
negative effects on the economic and clinical aspects of the health care markets. This can offer practical help policymakers develop the effective
regulations on DTC advertisings to reinforce the beneficial outcome while attenuating the potential harms that might take place.

Keywords Medical prescriptions, Advertising, Drugs, Consumers

Paper type Literature review

An executive summary for managers and executive
readers can be found at the end of this issue.
1. Introduction
As one of the fastest-growing components in the US health
care market, prescription drugs command much attention.
Spending on prescription drugs exceeded $150 billion in
2001, which is almost twice $79 billion spent in 1997
(National Institute for Health Care Management, 2002). In
2001, the industry spent more than $19.1 billion in
promotional activities. The spending for direct-to-consumer
(DTC) drug advertising increased from $1.1 billion in 1997
to about $2.7 billion in 2001, which is as dramatic as the
increase in drug companies spending on research and
development (R&D), from $19 billion to $30.3 billion (US
General Accounting Office, 2002).
The Emerald Research Register for this journal is available at
www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
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Journal of Consumer Marketing
22/7 (2005) 397 403
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631138]
Following a public hearing and debate in 1997, the FDA
issued a proposal for new guidelines on DTC advertising.
This proposal was designed to entitle prescription drug
manufacturers to give both the drugs name and the condition
without disclosing all of the products risks. The FDA
guidelines clarified and relaxed the quantity of balanced
information that was required in each broadcast
advertisement. Yet, advertisers were required to mention
important risks and to provide a statement explaining that
additional information is available from other sources, such as
toll-free telephone numbers and print advertising. The FDA
thereby ensured that persons with varying levels of education
and technological knowledge would have access to additional,
detailed information.
DTC advertising is defined as any promotional effort by a
pharmaceutical company to present prescription drug
information to the general public in the lay media[1]
(Conti et al., 1999). Among drug companies general
promotions, direct-to-consumer advertising (DTCA) of
prescription drugs is particularly interesting, because it
affects patients, doctors, and health care organizations in
profound but not always predictable ways. For example,
Wilkes et al. (2000) report in a recent survey that more than
one-third of respondents reported asking their doctors for
information about a drug they had seen or heard advertised,
and nearly one-quarter asked for the drug itself. Of these,
three-quarters reported that their doctors provided the

397
 Direct-to-consumer prescription drug advertising
Jaeun Shin and Sangho Moon
requested prescription (American Pharmaceutical
Association, 1997).
Since 1997 not only have the number of drugs advertised
increased, but so have the drug companies advertising
budgets directed at consumers. The advertisements have also
become far more sophisticated. The consumer is no longer
simply provided with information about a pharmaceutical
product. Advertisers enlist well-known celebrities to endorse
their products (THoen, 1998; Wilkes et al., 2000).
Drug companies promotional spending leads to exposure,
getting messages about prescription drugs to physicians and
patients. Physician-oriented marketing consists of detailing
(in-person visits by drug company representatives),
advertising in journals, and continuing medical education
events. Patient-oriented marketing has focused on advertising
in various media, including print, broadcast, and online.
The position of pharmaceutical companies behind the
rocketing increase in the DTCA spending is plain: We
believe that any health information for consumers is
beneficial (Kelly, 2004). However, there have been
concerns that this belief can be true only when certain
conditions are embedded: the information must be accurate
and lead to more and better physician-patient encounters.
2. Concerns
Of concern is the question about whether the consumers
exposure to the drug advertising fills a needed educational
gap, or it merely promotes inappropriate and unnecessary use.
Pharmaceutical manufacturers and other proponents of
DTC advertising claim that it is informative and educational:
it teaches consumers and physicians about health conditions,
new medicines and treatment options. It contributes to
increased disease awareness, greater detection and patients
compliance with medical care. Eventually, it improves the
quality of overall public health (Rosenthal et al., 2002; Fintor,
2002).
They argue that the FDAs existing regulatory regime is
sufficient to protect the public health and that the government
should not mandate unnecessary restraints on commercial
free speech. Indeed, there are studies to advocate drug
promotion and advertising showing its usefulness as a means
of educating the patient, its contributions to the doctor-
patient relationship and the beneficial quality outcomes
associated with new and, in some cases, high priority
diagnosis (Jeffords, 2004).
Opponents of drug promotion are concerned about that
information conveyed is inaccurate or unbalanced and
promotes the inappropriate and unnecessary use of drugs.
DTC advertisements may lead to inappropriate patient
demands on providers and to overuse of prescription drugs
against the doctors judgment. In some instances, it may
encourage the use of more expensive brand-name medicines
by consumers even with cheaper and equally effective
alternatives available.
Payers are also concerned about the promotion of non-
essential or lifestyle drugs, such as drugs to treat nail fungus
and sexual dysfunction, which drive up their pharmaceutical
spending without providing significant health benefits.
According to World Health Organization, even among the
drugs most heavily advertised directly to consumers, many are
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Journal of Consumer Marketing
Volume 22 Number 7 2005 397 403
believed less effective than expected (Batchlor and Laouri,
2003).
Critics counter that promotion has fueled the rise in drug
spending, chiefly in the form of inappropriate prescribing
caused by ad-induced patient demand or incomplete
information influencing physicians decisions, or both. As a
recent medical journal stated, The education of patients or
physicians is too important to be left to the pharmaceutical
industry (Wolfe, 2002). Whether this is a valid conclusion or
misguided assertion is one of the main questions around the
controversy on DTC advertising. How policymakers should
react to this controversy is another issue to be responded at
once.
This paper provides an overview of recent evidence, both
endorsing and defying, for the controversial issue. Using the
recent literature to date, we review the economic and clinical
impacts of DTC advertising on the consumer, the medical
professionals, and the health care system. The leading
concerns raised against DTC advertising are that it leads
doctors to write unnecessary prescriptions under pressure
from patients and that it increases the cost of prescription
drugs. Because some critics believe that DTC advertising
leads to overuse of costly drugs, it is not surprising that it has
come under increasing scrutiny (Bonifazi, 2002; Weissman
et al., 2004). Another concern is that if the information on
drugs is inaccurate and misguided, the active involvement of
patients in the medical decisions which is motivated by
DCTAs is likely to end up with serious clinical mistreatment
and eventually harm the quality of public health.
Recommended solutions to these problems reach from an
outright ban on DTC advertising, to removing business
expense tax deductions, and to strengthening the FDAs
oversight capacity (Jeffords, 2004). A critic on the role of
FDA on regulating DTC advertising is that FDA enforcement
against false and misleading advertisements have dropped
sharply in recent years, raising concerns over consumer safety
(Waxman, 2004).
2.1. Economic aspect: overuse of resources
Impact on consumers
From a public health point of view, the question we must
address is whether it is the best way to spend nearly $3 billion
on health communications to the American public. Avorn
(2003) states this question in a practical context: even if more
patients with high cholesterol or depression seek treatment
because of DTCAs for Lipitor or Proza, how many more
could be treated if they were instead prescribed the equally
effective generic drugs in the same classes, lovastatin or
fluoxetine?
The publication of the Anti-hypertensive and Lip-lowering
Treatment to Prevent Heart Attack Trial (ALLHAT) showed that
the older thiazide drugs are both better and cheaper than
many newer drugs in the management of hypertension. Then,
it raises skepticism on the net public health benefit of costly
advertisements and the promotion-driven use of these
expensive products.
When there is no fervent promotions for generic drugs,
DTC advertising for prescription drugs conveys the
information that mislead viewers to lean more on the drugs
whose prices embed the advertising costs even when they are
aware of the availability of cheaper and equally-effective
 Direct-to-consumer prescription drug advertising
Jaeun Shin and Sangho Moon
alternatives. Further, the frequent and repeated watching of
DTCAs may enhance consumers dependency on drugs.
Consumers are likely to demand specific drugs more than
necessary and demand it immediately (Bell et al., 1999).
Of course, there is counter evidence by Dubois, Alexander,
Wade, Mosso, Markson, Lu, Nag and Berger (2002) that
growth in a specific drug use, which corresponded to a time
period of much pharmaceutical promotion, was associated
not with inappropriate use or overuse, but rather with the
identification of additional patients in need of that drug. This
contends that promotion is not accompanied by excessive use.
Impact on manufacturers
Given the economic incentives, pharmaceutical companies
may provide a more than optimal amount of advertising from
a societal perspective (Carlton and Perloff, 2000; Dubois,
2003). Annual spending on DTC advertising rose gradually in
the 1990s and then tripled between 1996 and 2000, when it
reached $2.5 billion (Rosenthal et al., 2002). Although DTC
spending had been increasing prior to 1997, the FDA
guidelines issued in 1997 seem to correspond with the rapid
increases in DTC spending that were observed thereafter.
In 2000, drug companies spend more than a billion dollars
on marketing directly to consumers, up from $55 million in
1991 and represent five times larger amount compared to the
spending in 1994 (Wilkes et al., 2000). The driving force for
this rise has forced pharmaceutical manufacturers to stimulate
consumer demand (Tully, 1993; Hollon, 1999).
Impact on insurers
People who benefit from the pharmaceuticals often do not pay
for them directly. In recent years people with insurance have
paid relatively little out of pocket for their medicines. A large
proportion of the cost has been borne by their insurers and by
purchasers (employers) in the form of insurance premiums.
The fact that the consumers who view the advertising and are
influenced to consume the drugs do not generally pay for
them contributes to the controversy surrounding advertising
prescription drugs to consumers.
According to the report by American Pharmaceutical
Association, of all prescription filled in 1997, 79 percent are
paid for at least in part by some type of private or public
insurance. Even given the push from managed care and other
payers to increase the use of generic drugs, most prescriptions
written are still for brand-name medicines.
From the economic perspective, the impacts of DTCAs on
consumers are threefold: first, the amount of DCT
promotions may be socially excessive due to pharmaceutical
manufacturers desire for high sale and large market share.
High and rising spending for advertisements may result in
high price of the prescription drugs (price effect). Second, the
amount of consumption of prescription drugs may be far
above necessary, which is advertising-induced (quantity
effect). Lastly, as more drugs are prescribed, the insurance
companies are doomed to increase the associated premiums
charged on consumers (insurance effect).
2.2. Clinical aspect: inappropriate use of drugs
DTC advertising unfolds to consumers what kind of drugs is
available in the market and what extent those drugs work.
Typically, this sort of information has been monopolized by
medical professionals and pharmacists. Continuous viewing
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of DTC advertising may interest consumers in their health
conditions in a regular basis. The alert consumers can take
actions to prevent or detect the outburst of a health problem
in its early stage before it exacerbates. This entire conceptual
and behavioral response of consumers to DTC advertisings
can contribute to the improved quality of public health.
Well acknowledged of the medical information through
DTC promotions, consumers begin to involve in the decisions
on the medical treatment. By interacting with the physicians
vigorously, the patients compliance with physicians order is
expected to be enhanced. Subsequently, health outcomes of
any medical treatment on patients can be upgraded. However,
as Wilkes et al. (2000) argued, there is evidence to suggest
that clinical quality of care is harmed by DTC advertising.
Impact on consumers
From the DTC advertisement, patients and physicians receive
the repeated and consistent education on a drugs
characteristics and its potential role. This is deemed to
reduce the variation in therapy, that is, patients with a specific
symptom are uniformly prescribed more expensive brand-
name drugs they are exposed through the ads.
Although reduced variability of treatment is often translated
to quality improvement, there are challenges that greater
uniformity in use of medications may not necessarily
appropriate (Dubois, Batchlor and Wade, 2002; Dubois,
2003). Even when we assume that the uniformity in practice
render the improved quality of care, whether it is attributable
at least in part to the educational role of drug promotion to
physicians is neither proved nor refuted (Batchlor and Laouri,
2003).
In addition, receiving prescription drugs advertised in
broadcast rather than possibly equally effective generic drugs
may not be medically correct. Many new drugs are found to
offer few advantages over pre-existent drugs. For worse,
whose safety profiles are shown to be less well understood
(Kessler and Pine, 1990). It is because DTC ads tend to
emphasize the positive features of a drug and downplay the
negative or unknown aspects. Side effects are typically
discussed last or buried in the narrative. Only 35 percent of
advertisements invited the viewer to learn more about the
drug by obtaining information from the company (Wilkes
et al., 2000).
Even when the information in DTC advertisements is
balanced and accurate, it is still possible that consumers are
confused and construct erroneous perceptions of a drugs
effectiveness and safety. Because most of consumers do not
have the clinical and pharmacologic background to properly
understand and evaluate DTC advertisements, the
miscomprehension of drug advertisements is not a
surprising phenomenon (Cohen, 1988; Morris et al., 1986).
Ultimately, the argument that DTC promotions are
educational for the public about medical conditions and
their treatments hinges on the quality of drug information
available to consumers through advertising.
Impact on medical professionals
With the explosion of DTC drug advertising, physicians begin
to experience the change in their relationship with patients.
The American College of Physicians feels that DTCA is not
a proper practice and undermines the patient-physician
relationship (American College of Physicians-American
 Direct-to-consumer prescription drug advertising
Jaeun Shin and Sangho Moon
Society of Internal Medicine, 1998). However, Weissmans
et al. (2004) surveys of physicians show a mixed picture.
Some physicians appreciate DTCA for increasing patients
awareness, encouraging patients to seek medical advice for
conditions that might otherwise go untreated, and improving
doctor-patient communication (Allison-Ottey et al., 2002).
Negative views are more frequently reported including
concerns that when patients misperceive a drugs
effectiveness, physicians time is wasted in correcting the
biased view on a drugs pros an cons. DTC advertisements
may challenge physicians professional authority in the
medical decision as the better-informed consumers intend
to pressure their physicians to prescribe drugs either
inappropriate in effectiveness or excessive in quantity and to
order advertised drugs, perhaps against physicians judgment
(Avorn et al., 1988; Petroshius et al., 1995; Lipsky and Taylor,
1997). This active patient involvement encouraged by DTC
promotions is a main reason for physicians reluctance to
embrace the popular drug promotions.
3. Evidence
As the DTC advertising gets widespread and the associated
spending proliferates, there is an enlightened discussion to
know whether pharmaceutical promotion educates or
misleads. The recent debate is focused on whether the
potential benefit of educating physicians and consumers
outweigh the potential clinic and economic harm of overuse
(Kravitz, 2000). Although advocates of DTC advertising
argued that there are no objective data showing that DTC
advertising results in an inappropriate use of drugs (Ziegler
et al., 1995), this argument was not particularly persuasive for
opponents since there has been little reinforcing data for the
positive impacts of DTC advertisings.
Recently, a growing body of research shows that DTC
advertising is having some beneficial effect. Those studies
claim that consumer-direct advertising raises awareness of
diseases, treatment, and specific drugs and that patients
who are exposed to this information are more likely to request
specific drugs. In particular, the papers by Weissman et al.
(2004) and Woloshin et al. (2004) make indispensable
contributions to understanding how DTC drug advertising
is perceived by the two most important participants in this
policy debate: the physicians and the patients.
3.1. Consumers perception of the DTC advertising
effects
Woloshin et al. (2004) research question comes from
recognizing that DTC advertising offers limited information
on the efficacy of the drug. The US Food and Drug
Administration (FDA) requires the advertisements to include
information about potential harms. In contrast, information
on drug benefit is not specifically regulated, and most
advertisements assert that drugs do work using vague,
qualitative terms rather than presenting actual data (Bell
et al., 2000). Lacking from much of the debate surrounding
DTCA was empirical evidence of its impact on patients
health and health care.
Woloshin et al. (2004) describe consumers evaluation of a
prescription drug benefit box. The benefit box is a table
presenting the proportion of people experiencing various
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Volume 22 Number 7 2005 397 403
outcomes with and without the drug. In addition, one-word
summary to describe the direction of effect was included in
the benefit box. For each drug, the efficacy data came from
the published article of the randomized trial cited in the FDA
drug approval document, which matched the indication and
outcome in the advertisement.
For this study a total of 203 in-person interviews were
conducted with consumers selected from the greater Boston
area. Experiments are performed in two ways. Before-after
comparisons include the procedure that after people are
trained to familiarize with the three elements of interest (the
ad, the brief summary, and the drug benefit box), each
participant is shown the standard version of the drug
advertisements. They are then asked to indicate how they
thought effective the drug was using a standardized five-point
scale. Participants are then given the benefit box version of the
ad and are again asked to rate the drug effectiveness.
In the randomized comparison, respondents are asked a few
general questions about the benefit box itself such as whether
they think the information is important, should be required,
and is easy to understand to evaluate consumers perceptions
on the benefit information. Then they are randomized into
two groups. The intervention group is shown only the benefit
box version of an ad. The control group sees only the
standard version of the ad. Their findings are summarized as:
.
Most participants in the experiment rate the health
information provided by DTC advertising as very
important or important.
.
Almost all participants find the information in DTC
promotions easy to understand.
.
Most people can understand the data and are influenced
by the drug advertising.
.
Most people interviewed want benefit data in drug
advertising.
.
Perceptions of drug effectiveness drop after respondents
saw the benefit box (in before-after compassion).
. Perceptions of drug effectiveness are much lower for drug
advertising that incorporates the benefit box than for
advertising that does not (in randomized comparison).
The main weakness is pointed out that the findings are based
on an experiment over convenience samples. Nonetheless, the
study has important qualitative message only extraordinarily
powerful counter evidence could defeat. Consumers collect
useful information on drugs from DTC advertisings. They
have no particular difficulty in understanding the ads. Their
perceptions and presumably consumption decisions on drugs
are influenced by the ads. In general, the participants are very
optimistic about the effectiveness of each drug with the
standard form of drug advertising. However, the perceptions
of effectiveness drop after seeing the benefit box of actual
data. That illustrates the necessity of the drug benefit boxes
on its ad to prevent possible illusion among viewers on how
well and safely the drug works.
3.2. Physicians perception of the DTC advertising
effects
Weissman et al. (2004) use a national survey of physicians
who reported on recent patient visits during which they
discussed advertised drugs. Their goal was to describe
physicians perceptions of actual health care experiences and
 Direct-to-consumer prescription drug advertising
Jaeun Shin and Sangho Moon
their attitudes toward DTC advertising, and to predict the
resulting outcomes as it affects medical practice.
The sample was randomly selected from a national list of
physicians[2] provided by National Marketing Service. The
questionnaire was designed to give physicians equal
opportunities to express positive or negative views about
DTC advertising. Physicians are asked to report their
perception on whether the drug promotion might be
beneficial, inconsequential, or harmful. The largest portion
of the survey was designed to gather data on the health care
events surrounding the most recent visits in which patients
initiated discussions about prescription drugs they had seen
advertised on any means of multimedia, so called DTCA
visits. The findings are as follows:
.
The majority of physicians could not feel that DTC
advertising has pressured them to prescribe inappropriate
medications.
.
Patients reported that they benefited from their
interactions with physicians related to DTCA, including
diagnosis of new conditions and delivery of other health
care services that are widely perceived as beneficial.
.
DTCA discussions occurred in a small proportion of all
physician visits (31 percent), but more than half of
physicians had participated in at least one DTCA visit in
the past week.
.
Physicians perceived improved communication and
education but also thought that DTCA led patients seek
unnecessary treatments.
.
Physicians prescribed the advertised drugs in 39 percent
of DTCA visits but also recommended lifestyle changes
and suggested other treatments.
.
Referring to visits when the DTCA drug was prescribed,
46 percent of physicians said that it was the most effective
drug, and 48 percent said that others were equally
effective.
The study confirms that consumers get educational benefit
from the drug advertising. The information they gather from
the ads enables them to have more productive encounters
with physicians. Though DTC advertising induces
unnecessary DTCA visits and pressures on physicians to
prescribe the advertised drugs, these impacts are relatively
mild. Physicians are likely to maintain their professional
authority over patients in the decisions on the proper medical
treatments and prescription of drugs.
4. Discussion and policy implications
DTC drug advertising has been controversial since its
inception, with proponents and opponents debating the
educational value of ads and their impact on the physician-
patient relationship. For areas where it is known that a
particular treatment option works well but it is underused,
any means to educate and promote is probably beneficial.
DTC advertising operates as a beneficial market-expanding
mechanism, spreading awareness of newly drug therapies.
Perhaps the concern about promotion relates to utilization
of prescription drugs in the absence of consensus or strong
evidence for proper use. Most troubling is the potential for
advertising to stimulate inappropriate demand for drugs. For
instance, most would agree that Cox-2 inhibitors greatly help
some patients with arthritis and pain. However, less costly
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alternatives are available for the broader population of people
with these conditions and there is no consensus on its use.
Promotion of Cox-2 inhibitors might provide patients with
added clinical benefit, but perhaps at a higher cost.
Papers by Woloshin et al. (2004) and by Weissman et al.
(2004) provide some validation for the views of both sides of
the DTC advertising debate with more emphasis on the
supporting evidence that DTC drug advertising appears to be
a generally positive force for health. Yet, these studies are
critiqued to be limited to draw definitive conclusions about
key issues involving inappropriate use of expensive
medications and their substitution for cheaper medications
that are just as effective.
Avorn (2003) claims that the data presented in these two
studies do not justify the conclusions that the effects of
pharmaceutical promotion are beneficial. Further he argues
that some of the data they present suggest a different
conclusion. Since the factors initiating a visit to the doctor,
the topics discussed between physicians and patients, and the
subsequent events are all complex interactions so that it is not
straightforward to interpret the results as supporting evidence
for the consumers benefit from DTC advertising. Though it is
appealing to think that DTCA may alert patients to diagnoses
that have been undetected or under-treated by their
physicians, it is criticized that among consumers of direct-
to-consumer advertising, those heavily influenced by such
DTC advertising were no more likely to have laboratory
studies ordered or lifestyle changes recommended. Economic
inefficiency of pharmaceutical promoting is severely criticized
(Avorn, 2003).
Since the impact of promotion is neither uniformly efficient
nor inefficient from a societal perspective, it would be hard to
implement a rule that would selectively limit relatively
inefficient promotional efforts. Proposals for stricter
regulation may have to consider their potential impact on
the desirable outcomes that accrue from pharmaceutical
promotion.
Beyond the regulatory scope, the federal government, as a
major purchaser of pharmaceuticals, may enforce drug
makers to disclose information about safety and comparable
effectiveness in their DTC advertising as part of any
purchasing agreement (Jeffords, 2004).
From a market perspective, another approach is to regulate
the content of DTC advertising to improve their educational
content. The systematic provision of drug benefit data would
educate consumers and promote informed decision making
by providing easy access to scientific data on drug benefit
whenever a drug advertisement appears.
5. Conclusion
We review the literature examining one of the most
controversial issues in an ever more competitive health care
market, the goods and bads of the DTC advertising. By and
large, drug promotion is a mixed bag. In some cases it
promotes educational benefit for consumers and appropriate
use of drugs, but in others, it encourages inappropriate use.
When drug promotion is aligned with evidence-based
medicine, it may have a positive effect. Recently a growing
body of research supports the view that the information
presented in DTC advertising informs patients decision
 Direct-to-consumer prescription drug advertising
Jaeun Shin and Sangho Moon
making and leads to more productive physician/patient
encounters by reducing the information gap between the
two. Obviously, public debate should focus on making
information about both the benefit and potential side effects
clear and comprehensible so that consumers can get
maximum value possible from DTC advertising.
Notes
1 Increasingly, the drug advertisements offer additional
information to consumers through the internet. A total of
14 percent of advertisements provided a web site.
2 The list of physicians includes both American Medical
Association (AMA) members and non-members and is
updated in a weekly basis
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Jaeun Shin and Sangho Moon
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Consumer Magazine, March-April.
 Global marketing of lifesaving drugs:
an analogical model
Oswald A. Mascarenhas, Ram Kesavan and Michael Bernacchi
College of Business Administration, University of Detroit Mercy, Detroit, Michigan, USA

Abstract
Purpose In light of the desire to bring about an increase in the global distribution of lifesaving drugs at affordable prices, the purpose of this paper is
to focus on the global marketing of lifesaving drugs related to the current pandemic of HIV/AIDS.
Design/methodology/approach An analogical model is used to challenge companies to reengineer their products and their strategies to meet the
twin objectives of profitability and humanitarianism. Following analogical reasoning, it is argued that an innovative reengineering and redesigning of
lifesaving drugs can meet the great needs of developing countries with affordable prices.
Findings The paper proposes an analogical model that treats the marketing of drugs in general and of lifesaving drugs in particular, to the developing
countries as a target problem. This problem can be resolved by seeking analog candidate solutions from other source industries that have faced
similar problems.
Practical implications In recent decades the pharmaceutical industry and its free market model of marketing drugs have come under sharp criticism
both domestically and globally. Their pricing and distribution of lifesaving drugs to developing countries have been severely criticized. This paper helps
pharmaceutical firms to meet the need for lifesaving drugs in developing countries.
Originality/value Analogical reasoning as applied to marketing is new. The paper submits that this solution will be more effective in combating the
HIV/AIDS pandemic than any current solutions. The paper discusses the strategic marketing implications of the analogical model.

Keywords Medical products, International marketing, Developing countries, Acquired immune deficiency syndrome, HIV

Paper type Case study

An executive summary for managers and executive
readers can be found at the end of this issue.
In the domain of pharmaceutical marketing, the marketing of
lifesaving drugs has recently received explosive and critical
attention. The pricing and distribution of HIV/AIDS drugs in
particular has attracted an even more passionate media blitz
and political opposition. Several constituencies from both the
developed and the developing countries have accused the
pharmaceuticals of price gouging, overextended brand name
patent protection, blocking the production of cheaper generic
drugs, and for failing to prevent the millions of preventable
deaths in the poorest nations who have died and will die from
the HIV virus (Kennedy et al., 2004; Kremer, 2002; Rosen
et al., 2003).
Several conventional solutions have been proposed to solve
this problem such as free market-driven pricing (Calfee and
Bate, 2004), differential pricing (Danzon, 1997; Danzon and
Towse, 2003), socially responsible pricing (Vachani and
Smith, 2004), compulsory licensing (Ashcroft, 2001) and
pricing using the stakeholder model as a guide (Kennedy et al.,
2004). Each of these solutions, however, is ideological, very
general and fraught with a bevy of other problems. Based on
The Emerald Research Register for this journal is available at
www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0736-3761.htm
Journal of Consumer Marketing
22/7 (2005) 404 411
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631147]
Gavetti and Rivkin (2005), we suggest an alternative
analogical model that is independent of the
aforementioned models or ethical ideologies. The analogical
model solves a target problem by seeking and evaluating
candidate solutions from a source industry that bears
close resemblance to the target industry. Though one could
apply the analog model for the purpose of gaining access to
any lifesaving drug by those who need them most, our
application in this paper is related to the lifesaving drugs for
HIV/AIDS. Our thrust is to shape the right conditions so that
the poorest of the poor will be able to immediately access the
essential medication that they desperately need at affordable
prices.
We divide this paper into four parts:
(1) a description of the target problem of the HIV/AIDS
pandemic;
(2) an exploration of the source industries and problems
that might offer;
(3) a feasible set of candidate solutions to the pandemic;
and
(4) an evaluation of the target problem solution.
We submit that the analogical model that seeks a bilateral
case-by-case solution to this pandemic is well within the
domain, capabilities and long-term corporate interest of
pharmaceutical producers and distributors. Essentially, the
analogical approach is a bilateral, market-by-market, drug
brand by drug-brand, or even corporation-by-customer
(patient) approach. It has been noted that multilateral,
general and ideological models have failed to solve the
problem of obtaining lifesaving drugs to those who need them
most paying prices that they can afford (e.g. Ashcroft, 2001;
Garrett and Rosenstein, 2005). Even appeals to
pharmaceutical companys moral responsibilities, ethical

404
 Global marketing of lifesaving drugs
Oswald A. Mascarenhas, Ram Kesavan and Michael Bernacchi
corporate citizenship and the application of the distributive
justice principles to mandate the prevention of preventable
deaths have led to an impasse. These models do not generate
any effective remedy to the teeming millions of lives at risk
today, we need to look at alternative models such as the
analogical model to provide useful and doable solutions to the
global HIV/AIDS pandemic.
The analogical model
Recently, Gavetti and Rivkin (2005) have emphasized the use
of cases or analogies in framing and implementing business
strategies. Analogical reasoning (AR) makes efficient use of
information, but does not pretend to detail every marketing
issue of the problem at hand. AR pays attention to select
features of the information, sees patterns in it, and applies the
patterns to the present market challenges. For example, the
supermarket, a retail format pioneered during the 1930s in
the USA, has served as an analogical source to many
subsequent strategies. Charlie Merrill relied heavily on his
experience as a supermarket executive when he developed the
financial supermarket for the Merrill Lynch Co. Later,
Charles Lazarus employed the supermarket model when he
conceived and designed the Toys R Us in the 1950s. Then,
Thomas Stemberg, modeled Staples on the mini
supermarket Toys R Us. In each of these three instances
AR was applied. AR gives novel problems the opportunity of
being solved because precedent is used from a similar but
different problem set.
In short, a previous solution may be transferred to solve a
present problem. The value of application of precedent is fully
recognized in analogical reasoning. For instance, had Charles
Lazarus analyzed all of the interdependent configurations of
choices in toy retailing from marketing to operations, from
human resource management to logistics it is unlikely that
he would have discovered a strategy as coherent and effective
as the one Toys R Us he eventually adopted. In other words,
AR encourages one to think completely outside of the box.
The analogy of a supermarket gave Toys R Us an effective
framework, an integrated bundle of choices that included
exhaustive selection, relatively low prices, rapid replenishment
of stock, deep investment in information technology and self-
service with shopping carts (Gavetti and Rivkin, 2005).
We apply AR as follows: Given a target problem (i.e. the
rapid and effective distribution of lifesaving HIV/AIDS drugs
to the developing countries whose poor populations need
them the most at affordable prices), AR looks for similarity
mapping using source industries with their source problem
(e.g. other comparable industries that tackled similar
problems) that offer candidate solutions (product
redesigning and reengineering, wider distribution, close
collaboration with locals) to the target problem. Figure 1
outlines the analogical model.
The target problem: the AIDS pandemic
The HIV/AIDS crisis may well be the worst pandemic since
the fourteenth century AD Black Plague. The first case of
AIDS (acquired immune deficiency syndrome) was identified
in June 1981 at the US Center for Disease Control (CDC) as
a rare illness among homosexuals (Gottlieb, 2001). In 1983,
the retrovirus dubbed HIV (human immunodeficiency virus)
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Volume 22 Number 7 2005 404 411
was identified as the cause of the deadly AIDS disease.
Although the latency period between HIV infection and full-
blown AIDS can last for many years, untreated HIV
eventually kills all its victims.
HIV is extremely difficult to control or to eradicate after
infection has occurred. No one has developed a cure or
vaccine for HIV. Several companies have developed drugs that
inhibit the ability of the HIV virus to either replicate or enter
host cells. The best that can be done at present is to
temporarily suppress the virus in the HIV patient, thus
delaying the progression of the infection. The drugs that
suppress HIV are called anti-retrovirals. Burroughs Welcome
introduced AZT known also as Retrovir in 1987, the first
drug that suppresses HIV.
AIDS now kills more people worldwide than any other
infectious disease. Already, more than 22 million men,
women and children have died from AIDS since 1981,
including three million deaths in 2003 (UNAIDS, 2004).
Nearly all of the 42 million currently infected AIDS victims
will die from AIDS-related complications within the next two
decades (International AIDS Vaccine Initiative, 2005). More
than half of these HIV/AIDS victims are women and children.
An estimated five million people were newly infected with
HIV in 2003. More than 95 percent of all new HIV/AIDS
infections are in developing countries where medical and
economic resources are very scarce. By 2010, unless the
pandemic is drastically controlled, we may register more than
100 million HIV-infected people outside of Africa (Tenet,
2003). Even though the pandemic is predominant in the
developing nations, AIDS is now everybodys business (Rosen
et al., 2003). The national, international and global health-
security dimensions of the HIV virus are increasingly clear.
An effective solution to the HIV/AIDS pandemic, therefore, is
in the long interest of all, including USA and the rest of the
developed world.
We propose the analogical model as an action-oriented,
negotiating, holistic and compassionate approach to such
tragic human problems. Specifically, we submit that the HIV/
AIDS pandemic needs a case-by-case approach that translates
to a patient-by-patient, market-by-market, country-by-
country strategy. Reducing it to a price that transfers to
all or to an ideological issue oversimplifies the problem.
The source industries and problems
Thus, the target problem is how to rapidly produce and
effectively distribute lifesaving HIV/AIDS medication in the
developing countries that need them most. The source
industries are all those industries and corporations that have
effectively and profitably resolved the problem of producing
and marketing products and services critically needed by the
developing nations at affordable prices.
In general, the development of most brand name
pharmaceuticals takes place in developed countries (e.g.
USA, Canada, Western Europe and Japan) and targets health
problems that are prevalent in those countries. For instance,
there is no effective drug treatment for a number of tropical
diseases ravaging the developing countries. The developed
countries consume 85 percent of the pharmaceuticals even
though they represent less than 15 percent of the worlds
population. The need for pharmaceuticals is just as great in
the developing world, even though the resources and
 Global marketing of lifesaving drugs
Oswald A. Mascarenhas, Ram Kesavan and Michael Bernacchi
Figure 1 The analogical model applied to the pharmaceuticals
infrastructure necessary to create, purchase and deliver
pharmaceuticals are largely absent. Thus, the developing
world is characterized by very strong medical need and very
weak economic ability.
The markets of the developing nations are underserved in
relation to high-tech and quality products. The conventional
reasoning is that these markets though large have a very low
buying power and therefore, cannot afford lifesaving products
and services. In relation to lifesaving drugs, such reasoning
implies that they who cannot pay, die. New thinking has
proved that this conventional reasoning is flawed (e.g. Handy,
2002; Letelier et al., 2003; Prahalad, 2004; Prahalad and
Hammond, 2002).
The poor are human beings, and as far as lifesaving drugs
are concerned, society owes them the access to lifesaving
drugs by unsigned social contracts, un-contracted joint
responsibility and global distributive justice rather than by
patent laws. Not all diseases are self-inflicted, and most of the
victims of HIV/AIDS are children of HIV/AIDS infected
parents. Coming to the aid of these victims is
humanitarianism (Nierle, 2003), a response to the call of
respecting human dignity and the right to life of all the
peoples of the world.
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Serving the poor of the world that are the most affected by
HIV/AIDS, moreover, can be a great uncontested business
opportunity (Kim and Mauborgne, 2004; Prahalad, 2004).
The developing world offers multinational firms an
opportunity to find new sources of value and to be
profitable at the same time. There is an invisible
undiscovered, ignored and/or untapped market waiting at
the bottom of the economic pyramid a market of five billion
people who live on less than $2 a day, nevertheless, their
annual market exceeds $3.6 trillion. The poor can be
profitable (Prahalad and Hammond, 2002). Selling to these
poor is a uniquely powerful way of achieving breakthroughs in
the production and marketing of products and services
(Prahalad, 2004). The markets at the bottom of the economic
pyramid can be a sandbox for innovation, a powerful force to
rethink costs, scale of operations and use of capital (Prahalad
and Hammond, 2002). In the context of HIV/AIDS
pandemic, furthermore, the poor desperately need the
lifesaving drugs, and may even be able to afford them as
long as they are marketed to them in innovative ways
(Prahalad, 2004; Prahalad and Hammond, 2002). Let us
explore how the source industries addressed similar
problems in relation to the developing countries.
 Global marketing of lifesaving drugs
Oswald A. Mascarenhas, Ram Kesavan and Michael Bernacchi
Candidate solution types
When Aravind Eye Care in India proposed to offer affordable
cataract surgery to the poor of southern India, it knew that its
customers could never afford the usual procedure cost of
$3,000 prevalent in the developed world. The company,
therefore, reengineered the procedure and innovated a
process with high quality that decreased the cost from
$3,000 to $30 per procedure. Aravind Eye Care is now the
globes largest eye-care facility. It performs more than
200,000 surgeries a year. The quality of care Aravind
delivers is as good as any in the developed world. Debt-free
and highly profitable, Aravind Eye Care records an annual
return on equity of more than 75 percent. The poor can,
indeed, be profitable (Prahalad, 2004).
Casas Bahia, a Brazilian retailer, built a highly profitable
$2.5-billion-a-year chain of 300 stores primarily in the
nations shantytowns. This retailer has developed skills to
assess the creditworthiness of the poor even though their
incomes are uneven and often unreported. The company
offers credit at a low cost that enables its consumers to buy,
for instance, their favorite kitchen appliance or television. The
poor also hunger for credit, good products and technology.
Obsolete products and technologies cannot satisfy the bottom
of the economic pyramid anymore than it can its top.
In the 1890s, the Singer Company showed that the sewing
machine could be a great productive asset in poor countries.
Knowing that the poor of the world could not afford its then
price of $100 and more, Singer devised a credit system for the
developing countries whereby it charged customers $5 a
month. The ordinary poor women put the machine to good
productive and income-earning use, paid off their loans within
20 months, and even applied for second Singer machines.
The Singer Company was a roaring success in the developing
countries.
Similar is the story of Mohammad Yunus, the founder of
the Grameen Bank. The philosophy of Grameen was and is
that individual customers are not just consumers of credit or
mere laborers but entrepreneurs. Since 1983, and after five
years of successful pilot programs in Bangladesh, the Bank
has been extending credit to groups of the poorest of the poor.
Grameen does not make home loans to the poor but rather it
makes loans to their factories where they exercise their
entrepreneurial skills in handicrafts. Grameen has been
replicating credit programs in Indonesia, Africa, Latin
America, and now throughout South Asia. Grameen
achieves repayment rates of 98 percent and more, much
higher than what most banks receive on collateralized loans in
the developed world. When mainstream markets of the
developed world get saturated and competitive strategies
focused on differentiation indicate diminishing returns,
marketers are best positioned to penetrate sizable emerging
markets of the developing countries (Kim and Mauborgne,
2004; Letelier et al., 2003).
Cemex, a Mexican company and currently the worlds third
largest cement company, used core methods and
competencies to sell its premium-priced cement to an
increasing number of low-income, do-it-yourself
homebuilders who join patrimony-building (Patrimonio
Hoy) clubs. Like other traditional cement companies, it did
not merely sell cement by cubic yards; instead, it changed its
business unit to perfect deliveries. The company started
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Volume 22 Number 7 2005 404 411
delivering the exact amount of cement in a timely fashion to
each of its big and small customers (McGrath and
MacMillan, 2005). Cemex soon started selling homes or
parts of them to its customers throughout the world. Cemex
created the Patrimonio Hoy program a la carte Grameen
Bank. This club signs do-it-yourself homebuilders into a
system for building homes one room at a time. Patrimonio
customers join into groups of three who take joint
responsibility for making weekly payments. Their payments
entitle them to quality building materials for a full new room,
which are delivered, in general, about the middle of the
payments program. The Patrimonio Hoy also counsels
customers on designing their rooms, warehousing privileges,
rights to delivery, and other rights with preferred local dealers.
By summer 2003, the Cemex Patrimonio Club had 39,000
families as members, and over 100,000 had successfully
passed through the Hoy. This was a remarkable achievement,
given the fact that the largest subsidized Mexican government
plan had captured only 4,000 families. The rate of complete
payment after the building materials were received, moreover,
was 99.6 percent (Letelier et al., 2003).
Finally, in India, China, the Philippines, and in other
developing countries, single-serve packs of shampoo,
detergents, tea, aspirin, matches, pickles, and ketchup are
common. Almost 60 percent of the value of all shampoo sold
in India is in single-serve packets, sold for a penny a piece.
This market was a very profitable business for global
corporations such as Unilever and P&G and for local firms
as well. Profiting on penny sachets of shampoo or detergents
is just a start. The markets at the bottom of the economic
pyramid challenge managers to reengineer design,
production, quality and marketing.
The target solutions
In the past, the brand name pharmaceuticals of the developed
world have adopted several strategies to market lifesaving
drugs to the poor nations but with no significant long-run
effects. Some of these strategies include the following.
Discount pricing
Discount pricing has been a common solution in distributing
lifesaving drugs to developing countries. For instance, on
intense and increasing pressure from protestors (e.g. the ACT
UP coalition), including policy makers from the USA and
Europe, Burroughs Welcome (now GlaxoSmithKline or
GSK) pared the price by 20 percent in 1987 and again by
30 percent in 1989. Pressure for discounting HIV/AIDS
related drugs was sparked in the wake of Fuzeon that was
introduced early 2003 by Timeris and Roche at $23,000 price
per patient per annum, twice the price of any previous AIDS
therapy. With accelerated pressure from international
government agencies and especially, from sub-Saharan
African countries, GSK, Timeris and Roche and other
leading HIV/AIDS drug manufacturers have offered heavily
discounted drug prices to developing nations. In the year
2000, manufacturers began talking to various UN agencies
about offering AIDS treatments to African nations at
affordable prices.
But price discounts may not be an effective solution for the
HIV/AIDS pandemic. For instance, Bristol-Myers Squibb
(BMS) reduced the price of two widely used AIDS drugs, ddI
 Global marketing of lifesaving drugs
Oswald A. Mascarenhas, Ram Kesavan and Michael Bernacchi
and d4T, to $500 or so in Senegal. Senegal has over 80,000
HIV/AIDS patients. Besides drugs, patients need drug
therapy, hospitalization and rehabilitation, testing and
counseling, prevention and palliative care, which together
with the needed drugs could cost well over $2,000 per patient.
The median income in Senegal is around $550 per year that
makes discount pricing ineffective. Arguably, the case is
similar in almost all developing countries where HIV/AIDS is
a serious problem. Discount pricing, moreover, could be
bound by problems of time and quantity limitations and will
most often depend on the capricious goodwill of the
pharmaceuticals.
Donation of drugs
From 1987, Merck has donated its drug Mectizan
(ivermectin) to anyone afflicted with river blindness, as long
as the drug is needed. Most drugs go to Africa, the Latin
American countries and Yemen. In 2002, Merck donated the
250 millionth dose. Pfizer agreed to provide fluconazole to
South Africans affected by cryptococcal meningitis.
Boehringer-Ingelheim for a limited period of time donated
Nevirapene, a drug proven to drastically reduce the mother-
child transmission of HIV. To the extent that these donations
are voluntary and not coerced, they indicate an assumption of
moral urgency and moral responsibility by corporations. But
the problem with these handouts is that they offer ad hoc
solution, often fraught with dependency conditions, time and
quantity based limitations and the contingencies of corporate
goodwill. They also spell paternalism and a continuing
dependence of developing countries on the generosity of
pharmaceuticals for their healthcare planning. For these and
other reasons, this donation-solution may not be sustainable
or desirable over time, especially when millions of
immediately preventable deaths are at stake.
Differential pricing
Drug manufacturers engage in differential pricing or price
discrimination for patented drugs. That is, they charge higher
prices in markets with greater willingness to pay and lower
prices in countries with lower buying power (Danzon and
Towse, 2003). Higher prices in developed countries often
subsidize lower prices (just above marginal costs) in the
developing countries. The drug price differential between
developed and developing countries may be as much as
tenfold. This tenfold price differential has created many
problems such as parallel importing. The latter implies
parallel pricing and parallel trade, that is, it could well reverse
the shipment of drugs from low price markets to high-price
markets by unauthorized dealers, thus depressing domestic
prices in the USA and Western Europe. South Africas 1997
Medicines Act sought to legalize parallel imports and
compulsory licensing as part of a campaign to combat
AIDS. If markets cannot be separated (as with globalized
markets), massive parallel trade can undermine and soon
neutralize differential pricing and its benefits.
For these and other reasons, we do not support discount
and differential pricing nor the donation of drugs as long-run
effective solutions to the HIV/AIDS pandemic. We have
recourse to the candidate solution suggested by analogical
reasoning.
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Volume 22 Number 7 2005 404 411
Analogical candidate solution: innovative
production and distribution strategies
The analogy between source industries and the target industry
and between candidate solutions and the target solutions must
be real and well considered within a concrete framework (see
Figure 1). Both the source and the target industries must:
.
relate to critically needed products and services such as
eye care (Aravind Eye Care), credit for rural
entrepreneurship (the Grameen Bank), cement for
individual home construction (Cemex), and HIV/AIDS
drugs (pharmaceuticals);
.
relate to developing countries such as India, Bangladesh,
Mexico, and Brazil; and
.
relate to the distribution, prices and logistics that make
sense to vulnerable and disadvantaged customers.
The basic differences in the above examples are that the
source industries are the companies related to life enhancing
products and services (e.g. eye care, credit, home building,
rural entrepreneurship) while the target industry is focused on
life saving products and services such as HIV/AIDS drug and
therapy. Far from weakening, this difference even reinforces
analogical reasoning and urges its quick application for
preventing millions of preventable deaths due to HIV/AIDS in
the developing countries. That is, if the source industries
radically innovated production and distribution for life-
enhancing products services, the target industry should do
this all the more for life-saving situations. We now suggest
various strategies to this effect.
Reengineering the product/service bundle are
requirements
All the previously mentioned source industry companies must
have and did reengineer and redesign their products so that
they become relevant and affordable to the market conditions
of the developing nations. Rather than just entering,
penetrating and exploiting an existing market, the source
industry companies must have and did construct the markets
from a bottoms-up perspective of developing the credit
potential and worthiness of indigent customers by
collaborating with local distribution logistics and by
delivering a full product/service from the beginning to the
end. The target (pharmaceutical lifesaving HIV/AIDS drug)
industry must therefore, respond in its most efficient and
effective manner. In all of the above examples, the source
industry companies were successful in expanding revenues
and profits. The pharmaceutical industry will enjoy similar
outcomes as long as it can reengineer and redesign the drug-
therapy bundle from its start (prevention, testing, and
detection) to its end (therapy, control, and rehab).
This is possible. For instance, in February 2001, the Indian
pharmaceutical company Cipla offered to make generic AIDS
medicines available to the governments of developing nations
for $600 per patient per year. The same year, Cipla further
reengineered its product to decrease that price to $350 to the
Nobel Prize-winning healthcare aid agency, Medecins Sans
Frontieres.
Volunteer licensing
Innovative production of drugs in the developing countries
can be spurred by voluntary licensing, especially, by brand
name pharmaceuticals of the developed world. When patents
 Global marketing of lifesaving drugs
Oswald A. Mascarenhas, Ram Kesavan and Michael Bernacchi
expire, competing manufacturers are generally permitted (by
the 1984 Hatch-Waxman Act) to introduce generic versions
of the drugs that quickly drive down the prices of brand name
drugs. The 1984 Hatch-Waxman Act does not apply to
biologicals (drugs that are derived from biological
processes) as opposed to those synthesized from simple
chemical compounds. Some HIV drugs (e.g. Emtriva) are
biologicals.
Volunteer licensing should ensure quality generic
production in the developing countries with provisions to
block parallel trading. In 2001, Cipla, an Indian
pharmaceutical company, offered 5 percent royalties to
brand-name companies of the West in exchange for
licensing agreements to sell generic versions of their
medicines in developing nations (Slater, 2003). The
prospect of generic competition, however, prompted
significant price discounts by such brand-name innovator
companies as Bristol-Myers Squibb, GlaxoSmithKline
(GSK), Merck, and Pfizer. GSK has allowed South African
firms to produce and market its AIDS drugs (Zimmerman,
2001). GSK is the market leader in the USA with 40 percent
market share of AIDS related drugs. It also owns 66 percent
of all patents for AIDS in 53 African countries. Thus,
volunteer licensing, especially by GSK to African countries,
can be very effective. It can also stimulate the reengineering
and redesigning of the entire lifesaving product/service so that
millions of preventable deaths could be rapidly prevented.
Cooperation in prevention
Drug therapy is not keeping pace with the raging growth of
the HIV/AIDS pandemic. For instance, the UNs goal of
treating three million HIV patients by 2005 will not match the
eight million new HIV infections that will have occurred by
2005 (Nakashima and Brown, 2004). Unless the average
annual increment of five million HIV infections falls sharply,
treatment programs will not match the number of people in
need (Gayle and Lange, 2004). Prevention, hence, is better
than cure and HIV/AIDS remains a preventable condition
even in poor nations. For instance, the remarkable decline of
HIV infection rates in Senegal, Botswana and South Africa is
strongly correlated with fundamental behavior modifications
in sexual practices. Several African nations are working on
prevention strategies. Uganda has obtained a striking
reduction in the incidence of HIV from 21 percent in 1991
to 10 percent in 1998 to 6 percent in 2001 (Low-Beer, 2004).
While pharmaceuticals enable generic production of lifesaving
drugs, developing countries affected by HIV/AIDS must
simultaneously and actively engage their people in prevention
modalities that control the spread of the disease. Finally, on
obtaining lifesaving medication HIV victims must be educated
and encouraged to meticulously follow the entire drug-
therapy treatment regimen for an effective control of the
disease. The pharmaceuticals that volunteer licensing and
accelerate generic production should exert pressure on local
governments and on affected people and their families to do
their part in preventing the disease by appropriate behavior
modifications, and, if affected by the disease, to commit
themselves to the full drug regimen and therapy that can
avoid premature deaths.
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Volume 22 Number 7 2005 404 411
Managerial implications
Companies like Costco, Sams Club, Wal-Mart and other
wholesaler institutions encourage consumers to stockpile
based on bargain prices and convenience. Selling to poor
countries mandates the opposite perspective (Prahalad,
2004). Successful companies that retailed to match the
specific needs and capabilities of the poor like Aravind Eye
Care, Casas Bahia, Cemex, Grameen Bank, P&G, and
Unilever challenge the pharmaceuticals to do the same. The
secret here is a strong analogical reasoning being applied
creatively, without letting the conventional wisdom determine
the process or the outcomes.
Pharmaceuticals should be able to recover R&D costs
We understand that in the high-technology driven
organizations of HIV/AIDS drug manufacturers, it is critical
that funds are available to attract, develop and retain the best
scientists and to foster a R&D team research that would
expedite the new drug development process. In the past, high
prices and high profitability of major pharmaceutical firms
have enabled this continuous funding. Drug prices typically
have been well above the marginal costs of manufacturing and
distribution so that profits can quickly recover developmental
costs and continue to motivate investments in new and
ongoing research (Calfee and Bate, 2004). Studies also
indicate that R&D investment averages 12 percent of sales in
the pharmaceutical industry and about 21 percent of sales in
big R&D pharmaceutical firms (Danzon, 1997). If we factor
in the opportunity costs of the funds expended during the
long gestation period (average 15 years) that culminates in
commercialized drugs, R&D cost estimates could rise to 30
percent of annual sales revenues (Danzon, 1997). During
1993-2002, R&D spending by the top pharmaceutical
companies tripled to more than $30 billion annually
(Challener, 2003). The target solutions that we suggest
must keep the problem of rapid R&D costs recovery in
perspective. Serving the poor, indeed, can be profitable
(Prahalad, 2004) and help pharmaceuticals to recover R&D
costs and more.
The analogical model we suggest challenges
pharmaceuticals to explore new innovations in reengineering
and redesigning their products and services so that the
developing nations that need them the most can afford them.
In this connection, source industries and their great
corporations such as Aravind Eyecare, Casas Bahia, Cemex,
Grameen, Singer, P&G and Unilever provide outstanding
insights. These corporations did not compromise their
products or their quality. Instead, they either reengineered
their products to enable mass generic production, or they
reinvented their distribution (e.g. redefining business unit,
redesigning financing or credit-enabling) systems whereby the
poorest of the poor could afford it at the time they needed it.
Analogically, the brand name pharmaceuticals need to do this
in the context of all lifesaving drugs, and HIV/AIDS drugs in
particular.
Respect brand name patents
We also support brand name patent protection. In general,
pharmaceuticals are characterized by high technology, lengthy
drug development cycles, large capital investments and high
financial risks. Only about 30 percent of all new drugs are
 Global marketing of lifesaving drugs
Oswald A. Mascarenhas, Ram Kesavan and Michael Bernacchi
profitable and generate enough revenues to cover their
development costs (Grabowski et al., 2002). Some HIV drugs
are difficult and expensive to manufacture. During the 1990s,
on average, each new compound cost close to $800 million
and these costs have increased each year by more than
7 percent (DiMasi et al., 2003). In the USA, new drug patents
extend for 20 years from the filing date. Long clinical trials
and the FDA approval process itself totals to 8-15 years of real
patent shelf life. Patent protection is essential to the drug
industry. But while protecting their patents, brand name
pharmaceuticals can also engage in reengineering and
redesigning the lifesaving drugs so that they become rapidly
and effectively available to the increasing millions of HIV/
AIDS victims in the developing nations.
Generic drug manufacturers from the developing countries
have copied leading brand names, almost defying the patent
protection laws of the developed world. Compulsory licensing
as a solution (Ashcroft, 2001) can lead to such defiance, and
hence, we do not advocate it. Brazil passed a new patent
protection law in 1996 that requires brand name companies
to produce patented drugs locally within three years from
their introduction in the developed world or face compulsory
licensing by Brazilian state-run factories. Brazil enforced this
law to leverage price reductions. Apparently it worked, as the
incidence of HIV has been reduced by 80 percent since 1996,
though this success implied an open defiance of the
universal patent law. We do not advocate such patent
infringement. If price discounting, patent infringement in
the developing nations and patent threats in the developed
world continue, then the high-tech HIV/AIDS drug industry
may not be able to recover R&D costs on the one hand, and
allocate resources for future R&D on the other. This would be
a loss-loss situation. Furthermore, this may seriously
discourage if not paralyze HIV/AIDS research and new drug
development in the developed world, thus creating a problem
worse than the solution to the pandemic. This is where a case-
by-case analogical approach becomes an imperative and
effective solution.
Analogies are context-dependent. Depending on the
context, scholars or strategists may differently establish the
analogy between a target problem, the source industry
and the candidate solution and thus arrive at different
solutions to the target problem. Proper evaluation and
validation of the analogy and the candidate solution are
needed before decision and implementation. Analogical
thinking is independent of ideologies or ethical systems. It
does not engage them but may derive support from them. The
analogical model can help discussants communicate with one
another without unnecessarily getting trapped in the
ideological differences and details that underlie, for
instance, the stakeholder and capitalist models. It is for
these reasons that we invoke the analogical model as a
solution-approach to the HIV/AIDS pandemic.
AR can be a source of remarkable insight. Business schools
typically teach strategy using case studies that provide an
abundance of analogies from which students can draw
problem-solutions. The best strategy according to
consultants is to draw lessons from one industry and apply
them to another. AR, however, needs careful causal
reasoning. Dangers arise when strategists draw an analogy
based on superficial similarity rather than the real causal traits
between the target problem and the source problem. We need
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Volume 22 Number 7 2005 404 411
breakthrough thinking in the distribution of lifesaving drugs,
and AR provides a wonderful opportunity for it.
In producing and marketing lifesaving drugs, manufacturers
and distributors need to redefine their unit of business
analysis (McGrath and MacMillan, 2005). It cannot only be a
drug regimen for HIV/AIDS priced at affordable levels to the
developing markets. It should be a total patient experience of
education, medication, therapy, hospitalization and
rehabilitation. The pharmaceuticals need to immerse
themselves in this holistic experience of ministering fragile
patients and patient families whose lives reflect unspoken
resignations. This is what Medecins Sans Frontieres (MSF)
did, and the pharmaceuticals could take this lead. The credo
of MSF is humanitarian medicine, one person at a time. MSF
puts the individual at the center of its attention and deals with
the total patient in a very humanitarian way (Nierle, 2003).
MSF is a grand humanistic application of the case-by-case,
patient-by-patient analogical approach to the distribution of
lifesaving drugs and therapy. Strong humanitarian values can
empower pharmaceuticals to reengineer and redesign
products and services so as to reach the needy.
Concluding remarks
The pharmaceuticals that sell higher priced drugs to the
saturated markets of the developed world can expand the
market for their products and services by targeting low-
income customers of the developing countries. The
developing markets, however, need to be carefully
constructed and not simply entered.
The analogical model challenges pharmaceutical companies
to reengineer their products, the production process and the
marketing strategies such that the same product is distributed
to a much larger market of the developing countries at prices
they can afford, using the twin guideposts of profitability and
humanitarianism. To be profitable, firms cannot simply
compromise the products they sell to rich countries or to
simply give them away. Instead, they must thoroughly
reengineer products to reflect the very different economics
of the very different developing countries. In this manner
greater number will be served with a greater good outcome
but it will be on a basis of sound business not charity.
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 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
Department of Management, Harley Langdale Jr College of Business Administration, Valdosta State University,
Valdosta, Georgia, USA

Abstract
Purpose The purpose of this paper is to investigate the changing legal landscape associated with the growth of advertising of prescription drugs
directly to the consumer, and makes recommendations designed to assist advertisers in avoiding legal liability based on those advertisements.
Design/methodology/approach This study investigates the phenomenal growth of DTC advertising since 1997, when a profound change in the
FDA regulations took effect. These changes permitted advertisers significantly more flexibility in providing information about the advertised drug
directly to the consumer. Since then, however, DTC advertising has repeatedly come under attack. A review of the literature, changing law, and other
factors, reveals the primary criticisms of DTC advertising, and its tendency to expose pharmaceutical advertisers to legal liability.
Findings The paper recounts the development of the law concerning pharmaceutical advertising, and particularly, the application of the Learned
Intermediary Rule. Previously, this Rule operated to shield pharmaceutical companies for liability by passing liability on to the physician who wrote the
prescription for the drug. Now, that law is changing, with resulting liability for pharmaceutical advertisers.
Practical implications The study recounts the primary criticisms of DTC advertising, and provides a number of steps that can be taken to help avoid
legal liability for pharmaceutical companies that engage in DTC advertising.
Originality/value The study looks at DTC advertising from both a marketing and a legal perspective, and combines those disciplines to draw
conclusions helpful to DTC advertisers.

Keywords Advertising, Medical prescriptions, Laws and legislation

Paper type Viewpoint

An executive summary for managers and executive
readers can be found at the end of this issue.
Introduction
Direct-to-consumer (DTC) advertising is the subject of
intense debate. Proponents argue that it can educate
consumers about new treatments, increase treatment for
under-diagnosed conditions, and help patients make better-
informed health care decisions. Opponents contend that it
could interfere with the physician-patient relationship, raise
health care costs, and increase consumption of new, more
costly products over older, cheaper, and safer alternatives.
Opponents also argue that DTC ads oversimplify complex
issues and may confuse consumers who lack specialized
medical knowledge (Kaphingst and DeJong, 2004).
This article investigates the changing legal landscape
associated with the growth of DTC advertising of
prescription drugs, and offers some suggestions for ways in
which pharmaceutical companies can avoid liability arising
from their DTC advertisements. We limit our discussion to
prescription drugs, and do not address the sale of over-the-
counter drugs. In the next sections, we discuss the success of
DTC, and the views of proponents and opponents of DTC,
The Emerald Research Register for this journal is available at
www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0736-3761.htm
and then explain the current state of the law and regulations
governing a pharmaceutical companys advertising of
prescription drugs. We conclude the paper by offering
recommendations which we hope will provide direction
toward a harmonious co-existence between DTC and the
laws and regulations governing it, and toward a marketing
paradigm which recognizes its customers as patients first,
and consumers second.
The success of direct-to-consumer advertising
For decades, prescription drug makers promoted their
products exclusively to health-care professionals, who were
expected to interpret drug information for their patients. But
about 15 years ago, partly because of the increase in the
number of patients making their own health-care decisions,
some manufacturers began to produce ads targeted to
consumers. Since then, DTC advertising has become a
popular promotional tool (Mehta and Purvis, 2003).
The phenomenal growth of DTC advertising is a result of a
change in Food and Drug Administration (FDA) regulations
in 1997, which have made it easier for pharmaceutical
companies to advertise prescription drugs, especially on
television. These regulations include permitting advertisers
more flexibility in providing information about the advertised
drug. For example, the guidelines allowed advertisers to
include both the name of the drug and the health condition it
treats, along with a statement of major risks and side effects,
and a reference to a source of further information such as a
toll-free number or web site without requiring a complete

Journal of Consumer Marketing

22/7 (2005) 412 420 This research was partially funded through a summer research grant from
q Emerald Group Publishing Limited [ISSN 0736-3761] the Rae and Lillian Steele Foundation at the Langdale College of Business
[DOI 10.1108/07363760510631156] Administration, Valdosta State University.

412
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
statement of side effects and contraindications (Brumback,
1999). This made television broadcast ads possible (Mehta
and Purvis, 2003).
Consumer awareness of direct-to-consumer (DTC)
advertising has climbed from 75 percent in 2002, to an all-
time high 81 percent in 2003, according to data from
healthcare and pharmaceutical marketing research firm
Market Measures/Cozint. In all, this widespread awareness
extends to print and broadcast DTC ads across all 25 disease
states tracked by the firms annual DTC Monitor. Based on
input from more than 6,000 consumers, the study found that
sufferers are not only recalling DTC ads for their conditions,
but are also increasingly acting on the ads (Gatti, 2003).
In particular, doctor contact rates the percent of
consumers who call or visit their physicians as a result of
seeing a DTC ad have risen for the second consecutive year
to 23 percent. Moreover, among those patients contacting
their doctors, 47 percent specifically request the brand they
see advertised (up from 41 percent), while 74 percent of
physicians actually comply with these requests (up from 71
percent). Furthermore, 58 percent of DTC-driven
discussions lead physicians to write a prescription or provide
a sample for the advertised brand whether or not the patient
ever directly asks for the product (Gatti, 2003).
Clearly, DTC is a powerful tool, for driving both
awareness and action, said Sue Ramspacher, senior vice
president of consumer services for Market Measures/Cozint.
This is particularly true for magazine campaigns, which generate both higher
doctor contact rates and higher prescribing rates than television ads. In spite
of magazines superior performance, television continues to be the medium
of choice for DTC advertisers, due mostly to its broader reach. The gap is
narrowing, however, as marketers experience the impressive results that print
can deliver (Gatti, 2003).
Proponents and opponents of DTC
Proponents of DTC prescription drug advertising believe that
the knowledge and information function of such advertising
has enormous benefits. It is claimed that DTC advertising is
an excellent way to meet the growing demand for medical
information, empowering consumers by educating them
about health conditions and possible treatments (Holmer,
1999). DTC advertising helps to educate consumers about
the choices available in treatment, as well as provide
information about various health conditions, which may not
be widely known or easily recognized by patients. In some
cases, patients may not even be aware that treatment exists.
Armed with knowledge from DTC advertising, proponents
say, consumers may discuss their treatment options with their
doctors and be better qualified to help manage their own
health care. Patient compliance may also be improved as a
result of this interaction. With an aging population and the
cultural trend toward increasingly easy access of medical
information, DTC advertising is seen by many as appropriate,
relevant, and beneficial (Mehta and Purvis, 2003).
Opponents, on the other hand, believe that DTC
advertising, even when truthful, may not always be
completely read, so that consumers will not fully
comprehend the side effects and risks associated with a
drugs use. Further, some feel the increased patient
involvement in the prescription development process may
have unfavorable medical consequences since physicians may
be persuaded, even pressured, by patients to prescribe the
requested medication even when it is not the first choice of
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Journal of Consumer Marketing
Volume 22 Number 7 2005 412 420
the physician. Many believe that, in fact, the principal effect
of DTC marketing is to create consumer demand, changing
the physician-patient relationship to a physician-consumer
relationship (Hollon, 1999). It is claimed that
pharmaceutical manufacturers are using enlightened
health-care consumers to market their drugs through
health-care providers (Hoffman, 1993; Mehta and Purvis,
2003).
There is concern whether inappropriate prescribing is
leading to people obtaining drugs they should not be getting.
The problem with DTC advertisements for prescription
drugs is that patients think that drugs are right for them
without knowing the full story of their condition, says John
Bertolini, Director of DDB Remedy. I believe it puts extra
pressure on doctors and possibly inappropriate prescribing.
Not the least of all, DTC advertisings impact on costs of
medications is also a serious consideration (Sudhaman,
2004).
However, these conflicting views are only part of the
picture. What has changed, perhaps more than anything else,
is the way in which the potential buyer of a prescription drug
has come to be viewed as a consumer rather than as a
patient. DTC advertising is responsible for that change,
and because of that, the laws and regulations governing DTC
advertising are changing.
Laws and regulations governing the sale of
prescription drugs and medical devices
Drugs are dangerous products
As do all products, sales of prescription drugs and medical
devices are governed by state product liability laws. The
general rule of product liability law is that the manufacturer
and seller are liable to an injured consumer for injury caused
by a product which is unreasonably dangerous even if the
manufacturer is not negligent in the design or manufacture of
the product. Prescription drugs and devices, by their very
nature, are dangerous, because they pose risks to patients
even if they are used as intended. However, in 1965, the law
recognized that:
There are some products which, in the present state of human knowledge,
are quite incapable of being made safe for their intended and ordinary use.
These are especially common in the field of drugs . . . [B]oth the marketing
and the use of [prescription drugs] are fully justified, notwithstanding the
unavoidable high degree of risk which they involve. Such a product, properly
prepared, and accompanied by proper directions and warnings, is not
defective, nor is it unreasonably dangerous (Restatement 2nd of Torts,
Section 402A, comment k (1965)).
Therefore, even an unsafe product can be made and sold
without liability if it is properly prepared, adequate
instructions are given for its use, and warnings are given
about any risks, both known and knowable. The sale of
prescription drugs and devices is different in another way:
before the prevalence of DTC, such instructions and
warnings were not given to the patient-consumer directly,
but rather to his doctor.
The learned intermediary rule
Ordinarily, the manufacturer or seller who sells an
unreasonably dangerous product is liable if the consumer is
injured as a result of using the product. However, in the case
of the sale of prescription drugs and medical devices, the
Learned Intermediary Rule was developed as an exception to
the liability for failure to warn of risks and dangers. Simply
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
stated, the Learned Intermediary Rule (as to prescription
drugs) stands for this proposition:
A prescription drug manufacturer or seller is not liable for failure to warn a
patient-consumer directly of the dangers of the prescription drug if the
manufacturer or seller adequately warns the patients prescribing physician,
or other medical professional, (a learned intermediary) of the potential
risks inherent in the use of its product (American Law Reports, 5th 1, 2005,
Vol. 57).
Under the Learned Intermediary Rule, instructions and
warnings could be relayed to a patient-consumers doctor,
rather than directly to the patient himself. Although FDA
regulations later came to require direct warnings for some
products, such as birth control pills, this was the law in 1966
and until recently, when direct-to-consumer advertising
became widely used. Now, drugs are advertised directly to
the patient-consumer, bypassing the traditional physician-
patient relationship, and influencing a patients health care
decisions directly. The modern medical marketplace focuses
on the patient as consumer to an extent unimaginable forty
years ago (Hall, 2004, p. 197). The presumptions underlying
the sale and purchase of prescription drugs and devices have
changed, and the law is changing with them.
By 1998, the Restatement of Law relating to the sale of
prescription drugs and devices had modified its advice. No
longer would manufacturers and sellers be able to rely
completely on the Learned Intermediary Rule to escape
liability. No longer would the act of providing information
and warnings to a learned intermediary automatically
exculpate the drug manufacturer or seller from liability. Now,
it is recognized that in this changed landscape, warnings given
to a learned intermediary might do no good. It is not just
pharmacological advertising that has changed. It is much
more than that.
Changes in the health care system
Gone are the days of Dr Kildare and Marcus Welby, M.D.,
when physicians were autonomous providers of medical
advice and counsel in a traditional American health care
system. Then, a patients health insurer had nothing to do
with health care decisions. Today, however, 78 million
Americans under age 65 receive health care through
managed care organizations (MCOs), which exercise
significant oversight of the independent authority of the
physicians who treat them. Doctors are now required to
provide more services in a given amount of time, leaving less
time for each patient, and less time for doctor-patient
interaction, during which discussion of medications might
take place. These circumstances allow physicians little time
to process warnings provided by drug manufacturers into
forms in which they will be heard, understood and heeded by
patients (Hall, 2004, p. 195 197).
Patients without a primary care physician are treated at
clinics or in emergency rooms, where they see a doctor once,
and not again. Or they are prescribed drugs by a physician
they never see, who writes a prescription based on the
patients answers to a questionnaire, submitted to a web site.
Prescription drugs are being increasingly sold outside the
usual channels, and without any meaningful doctor-patient
relationship on which the patient may make an informed
decision. In this situation, no one in the supply chain has any
incentive to provide the patient with adequate warnings. The
internet pharmacy and physician, if any, may be outside the
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Journal of Consumer Marketing
Volume 22 Number 7 2005 412 420
jurisdiction of the US courts, leaving the plaintiff with no
recourse (Hall 2004, p. 239).
Under todays new health care system, the physician or
health care provider is not necessarily a learned
intermediary. Frequently, there is no doctor-patient
relationship, or there is no time for the kind of interaction
between doctor and patient which is required in order for the
doctor to function as a learned intermediary. This presents
a problem for marketers, because it is on the learned
intermediary that marketers rely, and because the learned
intermediary may not be able to do what is expected. Now, it
depends. Now, the restatement recommends that instructions
and warnings be given to:
.
prescribing and other health-care providers who are in a
position to reduce the risks of harm in accordance with the
instructions or warnings; or
.
the patient when the manufacturer knows or has reason to
know that health-care providers will not be in a position to
reduce the risks of harm in accordance with the instructions
or warnings (emphasis provided). (Restatement 3rd of
Torts, 6(d) (1998)).
In essence, there is now an exception from the Learned
Intermediary Rule for direct-to-consumer advertising an
exception to the exception. This new view of the law was
adopted by the New Jersey courts in the case of Perez v. Wyeth
Labs, 834 A.2nd 1245 [N.J. 1999][1], a case involving the sale
of a Norplant medical device, sold by prescription. The
courts well-reasoned opinion recounted that the Learned
Intermediary Rule was adopted in 1966, at a time when Dr
Kildare was a popular television show, doctors still made
house calls, and the relationship between patient and
physician was a comfortably close one in which doctor
advised patient, and patient believed that doctor knows
best. But, the court recognized, for good or ill, that has all
changed. The court posed the question whether our law
should follow these changes in the marketplace or reflect the
images of the past, and concluded:
. . .when mass marketing of prescription drugs seeks to influence a patients
choice of a drug, a pharmaceutical manufacturer that makes direct claims to
consumers should not be relieved of liability for its actions (Perez v. Wyeth
Labs, 834 A.2nd 1247 [N.J. 1999][1].
Some states still apply the Learned Intermediary Rule, but
others do not. Some states have never adopted the Learned
Intermediary Rule. And, some states have banished the Rule
by statute, incorporating into the states laws a duty to warn,
but excluding the Learned Intermediary Rule from the
statute, so that the Learned Intermediary Rule cannot be
adopted in those states. Increasingly, courts have come to the
realization that the Learned Intermediary Rule should not
apply when the reasoning behind the Rule does not exist.
(Hall, 2004, p. 239) Precedents drawn from the days of
travel by stage coach do not fit the conditions of travel [by
automobile] today. (Hall, 2004, footnote 342, citing
MacPherson v. Buick Motor Co., 111 NE 1050, 1053 [NY
1916][2]).
What all of this means for the marketer is that an ad that
appears in one state may be subject to very different laws in
another. The only way to be sure to avoid liability for a failure
to warn is for the drug manufacturer or seller who sells to the
patient-consumer to provide adequate instructions and
warnings directly to the patient-consumer. In essence, the
duty to warn which was always originally the duty of the
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
manufacturer or seller, has returned to the drug manufacturer
and seller. Today, a drug manufacturer or seller who sells its
products nationwide no longer enjoys a freedom from liability
across the nation based on state law. Moreover, there are calls
for reform at the federal level.
Many members of Congress would like to see stricter
policing of DTC messages. And that has prompted talk of the
mandatory pre-approval DTC ads. Two bills were recently
submitted to Congress for the purpose of further regulating
DCT advertising. One was an amendment to the Medicare
prescription-drug benefit bill, sponsored by Sen. John
Edwards, D-N.C. The second was a proposal to require
DTC drug ads to include information on how each drug
compared with others on the market. Both were defeated
(Thomaselli, 2003). But when Congress begins to suggest
legislation, it is time to take a look at the industrys practices
to see if further legislation can be avoided. Even if no new
federal legislation is passed, the drug manufacturer must
comply with existing federal laws
The FDA and direct-to-consumer advertising
The FDA oversees the advertising of prescription drug
products under the Federal Food, Drug, and Cosmetic Act
and related regulations. That means the agency must ensure
that prescription drug information provided by drug firms is
truthful, balanced, and accurately communicated. This is
accomplished through a comprehensive surveillance,
enforcement, and education program, and by fostering
better communication of labeling and promotional
information to both health professionals and consumers
(Lewis, 2003).
Bringing a prescription drug to market requires the
approval of the FDA. In addition, the FDAs Division of
Drug Marketing, Advertising and Communications
(DDMAC) controls the advertising of prescription drugs. In
1997, the FDA approved a trial run of direct-to-consumer
advertising without the necessity of including complete risk
information in each ad, as long as adequate provision was
made for the viewer to get complete information elsewhere.
This made television broadcast ads possible. DTC advertising
began in earnest. Since then, the FDA has continued to
monitor DTC, providing guidances for its use, and regulating
the content of ads and labels. Currently, pharmaceutical
companies face no limit on the amount of money that can be
spent on those promotions. In 2002, drug companies spent a
combined $2.5 billion on DTC ads (Thomaselli, 2003).
Prescription drug ads may be broadcast on television or
radio, communicated over the telephone, or printed in
magazines and newspapers. Under FDA regulations, there are
three categories of ads:
(1) Product-claim ads:
.
mention a drug by name;
. describe the condition it is intended to treat;
.
describe the risks and benefits of the drug.
(2) Reminder ads:
.
mention a drug by name;
. but do not say what it is used for;
.
need not include risk information.
(3) Help-seeking ads:
.
contain information about a disease, but do not
mention a specific drug;
.
need not include risk information;
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Journal of Consumer Marketing
Volume 22 Number 7 2005 412 420
.
often, these ads are extremely informative, and
helpful to the patient-consumer. Examples are ads
that mention high cholesterol or diabetes, then direct
the viewer to see a physician (Rados, 2004).
FDA compliance requirements
Among the requirements for product-claim ads for
prescription drug and medical devices are these:
.
Advertising for prescription drugs must disclose certain
information about the products uses and risks.
.
Ads must contain information about risks and benefits in a
brief summary.
.
Recognizing the time constraints of broadcast ads, instead
of a brief summary, a broadcast ad may include only
information about the major risks of the drug, if
adequate provision is made for the viewer to obtain
complete FDA-approved labeling information about the
product.
.
Adequate provision refers to the concept of providing
ways for consumers to find more complete information
about the drug. (Most ads fulfill this requirement by
including a toll-free telephone number, or web site
address, or advise viewers to see their health care
providers.)
.
Any ad directed at consumers, either print or broadcast,
may not make any claim that is not supported by scientific
evidence.
.
Ads may not be false or misleading, or omit material
(important) facts.
.
Each ad must show fair balance between the risks and
benefits. Risks and benefits must be presented with
comparable scope, depth, and detail.
.
Pre-approval of DTC ads is not required, but a copy of the
ad must be submitted to the FDA when the ad begins to
run. However, the Agency will preview an ad if requested
(Rados, 2004).
FDA guidance and warning letters
In 1997, the FDA released a draft guidance describing the
adequate provision requirements, and giving suggested
ways the requirement might be met, such as a toll-free
telephone number, a reference to print ads, or a suggestion
that the patient-consumer see a physician (Nordenberg,
1998). Based on its experience, and on comments from
patients, physicians and others, in August, 1999, the FDA
released its final Guidance for Industry, Consumer-Directed
Broadcast Advertisements, which did not differ substantially
from the draft. The final Guidance described the brief
summary as information in brief summary relating to side
effects, contraindications, and effectiveness (available online
at www.fda.gov).
The FDA monitors ads as they are presented or released. If
the agency finds that a company has broadcast an ad that is
false or misleading, the agency may take enforcement actions,
beginning with one of two types of letters. Untitled letters
are usually sent to first time violators, or for less serious
violations. Warning letters are sent to companies that have
violated the law repeatedly, or that have committed serious
regulatory violations in their advertising. Such letters typically
demand corrective advertisements to ensure that the audience
that received the original false or misleading information also
receives truthful and accurate information (Rados, 2004).
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
The FDA is more closely scrutinizing drug ads. Of 18
warning letters sent by the FDA in 2003, seven were for DTC
ads. Two were sent within 22 days of each other in the month
of August, 2003, to major pharmaceutical companies that
were asked to pull their advertising one to Bristol-Myers
Squibb for a misleading print ad for Pravachol, and the other
to Novartis for a television spot for Lamisil (Thomaselli,
2003).
In reprimanding the pharmaceutical companies for the
Lamisil and Pravachol ads, the FDA took issue with what it
called misleading claims of efficacy and for targeting illnesses
and ailments for which the drugs had not been approved. In
the case of the anti-cholesterol Pravachol, the FDA also asked
for prompt dissemination of corrective ads (Thomaselli,
2003).
Public input and FDA experience with DTC led to FDAs
publication of two new draft guidances in February, 2004,
one on the brief summary, and one on help-seeking ads (Both
may be downloaded from www.fda.gov). A continuing
problem the FDA has encountered had to do with the
requirements of particular kinds of ads. Rather than use a
product-claim ad, which requires the disclosure of risk
information, some marketers have been known to combine
help-seeking ads with reminder ads in a way that causes the
audience to perceive the two pieces as one advertisement.
Individually, these ads require no disclosure of risk
information. But by the use of this strategy, the patient-
consumer knows the name of the drug (pursuant to the
reminder ad), while the marketer has avoided disclosing risk
information by using a help-seeking rather than a product-
claim ad. The FDAs 2004 Draft Guidance bans such a
strategy, and mandates that if those two types of ads are used
in combination, there must be separation between them in
print ads, by space, and in television ads, by time.
With all of these efforts, the FDAs goal is to encourage
more informative, understandable ads. Nevertheless, a broad
public perception of escalating problems with DTC
continues.
Problems with direct-to-consumer advertising
Among the problems encountered with DTC advertising (as
reported by Rados (2004), unless otherwise indicated), are
those listed below.
Critics contend that DTC advertising:
(1) Encourages overuse of prescription drugs.
(2) Encourages the use of the most costly treatments,
instead of less expensive treatments that would be just
as satisfactory.
(3) May cultivate the belief among the public that there is
a pill for every ill. (quoting Michael S. Wilkes, M.D.).
(4) May contribute to the medicalization of trivial ailments,
leading to an even more over-medicated society.
(5) May encourage patients to withhold information from
their doctors or try to treat themselves.
(6) Can affect the dynamics of the patient-physician
relationship in negative ways. Some physicians report
it time-consuming trying to talk people out of
something they have their hearts set on(quoting
Carol Salzman, MD, PhD).
(7) Often masquerade as educational tools, but are more
promotion than education; ads provide little
information that not biased.
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Journal of Consumer Marketing
Volume 22 Number 7 2005 412 420
(8) Are not fairly balanced as required by FDA regulations,
and actually convey 30 percent more benefit
information than risk information (Kaphingst and
DeJong, 2004).
(9) Present risk information in one continuous segment
rather than interspersed with benefit information,
thereby reducing its impact (Kaphingst and DeJong,
2004).
(10) Did not change tone or speed when conveying risk
information, in order to convey different content
(Kaphingst and DeJong, 2004).
(11) Conveyed adequate provision information (where to
go for more information) entirely in text form, making
it much less understandable to those with limited
literacy.
(12) Had SMOG scores (SMOG readability formula) that
exceeded the maximum eighth-grade reading level
recommended for material used with the general
public, in all but one of the tested ads. College-level
reading ability would be required to read the brief
summary information (McLaughlin, 1969; Kaphingst
and DeJong, 2004).
(13) Showed several factors in the tested ads (Kaphingst and
DeJong, 2004), which increased reading difficulty
according to the suitability assessment of materials
(SAM) method, including:
.
extensive information was presented which was not
essential for consumers (for example,
pharmacokinetic data);
. lack of key idea summaries;
.
use of passive voice, complex sentence structure and
technical vocabulary;
.
lack of illustrations for key ideas;
.
lack of visual and typographic cues to highlight key
content;
.
use of small type, long line lengths and crowded
layout; and
.
presentation of text without sub-divisions (Doak et al.,
1996);
(14) The typical brief summary is not brief, and uses
technical language. Usually, it reprints the entire FDA
labeling information intended for physicians. Patient-
consumers cannot understand it (see Figures 1 and 2).
(15) A patient-consumer might not understand the
admonition to tell your doctor what other
medications you are taking to mean that other
medications could interact with the advertised
medication. Such an approach assumes the patient
understands the context, which may not be true
(Kaphingst and DeJong, 2004).
(16) Drug firms have tended to promote the sale of so-called
lifestyle drugs, such as Viagara, Rogaine and Botox,
which provide higher profit margins, leaving fewer
resources devoted to the research and sale of drugs
which are more medically necessary (Hall 2004, p. 197).
(17) Promoting a drug for a rare but minor condition which
arguably, does not warrant drug therapy, and
consequently detracting from the efforts to find
treatments for conditions which do warrant therapy
(Pollack, 2005).
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
Figure 1 Physician label version
DTC advertising faces mounting criticism, and if it continues
to escalate, then DTC ads may be regulated out of any
meaningful existence.
The FDA is not under a legal mandate to allow DTC and, as it has before,
may study the evidence and restrict or restrain the use of DTC for medical
reasons that can vary widely. The agency may discover evidence that
consumers are receiving many improper medicines from the doctors they
pressure for new products. They may find evidence of consumer perceptions
of ad claims being incorrect. They may be under political pressure related to
any number of public and political reasons to restrict an allegedly wasteful
tool that does not produce demonstrable benefits for patients better than a
world without DTC (Richardson and Luchsinger, 2004).
The FDA itself says:
Assessing DTC advertising is an ongoing process for the FDA. As more
research surfaces, the agency will continue to evaluate DTC drug promotion
and will take additional measures as appropriate to protect the public health
(Rados, 2004).
Attempts to use federal laws to pre-empt state tort laws have
failed for decades. There is a strong belief not only that states
have the right to govern the health, safety and welfare of their
citizens, but also that a patient must have the information
necessary to give an informed consent.
There are calls to change the Learned Intermediary Rule in
those states where it still exists from an absolute exemption
from liability to a fact-based case-by-case determination of
417
Journal of Consumer Marketing
Volume 22 Number 7 2005 412 420
whether the patient actually had a meaningful interaction with
a learned intermediary. If no meaningful interaction took
place, the rule should not apply, and the manufacturer would
be strictly liable (Hall, 2004). This change is not merely an
academic one; it directly affects litigation costs. If the Learned
Intermediary Rule is an absolute exemption from liability, a
manufacturer may be dismissed early in the litigation. But if it
is to be a case-by-case, fact-based inquiry, those cases will go
to trial, and the jury will decide whether the patient had any
meaningful interaction with a learned intermediary. If the
patient did not have the benefit of a learned intermediary, and
no adequate direct notice of risks was received, the
manufacturer will be strictly liable to the patient for his
injury, or to his family for his death.
Recommendations how to prevent DTC from
coming to mean direct to court
It is very easy to see the dilemma faced by the marketing
professional, who must find a way to promote a product while
disclosing certain information which is contra-promotional,
all within certain parameters and, in the case of broadcast
media, also within strict time-frames. Yet, this is the task
facing todays professional marketer of prescription drugs.
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
Figure 2 Consumer-friendly version
How can this be done in a way which protects the patient, and
does not jeopardize the future of DTC advertising?
First, many of the criticisms of DTC advertising appear to
be well-deserved, and would stand as the primary reasons to
abolish DTC advertising, or severely curtail it. Those
practices which have received universal criticism should be
changed first. And this is not to say that all DTC ads are
suspect. Many firms do a creditable job and a public service
with DTC advertising, but some do not. If the industry does
not regulate itself, the government will surely do it.
Second, DTC advertising of prescription drugs has the
potential to provide many benefits truly educating the
public, making the public aware of under-diagnosed and
under-treated illnesses such as high blood pressure and high
cholesterol, and helping to remove the stigma associated with
certain disorders such as erectile dysfunction and depression
(Rados, 2004). But that potential is not being realized. So
much opportunity exists to adopt and accomplish these goals,
and improve the perception of direct-to-consumer
advertising, and the pharmaceutical manufacturers, but that
opportunity is being wasted.
418
Journal of Consumer Marketing
Volume 22 Number 7 2005 412 420
If the perception of DTC advertising continues to worsen,
you may be sure that new laws and regulations will follow.
Even now, the Learned Intermediary Rule can no longer be
relied on to shield drug manufacturers from liability for their
products. Because the health care system has changed so
dramatically, and because DTC advertising has essentially
filled the void created by those changes, DTC advertising is at
risk. Can it fulfill its promise?
The authors offer these recommendations:
(1) Always remember that your customer is a patient
before he is a consumer. If you approach advertising
with this in mind, you will build credibility your most
important asset in any promotional endeavor. At the
same time, you will be protecting your customer, and
avoiding liability.
(2) Provide full disclosure of relevant information,
particularly about the risks of your products, directly
to the patient-consumer. Remember that any patient
needs enough information about your product to make
an informed consent. She must know the risks, as well
as the rewards. If you do this, you will protect your
patient-consumer, and avoid liability.
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
(3) Make it a primary goal to educate your patient-
consumer (Thomaselli, 2005), rather than to merely sell
to him. It is a change of perspective which will have
many benefits.
(4) Make sure your drugs come to market only after full
testing. Avoid the kind of disaster brought about by
Vioxx and Celebrex, both of which leave their
manufacturers facing expensive litigation. Adequate
pre-testing to make sure the product was safe would
have been less expensive in many ways, not the least of
which is the appearance to the public of the rush to
market of an unsafe drug in order to make huge profits.
(5) Comply with FDA regulations and guidances in all
respects; give no cause for further regulation.
(6) Comply with all state laws in all respects; avoid losing
what protection remains of the Learned Intermediary
Rule.
(7) Establish and safeguard your companys credibility:
.
Avoid the kinds of activities that have led to criticism
by doctors, patients and consumer groups. For
example, dont encourage overuse of prescription
drugs. Liquor ads tell viewers to drink responsibly.
Why not include in your ads some cautionary advice
like As with all medication, take it only if you need
it, or something similar. You will be doing a public
service.
.
If you promote new or costlier treatment, advise the
patient that other treatment may be available. And tell
him that his doctor will be able to advise which will be
best for him.
.
Make sure ads are fairly balanced between benefit and
risk information, and do it in a way that calls attention
to the risk information (Kaphingst and DeJong,
2004).
(8) Bring the physician back into the decision-making
process. Make sure your patient-consumer knows that
individual health factors may affect a decision to use
any medication, and that only her doctor can make this
assessment.
(9) Direct at least some product ads to the physician or
health-care provider. You will be building credibility
with both doctor and patient.
(10) Be mindful of the patient who does not read well. When
preparing adequate provision information, be sure
that everyone knows where to get more information
even those who do not read well (Kaphingst and
DeJong, 2004).
(11) Compose your advertising at the recommended level for
adults, an eighth grade reading level, and not to the
college level. Use sub-titles, bullet points and key ideas
to make your ads both more readable and more
understandable (Kaphingst and DeJong, 2004) (see
samples from FDA Draft Guidance for print ads,
included at the end of this paper; Samples may be
downloaded from www.fda.gov).
(12) Make sure that any admonition to tell your doctor,
includes the reason why because this medicine may
interact with others. You will be protecting your patient-
consumer, and avoiding potential liability (Kaphingst
and DeJong, 2004).
(13) Your brief summary should be just that brief,
written in laymens terms, relaying key ideas, and
understandable at an eighth grade reading level
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Journal of Consumer Marketing
Volume 22 Number 7 2005 412 420
(Kaphingst and DeJong, 2004). Be certain to provide
a way for your patient to get access to full information.
Do not default to copying the FDA labeling
requirement. Your patient-consumers cannot
understand it. This increases your risk of liability.
(14) Promote medically necessary drugs at least as much as
lifestyle drugs such as Viagara, Rogaine and Botox.
Make sure your priorities are correct. Your credibility
depends on it.
(15) Avoid creating a disease just to be able to sell a drug. In
the eyes of many observers, this is pharmaceutical
marketing at its worst, and cannot be justified.
(16) Do more than is required by the laws and regulations.
Your most important asset is your firms credibility.
Establish it; maintain it. A company which acts ethically
will avoid liability. An industry which acts ethically will
avoid new laws and regulations which are almost certain
to reduce its options for conducting business, and
increase its costs.
(17) Create more help-seeking ads. Provide the public
service of raising awareness of undiagnosed and under-
treated illnesses. With medical advice, include in your
ads symptoms (Kaphingst and DeJong, 2004) the
viewer should watch for, and if he finds them, tell him
to see his physician to determine if what he thinks may
be true actually is true. Educate your patient-consumer;
establish your credibility.
The goal is do all of this, and still sell your product. That is
undoubtedly a challenge. The professional marketer must
combine marketing skills with compliance dictates in a way
that is both appealing and understandable, and conveys all
information necessary to any patient-consumers informed
decision. This will require a new kind of creative thinking.
Compliance with creativity
The FDA has this to say about one DTC television ad:
You may have seen the advertisement: A melodrama of crime and
corruption, conflict and emotion, centering on indoor hit men like dust
and danger, and outdoor hit men such as pollen and ragweed, all threatening
to offend a young and very beautiful womans nose. The 45-second
broadcast ad covers everything from talking to your doctor to the possible
side effects that people can expect. Then the narrator mentions Flonase.
Entertaining though it may be, the Food and Drug Administration says
this promotional piece about nasal allergy relief also has all the elements of a
well-crafted, easy-to-understand prescription drug advertisement directed at
consumers, and it meets agency requirements for these ads (Rados, 2004).
Direct-to-consumer advertisers are becoming more
innovative, and are resorting to tactics more often associated
with consumer-packaged goods marketers such as buy-one-
get-one-free promotions and money-back guarantees. Its a
movement toward promotions as a form of marketing, which
is different than weve ever seen, at least to the consumer,
noted Lynda Maddox, professor of marketing and advertising
at George Washington University, who noted that physicians
have been subject to promotionally positioned pharmaceutical
messaging and samples for some time (Johnsen, 2004).
What youre seeing is an evolution of the strategy for
DTC, as well as the expectation, commented D. Chauncey
Smith, senior brand manager at Glaxo-Smith Kline
Consumer Healthcare and spokesman for the Medical
Marketing Association. The industry has transitioned from
fitting the square peg of stiff, pharmaceutical-oriented
marketing into the round hole of a broadcast television
format. It really stuck out, he said. The manufacturers and
 Does DTC mean direct to court?
Donna J. Cunningham and Rajesh Iyer
the marketing personnel have gotten a little more
sophisticated in following the consumer model for copy
development and what the creative strategies look like
(Johnsen, 2004).
However, some new ideas should be used sparingly and
only for appropriate products. Remember always that your
customer is a patient first, and a consumer only after
that. Achieving the proper tone is everything. Appealing to
your audience at the proper level is everything. Offering
volume discounts for patients who must take a medication for
the rest of their lives makes sense, and helps the patient-
consumer. But the offer of buy-one-get-one-free will not
always be appropriate. Any marketing practice which gives off
echoes of the days when hucksters sold snake-oil to unwitting
townspeople will raise the calls for an end to DTC
advertising. But marketers who maintain credibility and
professionalism will thrive.
Changing the face of DTC advertising will require many
things, not the least of which is creativity. It is the new
challenge facing the marketers of direct-to-consumer
advertising.
Notes
1 Perez v. Wyeth Labs, 834 A.2nd 1247 [N.J. 1999].
2 MacPherson v. Buick Motor Co., III NE 1050, 1053 [NY
1916] (see Hall, 2004).
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March 12.
Doak, C.C., Doak, L.G. and Root, J.H. (1996), Teaching
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Philadelphia, PA.
Gatti, J. (2003), Study: DTC ads are driving strong
consumer awareness and response, Direct Marketing,
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Hall, T.S. (2004), Reimagining the learned intermediary
rule for the new pharmaceutical marketplace, Seton Hall
Law Review, Vol. 35, pp. 193-254.
Hoffman, J.R. (1993), Direct to consumer advertising of
prescription drugs: an idea whose time should not come,
British Medical Journal, Vol. 31 No. 980, pp. 1301-2.
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Hollon, M.F. (1999), Direct-to-consumer marketing of
prescription drugs: creating consumer demand, JAMA:
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promotional?, Drug Store News, August 23, p. 96.
Kaphingst, K.A. and DeJong, W. (2004), Market watch: the
educational potential of direct-to-consumer prescription
drug advertising, Health Affairs, Vol. 23 No. 4, pp. 143-51.
Lewis, C. (2003), The impact of direct-to-consumer
advertising, FDA Consumer, March-April, p. 9.
McLaughlin, G. (1969), SMOG grading a new readability
formula, Journal of Reading, Vol. 12 No. 8, pp. 639-46.
Mehta, A. and Purvis, S. (2003), Consumer response to
print prescription drug advertising, Journal of Advertising
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that make sense, FDA Home Page, available at: www.fda.
gov/ fdac/features/1998/ 198_ads.html
Pollack, A. (2005), Marketing a disease, and also a drug to
treat it, New York Times Online, available at: www.nytimes.
com/2005/05/09/business/09avanir.html
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age, FDA Consumer Magazine, July-August, available at:
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 Pharmaceutical marketing on the internet:
marketing techniques and customer profile
Calin Gurau
Groupe Sup. de Co. Montpellier, Montpellier, France

Abstract
Purpose Attempts to investigate the perceived advantages and risks associated with online pharmaceutical transactions, and on this basis, to
propose a specific segmentation of consumers.
Design/methdology/approach Analyses the marketing procedures applied by pharmaceutical sites to emphasise the specific advantages and to
minimise the perception of transactional risks, as well as the segmentation techniques applied online.
Findings The results of the study indicate the existence of four main consumer categories. This schematic categorisation needs further development,
in order to define more precisely the decision taking process and the online shopping behaviour for each customer segment, as well as the level of post-
purchase satisfaction. On the other hand, the paper demonstrated that the marketing approach of various online pharmacies is determined by the
transactional model applied.
Originality/value The empirical analysis presented in this paper should be complemented by future qualitative study, in order to facilitate a deeper
understanding of the factors determining the growing success of online pharmacies.

Keywords Pharmaceuticals industry, Consumer psychology, Marketing strategy, Internet

Paper type Research paper

An executive summary for managers and executive
readers can be found at the end of this issue.
Introduction
The explosive development of the internet in the last ten years
has created new commercial opportunities. Despite the strict
regulations enforced by national states, the commercialisation
of medicines was introduced with success on the web by an
increasing number of online pharmacies. The therapeutic
products sold on the internet include over-the-counter (OTC)
and prescription drugs, as well as alternative remedies,
vitamins and nutraceutical supplements (Smith et al., 2002).
In most cases, the drugs sold online have lower prices that the
offer on the classical market (Sweet, 2001), either because the
pharmacies outsource generic drugs from developing
countries, or they take advantage of price differentials
introduced by health system regulations in different
countries (such as the difference between the medicines
prices in the USA and in Canada). This issue has created a
heated debate between national regulatory bodies, consumer
groups, and the large pharmaceutical companies.
In the USA, The American Medical Association and the
Food and Drug Administration (FDA) declared that doctors
who issue prescriptions without personally examining the
patient are engaging in substandard health care. FDA has
strongly recommended consumers to not buy drugs from
The Emerald Research Register for this journal is available at
www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0736-3761.htm
online pharmacies that offer an online consultation and
prescription (Rowland, 2005). However, on the other hand,
the practice of prescribing without a physical examination
does not violate the US federal law, as long as the sites do not
dispense narcotics or other controlled substances.
Despite the strong warnings launched by governmental
agencies, the online sales of medicines seem to prosper: in the
last trimester of 2004, 17.4 million Americans have visited
online pharmacies, an increase with 36 per cent compared
with the third trimester of 2004 (Rowland, 2005). A study
conducted by comScore Networks reported that the main
advantage sought by online buyers is price nearly two-thirds
of respondents used online pharmacies to save money. Also,
66 per cent of respondents considered that online pharmacies
provide a healthy competition to regular pharmacies (Kerner,
2005).
Customer satisfaction with online prescription drug buying
is high. A study conducted by eMarketer (2004) indicated
that only 10 per cent of the respondents felt less satisfied with
buying their drugs online than through a traditional
pharmacy, 32 per cent were more satisfied with the
experience, and 56 per cent were equally satisfied.
In Germany, the trend is similar: in 2004, 1.7 million
people have bought medicines over the Internet, which is
almost double the figure from previous year (Gfk, 2005).
Considering this situation, the present paper attempts to
investigate the perceived advantages and risks associated with
online pharmaceutical transactions, and on this basis, to
propose a specific segmentation of consumers. On the other
hand, the study analyses the marketing procedures applied by
pharmaceutical sites to emphasise their specific advantages
and to minimise the perception of transactional risks, as well
as the segmentation techniques used online.

Journal of Consumer Marketing

Online pharmaceutical marketing
22/7 (2005) 421 428
q Emerald Group Publishing Limited [ISSN 0736-3761]
The internet represents an attractive alternative channel for
[DOI 10.1108/07363760510631165] gathering information and purchasing healthcare products

421
 Pharmaceutical marketing on the internet
Calin Gurau
(Kanungo, 2004; Klein-Fedyshin, 2002). The US and
European audience for online health information is
substantial and growing. Web sites have become just as
important as some offline sources of health information. A
study published by Datamonitor in 2002 indicated that 57 per
cent of those who looked for health information in the past 12
months consulted internet sources (Datamonitor, 2002).
The deficiencies of regular medical services, such as long
waiting list, insufficient doctors and poor service quality, have
determined people to search for more efficient ways to treat
their diseases. For the elderly, ill, handicapped, or isolated
consumers, online health information and drug sales with
home delivery can be lifesavers. Other customers are attracted
by low prices, the virtual anonymity, or the discreet delivery
promised by online pharmacies (Spain et al., 2001).
The old people are particularly attracted by the
transactional convenience of the web. Wilson Health
Information (2005) reports that only 10.7 of the people
under 50 use online pharmacies as the preferred channel of
medication; but for the customers between 50 and 65 years
old, the percentage increases to 21.6 per cent, and for people
older than 65 years to 23.9 per cent.
Pharmacychecker (2004), an organisation specialised in
evaluating and validating the profile and the activity of online
pharmacies, has identified the following benefits of buying
medicines from the web:
.
Lower prices: lower drug prices in some countries, and
lower overhead costs compared to brick and mortar
pharmacies often result in savings compared to local
pharmacy prices. In addition, the Internet offers
specialised tools that can provide a quick comparison of
prices available in various online pharmacies.
.
Privacy/anonymity: some customer feel more comfortable
purchasing or asking questions online, for certain
medication as for example the so called lifestyle
drugs, treating obesity, hair loss or male impotence.
.
Access to more generic drugs: due to difference in patent
protection, more generic drugs can be available in foreign
countries, for medicines sold on the local market only
under branded names.
. Prescription not needed: some web sites do not require any
prescription for the medication sold, even when the drugs
are regulated in the domestic market. Other sites offer to
write a prescription based on an online consultation/
questionnaire.
.
Convenience: for people in remote rural areas, handicapped
or old customers, ordering online can be more convenient
than the physical visit to a pharmacy, especially when the
medicines are delivered by mail at their domicile.
.
Medical information: some pharmaceutical sites provide
rich information about diseases, symptoms and
medication, as well as links to other medical resources,
such as universities, specialised government agencies and
health organisations.
The same organisation has also outlined the associated risks
with the online purchase of medicines:
.
some web sites are not licensed pharmacies;
.
some online pharmacies do not adequately protect the
privacy of customers, selling personal information to third
parties; the web line for online payments might not be
secured;
422
Journal of Consumer Marketing
Volume 22 Number 7 2005 421 428
.
some online pharmacies do not give their address and/or
telephone number, which reduces the possibility to
contact them directly or to send a complaint;
.
additional fees are sometimes added to the drug price,
such as medical fees, order fees and/or account set up fee;
.
prices can change quickly online pharmacies reserve the
right to update their prices, some very frequently;
.
some online pharmacies do not provide adequate
protection for customers health: the sale of drugs
without a proper prescription, health history or a
medical exam, can be sometimes dangerous, due to
possible incompatibilities with the patient or with
additional medication.
Despite the importance of this phenomenon, there are very
few academic studies that analyse the marketing techniques
used by online pharmacies, or the profile of customers
(Maddox, 1999). Most of the publications published on this
topic focus on the legal/regulatory issues (Spain et al., 2001;
Sweet, 2001), analyse the impact of online sales on traditional
pharmacies (Schmidt and Pioch, 2003), or present isolated
cases of online marketing of medicines (Sweet, 2001; Wrobel,
2002). However, the existing interest for this topic is
indicated by the rich offer of professional reports, published
by market research organisations (Datamonitor, 2002; Gfk,
2005; Wilson Health Information, 2005).
In order to fill this empirical gap, the present study focuses
on the following research objectives:
.
To identify the advantages and risks associated with the
online commercialisation of medicines.
.
To investigate the consumers perceptions regarding
online pharmacies and their activity.
.
To identify the profile of various consumer segments that
would buy medicines online.
.
To analyse the marketing techniques used by online
pharmacies to emphasise the advantages, reduce the
perceived risk of internet sales, and segment the market.
After the presentation of the research methodology applied to
collect and analyse primary and secondary data, the findings
are discussed in direct relation to the formulated research
objectives. The paper concludes with a summary of research
findings and with propositions for future research projects.
Research methodology
To answer the research objectives presented above, both
secondary and primary data were collected and analysed. In
the first stage of the research process, secondary information
about the pharmaceutical sector, pharmaceutical marketing,
and online pharmacies were accessed using the academic and
professional literature, as well as the Internet. This
information facilitated the understanding of the main
advantages and risks related with online pharmacies, as well
as the specific application of pharmaceutical marketing
techniques on the internet.
In the second stage of the research project, a semi-
structured questionnaire was applied to 300 UK consumers.
The respondents were contacted in the city centre of five large
UK cities (60 respondents in each city), by applying a random
sampling technique, during May-June 2004. The questions
focused on the respondents perception about the advantages
and the risks related with online pharmacies, as well as the
consumer behaviour concerning the purchase of drugs on the
 Pharmaceutical marketing on the internet Journal of Consumer Marketing
Calin Gurau Volume 22 Number 7 2005 421 428

internet (type and location of preferred online pharmacies, The use of online pharmacies services
source of medicines). These data were then processed using A total of 102 respondents (34 per cent) indicated that they
the SPSS software for data analysis. buy or consider buying medicines over the net; 130 answered
Finally, in the third stage of the research project, the sites that they do no want to use the services of online pharmacies
on 300 online pharmacies were accessed, and the main (43.3 per cent), and 68 (22.7 per cent) said that they do not
marketing procedures used by online pharmacies were know, or it depends on particular circumstances. All online
identified and analysed. The survey also collected data buyers were exclusively using the NHS.
concerning the methods used by pharmaceutical web sites to Table I shows that the localisation of online pharmacies
segment the online population of customers. These data were (country of registration) and the country-of-origin of drugs
again analysed using the SPSS package. sold on the web, influences the choice of online buyers. The
large majority of respondents would only buy online from
Analysis and interpretation of data pharmacies located in economically developed countries that
have a clear system of drug regulation and high standards of
The socio-demographic profile of respondents quality (96.1 per cent of respondents). The respondents are
A total of 173 (57.7 per cent) of the respondents were male even stricter with the country-of-origin of the medicines
and 127 (42.3 per cent) female. 42 respondents were between acquired online 97.1 per cent want their drugs to originate
18 and 25 years old (14 per cent), 57 between 26 and 35 (19 from economically developed countries. However, in this case
per cent), 85 between 36 and 45 (28.3 per cent), 60 between a lower proportion of respondents indicated that they will buy
46 and 60 (20 per cent), and 56 older than 60 (18.7 per cent). only drugs produced in the UK, since it is common
86 (28.7 per cent) respondents had a low level of revenue (less knowledge that the pharmaceutical industry is a global sector.
than 1000 per month), 134 (44.7 per cent) a medium level
(between 1,000 and 2,000 per month), and 80 (26.7 per The perceived advantages and risks of online
cent) a high level of revenue (more than 2,000 per month). pharmacies
In order to understand the consumers behaviour and The results presented in Tables II and III indicate that
attitudes towards online pharmacies, it is important to assess consumer decision on using or not online pharmacies
the particularities of the UK National Health System (NHS). represent a complex, multidimensional process. Both buyers
In UK, the patients need to register to a medical surgery, and non-buyers are aware of the advantages and risks involved
which usually has more general practitioner (GP) doctors. in online transactions, however, the overall perception of
These doctors provide a wide range of family health services buyers is more positive proportionally, more online buyers
such as: advice on health problems, vaccinations,
examinations and treatment, prescriptions for medicines,
and referrals to other health and social services. Most Table I The preferences of online buyers concerning the location of the
surgeries can also provide family planning/contraception pharmacy and the country-of-origin of the drugs acquired on the
services, care during pregnancy, child health checks and internet
immunisations, health promotion/health screening services, Localisation of Country-of-
and other minor operations and procedures. The doctors can pharmacy origin of drugs
be seen on appointment, which can be sometimes quite long Possible answers n % n %
(three to ten days), depending on the number of patients
registered and on specific circumstances. However, there is UK only 35 34.3 14 13.7
also an emergency service for special cases. EU countries 36 34.4 40 39.2
The patients that require specialist consultation need a Economically developed
recommendation from the GP surgery. For cases that are not countries (e.g. EU
considered emergencies, the waiting list for a specialist countries, US, Canada,
consultation or operation can be as long as 6 to 12 months. Australia, etc.) 27 26.4 45 44.1
People with high revenues can register in a private medical Any country 4 3.9 3 2.9
system - The British United Provident Association (BUPA), Total 102 100 102 100
which has its own network of GPs, specialists, clinics and
hospitals. It is also becoming more common for people to
travel to Belgium, France, Germany, but also India or China,
to have their operations cataracts, hip replacements, Table II The advantages of online pharmacies perceived by various
hernias, heart by-pass surgery, gallbladder removal, etc. categories of respondents
These operations are performed at reputable hospitals to the Do not
same high standard as in the UK, but for less money than is Buy buy
usually charged in the UK private system. Category of respondents/ online online
Once a GP or a specialist prescribes a treatment, the patient perceived advantages of online pharmacies n % n %
can buy the medicines from a pharmacy, for a fixed,
affordable, price per medicine. The difference between the Price 78 76.5 75 57.7
real cost of a drug and the price paid by the patient is covered Convenience 76 74.5 35 26.9
by the NHS. The GP and the specialist consultation are also Choice 39 38.2 28 21.5
covered, entirely or in a high proportion, by the NHS. Anonymity 68 66.7 44 33.8
The majority of respondents were using only the National Information 72 70.6 51 39.2
Health System (262 87.3 per cent), and 38 were registered Total 102 100 130 100
with BUPA.

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Table III The risks of online pharmacies perceived by various Table V Cross-tabulation between the perceived risks of online
categories of respondents pharmacies and the gender of online buyers
Do not Male Female
Buy online buy online Chi-square
Perceived risks of online pharmacies n % n % Gender/perceived risks n % n % test values
Lack of proper license 32 31.4 87 66.9 Lack of proper license 15 24.6 17 41.5 3.242 p 0:072
Privacy 28 27.4 86 66.1 Privacy 12 19.7 16 39 4.611 p 0:032
Security of online payment 23 22.5 90 69.2 Security of online payment 9 14.8 14 34.1 5.280 p 0:022
Additional charges 22 21.6 79 60.8 Additional charges 7 11.5 15 36.6 9.139 p 0:003
Quality of drugs 18 17.6 89 68.5 Quality of drugs 8 13.1 10 24.4 2.145 p 0:143
Superficial prescription 22 21.6 89 68.5 Superficial prescription 8 13.1 14 34.1 6.411 p 0:011
Total 102 100 130 100 Total 61 100 41 100

perceive benefits and less of them perceive risks, in

comparison with non-buyers. It is also interesting to note Table VI Cross-tabulation between the perceived advantages of online
that significant percentages of non-buyers consider online pharmacies and the revenue of online buyers
drug sales attractive because of lower prices (57.7 per cent), Low Medium High
and health information (39.2 per cent). Revenue/perceived Chi-square
The respondents indicated that the decision to buy online advantages n % n % n % test values
medicines involved in most cases a detailed cost (risks)/
benefits (advantages) analysis, determined by their Price 24 96 29 76.3 25 64.1 8.615 p 0:013
dissatisfaction with the regular medical system. After the Convenience 17 68 27 71.1 32 82.1 1.965 p 0:374
first experience with online pharmacies, many people Choice 7 28 11 28.9 21 53.8 6.522 p 0:038
continue to use their services because of the benefices Anonymity 14 56 25 65.8 29 74.4 2.332 p 0:312
provided and the high level of satisfaction. Information 14 56 27 71.1 31 79.5 4.054 p 0:132
The female online buyers seem to be more receptive to the Total 25 100 38 100 39 100
advantages offered by online pharmacies (see Table IV),
especially concerning price, choice, and information services,
but on the other hand, they are also more concerned about statistical differences between various categories of customers,
the risks of online transactions the differences between male it can be noted that these advantages are positively considered
and female buyers regarding online privacy, security of online
by a high proportion of high-revenue buyers.
payment, additional charges and the superficial prescription
Table VII shows that there are no clear trends in the
of drugs are statistically significant to a level of p , 0:05 (see
perception of risks by various categories of online buyers. As it
Table V). These results indicate the need of market
is logical, many low-revenue customers are concerned about
segmentation, and the application of differentiated
marketing procedure to attract potential customers and the security of online payment. On the other hand, the high-
maintain the existing ones. revenue customers present the higher percentages concerning
The revenue of online buyers is significantly shaping their perceptions about possible lack of proper license, privacy,
perceptions about web-based pharmacies (see Table VI) in the quality of drugs, and superficial prescriptions. These
case of price advantage the lower the revenue, the higher is responses probably indicate a request for high quality
the percentage of people perceiving this advantage; and for services, for which they might be willing to pay additional
the choice offered online the higher the revenue of charges.
respondents, the higher is the proportion of people The data presented in Table VIII supports the previous
appreciating the advantage. Although the convenience of findings regarding the preference of various age categories to
online shopping, the virtual anonymity, and the health
information published online have not indicated significant Table VII Cross-tabulation between the perceived risks of online
pharmacies and the revenue of online buyers
Table IV Cross-tabulation between the perceived advantages of online Low Medium High
pharmacies and the gender of online buyers Revenue/perceived Chi-square
Male Female risks n % n % n % test values
Chi-square
Lack of proper license 5 20 13 34.2 14 35.9 2.015 p 0:365
Gender/perceived advantages n % n % test values
Privacy 6 24 10 26.3 12 30.8 0.390 p 0:823
Price 42 68.9 36 87.8 4.895 p 0:027 Security of online
Convenience 45 73.8 31 75.6 0.044 p 0:834 payment 8 32 6 15.8 9 23.1 2.279 p 0:320
Choice 16 26.2 23 56.1 9.262 p 0:002 Additional charges 4 16 9 23.7 9 23.1 0.611 p 0:737
Anonymity 39 63.9 29 70.7 0.510 p 0:475 Quality of drugs 4 16 5 13.2 9 23.1 1.365 p 0:505
Information 36 59 36 87.8 9.788 p 0:002 Superficial prescription 4 16 6 15.8 12 30.8 3.160 p 0:206
Total 61 100 41 100 Total 25 100 38 100 39 100

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Table VIII Cross-tabulation between the perceived advantages of online pharmacies and the age of online buyers
18-25 26-35 36-45 46-60 60 <
Chi-square test
Age/perceived advantages n % n % n % n % n % values
Price 14 93.3 13 76.5 24 66.7 16 72.7 11 91.7 6.005 p 0:199
Convenience 8 53.3 10 58.8 26 72.2 20 90.9 12 100 13.064 p 0:011
Choice 3 20 4 23.5 15 41.7 10 45.5 7 58.3 6.386 p 0:172
Anonymity 7 46.7 12 70.6 27 75 17 77.3 5 41.7 8.431 p 0:077
Information 7 46.7 12 70.6 26 72.2 16 72.7 11 91.7 6.797 p 0:147
Total 15 100 17 100 36 100 22 100 12 100

shop online medicines (Wilson Health Information, 2005).
The older respondents (more than 60 years old) have clearly
indicated the convenience of online shopping as a significant
advantage, but also the availability health information and the
low price. Price is also important for the majority of young
buyers (18-25 years old), while anonymity is important for a
large percentage of middle-age customers (26-60 years old),
probably as a result of their active social and professional life.
Table IX indicates that although the old customers can
represent an important target for online pharmacies, a
relatively large percentage of these buyers are concerned
about the risks of online transactions. These findings outline
the need for friendly customer interfaces and the
dissemination of information explaining in detail the
functioning of online pharmacies and the mechanism of
online transactions.
The transactional models used by online pharmacies
Not all online pharmacies use the same transactional model.
The analysis of secondary data Pharmacychecker (2004),
combined with the information collected through the survey
of 300 web sites of online pharmacies indicated four main
alternatives:
(1) Model A. The customer is required to send an existing
prescription, written by a licensed doctor, either by post,
fax, or e-mail. The validity of the prescription is than
verified by the pharmacist, who eventually approves the
online transaction. After the customer pays using online
systems, the medicines are delivered to his/her address.
Usually the medicines are delivered directly to the patient,
who has to provide a valid identification document and to
sign for their receipt. In some cases, the customer is also
required to provide the contact address of the doctor who
gave the prescription, in order to facilitate the validation
process. Most of these online pharmacies are selling
medicines only nationally, many of them representing
online alternatives of existing regular pharmacies.
(2) Model B. The online pharmacies applying this
transactional model ask customers to register, and then
to fill in and submit an online questionnaire requiring
information about the symptoms/disease of the patient,
his medical history, and his/her specific level of
responsibility (the patient has to acknowledge that he/
she has submitted truthful information and assumes
responsibility for the online order of drugs). Based on the
submitted information, a doctor prescribes a treatment,
and the online pharmacy sells the drugs to the patient.
These pharmacies usually sell internationally, and use a
system of additional delivery charges. Although remote
medical consultations are legal in many countries, this
model was strongly criticised in the professional
literature for failing to provide the required standards
of healthcare, because of the superficial nature of online
consultation (Rowland, 2005; Sweet, 2001). There are
also other possible risks associated with this system: it is
difficult to verify if the questionnaire was really analysed
by a licensed doctor, and sometimes the customers
themselves might provide false information in order to
obtain a specific medicine.
(3) Model C. This transactional model presents the highest
level of risk, since the medicines are sold without
prescription. These sites clearly indicate that the
responsibility for the selection and the purchase of
drugs is entirely assumed by the buyer. Usually these
pharmacies attempt to limit the perceived risk by stating
that they are not selling and delivering any illegal drugs.

Table IX Cross-tabulation between the perceived risks of online pharmacies and the age of online buyers
18-25 26-35 36-45 46-60 60 <
Chi-square test
Age/perceived risks n % n % n % n % n % values
Lack of proper license 2 13.3 3 17.6 13 36.1 9 40.9 5 41.7 5.650 p 0:227
Privacy 1 6.7 3 17.6 12 33.3 7 31.8 5 41.7 6.128 p 0:19
Security of online payment 2 13.3 2 11.8 10 27.8 4 18.2 5 41.7 5.177 p 0:27
Additional charges 0 0 1 5.9 9 25 5 22.7 7 58.3 16.454 p 0:002
Quality of drugs 0 0 1 5.9 7 19.4 3 13.6 7 58.3 18.826 p 0:001
Superficial prescription 2 13.3 3 17.6 6 16.7 4 18.2 7 58.3 11.005 p 0:027
Total 15 100 17 100 36 100 22 100 12 100

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They are selling internationally, and their headquarters respondents, maybe because of their clear conformity with
are located in developing countries. safety standards and regulations. Among all categories of
(4) Model D. These pharmacies sell only non-prescription respondents, the younger customers (18-25 years old) have
drugs, including vitamins, dietary supplements and shown the stronger willingness to buy from Model C
homeopathic remedies. The online customers can freely pharmacies (53.3 per cent) (see Table XII).
select and order the remedies, although the quantity of
drugs that can be purchased in one transaction is limited. Marketing procedures applied by online pharmacies
Despite the lower risks presented by these medicines, The mix of perceived advantages and risks associated with
there can still have secondary negative effects, which are online medical transactions indicates the necessity of an active
usually presented in detail by most of these web sites, in marketing strategy. The online pharmacies can increase the
order to offer the customer an informed choice. Many of acceptance of their offer and transactional model by providing
these outlets sell internationally, although there are cases on their web sites information that, on one hand, explain the
of sites that distribute only nationally or regionally, to selling process and provide guarantees reducing the
avoid possible incompatibilities between different perceived risks, and, on the other hand, that emphasise the
national regulations regarding OTC drugs. advantages of an online transaction. These organisations can
also increase the effectiveness of their communication
Table X presents the preference of male and female customers
strategy, by creating procedures for an effective
for various transactional models (the respondents were
segmentation of the online market.
required to indicate all the models that they use or would
Table XIII presents the information categories identified on
use to buy drugs online). The male customers prefer in a
the surveyed web sites, that can reduce the perceived risk of
slightly higher proportion the first transactional model (and
online transactions. All types of online pharmacies provide
the less risky one) than the female respondents. On the other
contact information, although the level of detail differs: in
hand, a very high percentage of women are inclined to buy
some cases only a brief postal address and/or an email address
drugs from non-prescription outlets (85.4 per cent), which
is published online, while the majority of sites include also the
can be explained by their high consumption of dietary and
telephone and the fax number. A large percentage of Model A
natural remedies.
pharmacies publish a privacy policy, information about the
The higher percentages of online buyers in all transactional
security of payment, and about their licence. At the other
models are the low-revenue customers, while the high-
extreme, many no prescription needed sites attempt to
revenue buyers clearly prefer less the web sites selling
reduce the perception of risk by providing information about
medicines without prescription (only 17.9 per cent of this
the source of their drugs. Many Model B sites are also
category of respondents indicated that they would buy from
characterised by a high level of transparency and details, that
this type of outlets) (see Table XI).
try to reassure customers about the feasibility of remote
The older customers prefer in large numbers the online
medical consultations.
pharmacies using models A, B and D, but they show a clear
In order to enhance the perceived advantages of online
avoidance of the no prescription required model. Overall,
transactions, the sites publish information concerning price,
the OTC pharmacies seem to be preferred by many
convenience, choice, and discreetness of service (see Table
XIV). In addition, many sites using the transactional models
B, C and D, that have the highest level of potential risks,
provide testimonials of existing customers to reinforce their
Table X Cross-tabulation between the transactional models of online positive messages.
pharmacies and the gender of online buyers The advantage of price is not particularly emphasised by
Model A pharmacies since in some case the range of prices
Male Female
proposed is quite similar with the regular system; however,
Gender/online model n % n %
they try to outline the convenience of shopping online. Price,
Send prescription 41 67.2 25 61 convenience and discreetness of service are used as main
Online consultation and prescription 27 44.3 23 56.1 arguments by Model B and C pharmacies, some of them
No prescription required 18 29.5 14 34.1 being specialised in lifestyle pharmaceuticals, such as
OTC medicines 41 67.2 35 85.4 Viagra for erectile dysfunction, Propecia for hair loss or
Total 61 100 41 100 Xenical for obesity (Sweet, 2001). The influence of the
transactional model is statistically significant for all categories
of information presented online.
The segmentation techniques applied by online pharmacies
Table XI Cross-tabulation between the transactional models of online are strictly determined by the specific characteristics of the
pharmacies and the revenue of online buyers internet (see Table XV). Since the customer has the control
over the information that he/she accesses online, the
Low Medium High
procedures applied are self-segmentation mechanisms, such
Revenue/online model n % n % n %
as lists of diseases or drugs, that can be selected by the
Send prescription 18 72 24 63.2 24 61.5 internet user, or mini-search engines.
Online consultation and prescription 14 56 18 47.4 18 46.2 The large majority of sites are using a combined
No prescription required 11 44 14 36.8 7 17.9 segmentation, applying sometimes two or three different
OTC medicines 22 88 27 71.7 27 69.2 criteria, such as gender, age (by presenting gender-specific or
Total 25 100 38 100 39 100 age-specific treatments), and diseases. Overall, the system
applied on most sites includes a first list of diseases, and then,

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Table XII Cross-tabulation between the transactional models of online pharmacies and the age of online buyers
18-25 26-35 36-45 46-60 60 <
Age/online model n % n % n % n % n %
Send prescription 12 80 9 52.9 20 55.6 16 72.7 9 75
Online consultation and prescription 5 33.3 11 64.7 16 44.4 10 45.5 8 66.7
No prescription required 8 53.3 7 41.2 11 30.6 5 22.7 1 8.3
OTC medicines 14 93.3 13 76.5 24 66.7 15 68.2 10 83.3
Total 15 100 17 100 36 100 22 100 12 100

Table XIII Cross-tabulation between the transactional models of online pharmacies and the information categories presented online to reduce the
perceived risk
Model A Model B Model C Model D
Online model/information n % n % n % n % Chi-square test values
Contact information 86 100 147 100 18 100 49 100 N/A
Privacy policy 84 97.7 127 86.4 10 55.6 27 55.1 50.16 p , 0:0001
Payment security 81 94.2 139 94.6 9 50 38 77.6 41.527 p , 0:0001
Licence pharmacy 75 87.2 114 77.6 8 44.4 32 65.3 19.182 p , 0:0001
Licence doctor N/A 84 57.1 3 16.7 N/A 10.54 p 0:001
Source of drugs 35 40.7 104 70.7 14 77.8 26 53.1 23.701 p , 0:0001
Professional certification 6 7 5 3.4 0 0 11 22.4 21.26 p , 0:0001
Total 86 100 147 100 18 100 49 100

Table XIV Cross-tabulation between the transactional models of online pharmacies and the information categories presented online to enhance the
perceived advantages
Model A Model B Model C Model D
Online model/advantages n % n % n % n % Chi-square test values
Price 43 50 136 92.5 18 100 34 69.4 62.366 p , 0:0001
Convenience 64 74.4 121 82.3 15 83.3 16 32.7 46.781 p , 0:0001
Choice 23 26.7 78 53.1 15 83.3 36 73.5 37.905 p , 0:0001
Testimonials 26 30.2 115 78.2 16 88.9 36 73.5 62.471 p , 0:0001
Discreetness 12 14 124 84.4 17 94.4 25 51 122.137 p , 0:0001
Total 86 100 147 100 18 100 49 100

Table XV Cross-tabulation between the transactional models of online Concluding remarks

pharmacies and the criteria used for market segmentation
The popularity of online pharmacies represents an intriguing
Online model/ Model A Model B Model C Model D phenomenon. On one hand, most people acknowledge the
segmentation n % n % n % n % risks of online transactions, but on the other hand a high
Gender 14 16.3 38 25.8 3 16.7 21 42.8 proportion of customers that buy drugs online declare a high
Age 2 2.3 17 11.6 0 0 8 16.3 level of satisfaction. As any commercial activity, the success of
Disease 67 77.9 123 83.7 7 38.9 34 69.4 online pharmacies is directly related to their capacity to
Medicine 12 13.9 6 4.1 11 61.1 15 30.6 segment the market, understand the customers and satisfy
Total 86 100 147 100 18 100 49 100 their needs. The popularity of professional market reports
that analyse consumer preferences and profiles prove the
importance of this marketing approach.
for each disease, a range of specific drugs. A large majority of This paper attempted to investigate and present the
no prescription needed sites offer only a list of drugs or a perceptions of UK customers about the advantages and the
mini-search engine, since the customer is supposed to select risks of online health transactions, and the marketing
him/herself the medication. procedures applied by online pharmacies to modify and/or
On the other hand, almost all sites require customer reinforce these perceptions. The information presented
registration, a procedure that collects general socio- permits the definition of specific consumer profiles:
demographic and medical information about buyers, which .
Consumer A: young, with low revenues, less interested in
can be eventually used for database analysis and online service quality and less sensitive to online risks, but
segmentation. concerned about price and online payment security.

427
 Pharmaceutical marketing on the internet
Calin Gurau
.
Consumer B: middle-aged, with good purchasing power,
requiring privacy and discreetness of delivery.
.
Consumer C: middle-aged, high-revenue customer that
requires a high service quality, anonymity, rich online
information and choice.
.
Customer D: old-aged, with low or medium purchasing
power, attracted by the convenience of online shopping
and home delivery, but highly concerned about online
transaction risks.
This schematic categorisation needs further development, in
order to define more precisely the decision taking process and
the online shopping behaviour for each customer segment, as
well as the level of post-purchase satisfaction.
On the other hand, the paper demonstrated that the
marketing approach of various online pharmacies is
determined by the transactional model applied. Model A
pharmacies emphasise their compliance with national health
regulation standards, and propose an alternative channel of
drug distribution, that for specific categories of customers
might be more convenient than the regular pharmaceutical
system. Considering that often these pharmacies have also a
physical presence in the pharmaceutical distribution, their
strategy can be considered as a diversification/development of
classical retail channels, to a bricks and clicks model.
On the other hand, the pharmacies that offer remote
consultations, or that do not require any medical prescription,
attempt to create an image of transparency and honesty by
providing detailed information about the online transaction
system, security of payment, and origin of drugs.
Finally, the pharmacies specialised in OTC remedies
emphasise the low prices and the rich choice offered by
their sites.
The present study has a number of limitations, determined
by its exploratory nature. The number of people and online
pharmacies included in the study were relatively small,
although the representativity of the sample permits the
generalisation of findings. The profiles of online customers
presented in this paper is valid only for the UK market, since
national and cultural conditions can determine specific
customer behaviour and preferences. From this perspective,
the findings can be used as a starting basis for future research
on this topic. A replication of this research methodology in
other countries can provide an opportunity for comparison
studies at international and transnational level.
On the other hand, the quantitative analysis presented in
this paper should be complemented by qualitative
information, in order to facilitate a deeper understanding of
the factors determining the growing success of online
pharmacies. Despite the risks created by some illegal web-
based organisations, it would be a mistake to demonise the
entire phenomenon. In fact, their very existence and
development proves that online pharmacies answer to a real
and present need expressed by customers. The online sales of
drugs should be surely improved, and the best way forward
428
Journal of Consumer Marketing
Volume 22 Number 7 2005 421 428
might be a stricter regulation of medicines sales at
transnational level, combined with better customer education.
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Direct-to-consumer advertising of prescription
drugs: help or hindrance to the publics health?
Greg Finlayson
Manitoba Centre for Health Policy, Community Health Sciences, University of Manitoba, Winnipeg, Canada, and
Ross Mullner
School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA

Abstract
Purpose The purpose of this paper is to review the issues regarding direct-to-consumer advertising that have been identified in the literature from
the perspective of consumers, consumer groups, physicians, the medical profession and the pharmaceutical industry.
Design/methodology/approach Literature from international sources was reviewed to identify themes relating to direct-to-consumer advertising.
Findings Direct-to-consumer advertising is expressly permitted in only two developed countries (USA and New Zealand). All other countries place
various limitations on the practice. The debate surrounds whether or not the advertising provides a public health benefit.
Originality/value The debate over direct-to-consumer advertising continues in jurisdictions around the world. This paper identifies and summarizes
the issues that are being considered.

Keywords Prescription medicines, Pharmaceuticals industry, Advertising, Public health, Health education

Paper type General review

An executive summary for managers and executive
readers can be found at the end of this issue.
Introduction
Pharmaceutical companies in the USA spent $3.45 billion on
direct-to-consumer advertising (DTCA) of prescription drugs
in the year ending March 31, 2004 (Lam, 2004). This
represents a substantial operating expense for the companies,
and the trend over the past few years is to spend an increasing
proportion of marketing budgets on DTCA. The USA is only
one of two industrialized countries in the world that expressly
permits DTCA of prescription drugs. In New Zealand, the
other country that currently allows DTCA, the issue has been
hotly debated over the past several years as a result of a treaty
between that country and Australia that would result in a
common drug standard between those two countries.
However, DTCA is not permitted in Australia, and several
professional and consumer organizations are supporting the
implementation of a ban in New Zealand. In the United
States no such debate is apparent.
This article will review the main arguments posited by both
sides of the debate. While New Zealand is considering
banning DTCA, other countries including Canada and the
countries of the European Union are considering relaxing
their restrictions on the practice.
The Emerald Research Register for this journal is available at
www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0736-3761.htm
Journal of Consumer Marketing
22/7 (2005) 429 431
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631174]
Direct-to-consumer advertising of prescription drugs can be
defined as the presentation of messages regarding
pharmaceuticals directly to the public. Strictly speaking, in
countries where DTCA is prohibited, no information about
prescription drugs may be provided to the general public
through print or the electronic media such as radio or
television. However, in practice, such bans may not be total.
For example, in Canada advertising of a product is permitted,
but only if the medical condition it is designed to treat is not
indicated; or a medical condition that may be treatable by a
drug can be presented, but the product that could be used
may not be mentioned. Further, marketing information on
drugs is readily available through the internet.
Those who support DTCA argue that drug advertising is a
form of public health education that will ultimately result in
the improved health status of the population. Detractors of
DTCA, however, see it as being exclusively driven by a profit
motive, and they argue that it encourages excessive,
unnecessary, and potentially dangerous use of prescription
drugs. The main arguments of both groups are presented
below.
DTCA is important for health education
The pharmaceutical industry actively promotes DTCA as a
method of getting important health information to the general
public. Pharmaceutical advertising messages make the public
aware of the availability of treatments, and it encourages them
to see a physician to talk about their health problems. Indeed,
appropriate messages could be a valuable public health tool
(Berndt, 2005). DTCA may result in people seeing physicians
earlier, receiving treatment earlier, and potentially avoiding
future medical complications. In addition, advertising may
result in people who would not otherwise have seen physicians
to make appointments, possibly allowing other health
problems (i.e. hypertension, diabetes, heart disease) to be
identified and treated (Holmer, 2002). Some consumer

429
 Direct-to-consumer advertising of prescription drugs
Greg Finlayson and Ross Mullner
groups agree with the pharmaceutical industry, and provide
additional support for DTCA.
Starting in the twentieth century and continuing today,
there has been a growing consumer movement directed to
empowering the public to take greater control of their health.
This has resulted in increased demands for information about
medical conditions and health care, and a heightened need for
physicians and other health professionals to disclose to, and
educate, their patients. Further, there has been an increase in
the medicalization of various human conditions. Medical care
is now expected to provide treatments for conditions that were
previously considered to be societal problems, such as
alcoholism, drug addiction, and domestic violence. As a
result of these two trends, the general public has an increasing
interest in prescription drugs. They also have heightened
expectations that drugs can be used to treat a wide array of
medical conditions. While physicians recognize the limitations
of drugs, they may also support DTCA because of the impact
that it can have on their practices, and the care they can
provide to their patients.
Studies have shown that DTCA increases the utilization of
physician services (Holmer, 2002). If a person sees a
physician earlier for a health problem, the physician may be
in a better position to provide treatment. Having a medical
appointment also allows the assessment of other possible
medical problems, which may allow prevention or treatment
that would not otherwise be possible. From a physicians
perspective, these are good reasons to allow and support
DTCA. Finally, physicians who receive fee-for-service
payments would expect to receive increased income due to
seeing more patients. Proponents of DTCA include the
pharmaceutical industry, the general public, and many
physicians.
DTCA is contrary to the public interest
Education in general, and health education in particular, is
considered important. What is it about the provision of
prescription drug information directly to the public in the
form of advertising that is objectionable to some?
In general, the argument is that DTCA is different from
other forms of health education because prescription drugs
are only one component of the health care system, and should
not be removed from the context of a continuing relationship
between a patient and their physician. As well, prescription
drugs may be considered different from other drugs (i.e. over-
the-counter drugs) in that they are generally used to treat
medical conditions that are more difficult to self-diagnose,
and may be more toxic than other drugs. In addition to these
general concerns, some consumer groups and some
physicians present additional arguments against DTCA.
Those who support the restriction of DTCA believe that
the primary motivation of the pharmaceutical industry is to
produce as large a profit as possible, not to educate the public.
Hence, the foundation for advertising of prescription drugs is
potentially contrary to the publics interest. Some consumer
groups argue that DTCA should be banned because it
encourages the unnecessary utilization of drugs, thus
increasing the overall cost of health care. Further,
advertising primarily focuses on drugs that are new to the
market. These drugs frequently do not have a proven safety
record compared to older more established drugs. And, the
actual content of DTCA may maximize benefits and minimize
430
Journal of Consumer Marketing
Volume 22 Number 7 2005 429 431
potential risks. While some consumers have these concerns,
there are also issues raised by the medical profession.
Despite the fact that DTCA may motivate people to seek
medical care, many physicians are concerned about this type
of advertising. In particular, some physicians may feel
pressured to give a prescription, or to prescribe a particular
drug, when they would not have, had the patient not made a
specific request for it, placing a strain on the physician-patient
relationship. Further, when the physician deems the requested
drug to be inappropriate, they may need to spend additional
time with the patient to discuss why they will not issue the
prescription, or why alternative pharmaceutical or non-
pharmaceutical approaches may be preferred.
Is the evidence for either side conclusive?
In spite of much study, there are only a few aspects of the
issue for which there is strong evidence, either supporting or
refuting the arguments raised. Research has clearly shown that
DTCA does indeed affect consumer behavior. And, DTCA
does result in physicians prescribing more. For example,
between 1999 and 2000, prescriptions of the 50 drugs most
heavily advertised in the USA rose by 24.6 percent while the
prescriptions for the remaining 9,850 drugs rose only by 4.3
percent (National Institute for Health Care Management
Research and Education Foundation, 2001). This increased
utilization understandably results in an overall increase in the
nations expenditure for drugs.
What is the answer?
Countries around the world are debating the merits of
DTCA. Options range from an outright ban, to setting no
limitations whatsoever on the practice. Many countries in the
future are likely to allow some form of DTCA, but it seems
likely they will regulate it. For example, the New Zealand
Ministry of Health (Meek, 2001) has proposed the following
regulations:
.
Only allowing drug advertisements in the public media
such as newspapers, magazines, or on the radio and
television, and preventing the practice of drug companies
promoting pharmaceuticals by directly writing to
individual patients, running competitions, giving free
offers, and paying for physicians visits.
.
Banning advertisements by pharmaceutical companies of
brand names on vehicles such as buses, because it is
difficult for the public to read the mandatory risk
information.
.
Banning sponsorship of events by pharmaceutical
companies using a brand name, because it may promote
a drug name, but without the responsibilities.
.
Increasing fines for non-compliance with legislation and
regulations.
.
Specifying the length of time for television advertisements
for the mandatory risk information to be presented, as
well as the font size of the information.
.
Requiring voice-overs of risk information (mandatory in
the USA).
.
Shifting the onus from the complainant having to find an
example of the offensive advertisement to the
pharmaceutical company.
.
Requiring a fair balance of benefit and risk information
(again, required in the USA).
 Direct-to-consumer advertising of prescription drugs
Greg Finlayson and Ross Mullner
While there is little support for unrestricted DTCA, those
proposing a full ban on the practice recommend that state-
supported public education campaigns be used as a means of
making people aware of treatments that are available, and
encouraging them to see a physician. The inherent additional
cost to already stretched health care budgets makes this
alternative politically unattractive.
In the USA, where freedom of speech, including
commercial speech, is constitutionally protected, it is
unlikely that a full ban would be effected. However, there
have been limitations placed on DTCA by the Food and Drug
Administration (FDA), particularly the requirement to
include information on risks, and that this information be
provided in a way that it is accessible to consumers such as
voice-overs in television ads.
This article has outlined the main arguments in support of
and opposing direct-to-consumer advertising of prescription
drugs. The discussion is one that has increased in intensity in
recent years, and it is likely to continue for some time to
come. Countries around the world where the debate is taking
place will be looking for the best balance between educating
the consumer, and protecting them.
References
Berndt, J. (2005), To inform or persuade? Direct-to-
consumer advertising of prescription drugs, New England
Journal of Medicine, Vol. 352 No. 4, pp. 325-8.
Holmer, A.F. (2002), Direct-to-consumer advertising
strengthening our health care system, New England Journal
of Medicine, Vol. 346 No. 7, pp. 526-8.
431
Journal of Consumer Marketing
Volume 22 Number 7 2005 429 431
Lam, M.D. (2004), A $20 billion bill and plenty of change,
Pharmaceutical Executive, September.
Meek, C. (2001), Direct-to-Consumer Advertising of Prescription
Medicine: A Review of International Policy and Evidence,
Royal Pharmaceutical Society of Great Britain, London,
available at: www.rpsgb.org.uk/ pdfs/dtcarep.pdf
National Institute for Health Care Management Research and
Education Foundation (2001), Prescription Drugs and Mass
Media Advertising, 2000, NIHCM Foundation, Washington
DC, November, available at: www.nihcm.org/
DTCbrief2001.pdf
Further reading
Canadian Health Services Research Foundation (2004),
Myth: direct-to-consumer advertising is educational for
patients, Mythbusters, December, available at: http://chsrf.
ca/ mythbusters/pdf/ myth16_e.pdf
Jeffords, J.M. (2004), Perspective: direct-to-consumer drug
advertising: you get what you pay for, Health Affairs Web
Exclusive, April 28, available at: http://content.healthaffairs.
org/ cgi/reprint/hlthaff.w4.253v!
Kelly, P. (2004), Perspective: DTC advertisings benefits far
outweigh its imperfections, Health Affairs Web Exclusive,
April 28, available at: http://content.healthaffairs.org/ cgi/
reprint/hlthaff.w4.246v1
Mansfield, P.R., Mintzes, B., Richards, D. and Toop, L.
(2005), Direct to consumer advertising is at the crossroads
of competing pressures from industry and health needs,
British Medical Journal, Vol. 330, pp. 5-6.
Milne, C. (2004), Direct-to-consumer drug ads still raising
debate, The Medical Post, Vol. 20 No. 34.
 Herbal product claims: boundaries of
marketing and science
Stephanie Y. Crawford
Department of Pharmacy Administration, University of Illinois at Chicago, Chicago, Illinois, USA, and
Catherine Leventis
McKesson Medication Management, Chicago, Illinois, USA

Abstract
Purpose The purpose of this article is to explore boundaries in marketing and science with respect to labeled claims of herbal products and other
dietary supplements.
Design/methodology/approach Supplement manufacturers are allowed to include claims on product labels without meeting an acceptable
substantiation standard, as long as such claims are accompanied by an FDA disclaimer statement. While manufacturers are prohibited (though the
regulation is often violated) from making specific claims about prevention or treatment of disease, the implied associated health benefits of using
dietary supplement products are usually clear from marketed claims. A case example on themes expressed in labeled structure-function claims for
ginkgo biloba is presented to illustrate the issues.
Findings Marketing of product claims is controversial due to differing perspectives about the truthfulness of claimed health benefits and quality of
information presented to consumers. Although dietary supplements could have pharmaceutical-like properties, they are not required to demonstrate
safety and efficacy before market availability. The US Food and Drug Administration (FDA) can take action only if supplements are shown to be unsafe
after market introduction.
Practical implications The need for consumer choice, meaningful information and free-market access to dietary supplements must be balanced
with the demands for truth-in-advertising and consumer protection from unreliable claims and adverse health events. Marketing and policy implications
are described.
Originality/value The outcome would help increase consumer confidence, while continuing to allow free-market forces for the dietary supplement
industry, to a large extent.

Keywords Diet, Natural products, Marketing, Labelling

Paper type General review

An executive summary for managers and executive
readers can be found at the end of this issue.
Introduction
This article explores boundaries in marketing and science
with respect to the labeled claims of herbal products and other
dietary supplements. Use of herbal therapies in the USA
predates the nations founding, experiencing a golden age of
usage during the latter nineteenth and early twentieth
centuries.(Tyler, 2000) The popularity of herbal remedies
waned and usage curtailed in the 1940s with the advent of
breakthrough, synthetically-derived pharmaceutical agents.
Renewed interest in herbal remedies rebounded in America
over the past 15 years. During this period, consumer efforts
shifted from avoidance behaviors (e.g. of bad nutrients or
The Emerald Research Register for this journal is available at
www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0736-3761.htm
Journal of Consumer Marketing
22/7 (2005) 432 436
q Emerald Group Publishing Limited [ISSN 0736-3761]
[DOI 10.1108/07363760510631183]
unhealthy ingredients) to behaviors that promote health,
prevent or treat disease.(Mason and Scammon, 2000) From
1990 to 1997, sales of herbal remedies increased by 380 per
cent.(Eisenberg et al., 1998) Sales of herbal products are
estimated to be greater than $4 billion annually,(Mar and
Bent, 1999; Eisenberg et al., 1998) which represents a sizeable
portion of the $18 billion dietary supplement market (Morris
and Avorn, 2003).
Herbal therapies are used by approximately 38 million US
adults and are the most common form of complementary and
alternative medicine (Tindle et al., 2005). These products are
readily available for purchase in a variety of retail settings (e.g.
pharmacies, health food stores, grocery stores and
supermarkets, and mass merchandisers) and the internet.
Passage of the Dietary Supplement Health and Education Act
of 1994 (DSHEA) and its regulatory implementation led to
unprecedented growth in sales and widespread promotion of
herbal products and other dietary supplements (Morris and
Avorn, 2003; US Department of Health and Human Services,
US Food and Drug Administration, 2000). The associated
promotional activities have become increasingly contentious
due to differing perspectives about the reliability of claimed
benefits and quality of information presented to consumers
(Mason and Scammon, 2000). Debate centers around the
need for consumer choice balanced with truth-in-advertising
and consumer protection from unsubstantiated claims
(Nesheim, 1999; Ernst, 2001).

432
 Herbal product claims: boundaries of marketing and science
Stephanie Y. Crawford and Catherine Leventis
Background on regulation of dietary supplements
under DSHEA
The DSHEA defined dietary supplements as herbs or similar
botanicals, vitamins, minerals, amino acids, enzymes, organ
tissues and metabolites that are intended to supplement the
diet (US Food and Drug Administration, 1995). The
definition is limited to products that are taken by mouth,
e.g. capsules, tablets, liquids, powders and other oral
formulations (Nesheim, 1999). Dietary supplements are in a
distinct category, neither considered to be drugs nor
conventional foods, which raises questions about product
classification and regulation (Harris, 2000). Categorization of
dietary supplements is based more on labeling than biological
data (Lewis and Strom, 2002). Product labeling for herbs and
other dietary substances is regulated by the US Food and
Drug Administration (FDA) under a much less stringent
regulatory system than what exists for drug products (Morris
and Avorn, 2003). Product labeling for dietary supplements
includes the affixed label, packaging, inserts or point-of-sale
promotional materials (Harris, 2000).
Supplement manufacturers are responsible for ensuring
product safety before marketing. Unlike drug products,
dietary supplements are not required to demonstrate safety
and efficacy before market availability. Supplement
manufacturers establish their own guidelines for
manufacturing practices because good manufacturing
practices for the industry have not been developed
(Fontanarosa et al., 2003). With limited exceptions,
manufacturers of dietary supplements are not required to
obtain FDA approval before producing or selling the
products. The FDA has authority to take action if
supplement products are deemed unsafe after market
introduction (US Food and Drug Administration, 2005a),
i.e. if the product poses a significant or unreasonable safety
risk for consumers (Harris, 2000; Fontanarosa et al., 2003).
In the most serious cases, FDA actions could include product
seizure and pursuance of injunctions and sanctions. In reality,
though, the FDA has limited resources and insufficient
manpower for these activities. Misleadingly labeled products
could remain commercially available for months or years
before possible regulatory action ensues (Hampton, 2005).
While there are voluntary guidelines, no regulation exists to
ensure the identity, purity, quality, strength, and composition
of dietary supplements (Fontanarosa et al., 2003). Many
herbal products have some pharmaceutical-like properties.
While often touted as natural, they are not harmless. Dietary
supplements often act in ways similar to drugs and
consumption of large or small amounts may lead to side
effects and untoward interactions with drugs and other
substances. Concerns have also been raised because of limited
evidence on product consistency and standardization issues
(Mar and Bent, 1999; Harris, 2000; Tyler, 2000). Currently,
reporting on adverse events for herbal products and other
dietary supplements is on a voluntary basis only.
Scientists and many in the medical and health communities
have decried the lack of scientific justification to establish
safety and efficacy (Hampton, 2005; Harris, 2000; Morris
and Avorn, 2003; Tolstoi, 2001). Product sales are often
driven by non-scientific, anecdotal evidence (e.g. word of
mouth, consumer perceptions) of potential health benefits
and manufacturer-marketing justification through labeling
and advertising (Harris, 2000; Grivetti, 2002). Controversies
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Journal of Consumer Marketing
Volume 22 Number 7 2005 432 436
abound with respect to the safety concerns, as well as
unsubstantiated and unreliable claims of dietary supplements,
with calls for increased regulatory scrutiny over the dietary
supplement industry (Hampton, 2005).
Controversies over marketed claims of dietary
supplements
FDA regulatory authority over health claims in labels and
labeling of dietary supplements was restricted by the Pearson v.
Shalala [1999] court decision[1], which the agency complied
with in its final rule (US Department of Health and Human
Services, US Food and Drug Administration, 2000) The
court ruled that dietary supplement claims could be based on
less than a significant scientific agreement, as long as such
claims were accompanied by an acceptable disclaimer, as
described later in this section. If manufacturers or distributors
choose not to make a claim, no disclaimer is necessary
(Mason and Scammon, 2000).
Herbal products and other dietary supplements are
prohibited from using a disease or therapeutic claim. In
other words, dietary supplements may not imply a drug, nor
use statements that claim to prevent, diagnose, treat, mitigate,
or cure a specific disease (US Food and Drug Administration,
1995) For example, a dietary supplement cannot claim to
cure cancer or treat heart disease. Health maintenance
and non-disease claims are allowed for dietary supplements,
including minor, common symptoms associated with life
stages, e.g. hot flushes, mild memory loss related to aging
(Harris, 2000). DSHEA provides for use of three types of
other claims, as appropriate, on the labels of dietary
supplements nutrient content claim, health claims, or
structure-function claims.
Nutrient content claims pertain to relative amounts of
nutrient levels in dietary supplements, e.g. high or good
source of calcium, based on guidelines provided by FDA.
Health claims express the effect of a dietary supplement on
preventing or reducing the processes of a disease or other
health-related condition (US Food and Drug Administration,
2005b) As such, health claims must be evaluated and
authorized by FDA in the preapproval stage, based on
significant scientific evidence. Examples of health claims
include reduces the risk of osteoporosis (or other disease) or
does not promote tooth decay. Structure-function claims
do not require FDA pre-approval and may describe how a
dietary substance is intended to affect or maintain the
structure or function of the human body. Structure-function
claims may state benefits of the dietary supplement related to
nutrient deficiency, general well-being of product
consumption, and other statements regarding maintenance
of body structure and function (US Food and Drug
Administration, 2005b) Examples are promotes vitality or
helps maintain healthy heart function.
Structure-function claims are often included on labels of
herbal products. Statements on structure and function cannot
be false or misleading. However, if the claims are
unsupported, that would potentially make them false and
misleading. Structure-function claims, if present, must be
labeled with an FDA disclaimer. A typical disclaimer would
be:
This statement has not been evaluated by the Food and Drug
Administration. This product is not intended to diagnose, treat, cure, or
prevent any disease (US Food and Drug Administration, 2005b)
 Herbal product claims: boundaries of marketing and science
Stephanie Y. Crawford and Catherine Leventis
Tyler (2000) criticized the hypocrisy of the dual message in
allowing nebulous statements on product labels in reference
to structure and function, while requiring a follow-up
disclaimer. Accompanying the structure-function claim is
the paradoxical requirement of language that essentially states
the herb is not good for anything, i.e. no therapeutic claim
(Tyler, 2000). Consumers tend to disregard disclaimer
language since they purchased the herbal products with the
expectation of some beneficial health purpose. From a
scientific perspective, structure-function claims can be valid
only if the supplement displays inherent biological activity
(Fontanarosa et al., 2003).The disclaimer is often of limited
utility when present (Morris and Avorn, 2003). Readability
and effectiveness can be easily compromised, e.g. small font
size, separation of the claim from disclaimer (such as claim on
front of label and disclaimer on back; or one near top of label
and the other near bottom), or placing the claim in an
inconspicuous location. Consumers who read the disclaimers
may consider them to be confusing or hard to comprehend
(Mason and Scammon, 2000).
The differentiation between structure-function claims and
express or implied disease claims is sometimes hard to
distinguish. For example, the claim, maintains urinary tract
health is allowable, but treats urinary tract infections
would not be permitted since it refers to a specific disease.
Disease conditions are sometimes included on trademarked
product names, such as Migraine B-Gone, as well as
pictures, symbols and vignettes on product packaging (Harris,
2000).
Although the FDA does not approve structure-function
claims, manufacturers are required to notify the agency of
such labeled claims within 30 days of product marketing
(Nesheim, 1999; Harris, 2000). Manufacturers are also
required to have data that substantiate the truthfulness of
claims on file, although that data is not reviewed by FDA or
made public unless there is the need for enforcement action
post marketing (Nesheim, 1999). The lax nature of this
requirement for substantiation of claimed effects limits the
accessibility and scrutiny of information to consumers, health
clinicians, and researchers. Consumers are not seeing the
scientific data, if any, on which the claims are based. Rather,
consumers see the manufacturers interpretation of the data.
It is questionable if a consumer could understand the data;
however, the issue is raised about the availability or
accessibility of data. Consumers are generally unaware of
the type of evidence used to meet a substantiation standard,
the type of evidence on which the claim was made (whether or
not the claim was made on the basis of clinical or scientific
study), and source of sponsorship (Mason and Scammon,
2000).
Advertising issues
The Federal Trade Commission (FTC) regulates advertising
of dietary supplements, including claims in print or broadcast
ads, infomercials, catalogs, direct marketing materials and the
internet (Harris, 2000; Fontanarosa et al., 2003). Advertising
is supposed to be truthful, not misleading and substantiated
by sound science. Regular users of dietary supplements are
more likely to believe that advertising claims are generally true
than non-regular users (Blendon et al., 2001). Hyperbolic
advertising of unsubstantiated claims is used by some dietary
supplement manufacturers (Tyler, 2000). There are questions
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Journal of Consumer Marketing
Volume 22 Number 7 2005 432 436
on the effectiveness of the monitoring and regulation of
dietary supplement advertisements, especially on the internet
(Morris and Avorn, 2003; Harris, 2000; Ashar et al., 2003).
One study reported that 55 percent of analyzed web sites
reported health claims that also included statements to
prevent, diagnose, treat or cure specific diseases in blatant
disregard of DSHEA regulations (Morris and Avorn, 2003).
Further, more than half of these web sites failed to include the
required FDA disclaimer statement. Findings have shown that
internet sites often fail to disclose potential adverse effects,
contraindications, and toxicities of herbal products (Morris
and Avorn, 2003; Ashar et al., 2003). The distinction between
labeling and advertising is often blurred for herbal products
and dietary supplements (Morris and Avorn, 2003).
Case example from Leventis (2001) study on
herbal product structure-function claims
To illustrate issues related to marketed claims, a case example
is presented on summarized findings from a 2001 thesis by
Leventis (2001). The thesis analyzed the structure-function
claims used for the then ten top-selling herbs in the USA,
which represented 54 per cent of market sales.(Richman and
Witkowski, 1998; Mar and Bent, 1999). Common names for
the herbs are echinacea, St Johns wort, ginkgo biloba, garlic,
saw palmetto, Asian ginseng, goldenseal, aloe, Siberian
ginseng, and valerian. These top-selling herbs have been
studied more extensively than other herbs on issues of safety
and efficacy (Tyler, 2000).
Leventis collected data for the herbal products sold in retail
sites (i.e. pharmacies and/or drug stores, natural products
outlets, supermarkets, and mass merchandisers) located
within Chicago, Illinois, web sites were excluded. After
removal of duplicate entries, the following results were found:
.
151 different products from 44 manufacturers;
.
103 (68 percent) of products listed a structure-function
claim on the label;
.
114 (75 percent) of the products did have the FDA
disclaimer statement;
.
37 (25 percent) of the products did not have the FDA
disclaimer, yet five (14 percent) of these products still
listed a structure-function claim on the label.
Structure-function claims were categorized into
macrothemes, which represented a subject or general theme,
and microthemes listing the actual structure-function claim
on the product label. Labeled claims were designated as
declarative or suggestive (included the words may or
might). A total of 61 macrothemes were identified. Most of
the structure-function claims were associated with words such
as regulate-maintain-support or promote-assist-enhance. As
an example, Table I presents results for ginkgo biloba
(Leventis, 2001). While no disease condition is listed, the
themes might imply health benefits to some consumers that
the herb is associated with the treatment or prevention of
Alzheimers type diseases, dementia and/or peripheral
vascular disease.
Leventis also reviewed the published literature to investigate
if there was support for the labeled structure-function claims.
Depending on the literature source evaluated, literature
support (albeit inconsistent) ranged from 44 per cent to 68
per cent for the listed structure-function claims among the
top-selling herbs (Leventis, 2001). With ginkgo biloba, for
 Herbal product claims: boundaries of marketing and science Journal of Consumer Marketing
Stephanie Y. Crawford and Catherine Leventis Volume 22 Number 7 2005 432 436

Table I Examples of labeled structure-function claims of ginkgo biloba (Mason and Scammon, 2000). This has created a safe
harbor for supplement manufacturers to market products
Macrothemesa Microthemesb that fall into the gray area of acceptable claims. Herbal
Enhances focus/ Enhances mental focus products, especially, are not inert commodities. In addition to
concentration Promotes focus their use by some consumers as supplements to the diet, other
Improves concentration consumers purchase the products in the attempt to provide
Promotes concentration self-care in the treatment or prevention of serious disease and
Maintains focus/ Maintains focus health-related conditions (Mason and Scammon, 2000;
concentration Helps maintain concentration Tolstoi, 2001). This paper has attempted to summarize
Maintains concentration
some of the compelling reasons for more attention to the
problems.
Enhanced mental Herbal supplement for enhanced mental
Appropriate use of quality herbal products and other
alertness alertness
dietary supplements can have medical and economic benefits.
Maintains mental Helps maintain normal mental alertness
The US relies primarily on the free-market system to balance
alertness Mental alertness dietary supplement and control issues regarding safety and efficacy of dietary
Improves mental Improves mental sharpness supplements. Reconsideration of requirements for product
sharpness For improved mental sharpness marketing is evident because the current system is ineffective
Promotes mental sharpness (Lewis and Strom, 2002). National surveys have shown
Supports memory Supports memory positive views on derived benefits of dietary supplements, as
Helps maintain memory well as support for increased government regulatory efforts on
Improves memory Improves memory issues of safety and claims (Blendon et al., 2001). While this
Dietary supplement for improved short-term paper has focused on the American system, the need for
memory global harmonization on health claims of herbal products and
Supports circulation Supports circulation other botanicals has also been recognized (Mahady, 2001).
Supports circulation to the Supports circulation to the brain In 2000, the FDA Center for Food Safety and Applied
brain Helps circulation to the brain Nutrition published its Dietary Supplement Strategy: Ten
Cerebral circulation Year Plan (US Food and Drug Administration, 2000). Among
Increase blood circulation Helps increase blood circulation to the brain the planned objectives is future publication of a final rule on
to the brain Supports increased blood flow to the brain structure-function claims and the need to establish valid
May enhance blood flow to brainc substantiation of such claims. The document also listed plans
Enhances peripheral Helps enhance peripheral circulation to clarify boundaries between dietary supplements and drugs,
circulation as well as boundaries between dietary supplements and foods.
The need for this clarification is great, especially in light of the
Notes: a General subject area; b Actual structure-function claim statement new marketing of so-called nutraceuticals or functional foods,
on product label; c Suggestive claim statement (contains may); all other which are food products that have been enriched with herbs
listed claim statements designated as declarative or other dietary supplements (Ernst, 2001). Examples include
cereals with ginkgo biloba, kava candy bars, and fruit drinks
with echinacea. While these food products cannot use
example, evidence-based literature supported an effect in therapeutic claims, the industry has been successful in
circulation or peripheral circulation. There was no substantive getting consumers to associate their products with implied
literature evidence on the relationship between ginkgo biloba health benefits despite the small amounts of
and brain circulation. For the common memory/focus/ pharmacologically-active ingredients in the products, as well
concentration macrothemes, there were inconsistent findings as unknown and potentially destructive effects of the
about benefit of use among targeted populations. manufacturing processes on the herbs or other active dietary
Other authors have published literature support on the substances (Ernst, 2001).
benefit of using ginkgo biloba for dementia (Mar and Bent, To some extent, the overlapping jurisdiction of the two
1999). While generally well tolerated, side effects of the herb government agencies responsible for dietary supplements
include mild gastrointestinal distress, headache, and allows problems with product claims to fall through the
anticoagulant effects. Side effects are not required to be cracks. The FDA and FTC are working together on an
listed in product labeling. increasing basis. The two agencies recently formed a Dietary
Supplement Enforcement Group in the attempt to thwart
Marketing and policy implications health care fraud (Hampton, 2005). Individual and joint
initiatives by the agencies have included Internet searchers to
Promoting consumer empowerment to make choices and identify and police fraudulent marketing, which resulted in
facilitating access to desired products are laudable goals. The warning or advisory letters sent to hundreds of product
marketplace should share the burden of providing useful and distributors and internet supplement marketers who
meaningful information that will assist consumers in making promoted unsubstantiated claims (considered to be product
decisions about potential health benefits related to particular misbranding by FDA and deceptive practices by FTC)
dietary supplements (Mason and Scammon, 2000). The (Hampton, 2005; Harris, 2000; Fontanarosa et al., 2003).
Pearson v. Shalala decision expressed the courts preference in Dietary supplements are subject to far less regulation than
disclosing limitations of marketed claims of dietary prescription drugs, non-prescription drugs, food additives,
supplements, rather than suppressing such claims in the infant formulas, and virtually any other products subject to
absence of meeting an acceptable substantiation standard public consumption (Fontanarosa et al., 2003).

435
 Herbal product claims: boundaries of marketing and science
Stephanie Y. Crawford and Catherine Leventis
Unsubstantiated claims of benefit represent a threat to
business and the public health. After the unprecedented
growth experienced in the 1990s, sales of herbal products and
other dietary supplements have been strong, but flat (Tyler,
2000). Possible reasons include negative publicity about
adverse events and the availability of junk products, which
may prompt consumer word-of-mouth about ineffectiveness.
We agree with other authors that increased government
regulation is inevitable in realizing the goal of promoting
claims that are truthful and not misleading. Such an
undertaking will likely take a dozens of years because of the
enormous costs and efforts that would be necessary. The
outcome would help increase consumer confidence, while
continuing to allow free-market forces for the dietary
supplement industry, to a large extent. In addition to
increased government scrutiny, however, is the need for
greater involvement by physicians, pharmacists and other
health practitioners, the business community, and the
ultimate consumers in reporting problems and demanding
product quality.
Note
1 Pearson v. Shalala [1999], 164 F.3d 650 (D.C.Cir.)
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S., Van Rompay, M. and Kessler, R.C. (1998), Trends in
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Executive summary
This summary has been provided to allow managers and executives
a rapid appreciation of the content of this issue. Those with a
particular interest in the topic covered may then read the article
in toto to take advantage of the more comprehensive description of
the research undertaken and its results to get the full benefit of the
material present.
What is wrong with consumers having a
little more information?
Healthcare is an enormous industry absorbing a considerable
and growing proportion of what we earn. At the same
time the wider health debate is of central political significance
with every aspect of the industry under some kind of scrutiny.
The debate in the UK over the non-availability of expensive
cancer treatments through the National Health Service, the
disaster of last summer when a heatwave drove the French
care system into crisis contributing to the death of thousands
of elderly people, the critical importance of Medicare and the
prescription drugs debate to swing states like Florida these
are big issues.
At the same time as we in the developed world argue over
whether we should put up taxes to pay for an enhanced
healthcare system, the developing world struggles on with
limited resources for the basic health provision we take for
granted. Our complaints about facilities at public hospitals
seem churlish when we consider the kind of conditions in the
third world.
Beyond this central debate over health sits a still wider
debate around health promotion, disease prevention and the
thoroughly modern concept of well-being. These debates take
us into the realms of regulations, bans and non-traditional
medicine. Whole new categories emerge foods offering
medical benefits such as reducing cholesterol, for example.
And then there is the growth in supplements.
Healthcare is huge and, because it is so important, subject
to considerable regulatory control, legislative restraint and
risk. In places such as the USA, growing consumer activism
and awareness leads to the growth in medical liability and
malpractice law suits and the creation of a whole new
industry servicing this process. And, as people live longer, we
see still more pressure on medical services and growing
demand for new care services delivered cost-effectively. The
days of the local council providing a couple of day care centres
and a few home helps are gone this will never satisfy the
requirements of a richer, more aware and more active older
population.
And, to return to politics for a moment, old people vote!
Which makes them the most pampered old folk in history. It is
not far from the truth to observe that the purpose of the
USAs welfare system is not the transfer of resources from rich
to poor but the transfer from younger to older. It is no
surprise therefore to find that healthcare and pharmaceuticals
marketing are a huge concern to some and a big issue to all.
Journal of Consumer Marketing
22/7 (2005) 437441
q Emerald Group Publishing Limited [ISSN 0736-3761]
437
This special issue scrutinizes aspects of this marketing
especially against the backdrop of liberalization in the
promotion of prescription drugs in the USA. In some
respects this is the most significant change in drugs marketing
and has to be seen in the context of drug company
performance, the ethical limits of marketing in healthcare
and political pressures to remove (or at least limit) big
business involvement in health.
Commercial freedom of speech is there
a limit?
The debate over commercial freedom of speech is significant
(although the term is seldom heard outside of the USA) since
it governs our appreciation and understanding of advertising.
And we should remember that, in operational terms,
advertising lies second only to direct sales in its significance
to marketing. We start with the idea that, all other things
being equal, we have an absolute right to advertise. This does
not excuse misrepresentation, passing off or the slandering of
competitors but it does say we have a right to communicate
our message to those who may wish to buy what we make or
do.
The limits to commercial freedom of speech have been
debated in such areas as tobacco advertising and we now have
an emerging debate around the targeting of advertisements to
children especially those promoting unhealthy food and
drink. Within this big debate sits this issue of directly
advertising prescription drugs to consumers and whether it
provides benefits or represents a retrograde step in the
effective delivery of health care.
Most of those commenting on this debate within this special
issue start with the US Food & Drug Agencys (FDA)
decision in 1997 to allow the direct-to-consumer advertising
of prescription drugs in such a way as to open up mass media
channels. Prior to this removal of requirements for detailed
statements of risks and side effects, direct-to-consumer
advertising, while technically possible on TV, was limited to
specialized publications.
The results of this liberalization have got something of a
mixed press. The industry has welcomed the opportunity to
extend brand development beyond the medical profession and
argues that direct-to-consumer advertising is of real social
benefit. On the other hand others health activists, some
physicians, politicians and consumer campaigners argue
that such advertising undermines the doctor-patient
relationship, adds to already high drug prices and gives a
false sense of empowerment to the consumer. Some of the
work in this special issue while it cannot set aside
ideological objections to the US healthcare system helps us
to place support and criticism of direct-to-consumer drugs
advertising in the context of factual information about
consumer response.
As Singh and Smith point out in the opening article: . . .the
central question revolves around whether or not DTC (direct-
to-consumer) advertising is truly beneficial to consumers and,
if so, how?
Three in the bed? Drug ads and the
doctor-patient relationship
One of the central accusations from those who argue against
direct-to-consumer advertising of prescription drugs is that is
compromises the doctor-patient relationship. Rather that the
 Executive summary
doctor dealing with the symptoms presented by the patient
and making an appropriate diagnosis and prescription, the
doctor is faced by an informed patient demanding a
specific, branded solution they have seen advertised on TV.
The doctor runs the risk of falling out with the patient by
refusing to prescribe (at which they may well take their
business elsewhere) or else goes with the flow and prescribes
the desired drug.
Singh and Smith, Baca et al. and Shin and Moon appear to
concur in their assessment of this situation. While the
concerns about DTC advertising remain, most of the
evidence suggests that such advertising is, on balance,
benefiting consumers. This chimes with the FDAs review
(reported by Baca et al.) describing the benefits of DTC as
. . .creating increased levels of awareness, involvement,
compliance, reach and doctor-patient interaction.
The advent of DTC advertising has resulted in rather better
informed patients rather than misled consumers demanding
inappropriate prescriptions of potentially dangerous drugs. As
Singh and Smith argue, where consumers . . .once felt
entrapped in their relationships with their physicians, the
acquisition of information regarding branded drugs has given
consumers more power than ever before. The system is not
perfect and does run some risk of abuse but it is an
improvement over the third party moderated system that
prevailed before 1997.
Perhaps the main concern that remains and is hard to set
aside stretches beyond the issue of advertising and into the
much wider debate about health care. This is the ethics of
taking profit from making and selling drugs and from
providing health care. To some (and you only have to peep
at the health debate in the UK or Canada to appreciate this)
any involvement of the private sector in health is a matter for
at best regret and often anger. And the big, bad drug
companies are a favourite target of many looking for reasons
behind failures or problems in the health system.
Why is profit such a rude word in health
care?
Holdfords article looking at applying a social marketing
framework to health campaigns (of which more later) shows
us why there are so many criticisms of the perceived
profiteering of drugs companies. Not only do these
companies make enormous profits on the back of the USAs
strict patent laws but they work actively and assiduously to
prevent any move towards more affordable drugs.
We read that (taken in aggregate) consumers have little or
no trust or confidence in drug companies or their executives.
These businesses protect a system that allows little or no
consumer interaction with the market. As Holdford points out
many take the view that . . .the pharmaceutical industry
makes excessive profits by taking advantage of perverse
incentives in a market where consumers rely on third parties
. . . to choose drugs for them and prescription drug insurance
coverage . . . that shields consumers from the full cost of
paying for those drugs.
The result of this perverse system (and despite the debate
around DTC advertising 80 per cent of drugs marketing
spend is still directed to the medical profession) could be
inappropriate prescribing, incorrect drug use, unreasonable
consumer expectations and wasteful expenditure. Unlike most
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Volume 22 Number 7 2005 437 441
markets in the USA, the drugs market acts ineffectively
resulting in far higher prices than we find elsewhere. And
while Holdford does not propose specific strategies or policies
to correct this dysfunction, it is clear that market reform is
one way in which US healthcare might improve (or at least
become more efficient).
The problem with the system is not that drugs companies
are making profits but that the industry is acting to sustain an
inefficient system that acts to the benefit of producers rather
than to the advantage of consumers. And any market that acts
in this way is perverse since the operation of free markets
usually results in direct benefits to the consumer (e.g. lower
prices or higher quality). In order to reform the system we
have to get over our occasional distaste at the profiteering of
drugs companies and set about getting greater consumer
control over the system and hence a downward pressure on
costs.
One factor that will begin to drive down drug costs is the
Internet and the emergence of online pharmacies. Holdford
refers to the use of Canadian online pharmacies by consumers
in several US states and notes that some states have actively
encouraged such use in order to apply pressure to the drugs
companies. The challenge online is dealing with the need for
input from a medical practitioner in many drug choices.
Gurau explores the growth of online pharmacies noting that
they can be seen as a way round national regulation and (as
we have seen above) a means of reducing the cost of drugs to
the consumer. Indeed this grey market for prescription drugs
is significant as it takes advantage of the long-term price
differentiation practiced by most multinational drug
companies. The result is that, for important and widely
prescribed drugs, there is a significant downward pressure on
the price.
However, lower prices are not the sole perceived benefit of
online pharmacies and we need to understand that, as with
other areas of business, the internet represents a massive
challenge. Indeed, many of the peculiarities of general
practice and primary care across national boundaries may
be undermined by the role of the internet.
Online healthcare the way of the
future?
In looking at the growth in online pharmacy, Gurau refers to
the deficiencies of regular medical services arguing that
. . . long waiting lists, insufficient doctors and poor service
quality . . . are leading people to seek out more efficient ways
to obtain good medical care. We have little confidence that the
everyday health care systems (and this is especially the case
where socialized medicine predominates) will go the extra
mile in improving service or support.
At the same time as one section of the medical and
pharmacy professions is using the Internet to deliver real
improvements in service quality, others continue to resist the
use of online advice, support and service. In many ways this
mirrors the debate over direct-to-consumer advertising where
some consumer advocates and some medical practitioners are
enthusiasts for the extension of advertising whereas others see
only problems, risks and dangers in such an extension.
It is clear that the online supply of drugs presents some risks
to the consumer and there has to be some reassurance. But
the general public experience of online pharmacy (as reported
 Executive summary
by Gurau) suggests high levels of consumer satisfaction. In
Guraus UK sample around one-third of respondents had
used online pharmacies a significant percentage in a
country that is not especially adventurous when in comes to
healthcare markets. It seems to be that case that other factors
are as significant as the price protection of privacy and
convenience are especially important. Gurau reports that
online pharmacy is especially popular with older people who
value the convenience it affords.
This last point is significant we do not have the
information to hand as to the proportion of prescriptions that
are straightforward repeats but for many older people there
will be the regular bother of renewing supplies of drugs taken
to manage chronic conditions such as arthritis and heart
conditions. The ability to get this service from the
convenience of the home computer represents a significant
step forward. And, if the medical profession stop and think for
a moment, such a system frees up doctors time currently
spent writing out repeat prescriptions.
The other aspect of online activity takes us back to the
discussion about direct-to-consumer advertising and the
extent to which it provides real consumer benefits. It seems
likely that those seeking to preserve the doctors gatekeeper
role will win the short-term battle and secure tighter
regulation (or as is possible in New Zealand a ban of DTC
advertising). But in the long-term consumers will via the
medium of the internet get the detailed information about
drugs, medical conditions and treatments.
Consumer awareness the main
objective of DTC advertising
Given that most of the information and much more
currently given to consumers via DTC advertisements is
available online in an almost entirely unregulated
environment, is seems rather foolish to spend so much time
worrying about such advertising. The 1997 FDA guidance on
DTC advertising opened up the use of such advertising as a
gateway to far greater information supplied on web sites. This
is not to say that drug companies are wholly honourable in
their advertising the detailed assessment of the US legal
environment presented by Cunningham and Iyer shows some
of the problems and Finlayson and Mullners brief review of
the current state of play reveals some real worries about the
approaches adopted by some drugs advertisers.
If we set aside the online diagnosis and prescription offered
by some internet pharmacies, most drugs advertising is aimed
at driving consumers to visit their physician to discuss a given
condition and drugs associated with its treatment. The
positive side of this activity is that, as Finlayson and Mullner
point out, consumers may be . . .seeing physicians earlier,
receiving treatment earlier and potentially avoiding future
medical complications. The contra-argument that this
promotion of public health is a specific public sector
function not only gets drugs companies off the hook (the
Government takes responsibility) but the costs would be
considerable.
If drugs companies are spending over $3 billion per year
promoting drugs directly to US consumers, it represents an
enormous opportunity to develop substantial public health
promotion budgets outside the limited scope of public
investment. Rather than trying to regulate the advertising to
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Journal of Consumer Marketing
Volume 22 Number 7 2005 437 441
the stage where it becomes pointless, public authorities
charged with promoting health messages should seek
partnerships with pharmaceutical advertisers intended to
embed core public health messages into such advertising.
Taking such a proactive approach would be a considerable
shift away from the traditional command and control
approach beloved of bureaucracies.
However, this does not exonerate marketers involved with
drugs promotion from the job of acting ethically and
responsibly. Cunningham and Iyers checklist is an ideal
start for anyone looking at developing strong strategies to
DTC advertising in the USA. And the list is underscored by
the real risk that one or more drug company will find itself in
court as a result of claims made in DTC advertisements.
However, the most important observation that Cunningham
and Iyer make is that the drugs industry in the USA has done
nothing to sort out its own house. Aided and abetted by the
advertising business (who have to take some responsibility
here), drug companies have created a rod for their own back
through weak strategies predicated on shifting boxes rather
than developing long-term engagement with consumers.
Drug brands and DTC advertising
The pharmaceuticals industry is unusually placed in respect
of brands since its most profitable products exist behind a
strong patent protection. This protection is necessary because
of the significant costs associated with research and
development in the drugs business. Getting a drug from the
lab, through trial, tests and approvals to the point where it can
be sold represents a huge commitment. The patent allows the
firm to get a satisfactory return on that investment in R&D.
Without this return future investment in the development of
new drugs is jeopardized. As with the health promotion
situation, the argument that governments can pick up this
strain does not hold up since the industry invests over $30
billion each year in research (and that is just in the USA).
So drug companies enjoy greater protection for the brand
than is the case in many other markets. And the opportunity
to promote directly to the consumer gives a brand building
opportunity too good to miss. However, because drug
businesses are concerned with driving consumers into seeing
their doctors with short term sales brand development is
overlooked. And this oversight is exacerbated by a sales-
oriented marketing culture. It is ironic that the skills and
expertise many drug companies have developed in the
promotion of branded over-the-counter drugs have not
transferred to the development of prescription drug brands.
It is reasonable to assume however, that most drugs
marketing strategies assume a huge change at the point when
the patent expires. Given the current approach in respect of
patents where the high margins are sustained behind the
protective barrier of the patent, it is not surprising that any
long-term strategy depends on existing patented drugs being
replaced by a new generation of patented drugs. Once a drug
is out of patent, it becomes a mere formulation that any
manufacturer can produce. The result is that generic drugs
are treated as commodities sold unbranded.
Perhaps this need not be the case (and we should note that
some manufacturers have begun to appreciate that there is a
far wider issue that extends beyond price). In some cases drug
promotions have been assisted by the development of OTC
 Executive summary
versions of prescription drugs the liberalization of OTC
drug markets has assisted this process in some countries. But
the company should be considering how the investment in
brand development during the drugs protected period is
captured and maintained after the drug loses its patent. There
is an argument to be made that drug manufacturers should
develop corporate brands and should pull away from the
individual product branding approach that prevails at present.
Such a change represents a radical step for the drug
manufacturer but, as we have seen, the market is changing
rapidly. Consumers will be better informed, price levels will
be pushed down by online trading and the general practitioner
will lose a great deal of the gatekeeper role that currently
contributes to the drug companies power patients do not
have the specific medical knowledge, nor do they know how
much the drug costs or how much money the drug company
have spent promoting the drug to the doctors. In the new
environment there should be greater openness and a level of
product knowledge sufficient for many patients to make a real
assessment of the advice they receive from the doctor.
Cunningham and Iyer report on one legal ruling (Perez v.
Wyeth Labs, NJ [1999]) that recounted how many aspects of
the laws governing drug promotions date back to a time when
. . . Dr Kildare was a popular television show, doctors still
made house calls and the relationship between patient and
physician was a comfortably close one in which doctor
advised patient and patient believed that doctor knows
best. This is no longer the case and becoming less so with
each passing day new means of communications, the size
and significance of the health care system, the growth in
Government involvement and intervention and the
complexity of treatment all make for a less personal system.
What ever we do to make the most of this changed world, it
should centre on the provision of good quality information to
the patient as a consumer of health care.
To achieve this, drugs companies need to examine their
business and marketing models. The emerging challenge to
patent-based systems from developing countries is significant
as is the focus in the development world on wellness. These
two considerations are the subject of the remaining two
articles in this special issue: Crawford and Leventis looking at
the growing market for herbal remedies and Mascarenhas et al.
examining radical business models for addressing the moral
challenge of delivering drugs and health care in poor
countries.
In a connected world health care in Mali
really does matter
In the latter case we should start by understanding that we
cannot isolate ourselves from the health care and medical
challenges in the developed world. It is not just the high
profile pandemics like SARS, avian flu and AIDS/HIV but
many other conditions resistant TB, malaria and hepatitis
variants are all significant challenges in the developing world
that will affect us in the developed world if we do not take
actions to assist in managing their spread. Mascarenhas et al.
focus on the challenge of AIDS/HIV which has been the
subject of considerable debate and controversy especially
given the complex nature of treatment for the condition and
the expense of the antiretroviral drugs used in that treatment.
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Journal of Consumer Marketing
Volume 22 Number 7 2005 437 441
Despite a widespread recognition that endemic diseases in
the developing world require urgent action, there has been
reluctance (from all sides) to see a significant role in such
action for the private sector. The assumption is that
developed world Governments will use their taxpayers
money to fund health programmes elsewhere. And, while
some of such actions are probable (e.g. the US Governments
considerable contribution to the AIDS/HIV crisis in sub-
Saharan Africa), they will never be sufficient or sustainable.
The long-term solution lies with local Governments and with
the private sector. And, as Mascarenhas et al. point out, to get
the most out of the private sector you present them with the
opportunity to make some money.
Mascarenhas et al. stress the significance of entrepreneurial
actions in the successful delivery of health care in the
developing world some of this is through NGOs (the
authors cite the example of Medicines sans Frontieres) while
other success is via local managed private businesses. The
central tenet of Mascarenhas et al.s essay is that we must
package the goods in such as way as to make them
affordable by those at the bottom of the income pile and that
it makes sense to use communal institutions and associations
as a way to sustain very local business models.
The lesson for the drugs companies here is that they can
package drugs to make them applicable in the developing
world without necessarily crippling pricing strategies
elsewhere. With the right model we can avoid (or at least
significantly reduce) the risk of low priced drugs leaking back
into higher priced markets. For drug companies the changed
business model will require a very different approach that
works very closely with local people on the ground. But this
approach stands more chance of succeeding than does the
unsustainable approach of governments in the rich world
subsidizing wealthy drug companies to provide low cost drugs
to people in the third world. This approach appeals to the
moralists but fails to deliver the change we need on the
ground.
Importantly, this need to look at the strategies used in the
developing world presents an opportunity to re-examine the
strategies used in the rich world. We have noted that the
internet, consumer activism and other factors are changing
the dynamics of the health market. If drug companies are to
sustain their position, they will need to adjust business models
to deal with this new reality. And all this takes places at the
same time as the wellness market begins to take off.
Health foods, diet supplements and
alternative medicine
The US market for dietary supplements is very large at $18
billion (although not so massive set next to the market for
traditional pharmaceuticals which sits at around $180 billion).
In addition there is a growing market made up of foods with
health claims (led by the dairy industry). Much of this market
focuses on overall well-being rather than on addressing
specific conditions indeed, the limitations on herbal remedies
are such that is suits their promoter to pull them back from
specific claims as to the herbs effect.
Compared to other parts of the healthcare sector, the
marketing of herbal remedies and supplements is relatively
unregulated. And we should note that the drugs companies
and many parts of the medical profession are very protective
 Executive summary
of health claims relating to anything other than a properly
formulated and clinically tested drug. There is often
frustration about this but it is wholly reasonable given the
protection that governments wish to extend to the population
and the extensive regulation that applies to traditional drugs.
Nevertheless, there is a lesson for drug companies in the
success of dietary supplements and herbal remedies. This
market builds on levels of health awareness, on the desire to
promote our own good health and on the view that we should
regulate what we put into our body. This health awareness
extends beyond the market for supplements and we can see it
as one factor in the positive response from consumers to DTC
advertising of prescription drugs.
Consumer empowerment is to be
welcomed not restrained
Those who resist the opening up of access to information
about drugs run counter to the trend in consumer marketing.
This is especially the case with DTC advertising of
prescription drugs where one of the commonest arguments
against such advertising is that consumers might not
understand the information. Leaving aside the rather
patronizing implications of this stance, we need to recognize
that prescription drugs are a directly regulated market where
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Journal of Consumer Marketing
Volume 22 Number 7 2005 437 441
the prescribing doctor and dispensing pharmacist act as
protectors for the consumer.
The consumer in todays developed market is looking for
the information that allows sensible choice. Sometimes the
use of information is moderated (in this case via a physician)
but this does not provide a reason for withholding that
information. However, there remains a worry for consumers
that the advertiser is being less than complete in their
provision of information. Nevertheless, much of this is
verifiable and we operate on the principle that our doctor is
not going to prescribe drugs we do not need (there is a
separate debate to be had on the extent to which the
promotional tactics of drugs companies could compromise
the independence of physicians).
The articles in this special issue direct us as marketers
towards the appreciation that, in general terms, what we do is
morally good. Despite the dreadful stories of misplaced
marketing and the voices opposing the making of profits,
allowing consumers to be fully informed about the drugs
others are buying for us improves the quality of health care.
Given the opportunities presented by the Internet and by the
sophisticated broadcast media available to advertisers it seems
rather foolish to prevent their use because we are worried
about the ability of consumers to understand the information
it brings.

Book reviews
The 18 Immutable Laws of
Corporate Reputation
Ronald J. Alsop
Kogan Page Ltd
London
2004
286 pp.
17.99
Keywords Corporate identity,
Organizational behaviour,
Corporate communications
Review DOI: 10.1108/07363760510631192
When the Journal of Consumer Marketing,
sent me The 18 Immutable Laws of
Corporate Reputation I thought, Great:
another book of lists for success And, I
tossed it on my desk for a couple of
months. I was the poorer for those
months because this substantive, well-
documented book basically shows how
proper management leads to strong
public image and reputation. Not a
book for your public relations and
advertising people, it is a book for your
entire management team.
Alsops basic argument is that
corporate reputation is ultimately a
function of corporate practice. While
there are occasions when a public
relations crisis must be managed, the
bottom line is, every functional area of
the business and every management
decision either builds or diminishes
your reputation.
You can skim the books cases and go
straight for the key points of each
chapter they are nicely marked with
bold headers and have a relatively quick
read. On the other, reading the
contemporary substantive cases reveals
how each principle played out or was
violated in the real world. As each
chapter develops a law, there are boxes
with important research information
that supports the key point. Divided
into roughly three equal parts, Part 1:
Establishing a good reputation, Part
2: Keeping it, and Part 3: Repairing
it; The 18 Immutable Laws of Corporate
Reputation can help you if you are in
good shape, if you want ideas on
maintaining your reputation, or if you
are in the middle of a crisis.
Law 1: Maximizing your most
important asset opens with FedExs
nightmare of losing a truck to fire being
prominently featured on televised news.
Alsop lays out how FedExs established
reputation, thorough preparation, and
planning for dealing with such a disaster
via an aggressive but substantive and
thoughtful response, minimized any
damage. A firm needs to actively
develop its reputation, build an
organizational culture that weighs
decisions in terms of impact on
reputation, and uses its reputation
capital wisely.
Laws 2, 4, and 6 are the heart of this
first section as Alsop calls on firms to
know themselves and operate on that
basis. His suggestion that firms make
decisions in the light of reputational
impact is not suggesting duplicity but
rather looking at your firm positively.
Does this decision represent who we
really are? Is it consistent with our own
values and ethical standards? The
author suggests that a firms
leadership, its CEO, needs to cast a
compelling vision that builds on its
values, as both BP or Dell have. Then
its managers and employees will make
decisions that do right by the customer
and confirm the companys reputation.
In fact the personality of the firms
public figures, the CEO, president, are
often closely linked to the vision and the
firms reputation.
Laws 3 and 5 demonstrate the
importance of a company knowing its
constituencies and regularly giving back
to its community. But it is not
calculation and weighing costs and
opportunities; it is about creating
emotional attachment and
commitment. It can be as simple as
Sue Harness at Wawa baking cookies
for departing employees or as expensive
and time consuming as the effort to
redesign the airplane seats and flight
crew uniforms by Continental, moves
that significantly improved customers
feelings about the airline. Companies
need to consider the feelings of their
internal and external constituencies and
ask themselves what business decisions
will enhance their customers and
employees satisfaction, thereby communicate that consistent message
building reputational capital that can in all they say and do. The author closes
be stored and used in times of need.
Unfortunately, carefully establishing a
good reputation by doing the right
things and making good decisions is
not enough. Hence why Part 2 and
Laws 8 through 13 address the need to
protect that reputation. As Home
442
Depot learned, a firm needs to track
its reputation and be aware of its
shortcomings (Law 8). Home Depot
lost its focus in its drive to profitability
and moved away from its vision. It took
a survey to bring HD back to its senses,
and it took specific, concrete actions to
address customer service.
Consequently, over time its reputation
rebounded. This is Alsops point.
Reputation is a function of doing
business correctly; it is not an add-on
through manipulation or heavy
promotional budgets. Understanding
this, HD held back on emphasizing
service quality in its advertising until it
felt they could legitimately claim it.
Laws 9 and 11 are the ones that will
keep you awake at night. Law 9, Stay
vigilant to ever-present perils, opens
with the mistake of a misguided
employee in a moment of high stress
deciding to sell water (rather than give it
as other businesses in the area did with
food, etc.) to the firefighters and rescue
personnel at the Twin Towers site on 9/
11. Then Starbucks sought to defend
itself by setting the facts straight, even
though it was in conflict with their own
published customer service policies.
They underestimated the power of
word-of-mouth and the internet in
spreading the story, not to mention the
print media. Law 11 Control the
internet before it controls you, brings
home the power of the internet for good
and ill for any business. The case of how
Tommy Hilfiger countered a negative
urban myth by aggressively countering,
seeking its origins, etc., is consistent
with Alsops continuing proactive
message. Reputation is something you
actively build and defend. Alsop then
goes into how companies can positively
use the web to enhance reputation by
providing customers with product
information, company information,
even posting myths and legends and
offering counters to them.
In Laws 10, 12 and 13 we learn the
importance of consistency in a public
message and having employees who
Part 2 by reminding us of the
importance of deciding and acting in
ways consistent with whom the
company is, even to the point of being
careful of partnerships, strategic
alliances, etc. Do these cooperative
efforts not only make business sense
but are they consistent with whom we
are as a company?
The four of the last five laws under Part
3 Repairing a damaged reputation,
carry a consistent message fixing a
reputation problem requires skill,
honesty, and humility, and it needs to
be done right the first time. The closing
Law 18 If all else fails change your
name, may seem like an attempt at
humor but it is practical advice with a
caveat. Even that may not be enough.
While this is the most defensive
portion of the book, Alsop wants us to
understand that anyone, even DuPont,
can recover from a crisis. Responding
with the customer in mind, being willing
to humbly accept even what is not the
firms fault, and acting at the right time,
usually sooner than later, go a long way to
restoring company image. The publics
cynicism Law 16 and their desire for
contrition Law 17, make it critically
important that a company deal with the
issue right the first time Law 15, and
with care Law 14. It is clear that no
course of action, no event is isolated. It is
the coordination of doing the right
things, of basically good humane
management, and appropriate timing
that result in success in dealing with
crisis. The authors final advice in Law 18
seems mixed. He offers as many
examples of name changes not working
as working. I believe he included it to
argue the opposite. It is not change your
name; it is do everything you can to not
reach this point because you only have a
50-50 chance that this last-ditch strategy
will work.
Entertainingly written, exemplified
with many current and some classic
case studies, and adequately supported
with research, The 18 Immutable Laws of
Corporate Reputation is a practical
management tool for understanding
both the importance of corporate
reputation and how ethical, humane
management practices support and
enhance it.
If you react to the title and judge the
book by its cover, you will miss an
excellent, integrated management book
that your entire management team will
benefit from. And, it may help you head
off a future reputation crisis. Because
while we can control our firms to some
extent, we cannot control the future.
Jim Dupree
Professor of Business, Grove City
College, Grove City, Pennsylvania,
USA
ageless marketing: Strategies
for Reaching the Hearts &
Minds of the New Customer
Majority
David B. Wolfe with Robert E. Snyder
Dearborn Trade Publishing, a Kaplan
Professional Company
Chicago, IL
336 pp.ISBN 0-7931-7744-3
US $25.00, Can 37.95
Keywords Ageless marketing,
Anti-being experience, Being experiences,
Boomers, Experiential segmentation,
Left brain/right brain, Seasons of life,
Value portraits
Review DOI: 10.1108/07363760510631200
ageless marketing, divided into five parts,
of three chapters each, presents a
compelling charge to marketers,
advertisers and salespeople to look at
the market in a new light. Beginning
with Part I, An era of new rules, all
the way through and including Part V,
Preparing landing sites for marketing
messages, readers will find new ideas
and concepts mixed with classic
philosophical quotations that support
the new. A delightful twist in format is
offering the readers an interlude in the
middle of the book and then a later
chapter that chronicles five generations
of a family. The Erskine family logs give
enhanced credibility to all of the
authors seasonal concepts. Wolfe
uses this particular family as a
microcosm of the marketplace
(p. 217). Its members range from ten
months to 91 years of age.
Mr Wolfe, with Mr Snyder, insists
that marketing is missing the boat
without recognizing, addressing, and
implementing many ideas he has
brought together. For serious
marketers, this business book requires
thorough reading with attention to, and
retention of, the many terms the author
creates and uses. It comprehensively
includes and builds upon these terms,
the most frequently uses of which I list
above as keywords. While many may
argue that younger consumers pay more
attention to advertising and act on it,
the new consumer majority becomes
larger each day and thus has the
potential for greater revenues. Their
sheer volume makes appropriate
advertising a must.
443
There is often much-appreciated
connectivity in the book to examples
and relationships from past chapters.
These serve readers as both a review of
major applications and, while the same
time, introducing new topics. For one
example, in Chapter 12, where the
discussion of the marketer as a healer
arises, the author takes readers back
only one chapter, to Chapter 11, where
he cited the success of a Trappist monk,
Abbot Joseph, for the importance of
story telling. Another example of
connectivity is in the Conclusion to
Chapter 13. Here, when discussing the
importance of symbols and avoidance of
anti-being experience symbols, Wolf
and Snyder take readers back to
Figure 7.1 that delineates the seasons
of life in matrix form.
The authors begin, and continue
throughout the book, by stressing the
importance of developmental
psychology, a field almost completely
ignored in consumer research (p. 37).
They call on marketers to understand
the relationships of related fields to
current marketing needs. They spend a
good deal of time providing an
understanding the roles of the right
and left brain. Their major contention
states that we can no longer target
markets by chronological age and by the
statistics we gather from questionnaires.
The first challenge presented is the
extraordinary population shrinkage
taking place in the historically-most-
important age group in the consumer
economy adults from 25 to 44. The
grim outcome of this is a total absence
of sales growth in this age group
throughout this decade (p. 331).
To meet the new demands of ageless
marketing, we need to understand fully
the three Experiential stages of adult
life:
(1) possession experiences of the
earlier years;
(2) catered experiences of the mid
years, or the first stage of being
someone versus becoming
someone; and
(3) Being experiences of the later
seasons of life (p. 242).
The authors go on and quote Peter
Kim, who said:
As Americans redefine what it means to grow
old, age, in many ways, will become an obsolete
marketing concept (p. 243).
Instead of putting our beliefs into focus
group outcomes and questionnaire
results exclusively, we must look at the
life span as two halves, under and over
age 40. Wolfe includes comments for
and against focus groups and suggests
times to have panelists record their
thoughts rather than speaking aloud to
influence one anothers responses.
A major problem Wolfe deals with is
that the often, and incorrectly,
sympathetic symbols and words
addressing the senior market, those in
the winter season of life, are offensive
and, equally important, probably
causing companies to lose business.
He gives examples of people, who
probably think they are being
courteous, without request take the
arm of the elderly to help them walk.
There is grave concern about
advertising and marketing people, who
are still in their first halves of life, having
responsibility to create messages
targeting those in later seasons of life
without yet having had the personal
experience of the second half of life.
Thus, there is an urgent and immediate
need to correct the many inappropriate
ads targeting people in the fall and
winter life stages. These messages
convey a lack of awareness of things in
which seniors are still interested in, such
as excitement and sex, to name only
two. The author suggests such creators
have coaching and guidance from those
in the winter stages.
Offensive advertising and marketing
to those in the second half cannot
continue with the rapid growth of the
fall and winter markets. Values of
members in each season accompany
this discussion. Unchanging values
mold the behaviors and actions of
most consumers.
An emerging segment Wolfe feels
marketers overlook, because of current
and inappropriate segmentation
precepts, is comprised of another
unaddressed group: those who have
wound up in different circumstances,
such as divorced people, single people
who have always been single, and others
out of the anticipated molds.
Wolfe faults corporations for being
more concerned with moving product
than for understanding their customers.
He does give examples of companies that
have been unusual in their successful
customer recognition programs, such as
Southwest Airlines. He and Robert
Snyder have worked in community
development and senior housing.
They get to the crux of the matter by
pointing out that most senior
developments advertise golf courses and
other amenities that presume those in the
winter season of life either place strong
value on these amenities or have no other
values they treasure and want to use in
their retirement. Promotions
inappropriately and regularly show
pictures of a senior couple walking hand
in hand with pasted smiles on their
faces.
In this section, Wolfe provides many
enjoyable ways in which he has listened
to, and then accommodated,
consumers. He even continues by
advising the best practices for
attracting people in different seasons
of life at the same time to the same
property, rather than limiting the
property to seniors. He provides
photos of collateral publicity he and
his clients used to coax the younger
segment to share events in one formerly
senior-only housing complex. Later, he
concludes that in over 400
communities, representing over
600,000 homes, no developer client
was ever sued (p. 303). They
maintained dialogs with residents by
invoking what they called the four Cs
communicate constantly with candor
and control. Until then many people
had stereotypical images of housing
especially for seniors. This practice of
listening to, and talking with,
consumers of various life seasons, and
his amalgamation of the members of the
Spring stage of the life cycle with the
Winter stage people, is one way Wolfe
addresses the questioned ability of
marketing to bring various groups
together.
Wolfe is consistent with his argument
against restricting market knowledge to
numbers when he says that customer
relationship management (CRM) has
not worked. He talks in the opening
chapter, with a sub-heading of Why
marketing stopped working, of the
dehumanization of customer
experiences with a company (p. 7).
There needs to be a way to learn about
customers, especially the ever-growing
customer majority, which mostly the
boomers comprise. To do this, we must
consider that people are in four seasons
of life, beginning with spring. We must
understand what values exist in each
season and how the members of that
group relate to the corresponding
season.
The end of ageless marketing
directs attention to the ever-growing
consumer majority, the seniors. Wolfe
identifies symbols, nomenclature, and
444
terms that this huge group of winter
people (seniors) like and dislike. To use
better terminology is imperative. These
negative symbols repel people from
advertising. At one time, Wolfe asked
a 66-year old to review a stack of
brochures from extended service
communities. These brochures opened
with a promise to people that they
would remain independent. After one
paragraph, the brochures told
everything about what the property
would offer to keep people from being
independent; i.e. how they are going to
feed you, clean your apartment, launder
your linens, bus you to where you want
to go, and, with a social director, decide
what you will do each day.
The book provides additional
knowledge to marketers of the state of
the five senses during aging. Anyone
committed to getting a 360-degree view
of customers in their 50s and older
needs to be aware of these changes
because they can influence product
design, marketing, sales, point-of-sale
environments, and post-sale servicing
(pp. 305-306). Marketers must address
these issues. He wants to know why
companies put so much effort and
money into package design and yet
pay no attention to whether or not
seniors have the strength with which to
open the packages.
Before the appendix, which defines
the research that went into this book,
the author concludes by repeating his
objective was to provide for the first
time in a business book (p. 332) the
integration of psychology with
marketing and more. The legacy Wolfe
wants to leave readers with by the end
of the book is a much greater
understanding of self, those around us,
and, in fact, the Family of man.
This book is a must read for those
in marketing, advertising, publicity, and
sales. It could be a light read for
seniors and those interested in
segmentation. Wolfe accomplished his
objective with me, and I implore those
involved in marketing and related fields
to carry on to the end of this book. It is
a slow read of changes requiring high
speed.
Sylvia Keyes
Professor, School of Management,
Bridgewater State College, Bridgewater,
Massachusetts, USA and Immediate
Past Vice President, American
Marketing Association, Collegiate
Chapters Division
Celebration of Fools: An Inside
Look at the Rise and Fall of
JCPenney
Bill Hare
AMACOM
New York, NY
www.amacombooks.org
284 pp.
$24.95
Keywords Partnerships,
Merchandise versus Merchandising, Specialist
Review DOI: 10.1108/07363760510631219
Who knew or cared what was
happening? In 1994, after all, they
had a record year of immense profit.
The party was Texas-sized, with praise
and rewards all around. It was a
celebration of fools (p. 173).
When I saw the jacket covering the
hard copy of Celebration of Fools, the
authors background as a speechwriter
and filmmaker was notable. I presumed
the book would contain discrete press
releases and short stories of the
corporate history. Instead, Bill Hare
presents a saga, in non-fiction, that I
did not want to put aside. He recounts
the ups and then the downs of this
leading department store chain from his
own eight years with its executives and
combines it with knowledge of others
from JCPenney. Since the company
tended to maintain an insular position
in the retailing and business world,
there was little for the writer to find
externally. Thus, admittedly, Hare
presumes his conclusions from many
conversations. He makes it clear on that
the book concentrates on the major
events that drove the company up . . .
and down (p. 3).
I enjoyed every page of this book.
However, I showed it to a professor
from a Texas university, who was unable
to get beyond the first chapter even
though, ultimately, JCPenney moved its
corporate headquarters to Dallas.
Perhaps Hares story had so much
meaning for me because, in the 60s,
for a short-lived part of my career, I
worked for Federated Department
Stores. There were no first names in
the JCPenney nor in the Federated
vintage, when I reported to Mr Maurice
Lazarus, the Vice Chairman of
Federated and the President of
Filenes, its Boston Federated store. At
the same time, Mr Harold Krensky rose
to be the successor to Mr Maurice
Lazarus as the President of Filenes and
then replaced Mr Ralph Lazarus, who is
mentioned ion this book as the top
officer of Federated. So, to me, the
climb to the top was similar in the two
famous organizations. In fact, as I read
about a CEO of JCPenney trying to
systematize its business by a secret,
manual record of consolidated
transactions, I was, in the same year,
working on what sounded like the same
project for Mr Lazarus. Similarly to
Filenes, the people at the top of
JCPenney rose from their ability in
merchandising or strategy and overall
vision; and their wives became a part of
the interviewing process. In fact, James
Cash Penneys wife was always Mrs
Penney, even to him. For me, this was
of interest in demonstrating the need for
a company to establish a posture in
consumers minds, its human resources
development, and its contributions
within surrounding communities.
To most readers, who are probably
those with interest in retailing and
management, either from experience
or from study, Bill Hare presents a
continuing and convincing argument in
favor of the retail giants founding
fathers, beginning with J.C. Penney
and continuing through Walt Neppl
and Don Seibert, of the wonderful years
that included success in acquiring
personnel and training them in the JC
Penney ways. In 1936, in Salt Lake
City, at a company gathering of then 36
stores, Mr Penney introduced the body
of doctrine of H-C-S-C. He invoked
this acronym, which represented
Honor, Confidence, Service, and
Cooperation (p. 37). As simplistic as it
seemed, numerous CEOs followed this
credo until the time of Bill Howell, the
chairman and CEO, responsible for
moving the company from New York
to Dallas. The leaders, prior to Howell,
followed the beliefs of both
merchandise and merchandising, had
the ability to withstand and ameliorate
the differences among people at the
store level and others at the buying
level, held appreciation for a varied
product mix in spite of these
managers leading the path to the malls
of America and showed foresight in
attempting to computerize systems with
leaders in the cash register industry.
Mr Hare, at the other extreme, presents
a convincing argument against those at
the helm, beginning with W.R. Howell,
445
and, especially Jim Oesterreicher. These
top officers were preening themselves
(p. 169), and pushing toward further
self-aggrandizement by acquiring the
Eckerd Corporation, an unsuccessful
venture into the pharmacy business.
It is not surprising that AMACOM
published this book. In addition to
retailing, it contains many management
lessons. In the early years, Penneys
management training endorsed leading
by example. Employees moved up who
followed the H-C-S-C doctrine and the
procedures that related to it. Hare
explains the result of this philosophical
underpinning by saying: Remember,
Penney was the godfather of sharing. If
you produced, you did very well
(p. 15).
An important word from the
beginning of James Cash Penneys
regime was partnerships. After
people of the Golden Rule Stores
proved their worth, they received
offers to become partners, a
managerial technique that accounted
for the stores ability to thrive. They
paid attention to the customers and
provided the product mix important to
those customers. Many years later, the
top officers lost this objective and
replaced it with profit.
In the center of the book, among
glossy photographs, readers can see the
James C. Penney Meat Market. Jim
Penneys first venture failed because he
would not pay bribes. The picture
shows both Jim Penney and his
beloved, Berta, who worked in the
market where they met. Berta had
arrived in Jims hometown after
deserting the location of her first
marriage, which ended in divorce. She
and Jim worked together in his first
Golden Rule Store and, while he was
away on a buying trip, Berta learned she
was pregnant. Jim returned much later
and, on learning of the pregnancy,
proposed to Berta. She worked
tirelessly in both the home and the
business, keeping the babys basket on
the premises. When she needed to have
her tonsils removed, she walked to and
from the surgeons office, and thereafter
became very ill. Jim had planned a trip
for the then family of Berta and two
children because they never had a real
vacation. However, Berta never
recovered from her illness and Jim
never recovered from the fact she was
gone even when she died. This caused
him to institutionalize himself much
later in life. Fortuitously he did recover.
Frugality did remain a major part of his
life, as his tips were an embarrassment
to those around him.
From a company that began around
1903 and that had no Jewish employees
until the 1960s, it turned into a
company that later claimed to be
interested in equal opportunity for
women and minority members. Long
before this, the wife of one manager was
rude and haughty to a woman
salesperson. Another CEO soon
thereafter tried to picture his own wife
having to stand there all day for less pay
than her male counterparts. Along
came the upwardly mobile Gale Duff-
Bloom, who oversaw the successful
movement toward equity. At the same
time, Gale suffered hurt when she went
to celebrate her achievements for
women with the top officers. The men
were whispering to one another before
and during this jaunt, and, only on
arrival, Ms Duff-Bloom, learned she
had to return to her office alone, as the
men remained to play at this golf course
that did not welcome women. The men,
allegedly supportive of her efforts, did
not leave and return with her.
A further personal frame of reference
in the Celebration of fools led me to
read about Dr Barton Weitz. Dr Weitz
received the full respect of Gale Duff-
Bloom. When she arrived on his
campus, she felt a pang of regret that
she had, by her own design and
demands, risen to the top without a
formal, on-campus college education.
Barton is the JCPenney Scholar at the
Warrington School of Business at
University of Florida. Moreover, I
agree with Duff-Blooms assessment of
Professor Weitz, who was Chairman of
the Board of the American Marketing
Association, when I was its top officer of
the collegiate division in 2002 and
2003. He is as bright, amiable, and
effective as Ms Duff-Bloom describes
him.
Hare divides the book into four
chronological parts:
(1) The founder;
(2) The visionary;
(3) The betrayer; and
(4) The end.
446
There are 27 chapter titles, which
become apparent and appropriate as
readers understand the text preceding
each heading. For example, Chapter 9
bears the title of The common touch.
This chapter describes the
commonalities of JCPenneys top
executives. Only one, Mil Batten, who
was the fourth Chairman and CEO,
never managed a store. He did train
under and work with others in the
organization and moved up until he
retired to become the head of the
United States Securities and
Exchange Commission.
Most chapters were under 20 pages.
For me, not one chapter dragged and
there was no redundancy. It is a read
those in retailing and management
should not miss.
Sylvia Keyes
Professor, School of Management,
Bridgewater State College, Bridgewater,
Massachusetts, USA and Immediate
Past Vice President, American
Marketing Association, Collegiate
Chapters Division

Computer currency
Edited by Dennis A. Pitta
University of Baltimore
A fast and secure wireless network for
home or office
When Bill Gates recognized the internet as the next big
opportunity, he repositioned Microsoft to emphasize Internet
Explorer and added networking capabilities to Windows 98
Second Edition. At the time, the networking was
accomplished using network cards and cables. Networking
in turn spurred cable and telephone providers to roll out
broadband connections for small businesses and individual
consumers. The reliance on cable connections was logical. At
the time only cables provided the speed necessary to give fast
internet access.
Cable installation was one of the more difficult tasks,
especially in older business buildings. When necessary, the
task of drilling through concrete walls made the task more
costly. As a result, companies and individuals faced with
laying out the networking infrastructure embraced wireless
connectivity. As the internet and networking grew in
popularity, wired networking became a challenge for both
the individual with a small office at home and the small
business owner.
The following review represents actual experience in
entering the wireless domain. Our personal wired
networking experience concentrated on integrating hardware
made by Netgear. Netgears equipment earned a reputation
for easy configuration, flawless performance and economy. It
was logical that we chose Netgear equipment for a wireless
network. Netgear marketed a new wireless router, which
forms the heart of a wireless network. Our choice was the new
WGU624 wireless firewall router. Wireless routers require a
communications protocol to communicate. The protocol
determines the ceiling of communication speed. When a radio
frequency current is supplied to an antenna, it creates an
electromagnetic field that can propagate through space. The
protocol determines how that field is used for
communication. Many wireless technologies are based on
radio frequency field propagation. Since the WGU624 uses
two protocols, 5 GHz 802.11a and 2.4 GHz 802.11b/g, it
allows sending data in two separate radio frequencies instead
of just one. 802.11 refers to a family of specifications
developed by the Institute of Electrical and Electronics
Engineers, (IEEE pronounced I-triple-E). 802.11 specifies an
over-the-air interface between a wireless client and a base
station or between two wireless clients. The IEEE accepted
the specification in 1997. That specification promises
enhanced performance.
Netgear also promises that its router will deliver fast
delivery of data over significant distances using either
frequency. Independent laboratory tests support the claim.
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For example, the WGU624 garnered excellent overall
throughput scores in CNET Labs technical tests. CNET is
a website that maintains a professional evaluation staff and
performs numerous tests of software and hardware.
Speed is only one aspect of wireless technology: the other is
security. Since it is based on radio waves, security is of special
concern. All radio waves can be intercepted. To provide
security, a security protocol is necessary. The router uses
secure WPA technology. WPA is short for Wi-Fi Protected
Access, a standard that was designed to improve upon the
security features of protocols. Wi-Fi is short for wireless
fidelity and is meant to be used generically when referring of
any type of 802.11 network, whether 802.11b, 802.11a, or
other.
WPA technology and extensive firewall features should
protect your transmissions in both modes. This sounds good
but there is another requirement. Not only do you need a
router, you need a specific wireless PC card to reap these
benefits. In this case, the WGU624 requires use of a Netgear
WG511U PC card or another brand of dual band adapter, in
each of the computers on your network.
Setup
Netgear provides a browser-based tool to configure the
WGU624. The setup tool allows the user to manipulate
aspects of its integrated 802.11as well as its 802.11b/g access
points. Using the tool one can create keys for 64-, 128-, and
152-bit Wired Equivalent Privacy encryption. Wired
Equivalent Privacy (WEP), is a security protocol for wireless
local area networks defined in the 802.11b standard. It is
designed to provide the same level of security as that of a
wired LAN (WLAN). In essence LANs are inherently more
secure than WLANs. Because they rely on physical
connections, they do not have the radio wave leak point
that wireless LANs have. In fact, national security agencies,
which know how to hack an enemys communications, view
WLANs as security risks and tend to rely more on wired
networks.
Since WLANs are more vulnerable to tampering, other
safeguards are needed. WEP attempts to provide security by
using encryption to protect the data sent via WLANs. In the
world of secrecy, it is clear that few encryption schemes are
totally secure. If communications use the same encryption
algorithm over time, eventually the cipher becomes
vulnerable. Spies sometimes use a one-time encipher pad,
a non-repeated cipher that cannot be broken because it is not
repeated to give clues to help the code breaker. Since WEP is
used repeatedly, it is not as secure as once believed. If security
is paramount, perhaps wired LANs will be required. The tool
does provide a log of access attempts so that a vigilant LAN
manager may use it to discover attempts to penetrate security.
The WGU624s configuration tool allows users to foil
external attempts to gain access to LAN connected
computer contents.
The WGU624s setup guide and documentation are
supplied on a CD. The WGU624 setup guide is clear and
offers a good explanation of how to hook up the routers
hardware. The documentation on the CD is detailed and
explains the configuration tool well.
Users report that it is easy to setup and get working out of
the box
Performance
Netgear WGU624 seems to deliver the speedy performance it
promises. Tests in both the 2.4 GHz and 5 GHz bands showed
 Computer currency
fast data throughput. LAN performance is measured in Mega
bits per second. Modern wired LANs may reach 100 Mbps.
The WGU624 mode, the router can attain 42.1Mbps, slower
than wire but still fast. There are other wireless routers that
are rated a bit faster. However, the WGU624 performs very
well compared to most routers.
Speed is a critical metric of LANs. WLANs also must
deliver performance at a distance from a router. Like the old
portable telephones, the farther the handset traveled from
the telephone base, the weaker the signal became. Tests of the
WGU624 at 200 feet showed that the router transferred data
quickly.
Warranty
The WGU624 comes with one-year warranty. In addition,
Netgear provides 24/7, toll-free phone support during the
warranty period. The FAQ and troubleshooting info on the
companys support web site is okay. However, Netgear sees
the value in customer-to-customer communication and set up
a nicely organized customer forum. A sampling of the
communication shows it to be helpful in getting router advice.
Cost
The WGU624 lists for $105. If you use the WG511U PC
Card, each will cost $65. Thus the cost for the router and a
few wireless connected PCs can add up.
Caveats
While wireless hardware is better today than it was last year,
there can be lurking problems. PC configurations vary and
some can cause unforeseen performance problems. While
some users praise the unit for ease of setup and performance,
others report stability problems with the WGU624. They
range from having to reboot once a month to once each
morning.
Some users report that the router is buggy. Actually the
Netgear user forum had numerous complaints. One of the
most damaging is that users have to constantly reboot the
router to get it to work for just a few hours. In many cases
the router just seems to continually reboot. Sadly, Netgear
does not seem to respond to consumer complaints about
stability.
Users also complain about the technical support. It is 24/7
but as with many products, technical support is offshore.
Users report that the support is not effective in solving their
problems.
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Still others report that the unit fails to deliver its promised
range, even at distances much less than 200 feet.
Specifications for the Netgear WGU624
.
Networking form factor external.
.
Connectivity technology wired, wireless.
.
Data transfer rate 108 Mbps.
.
Data link protocol Ethernet, IEEE 802.11a, IEEE
802.11b, IEEE 802.11 g, Fast Ethernet.
.
Transport protocol L2TP, PPTP, IPSec, PPPoE,
TCP/IP.
.
Features DMZ port, Manageable, Auto-uplink, NAT
support, DHCP support, E-mail alert, URL filtering,
VPN pass through, Content filtering, Firewall protection,
DoS attack prevention, MAC address filtering, Intrusion
Detection System (IDS), Stateful Packet Inspection (SPI)
.
Networking compliant standards IEEE 802.11a, IEEE
802.11b, IEEE 802.11 g.
.
Routing protocol RIP-1, RIP-2.
Overall evaluation Netgear WGU624
As far as wireless routers go, the WGU624 offers a well-
rounded bundle of fast throughput, long range, and tight data
security. On the plus side it has 802.11a/b/g support; fast
maximum throughput at both short and long ranges; good
security via WPA and firewall settings. On the negative side, it
is more expensive than other routers, and its one year
warranty is considered short.
Personally, it was found to be very good for exploiting both
of its internal protocols to send multiple streams of data
across a wireless network simultaneously. Therefore it was
speedy and speed is vital.
I am somewhat technically oriented and like to play with
new technological toys. For my office, and me the router
worked well and gave me the performance I expected. I have
several PCs networked without the need to run cable over the
building. Truthfully, it is a little less tweakable than I like but
relatively unsophisticated users (with standardized
configurations) will find it fine.
In summary, time and money are required to properly
install the WGU624. Therefore it is most suitable for
companies with an available technical staff or individuals with
a technical bent. Without these, it might be better to find
another alternative.
Robert Jameson
Practice Management LLC, Columbia, Maryland, USA

Internet currency
Edited by Dennis A. Pitta
University of Baltimore
One to one marketing finally hits its
stride
Not too long ago, marketers talked about one to one
marketing and mass customization. The idea, which was
promoted by Pepper and Rogers, sought to satisfy customer
wants at a profit by giving them exactly what they wanted.
The idea was based on getting to know exactly what the
customer wanted and creating want satisfying goods and
services that met those wants. Information technology was
vital in helping companies learn and remember the wants of a
specific customer. Some of the earliest examples involved
items like coffee purchased from a Starbucks like shop or
specific preferences of hotel guests.
The one to one concept requires that customers divulge
what they want when they interact with an organization. The
communication occurs naturally in some settings. For
example, the hotel guest who wants a larger number of
towels, an extra pillow or a bathrobe to use at the pool would
ask the front desk. Similarly, revealed preferences for a special
type of room service meal, or a room located on a lower floor
would help the hotel keep satisfying the guest. Pepper and
Rogers and other authors stressed the need to remember that
information using sophisticated databases. For chain retailers,
the customer information could be stored in a central
database accessible from any retail location. The benefits
include being able to access customer address and contact
information, payment data, and preferences without having to
ask the customer every time he or she trades with the
company.
In fact, the concept was more easily applied to services
rather than products. Customizing products for individuals is
often beyond the means of the typical manufacturer. Often
the emphasis is on making a uniform product or a uniform set
of products to satisfy the largest number of consumers. The
limitations of production have only recently been overcome.
Now, computer aided design and computer aided
manufacturing have made it possible to allow the customer
to design his or her own customized product.
In this issue we look at a recent project devised by a
venerable shoe manufacturer, Nike.
Nike
(www.nike.com/main.html)
The Nike web site is animated and asks the visitor to choose
his or her geographic region of interest. The rest of the site is
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professionally done which is expected. The one aspect of
interest in this review is the facility that allows individuals to
design his or her own Nike products.
Other companies have used the design a product idea to
gain insight into the customers preferences. For example,
Proctor Silex the small appliance manufacturer used the
Design a toaster interactive module to plumb customer
preferences. Their results were mixed since toasters may be
inherently less interesting than other products. No consumer
supplied a category busting design. There were some
interesting features that customers designed into their
products but there was no provision to assess a consumers
tradeoff of cost versus features. The lesson is that it takes
more than a slick computer module to learn what bundle of
features might make a successful product. It also requires a
knowledgeable and skilled staff to sort out the noise and fun
and isolate the voice of the customer.
Nikes site offers a breakthrough feature: it allows
individuals to Design and Buy products that can
actually be produced for sale. It exemplifies one to one
marketing perfectly.
We decided to explore a sample of the design it yourself
choices that Nike offers. The designer required a choice of
region and then a further choice of country. We chose the
UK. The next step is to select a reference shoe (the inspiration
for the design) and a shoe size. In this case we chose a shoe,
the Nike Dunk Low Parque iD, described as the Soul of
Brazil. Notably, the description also features the price:
US$75. One can take a basic shoe and customize the color of
five interchangeable components: the base color, the
secondary color, the lining, the Nike swoosh accent and the
outsole. Different combinations of each element create
strikingly different designs. It is fun to change one element
and see the effect on the total shoe design.
Design choices are strictly multiple-choice to minimize the
difficulty in manufacturing. Mercifully, the combinations of
several designs we played with yielded few horrid results.
Most were at least acceptable. Several had a striking
appearance. For individuals or groups of individuals like
sports teams, the chance to customize a style of footwear is
valuable. The price is also attractive and approximates the
normal retail price.
Nike has selected a series of styles each of which has enough
customizable elements to create a shoe with a distinctive
appearance. They have also minimized the manufacturing
difficulties by concentrating on assembly. In other words,
shoes can be assembled using elements that correspond to the
customers color choices. So a red base color upper can be
combined with a white Nike swoosh (accent) and a gray
secondary color outer cover. There is a lot of computer aided
design and manufacturing behind the scenes here.
The results are not totally unique, since statistically
someone on the net will have chosen our exact design. In
addition, one cannot yet specify a particular style of sole
pattern that is not part of the basic shoe design. However, the
website conveys the benefits of mass customization, namely
allowing individuals to buy something they would have
designed for themselves and really want.
 Internet currency
Overall comments
After years as a concept and topic of marketing discussion, a
company has finally implemented mass customization for a
physical product well. Hotels and restaurants may have
pioneered the one to one marketing concept in the service
industry. Nike has done so in manufacturing and product design.
Moreover, Nike has not neglected the pricing or
promotional aspects of its customized shoes. It has
progressed beyond the limited product design websites of
the past. Currently, Nike has created another engine for
online sales. As online retail sales continue to grow, Nike may
find its distinctive create a shoe design web site is a valuable
competitive tool.
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Volume 22 Number 7 2005 449 450
In our next issue, we will investigate other informative sites
and invite readers to submit their favorite internet sites for our
consideration.
Reader requests
Please forward all requests to review innovative internet sites
to: Dr Dennis Pitta, University of Baltimore, 1420 North
Charles Street, Baltimore, MD 21201-5779, USA.
Alternatively, please send e-mail to: dpitta@ubalt.edu for
prompt attention.

Note from the publisher
Outstanding Doctoral Research Awards
As part of Emerald Group Publishings commitment to
supporting excellence in research, we are pleased to announce
that the 1st Annual Outstanding Doctoral Research Awards
have been decided. Details about the winners are shown
below. 2005 was the first year in which the awards were
presented and, due to the success of the initiative, the
programme is to be continued in future years. The idea for
the awards, which are jointly sponsored by Emerald Group
Publishing and the European Foundation for Management
Development (EFMD), came about through exploring how
we can encourage, celebrate and reward excellence in
international management research. Each winner has
received e1,500 and a number have had the opportunity to
meet and discuss their research with a relevant journal editor.
Increased knowledge-sharing opportunities and the exchange
and development of ideas that extend beyond the peer review
of the journals have resulted from this process. The awards
have specifically encouraged research and publication by new
academics: evidence of how their research has impacted upon
future study or practice was taken into account when making
the award selections and we feel confident that the winners
will go on to have further success in their research work.
The winners for 2005 are as follows:
.
Category: Business-to-Business Marketing Management
Winner: Victoria Little, University of Auckland, New
Zealand
Understanding customer value: an action research-based study
of contemporary marketing practice.
.
Category: Enterprise Applications of Internet Technology
Winner: Mamata Jenamani, Indian Institute of Technology
Design benchmarking, user behaviour analysis and link-
structure personalization in commercial web sites.
.
Category: Human Resource Management
Winner: Leanne Cutcher, University of Sydney, Australia
Banking on the customer: customer relations, employment
relations and worker identity in the Australian retail banking
industry.
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.
Category: Information Science
Winner: Theresa Anderson, University of Technology,
Sydney, Australia
Understandings of relevance and topic as they evolve in the
scholarly research process.
.
Category: Interdisciplinary Accounting Research
Winner: Christian Nielsen, Copenhagen Business School,
Denmark
Essays on business reporting: production and consumption of
strategic information in the market for information.
. Category: International Service Management
Winner: Tracey Dagger, University of Western Australia
Perceived service quality: proximal antecedents and outcomes
in the context of a high involvement, high contact, ongoing
service.
.
Category: Leadership and Organizational Development
Winner: Richard Adams, Cranfield University, UK
Perceptions of innovations: exploring and developing
innovation classification.
.
Category: Management and Governance
Winner: Anna Dempster, Judge Institute of Management,
University of Cambridge, UK
Strategic use of announcement options.
. Category: Operations and Supply Chain Management
Winner: Bin Jiang, DePaul University, USA
Empirical evidence of outsourcing effects on firms performance
and value in the short term.
.
Category: Organizational Change and Development
Winner: Sally Riad, Victoria University of Wellington,
New Zealand
Managing merger integration: a social constructionist
perspective.
.
Category: Public Sector Management
Winner: John Mullins, National University of Ireland,
Cork
Perceptions of leadership in the public library: a transnational
study.
Submissions for the 2nd Annual Emerald/EFMD
Outstanding Doctoral Research Awards are now being
received and we would encourage you to recommend the
awards to doctoral candidates who you believe to have
undertaken excellent research. The deadline by which we
require all applications is 1 March 2006. For further details
about the subject categories, eligibility and submission
requirements, please visit the web site: www.emeraldinsight.
com/info/researchers/funding/doctoralawards/2006awards.
html