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Influence of direct to consumer pharmaceutical
advertising and patients’ requests on prescribing
decisions: two site cross sectional survey
Barbara Mintzes, Morris L Barer, Richard L Kravitz, Arminée Kazanjian, Ken Bassett, Joel Lexchin,
Robert G Evans, Richard Pan, Stephen A Marion
Only the United States and New Zealand allow adver-
tising of prescription drugs directed at patients. US
spending on such advertising grew rapidly during the
1990s, reaching $2.47bn (£1650m) in 2000.
dramatic increase in investment by the US pharmaceu-
tical industry is evidence of an expected effect on sales.
On the rationale that such advertising provides impor-
tant information to consumers and patients who may
benefit from advertised products, pharmaceutical
manufacturers have campaigned in the European
for the relaxing of current regula-
tory restrictions. We examined the relation between
direct to consumer advertising and patients’ requests
for prescriptions and the relation between patients’
requests and prescribing decisions.
Participants, methods, and results
We carried out a cross sectional survey of a cluster
sample of primary care patients in Sacramento,
California, from March to June 2001 and in
Vancouver, British Columbia, from June to August
2000. We used questionnaires to determine the
frequency of patients’ requests for prescriptions and of
prescriptions resulting from requests. Seventy eight
physicians participated in the study, 40 in Vancouver
(all family physicians) and 38 in Sacramento (14
general internists and 24 family physicians).
Patients were all 18 years and over, spoke English,
and provided informed consent. The unit of analysis
was a matched set of patient-physician questionnaires
covering a single consultation. We estimated adjusted
odds ratios using a generalised estimation equation.
We classified drugs as advertised to consumers if they
were among the 50 drugs with the highest US advertis-
or were described as advertised to
consumers in Canadian media reports
Sixty one per cent of patients attending physicians’
offices on preset study days participated (1431 total;
683 in Sacramento and 748 in Vancouver). Patients in
the two cities had similar demographic characteristics,
socioeconomic status, and attitudes toward the doctor-
patient relationship. In both settings, income was
higher than average, and 80% were of European
Patients requested prescriptions in 12% of sur-
veyed visits. Of these requests, 42% were for products
advertised to consumers. The table provides details of
factors associated with requests. Physicians prescribed
the requested drugs to 9% (128) of patients and
requested advertised drugs to 4% (55) of patients. The
prescribing rate was similar for advertised and
non-advertised drugs (about 74%).
After we controlled for health status, demograph-
ics, socioeconomic status, drug payment, and physi-
cians’ sex, specialty, and years of practice we examined
the influence of requests on the probability that a
patient received a new prescription. Patients who
Details from questionnaires given to patients and physicians regarding requests for prescription drugs
Factors associated with
Patients who requested >1 drug (any drug) Patients who requested >1 direct advertised drug
No (%) of patients Odds ratio* (95% CI) No (%) of patients Odds ratio* (95% CI)
Does the patient believe a new prescription was needed?
Yes 75/264 (28.4) 4.2 (2.9 to 6.1) 39/264 (14.8) 5.5 (3.2 to 9.5)
No 100/1167 (8.1) 35/1167 (3.0)
Has the patient requested drugs before?
Yes 67/348 (19.3) 2.0 (1.5 to 2.8) 32/348 (9.2) 2.3 (1.4 to 3.7)
No 108/1083 (10.0) 52/1083 (4.8)
Does the patient have a condition treatable by an advertised drug?
Yes 67/365 (18.4) 1.9 (1.4 to 2.8) 38/365 (10.4) 3.1 (2.0 to 4.9)
No 108/1066 (10.1) 36/1066 (3.4)
Does the patient use advertising as an information source?
Yes 17/84 (20.2) 1.6 (0.9 to 2.8) 13/84 (15.5) 3.2 (1.8 to 6.0)
No 158/1347 (11.7) 61/1347 (4.5)
Does the patient recall having seen adverts for at least three of six listed drugs?
Yes 123/800 (15.4) 1.7 (1.2 to 2.4) 56/800 (7.0) 2.0 (1.1 to 3.6)
No 52/631 (8.2) 18/631 (2.9)
Does the patient recall seeing more than five prescription drugs advertised in the past year?
Yes 111/822 (13.5) 1.3 (0.9 to 1.9) 54/822 (6.6) 2.2 (1.3 to 3.8)
No 64/609 (10.5) 20/609 (3.3)
Total requests 175/1431 (12.2) 74/1431 (5.2)
Requested drug prescribed 128/1431 (8.9) 55/1431 (3.8)
*Odds ratios adjusted for age, sex, health status, income, drug payment, and cluster sampling.
Centre for Health
Services and Policy
of British Columbia,
Canada V6T 1Z3
g raduate researcher
Morris L Barer
Robert G Evans
Health Care and
University of British
Stephen A Marion
Center for Health
in Primary Care,
Richard L Kravitz
professor and director
School of Health
for Health Services
278 BMJ VOLUME 324 2 FEBRUARY 2002 bmj.com
requested a prescription (for advertised and non-
advertised drugs) were more likely to receive one
(139/175 v 329/1256, odds ratio 8.7, 95% confidence
interval 5.4 to 14.2).
We asked physicians: “If you were treating another
similar patient with the same condition, would you
prescribe this drug?” An answer of “very likely”
indicated confidence in choice and “possibly” or
“unlikely” indicated some degree of ambivalence. Phy-
sicians were ambivalent about the choice of treatment
in around 40% of cases when patients requested drugs
(advertised and non-advertised, 62/143 v 62/500, 5.4,
3.5 to 8.5) and about half the cases when patients had
requested advertised drugs (30/60 v 62/500, 7.1, 4.0 to
12.6) compared with 12% for drugs not requested by
Patients’ requests for medicines are a powerful driver of
prescribing decisions. In most cases physicians
prescribed requested medicines but were often
ambivalent about the choice of treatment. If physicians
prescribe requested drugs despite personal reserva-
tions, sales may increase but appropriateness of
prescribing may suffer. Concerns about the value of
opening up the regulatory environment to permit
direct to consumer advertising in the EU and Canada
seem well justified.
We thank Robert Woollard for assistance with recruitment of
physicians in Vancouver and the physician questionnaire; the
research assistants who administered the survey: Amit Ahuja,
Danielle Lapointe, Michael Tsang, Christine Choi, Vanphen
Chanthalangsy, Min H Ku, Laura Shively, Erica Stranger, Nicol-
let Knopf, Bryan Faulstich, Karry Nagai, and Meridith Cobari;
Sara Lu Vorhes and Valerie Olson for research coordination in
Sacramento; and Nhue L Do and Alicia Mintzes for data entry.
Members of a multidisciplinary expert advisory panel assisted
with the study design: Wendy Armstrong, Alan Cassels,
Jean-Pierre Gregoire, Matthew Hollon, Patricia Kaufert, Joel
Lexchin, Bob Nakagawa, Nancy Ostrove, Richard Pollay, and
Ingrid Sketris.We also thank all of the physicians and patients
who participated in the survey.
Contributors: BM and MLB contributed to all aspects of
study planning, design, analysis, and reporting. RLK, AK, and
KB contributed to interpretation of the data, review of drafts the
manuscript and, to a lesser extent, study planning, questionnaire
design, and data collection. JL and RGE contributed to study
design, interpretation, and review of the manuscript. RP
contributed to US components of study design and organised
and supervised data collection and entry in Sacramento. SAM
contributed to the analysis plan and interpretation and to
subsequent discusssion of these components of the manuscript.
BM and MLB are guarantors.
Funding: Health Transition Fund, Health Canada. Barbara
Mintzes also received a PhD training fellowship for this research
from the National Health Research and Development
Programme (NHRDP) and the Canadian Institutes of Health
Competing interests: None declared.
Like many journals the BMJ derives income from
pharmaceutical advertising. Direct to consumer advertising of
prescription drugs competes with this channel.
1 IMS Health. US leading products by DTC spend. January 2000-December
2000. Fairfield, CT: IMS Health, 2001. www.imshealth.com/public/
structure/dispcontent/1,2779,1203-1203-143221,00.html (accessed 19
2 Watson R. EC moves towards “direct to consumer” advertising. BMJ
3 Therapeutic Products Programme. Direct-to-consumer advertising of
prescription drugs. Discussion document. Ottawa: Health Canada, 1999.
4 Findlay S. Prescription drugs and mass media marketing.Research brief. Wash-
ington, DC: National Institute of Health Care Management, 2000.
www.nihcm.org (accessed 15 March 2001).
5 Silversides A. Direct-to-consumer prescription drug ads getting bolder.
Can Med Assoc J 2001;165:462.
(Accepted 14 January 2002)
Two memorable patients
Two deaths, two lives
Some days in general practice are surprising. On a Tuesday
morning last June I was due to see Miss Jean Smith at 10 20. She
had longstanding angina and recently had worsening
breathlessness. We had discussed my referring her to a specialist,
but in her old fashioned polite and deferential way she’d said, “It’s
up to you, doctor, but maybe we could wait.” I had known her for
many years but had never visited her at home, and I had formed a
picture of her as a spinster, living very much alone, supported by
a few friends from the church.
At 9 50 the telephone rang, and a receptionist told me that
Jean Smith has been found dead in her bedroom by the police.
Could I go and certify the death? I drove down and was greeted
by a policewoman. In the lounge sat an elegantly suited grey
haired man. “Oh hello, Dr Memel, I am so pleased to meet you.
Jean told me so much about you. I came to pick her up for her
appointment with you, like I always do, but the front door was
bolted ....Wearegood friends, of course, but I am not the next of
kin.” A two minute chat, then I went upstairs to confirm that she
was dead before returning to my half completed surgery.
An hour later, and Susie came to see me. Her estranged
husband, Donald Hill, had died two weeks earlier from a bleeding
peptic ulcer, alone in his flat. He had been to see me several times
over the previous months, complaining of vomiting and
depression. Slowly from him a story of sad alcoholism had
emerged, of a lonely divorced man whose only solace and social
life was going to the pub.
Susie now told me a very different story. A bubbly lady, she was
my patient 10 years ago, before moving on to one of my partners.
“Don’t you remember how I told you about Donald, how I could
not stand to live with him and his drinking?” I did not remember.
She told me how she had continued to see him regularly over the
years, and still loved him. She was devastated by the way he had
died alone. She showed me a newspaper that she had found in
his flat. On it was scrawled in different places, “Sicked blood, feel
awful,” “Must phone Susie,” “Passed out, sick again.”
I thought about these two patients recently while attending a
fascinating conference on narrative based medicine, organised by
the BMJ. The anthropologists’ presentations emphasised that
within the stories of people’s lives there are often more than one
that of the subject, those of other participants, and that of
the narrator, with each adding his or her own interpretation. These
two patients, who are now dead, told me some things about their
lives but did not tell me others. I asked some questions but did not
ask others, or did not hear the answers, and I fantasised to fill the
gaps. As their general practitioner over many years, I thought that I
knew these two patients well, but I realise that I did not.
David Memel general practitioner, Bristol
We welcome articles up to 600 words on topics such as
A memorable patient, A paper that changed my practice, My most
unfortunate mistake, or any other piece conveying instruction,
pathos, or humour. If possible the article should be supplied on a
disk. Permission is needed from the patient or a relative if an
identifiable patient is referred to. We also welcome contributions
for “Endpieces,” consisting of quotations of up to 80 words (but
most are considerably shorter) from any source, ancient or
modern, which have appealed to the reader.
279BMJ VOLUME 324 2 FEBRUARY 2002 bmj.com