In 1997, the Food and Drug Administration relaxed its restrictions on direct-to-consumer marketing of pharmaceuticals. Prior to this ruling, drug manufacturers were prohibited from mentioning both the name of the drug and its indications in consumer-directed advertisements without also including a large amount of technical information about the drug, including all known side effects, contraindications, and dosage recommendations (Stevens, 1998).

In addition to interfering with the appeal of the advertisements, such requirements rendered broadcast ads infeasible due to time constraints, and hindered ads in print media due to cost and space availability. These requirements were abolished in the 1997 FDA policy changes, and pharmaceutical companies were permitted to market drugs by name as treatments for specific conditions, with the minimal requirement that ads give mention to major risks identified in clinical trials (Melillo, 2001). As a result, manufacturer expenditures on direct-to-consumer advertising, which totaled $791 million in 1996, rose to $2.6 billion for the year 2000 (Mitchell, 2001). Television, radio, and print media became saturated with ads promoting treatments for conditions ranging from depression to high cholesterol.

Names such as Zoloft, Claritin, and Lipitor, which were previously known mostly to health professionals, quickly became part of the national vocabulary. Consequently, spending on prescription drugs has increased significantly over the past several years as consumers are enticed to seek advertised medications (HealthBizNews.com, 2001). This new face of drug marketing has sparked a raging debate about the accompanying effects on the health of the American public: does direct to consumer marketing benefit the public by providing education about available treatments, or does it diminish the quality of healthcare by raising costs and causing unnecessary treatment? Proponents of direct-to-consumer, or DTC, pharmaceutical advertising, most prominently the drug companies themselves, argue that DTC marketing results in improved public health by increasing consumer awareness. According to this view, direct marketing to the consumer alerts the public of the availability of treatment for a given condition, a fact of which it may not otherwise be aware. This knowledge may prompt people to seek medical help rather than unnecessarily accepting their ailments (Miller, 1998). Furthermore, supporters claim that ads raise awareness of undiagnosed conditions by providing information about symptoms.

Since countless Americans suffer from undiagnosed disorders-only half of the estimated 16 million Americans with diabetes know they have the disease-the motivation to seek treatment provided by these ads is a valuable public benefit (Health Matters, 1998). Similarly, by prompting people to visit a doctor, ads may help identify conditions unrelated to the specific area of concern. For example, according to Mike Magee, a medical adviser for Pfizer, a large proportion of consumers seeking Viagra would not otherwise see a doctor, so visits seeking help for erectile dysfunction often uncover conditions warranting medical attention, such as diabetes (Shapiro and Schultz, 2000). Some doctors support DTC ads as well, claiming that they make their jobs easier by resulting in better informed patients. Many ads, particularly for diabetes, stress the importance of self-management of disease, which may increase compliance with doctors orders and result in reduced need for more extensive medical care (New York Times, 2001).

Doctors appreciate having patients who are already briefed about current drug therapies, which saves time in a medical system that often requires doctors to see as many as thirty patients per day (New York Times, 2001). Critics of direct-to- consumer drug ads, including the American Medical Association, insurance providers, and many physicians cite increasing healthcare costs, improper prescriptions, and corrupted doctor-patient relations as this type of marketing's major resultant evils. Substantial evidence exists that the escalation of DTC advertising has increased expenditure on pharmaceutical purchases. Prescription drug spending increased 84% between 1993 and 1998, and it is estimated that consumer-directed advertising increased drug expenditure by $13 billion in 1998 alone (Cassels, 2001).

The twenty-five most advertised drugs of 2000 accounted for forty-one percent of expenditure on new prescriptions (Sherrid, 2000). Escalating prescription cost is of particular concern to healthcare providers such as HMOs and large corporations, which face a choice between curbing costs and cutting benefits (Cassels, 2001). Additionally, those without prescription drug coverage must pay the increased rates out-of-pocket (Shapiro and Schwarz, 2000). DTC proponents counter arguments centered on rising costs by claiming that increased outlays on prescriptions save money in the long run by preventing the need for more extensive medical care (Moore, 2000). Critics, however, cite the fact that the largest portion of the drug industry's advertising budget goes toward drugs for non-critical ailments such as heartburn, allergies, and hair loss (Moore, 2000).

Another argument presented by DTC opponents holds that these ads result in incorrect prescriptions by creating consumer demand for products regardless of actual need. Critics believe that consumers are sold the idea that a pill can instantly provide them with good health (Health Matters, 1998). Often, however, the drugs to which consumers are exposed are not even the most effective, but simply the ones with the largest advertising budgets (Headden and Melton, 1998). According to Shapiro and Schultz, patients, if refused specific prescriptions, will frequently visit another physician, who may comply with the request (2000). In addition to unnecessarily adding to healthcare costs, patient demand pressures doctors to give patients the drugs they request for fear of losing business (Shapiro and Schultz, 2000). Specific drug requests, according to Dr. Angelo Agro, often cause physicians to lose credibility in the eyes of the patient, who has been convinced by advertisements that the drug a physician refuses to prescribe is nonetheless the best option (Tanner, 2001).

Responding to such concerns, the AMA, at its July 2001 meeting, debated a proposal for the organization to encourage the federal government to ban all DTC prescription drug advertising (Tanner, 2001). While I agree that public exposure through advertising of the latest treatments for common conditions raises public awareness and prompts people to visit physicians, I nonetheless believe that direct- to-consumer pharmaceutical advertising does not adequately justify its social costs. In the case of overt maladies, such as allergies or depression, for which a large share of advertised drugs are indicated, a condition affecting a person's life to the point of warranting medication would certainly cause him or her to notice it and presumably to seek treatment. While many other products, such as cholesterol lowering drugs, are used to treat conditions of which an individual may not be aware and that may eventually adversely impact health, these conditions would, in nearly all cases, be uncovered during a routine examination. In both cases, the central benefit accomplished by these ads is getting people through the doors of doctors' offices, an end that can easily be achieved more cheaply without the use of DTC advertising. For example, less expensive public service campaigns encouraging people to have routine checkups and informing the public of warning signs of common conditions would achieve the same results without affecting the cost of healthcare. As the situation now stands, the benefits that do result from DTC advertising are purchased at the price of reduced healthcare quality for some.

As drug advertising drives up the cost of treatment, healthcare providers will be forced to cut costs in other areas and may find it necessary to compromise coverage by denying certain procedures or raising premiums. Increased premiums may drive people who fund their own health insurance out of the system by making personal insurance unaffordable. Additionally higher premiums may discourage large employers, which often independently provide their employees with health coverage, from continuing this practice. General Motors spent $900 million covering prescription drugs in 2000, a 19% increase over the previous year (Cassels, 2001). Escalating costs may render those without prescription coverage unable to afford necessary medications. Furthermore, the production of a drug is only possible when the disease it treats becomes understood through years of basic research, most of which is conducted by publicly funded academic investigators. Since public money lays the groundwork for pharmaceutical production, drug companies have a responsibility to the taxpayers not to engage in practices that will result in a reduction in the quality of healthcare.

The major problems underlying this situation is that, under our current insurance structure, the costs of increasing drug prices do not accrue to the consumer and thus do not decrease demand as they should in a free market system. As a result, the pharmaceutical companies are not given proper incentive to control prices. Insurance providers, rather than transferring rising costs to consumers through reduced care, need to restore the incentive to curb drug prices and hold the pharmaceutical companies responsible for their exorbitant budgets.

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