Transcript Oral Presentation 1

How commercial promotion
affects the use of medicines:
from Evidence to Action
Andrew Herxheimer, Joel Lexchin
Why the WHO/ HAI database on
pharmaceutical promotion? (1)
to document how much drug
promotion is inappropriate
to document the health impact of
inappropriate promotion
to identify topics not so far studied
to recommend needed research
Why the WHO/ HAI database on
pharmaceutical promotion? (2)
to review tools for use in teaching
health professionals about drug
promotion;
to provide tools to monitor drug
promotion
to facilitate networking by linking
people concerned about promotion
through the website
How it was built
by collecting the widest possible range of material
describing, analyzing, reporting or commenting on any
aspect of pharmaceutical promotion :

articles, letters, news in various journals*
magazine articles*
articles from drug bulletins/newsletters
unpublished reports/studies
videos
radio/TV reports with accessible transcripts
theses
guidelines from diverse professional sources
books & chapters from books
then analyzing and reviewing all this material
*BUT few from industry publications
New drugs are the major
problem – they are the most
heavily promoted
• they are expensive
• there is still little experience of
their use in practice outside
clinical trials
• the safety profile is not yet well
established
Persuading doctors, pharmacists,
and the public to use a new drug
requires strong advocacy – like
any other sales promotion
Advocacy is one-sided – no balanced
comparisons with alternative
treatments. Claims are bold,
disadvantages played down or
ignored, but plain lies are unusual.
My caricature of
pharmaceutical promotion:
The truth,
the half truth,
and nothing like the truth
Analysing claims
and the data that may support
them takes time and skills –
most doctors lack both
Anyone interested can learn the
skills – courses in evidence-based
medicine are a good starting point,
& clinical pharmacology helps
Conclusions (1): Doctors’
attitudes to promotion
Attitudes vary, and don’t necessarily match their
behaviour. Their opinions differ on the value of reps.
Most doctors think information from drug companies is
biased, but many think it is useful. Most find small
gifts from drug companies acceptable,
& believe that drug reps or gifts do not influence them
personally, but do influence many colleagues. Few
patients know that doctors receive promotional gifts.
Doctors who rely on promotion tend to be older, less
conservative, see more patients, are GPs rather
than specialists, have less access to peers and have
a more positive attitude towards medicines.
Conclusions (2):
Effects on doctors’ knowledge
They often use promotional information
about new drugs, and for drugs used
outside their usual therapeutic field.
Doctors in private practice, or who
graduated long ago, are the heaviest
users of promotion as a source of drug
information.
Conclusions (3):
Effects on doctors’ behaviour
More promotion is associated with greater drug
sales, promotion influences prescribing more than
doctors realise, & they rarely acknowledge that
promotion has influenced their prescribing. Doctors
who report relying more on promotion prescribe
more often, less appropriately, & adopt new drugs
more quickly.
Samples stimulate prescribing.
Doctors who receive company funds tend to request
additions to hospital formularies. Company
sponsorship influences the choice of topics for
continuing education, the choice of research
topics, & the outcomes of research. It leads to
secrecy, delays publication for commercial
reasons, and conflict of interest problems.
Researchers often don’t disclose funding from
drug companies.
Countering bad promotion –
what’s ineffective
• Voluntary regulation, eg by industry
• Guidelines –
for sales reps
for post-marketing surveillance
on conflict of interest in research
for package inserts & compendia
about gifts
for trainee doctors & for hospitals
Countering bad promotion –
interventions that work
• Government regulation
• Training students – before & after
graduation
• Media exposure of abusive promotion
• Giving abundant free & reliable
therapeutic information to
professionals and the public
Research has focused on health
professionals – little has been
done on consumers or patients
Phase 2 of the project will look at
interventions for medical and pharmacy
students, and studies evaluating them
It is intended to update the database every 2
years
Industrialized v.
non-industrialized countries
• Much more research on promotion
has been done in industrialized
countries than elsewhere
• The problems and issues are basically the
same everywhere
• But the appropriate and practicable
solutions may not be the same
•A research strategy is needed for every
region and every country
What should happen in the next 5 to 10
years? (in my opinion)
1. Governments should
Remove responsibility for the pharma
industry from the health ministry
Fund the regulatory agency from the
health budget, not from licensing fees
Require balanced information, including
clinically relevant comparisons, as
well as present requirements, and clear
warnings about adverse effects
At the same time
Encourage pharmaceutical companies
to join constructively in the development
of national health policies
to do research addressing important
health needs (educate politicians on this)
to distinguish between real therapeutic
innovations, & new products that
offer no clear advantage over existing
therapies (educate politicians on this too)
An obvious but controversial
suggestion
Recognizing that promotion causes increased
spending on drugs by government &
citizens, introduce a modest levy of 5 to
10% on promotional spending, maybe
only on promotion of new drugs, but not on
promotion that supports national health
policies and guidelines.
Promotion must of course be clearly defined
2. Training students & graduates
to evaluate therapies and claims
• Programmes of education in evidencebased medicine (EBM) in schools of
medicine and pharmacy
• EBM courses in the continuing education
programme, including web-based distance
learning
• Local and e-discussion groups, eg as part
of journal clubs
3. Providing professionals and the
public with abundant free & reliable
therapeutic information
Funding or subsidising independent
professional bulletins, formularies, compendia
and information services as part of a national
health information policy, eg
in UK, Drug & Therapeutics Bulletin, British National Formulary,
National electronic Library of Health, Therapeutic Notes
In Oz, Australian Prescriber, Australian Medicines Handbook,
Australian Adverse Reactions Bulletin
4. Media exposure of abusive promotion
The aim would be
(1) to discourage abusive promotion by
expressing disapproval on behalf of the
professions and the public, so influencing
the company and its owners
(2) To raise general awareness of the issues
underlying the harmful behaviour
5. Benign competition and
collaboration between countries?
 Drug exporting countries have traditionally
promoted and have tried to protect their pharma
industry, which is politically powerful.
 But these countries also want affordable drugs for
their citizens – an unresolved conflict in many
 Countries that do not export drugs, can more
easily put public health needs first, but some don’t
– these countries should collaborate
 WHO, INRUD and many other NGOs are trying to
bridge the gap, and need support
6. Research
 Every country needs to understand the
effects of promotion on its health system
and its people
 At present only pharma companies do
research on promotion to help them sell
expensive drugs – but the results are secret
 Independent public research is needed to
ensure that promotion does more good than
harm