New Zealand is one of the few countries in the world to permit DTC communications on therapeutic drugs, including advertising, but it is an area fraught with debate. Advertising in particular has come in for rigorous criticism from many sides.
The year-long review of DTC advertising of prescription drugs by the NZ Ministry of Health, which concluded last year after a hard-fought battle by the leading players, illustrates the key issues still being debated.
PHARMAC, the government agency in charge of medicine funding, argued that DTC advertising of prescription medicines 'places a fiscal strain on the pharmaceutical budget' by increasing demand.
The Researched Medicines Industry Association of New Zealand (RMIANZ) countered by suggesting that there were other factors driving demand and that to ban advertising on such grounds would be unjust.
Merck Sharp & Dohme NZ corporate public affairs manager Phil Johnstone feels that 'extreme cost-containment policies enacted by PHARMAC' have denied patients access to innovative new medicines.
'Over time, it has become explicitly understood by New Zealanders that they are missing out on important medicines which are fully funded by the state in countries such as Australia, Canada or the UK. In such an environment, it has been accepted by patients and their care-givers that appropriate DTC activity has an essential role in alerting them to medicines which are available, but not currently funded by the state,' Johnstone claims.
The practice of DTC PR is, however, not strictly enforced by a single code of practice. Some pharma companies abide by the Therapeutic Advertising Pre-vetting System established by the New Zealand Advertising Standards Authority which outlines seven principles, including the need for advertising to be socially responsible, while others use the RMIANZ code of practice (see box). In the absence of a single code, marketers refer, in general, to either/or, and the debate about DTC advertising has therefore had a great impact upon PR.
Ralph Sutton, former MD of Burson-Marsteller's Australia & New Zealand healthcare practice, says: 'Critics of the pharmaceutical industry and of DTC advertising have accused pharmaceutical companies of using DTC campaigns as an aspect of lobbying. There is some perception that companies have used advertising as a way to drive patients to GPs asking for an explanation of their particular drug, but the pharmaceutical industry argues that it is rigorous in its self-regulation of the content and manner of DTC advertising.'
RMIANZ chairman Stan Rodger counters with an argument about lifestyle drugs: 'A glance at the list of prescription medicines being advertised on TV in New Zealand will reveal that they are largely aimed at conditions affecting men, who are traditionally reluctant to visit their doctor, or aimed at conditions that are generally under-diagnosed.
'We have worked hard to introduce a compulsory pre-vetting regime which combines with a plethora of checks and balances to ensure that only safe and effective medicines are available, and that information to consumers is balanced and supported by comprehensive additional material and services,' explains Johnstone.
The DTC debate continues while healthcare PR practitioners in the UK are taking stock of how the introduction of a similar environment could affect healthcare PR.
PRWeek examines three case studies illustrating how DTC PR is used in New Zealand.
RMIANZ CODE OF PRACTICE
The following points and principles in the code of practice pertain to DTC communications
Methods of Promotion: Methods of promotion must never be such as to bring discredit upon, or reduce confidence in, the pharmaceutical industry.
Public: Requests from the patient for advice on personal medical matters must always be refused and the enquirer recommended to consult his or her own doctor. Educational material for distribution to the public should be presented in such a way as to be non-biased and not product specific.
Such information must be presented in a balanced way to avoid the risk of raising unfounded hopes in the public mind as to the results of treatment with the product. Information provided for patients or the public which, while not mentioning a trade name, promotes a particular medicine or class of medicines and which carries a company name is direct-to-consumer advertising.
Unless it complies with the relevant legislation, a medicine name must not appear on any section of items given to health professionals which are intended for distribution to patients, e.g. forms for use as account statements (regarding fees owing) or leaflets or other educational material on health matters.
Press Releases: It is permissible for a manufacturer to supply information about a medical specialty product to the lay press and news media in the public interest or where the object is to inform the public of scientific or technical achievement. An announcement of the introduction of a new medical product must not be made by press conference or formal press release until the appropriate steps have been taken to inform the medical profession of its availability.
Roche's Xenical was one of the first prescription only medicines to be advertised direct to the public when it was launched in New Zealand in 1998. The decision to advertise the drug, used for weight loss and weight management, was based on research showing that consumers were unlikely to discuss weight loss with their doctor, and doctors were unlikely to initiate treatment for patients.
In 2002, Sibutramine, a prescription only appetite suppressant, began DTC advertising in New Zealand. The challenge for Xenical was to convince New Zealanders that dietary fat was the culprit when it came to unwanted weight gain.
Unbranded PR was chosen to condition the market, with DTC magazine ads working to break down consumer barriers to Xenical such as side effects, mechanism of action, and the fact it was not a replacement for diet and exercise. TV was used to drive the call to action to see a doctor.
The 'Fat is the culprit' PR campaign needed to communicate that New Zealanders eat too much fat, and that fat is the most calorie dense food group.
A partnership with the New Zealand Nutrition Foundation was formed to add credibility to the messages and increase the use of releases.
PR activities included a consumer diet poll covering information on bizarre/fad diets and rates of success, with the message that reducing fat intake and watching energy in/out helps weight loss. A breakfast comparison - high-fat verses low-fat - story was placed in a popular weekly magazine, with the breakfasts being delivered to radio stations on the morning the story was released.
Also planned is a survey of magazine diets over the last six months, highlighting the dangers and lack of success with fad diets and the importance of reducing dietary fat while watching the energy in/out equation.
The ongoing campaign will be tested in February 2003. Early results show July sales for Xenical were up five per cent on July 2001, and August sales 56 per cent ahead of August 2001.
Symbicort is a new treatment for asthma containing both a preventer and symptom reliever in one inhaler. Symbicort was launched in NZ in October 2001. Despite significant promotional efforts, sales had been relatively flat for the first part of 2002.
Research shows that 60 per cent of NZ asthmatics do not control their symptoms well, ie. waking at night, frequent use of reliever, limiting physical activity. Yet most patients think they are as well as they can be and do not expect that these symptoms can be relieved. They are also in denial of the symptoms. Further, doctors have little perception of this poor control and do not actively screen asthma patients on breakthrough symptoms.
The 'kick asthma' campaign is a branded campaign designed to raise awareness of poor asthma control. The greatest challenge was to cut through the high awareness of Flixotide (extensively advertised since 1999), and to drive patients to see their GP despite a high level of apathy and denial.
The campaign involved mainly a TV campaign supplemented by radio and some newspaper ads. Activities were pre-empted by an intensive sensitisation campaign to GPs to familiarise them with the product and doses, etc, and to support them in handling patient requests.
PR activities included work with patient organisations, patient information leaflets distributed via GP surgeries, and some press coverage was achieved with the poor control message.
Further activities included sponsored asthma clinics that allowed GPs to offer subsidised visits to their asthma patients for a review of their patients. The campaign ran over the winter months and is still running now.
Sales of Symbicort have increased 376 per cent since the start of the campaign in March, and continue to grow.
The Losec campaign is running in its second year and the results have been astounding. Losec, omeprazole, a proton pump inhibitor (PPI), is used for the treatment of the full spectrum of acid related conditions, the most common being Gastro Oesophageal Reflux Disease (GORD). The Losec DTC campaign has focused on this particular condition, the main symptom of which is heartburn.
The decision to advertise direct to consumers was based on a key piece of research, which highlighted that one in three New Zealanders suffers from GORD but only 17 per cent of sufferers present to their GP for treatment.
The vast majority self-medicate with antacids believing they simply have indigestion.
The challenge for the Losec campaign was to get more GORD sufferers to present to their GP rather than to continue to self-medicate with antacids.
The key messages for achieving this transition revolved around raising awareness of heartburn as a key indicator for GORD.
The main thrust of the campaign was a branded TVcampaign, supported with magazines, newspapers, adshells and leaflets. Pre-conditioning of the market was carried out through a series of TV and radio health spots to increase disease awareness.
A major project was carried out in shopping malls nationwide where skilled staff had one-to-one discussions with heartburn sufferers to complete the 'Acid Test' (a questionnaire for identifying potential GORD sufferers). This project enabled the distribution of leaflets improving awareness of the condition and encouraging presentation to the GP.
A key element of the campaign was ensuring that GPs were fully aware of the details of the campaign and that they had been involved in research to ensure that only relevant consumers would present to their GPs. Subsequent research has highlighted that GPs felt that the Losec campaign impacted on the correct target group, gave access to patients that may otherwise not visit the GP and demonstrated sensible support of a safe treatment, Losec.
As a result of the campaign, around 70 per cent of GORD sufferers are aware of Losec. Losec unit sales in July 2002 are up 65 per cent compared with July 2001 (pre-DTC campaign).