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Framing Analysis of Pfizer's Strategies to Manage Public Policy Issues
Regarding Direct-to-Consumer Advertising
by
Jin Seong Park, B.A.
A Thesis submitted to the Faculty of the Graduate School, Marquette University,
in Partial Fulfillment of the Requirements for the Degree of
Master of Arts
Milwaukee, Wisconsin
August, 2004
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Preface
Working as a research assistant for Dr. Jean Grow at
Marquette University, I had an opportunity to investigate
how pharmaceutical companies promote anti-depressants.
Through an in-depth analysis of direct-to-consumer
advertising for anti-depressants, Dr . Grow and I tried to
reveal what messages the pharmaceutical industry conveys
to the public regarding health, mental illness, and
recovery in society.
Reviewing the literature for the project, I received
the unmistakable impression that while pharmaceutical
companies promote their drugs directly to the public
through advertising campaigns, at the same time the
industry launches another layer of campaigns with the aim
of making DTC advertising appear more acceptable to the
public and therefore creating a favorable marketing
environment. This inspiration also fits the perspective
that today's marketing communications are being heavily
integrated in order to make them support each other. With
this train of insights, I planned a study to explore what
messages the pharmaceutical industry conveys to the
public through their public relations documents about
health, disease, and society while it attempts to support
DTC advertising.
This study attempts to investigate the persuasive
strategies that Pfizer is using to frame the issues
regarding public policy over DTC advertising in its favor
and therefore create' a favorable marketing environment.
Under the assumption that the company's framing
strategies will emerge throughout their public relations
documents, news releases and other public relations
materials that directly address the issue of DTC
advertising were collected from Pfizer's main web site.
Through an in-depth, qualitative frame analysis of
the collected documents, this project reveals how the
company tries to frame the public policy debate over DTC
advertising. The study also investigates how Pfizer also
frames the overarching concept of who the company is,
thus setting the tone to a controlled public discourse.
The results indicate that Pfizer's public relations
materials have the potential to lead consumers to
approach the issue of DTC advertising through a number of
Pfizer-initiated perspectives, encapsulated by the
following four frames: DTC advertising is information,
passive patients vs. empowered consumers, maximum
benefits & minimum risks, and no proven economic effects
upon drug expenditure. Through these four frames, Pfizer
ultimately conveys the fundamental message that DTC
advertising benefits society. One can understand the
message as reflecting both the company's IMC initiative
iii
iv
to create a favorable marketing environment and Pfizer's
willingness to fulfill its own sense of good corporate
citizenship as a leader in the pharmaceutical industry.
I
The findings of this project will have significance for
society for a number of reasons. First, the project will
help enrich the social discourses on OTe advertising,
because it deals with a potentially significant topic of
which scholarly discourses have lost sight. Second,
understanding Pfizer's framing strategies to promote OTC
advertising will help public relations practitioners to
judge if the company uses sound and valid argumentation
to represent and support its policy position. Most
importantly, for consumers, understanding Pfizer's
strategies to frame OTC advert-ising will lead them to
distance themselves from the pharmaceutical industry's
persuasive messages to contemplate the messages'
implications for public health.
v
Acknowledgements
This thesis is a collaborative work for a number of
reasons. First, a considerable portion of this project is
grounded in the works that I completed for the classes
that I have taken at Marquette. Interaction with my class
instructors and colleagues through numerous occasions has
been a great source of inspiration and advice. These
people include, but are not limited to, Dr. Lawrence
Soley, Dr. Joyce Wolburg, Dr. Steve Goldzwig, Robert
Griffin, Dr. Ana Garner, and Dr. Karen Slattery.
Second, the thesis committee members, Dr. Jean Grow,
Dr. Ana Garner, and Dr. Daradirek "Gee" Ekachai, have
been more co-workers than supervisors throughout the
process of completing the thesis, because they actively
participated in conceptualizing the research design,
constructing research questions, etc. Without their
critical and helpful comments, this thesis would be much
different. In addition, when I suffered from lethargy and
sagging motivation, the committee members showed their
vi
patience to wait for me to regain my morale. I cannot
appreciate their understanding, patience, and tolerance
enough.
Third, I especially thank Dr. Jean Grow and Dr. Ana
Garner for their listening to me when I needed them most.
Throughout the two years at Marquette, I visited their
office whenever I felt like sharing my personal problems,
creative ideas, and pure curiosity. Their sincere and
genuinely open-minded attitudes made my days at Marquette
much more meaningful and productive. Interacting with
them, I could internalize how to generate new ideas and
turn them into meaningful research projects.
Last but not the least, I especially thank my best
friend and life partner Jeong Ei Park for being with me
for the past one year. Since I met her an year ago, she
has stayed with me and tried to listen to my innermost
voice in the most difficult times. A shy and easily
depressed person, I cannot imagine how I could have
completed the master's program at Marquette with this
kind of success, if it had not been for her staying with
vii
me.
I thank all of these people for what I am today and
what I could achieve at Marquette.
viii
Table of Contents
PREFACE ii
ACKOWLEDGEMENTS v
CHAPTER 1: INTRODUCTION 1
CHAPTER 2: THE LITERATURE ON DTC ADVERTISING 13 Policy & Regulatory Issues 15 Public Reaction Issues 19 Content Issues 23 Social Impact Issues 1 27 Social Impact Issues 2 31 Limitations With the Literature 32 Lack of Theory-Guided Models 33 Focus on a Narrow Range of Variables 35 One-Dimensional Conceptual Model of Impact 37
CHAPTER 3: METHOD 44 Data 44 Frame Analysis 52 Frame Analysis in Journalism Research 53 Frame Analysis in Public Relations Research 55 Strengths & Weaknesses of Frame Analysis 59 Application to the Current Study 60 Analytic Procedure 63
CHAPTER 4: RESULTS 67 Frame 1: Advertising is Information 69 Frame 2: Passive Patients vs. Empowered 73 Consumers Frame 3: Maximum Benefits vs. Minimum Risks 78 Frame 4: No Proven Economic Impact 82 The Overall Frame 86
CHAPTER 5: CONCLUSION & DISCUSSION 90 Suggestions for Future Research 103
BIBLIOGRAPHY 107
Chapter l:Introduction
Advertising prescription drugs directly to consumers
(DTC advertising) has been around for decades. For example,
the first American advertisement of prescription drugs
directly targeted to consumers appeared in Reader's Digest
in 1981. The subsequent years witnessed a slow increase in
DTC advertising until the mid-1990s, when the new type of
marketing rapidly became popular (Pine, 1999).
1
Since the recent growth in DTC advertising, the public
has become interested in the potential role DTt advertising
plays in contemporary society. However, relatively little is
known about DTC advertising's effects on public health. To
this effect, Roth (2003) states, "two things are well known
about direct-to-consumer (DTC) advertising of prescription
drugs--annual expenditures keep going up and the debate over
the merits and effectiveness of DTC drug advertising
continues" (p. 180).
Even though critics have not generally agreed upon DTC
advertising's social impact, "the pharmaceutical industry,
other private and public sectors have continued to issue
opinions" (Allison-Ottey, Ruffin, Allison, & Ottey, 2003, p~
120). In today's integrated marketing communications (IMC),
all channels of communication are systematically mobilized
to promote products and create a favorable marketing
environment as well. In this context, pharmaceutical
marketing professiona+s can consider governmental
regulations and the public's perception of OTe advertising
as an important factor in the pharmaceutical industry's
business environment. The following statement by Pfizer
attests to this point:
"Every day, state and federal governments make decisions that affect Pfizer and our business operations. Patent restrictions, importation, ant~DTC and marketing regulations, supplemEntal rebates, and preferred drug lists are just a few examples of the challenges that we are facing (Our Voice, 2004).
2
The above statement leads one to assume that pharmaceutical
companies might feel the need to frame the public debate
over OTe advertising in favor of their business interests.
Based upon the above assumption, this thesis explores
the strategies that Pfizer, a pharmaceutical company with
the second largest expenditure on OTe advertising, uses to
frame the social debate over OTe advertising. To achieve
this overall research purpose, public relations materials in
which Pfizer directly expresses its polity position upon the
new marketing practice will be collected. Frame analysis
will be employed to analyze the strategies Pfizer uses to
spin the public debate over OTe advertising.
OTe advertising refers to "any advertisement developed
by the pharmaceutical industry including radio, print,
and/or television of prescription medication that targets
3
the consumers/patients" (Allison-Ottey et. aI, 2003, p. 121).
Regarding potential contributors to the rise of DTC
advertising, some allyde to the possibility that the Food
and Drug Administration (FDA)'s 1997 provision of the draft
Guideline for Industry and the 1999 final Guidance were
major driving forces (Calfee, 2002; Kravitz & Wilkes, 2000;
Wechsler, 1999). However, commentators seem to consider the
proliferation of managed care organizations and the
resulting erosion of physicians' authority to prescribe
drugs (represented by the term "preferred drug lists") as
the leading propeller of DTC advertising's rapid growth
(Bell, Kravitz, & Wilkes, 1999; Kravitz, 2000; Matthews,
2001; Morris & Griffin, 1992; Pinto, Pinto, & Barber, 1998;
Terzian, 1999).
The FDA, a government agency charged with regulating
the promotion of prescription drugs, initially expressed the
position that the new advertising practice is not inherently
in violation of FDA regulations. Nevertheless, in September
1982, the FDA initiated a moratorium on DTC advertising,
because it became worried about DTC advertising's potential
adverse influences on the public (Calfee, 2002). In 1985,
however, the FDA lifted the moratorium because of concerns
about freedom of speech, regardless of its previous position
that DTC advertising is not necessarily in the public
interest.
4
Reflecting the consensus at that time, it was thought
that regulations already in place to monitor doctor-targeted
advertising were sufficient to protect the public. The FDA
required that DTC advertising meet the same standards as
those applied to advertising aimed at doctors (FDA, 1985).
Specifically, the FDA required that the content of DTC
advertising include a "brief summary" of risk information
for print executions, a "major statement" of risks, and
"adequate provision" for viewers to obtain full FDA-approved
prescribing information. The above requirements were
potential constraints on the growth of the new marketing
practice. However, DTC advertising expenditure gradually
increased from $12 million in 1989 through $55 million in
1991 and $579 million in 1996 (Nordenberg, 1998; Pines,
1999) to $2.4 billion in 2000 (Rosenthal, Ernst, Berndt,
Donohue, Frank, & Epstein, 2002).
The overall increase in expenditure on DTC advertising
becomes more salient when compared with expenditure on
pharmaceutical advertising in medical journals, which had
been the main advertising venue before DTC advertising came.
In 1999, the pharmaceutical industry spent four times as
much on DTC advertising compared to its spending on medical
journal advertising. In 2000, the ratio increased to five to
one (Rosenthal, et. al., 2002; Woloshin, Schwartz, Tremmel,
& Welch, 2001). DTC advertising still does not constitute a
major share in the pharmaceutical industry's total
expenditure for promotion (Rosenthal, et. al., 2002).
However, the shift of , weight between the two advertising
venues illustrates the importance the pharmaceutical
industry increasingly puts on the new marketing channel.
The idea of promoting prescription drugs directly to
consumers is a cause for concern, driven by the fact that
the product category is directly related to public health.
Regarding DTC advertising's social impact and regulatory
issues, critics' positions are largely polarized into the
following two groups: those who view it as socially
beneficial and propose that FDA should relax its current
regulation; and those who attend to its potential harm on
the public and press for more intense regulation by the
government agency.
5
The polarization of opinion among critics reflects the
highly sensitive nature of the new marketing development,
i.e., promoting directly to consumers a product category
with impact, actual or potential, on public health. Since
the beginning of the new marketing practice in the mid-1980s,
and especially with DTC advertising's rapid growth in the
late 1990s, politicians, academics, and physicians have
incessantly expressed concerns about DTC advertising's
potential adverse influences on public health.
6
Some physicians, for example, have attacked DTC
advertising because they believe information provided in DTC
advertising is unbalaqced about benefits and risks of the
drug and therefore could mislead the public. They suggest
that it leads patients to push doctors into prescribing the
drugs they want. Further, it increases drug prices and
expenditure; and it medicalizes common life problems and
encourages drug use over other effective treatment options
(Bell, Wilkes, & Kravitz, 2000; Coney, 2002 ; Davis, 2000 ;
Hoffman, 1999; Hollon, 1999; Kessler, Rose, Temple, Schapiro,
& Griffin, 1994; Kravitz, 2000 ; Kravitz & Wilkes, 2000;
Woloshin, Schwartz, Tremme l, & Welch, 2001).
The criticism that DTC advertising increases drug
prices and expenditure and therefore presents a bigger
economic burden t o the public has become a political issue.
For example, in the race for the 2004 Democratic
presidential nomination, candidate Howard Dean called for a
ban on DTC advertising as an element of his six-point plan
to reduce prescription drug costs. Two other candidates,
Richard Gephardt and John Edwards, expressed similar, though
less harsh, criticisms (Teinowitz , 2003).
Anecdotal accounts suggest that there have been
attempts from the pharmaceutical industry and advertising
and public relations interest groups to defuse public
concerns about DTC advertising's potential adverse effects
7
upon public health. For example, Pfizer admits that it
considers "anti-OTC and marketing regulations," along with
patent restrictions i~portation and preferred drugs lists,
as an example of "the challenges that the company is facing
" ... because federal and state legislation and regulation
directly impact the financial well being of our company"
(Our Voice, 2004). When candidate Howard Dean's pledge to
ban OTC advertising received media coverage, Dan Jaffe,
executive vice president of the Association for National
Advertisers, called the candidate's plan "a prescription for
disaster" and argued that:
there is compelling evidence that this advertising often provides consumers [with] extremely valuable in~rmation that can save lives, often avoids seriou s health problems and in so doing often lowers health costs (Teinowitz, 2003, p. 1).
In the same vein, at the 2003 annual OTC National Conference,
keynote speaker Pat Kelly, president of U.S. pharmaceuticals
at Pfizer, "challenged marketers to make OTC represent more
than mere advertising and ... proposed changing the acronym to
HIFC or Health Information for Consumers" (Tosh, 2003, p. 8).
The above anecdotal accounts illustrate Pfizer's
public relations efforts to address the public policy issue
concerning OTC advertising. This series of attempts comes as
no surprise, because professionals and executives in the
pharmaceutical industry increasingly point out that public
relations must be strategically integrated into the
8
decision-making process, "more aligned with long-term
business objectives, and able to meet the new challenges of
a highly regulated ... health care marketplace" (Schreiber ,
1997, p. 338). This approach is an extension of the
principle of I MC advertising. Given the controversy over DTC
advertising, it is not surprising that pharmaceutical
companies continue to fight back to defuse criticisms and
create a favorable market environment through a var iety of
marketing communications. Without question, an important
part of the overall marketing communications objective is to
add an alternative vision of DTC advertising to the nation
wide debate and mold public perception and government policy
regarding DTC advertising.
The current literature on DTC advertising focuses only
on the new marketing practice's short-term impact on public
health and the way the public responds to it. Specifically ,
the current research, mostly based upon quantitative methods,
focuses upon a limited range of variables such as consumer
attitudes, recall, recognition, and certain behavioral
concepts such as compl iance with the regiment. Research that
conceptualizes DTC advertising as an integral part of the
complex persuasion network employed by the pharmaceutical
industry is missing from the current literature. The dearth
of such research runs against the current marketing
environment , in which the distinction between advertising
9
and public relations is being increasingly blurred.
Accordingly, the current literature largely ignores
the pharmaceutical in~ustry's efforts to influence public
policy over DTC advertising. However, this ignored research
area has a few significant social implications. First, the
pharmaceutical industry and public relations professionals
can have an opportunity to evaluate their issues management
approaches in terms of ethics as well as effectiveness.
Second, and more importantly, it is also a significant topic
for the public, because it deals with a marketing practice
with potential effects upon public health. Marketing
communications that directly address public health but
target consumers with allegedly limited ability to
understand medical information can potentially have adverse
consequences. Furthermore, one may reasonably assume that in
their attempt to influence national controversy over DTC
advertising, pharmaceutical companies are conveying, with
long-term cultural ramifications for society, more
fundamental messages about health, disease, and recovery in
people's lives.
Because of the significant potential consequences of
DTC advertising, this study touches upon the above uncharted
area of research. Particularly, it will explore how Pfizer
frames the social debate over DTC advertising. Of all the
companies in the pharmaceutical industry, Pfizer is chosen
10
for a number of reasons. First, the company's expenditure on
DTC advertising is the second biggest in the industry,
closely following Gla~oSmithKline (Branch, 2 003). Second,
Pfizer excels over other companies in producing drugs with
the strongest sales records. Pfizer produces 3 of the 10 DTC
promoted drugs with the strongest sales records (Anonymous,
2003). This point roughly indicates the considerable vested
interests that Pfizer has in maintaining a favorable
marketing environment for DTC advertising. Finally, Pfizer
is the only company that most openly and continuously
expresses their position over the issue of DTC advertising.
More specifically, only Pfizer makes available various
public relations materials to support its position on the
issue through its web site.
Specifically, this project addresses the following t wo
research questions.
RQ 1: What frames does Pfizer1 use to spin the
public policy controversy over DTC
advertising in favor of its business
1 This study originally attempted to collect data from ten leading pharmaceutical companies with heaviest expenditures on DTA advertising. Interestingly, however, of the ten companies, only Pfizer, with its second biggest expenditure on DTC advertising in the industry (Branch, 2003), had public relations materials that directly deal with public policy issues over DTC advertising. Therefore, this project changed from its original plan to discussing Pfizer's rhetorical strategies of issues management, rather than those of the ent i re industry.
interests?
RQ 2: What is the overarching message of DTC
advertising ,that Pfizer promotes through
the frames?
11
In short, this study attempts to investigate the persuasive
strategies that Pfizer is using to frame the issues
regarding public policy over DTC advertising in its favor
and therefore create a favorable marketing environment.
To achieve this overall research purpose, news
releases and other public relations materials such as policy
reports and research papers that directly address the issue
of DTC advertising will be collected from Pfizer's main web
page. If the company intends to persuade the public to
accept its policy position, one has good reason to believe
that the company's framing strategies will emerge throughout
the collected public relations materials, because such
materials are official documents that Pfizer makes public to
consumers.
The findings of this project will have significance
for society for a number of reasons. First, the project will
help enrich the social discourses on DTC advertising,
because it deals with a potentially significant topic of
which scholarly discourses have lost sight. Second,
understanding Pfizer's framing strategies to promote DTC
advertising will help public relations practitioners to
12
judge if the company uses sound and valid argumentation to
represent and support its policy position. Most importantly,
for consumers, unders~anding Pfizer's strategies to frame
DTC advertising will lead them to distance themselves from
the pharmaceutical industry's persuasive messages to
contemplate the messages' implications for public health.
13
Chapter 2: The Literature on DTC Advertising
There is a large body of literature on OTe advertising.
However, the current literature focuses on OTe advertising's
short-term impact upon public health and the public's
response to it. As stated earlier, regarding OTe
advertising's social impact and regulatory issues, critics'
positions are largely polarized into the following two
groups: those who attend to its potential harm on the public
and argue for more intensified regulation by the FDA; and
those who view it as socially beneficial and propose that
the FDA should relax its current regulation.
Although general positions on policy and social issues
are largely polarized, a literature review reveals that the
overall controversy is harder to grasp than one might expect.
Discourses on DTe advertising are multifaceted, with a wide
range of topics entangled within each other. This point will
surface when one looks through the titles of academic
periodicals that publish articles on the controversy. These
periodicals include the medical journals (New England
Journal of Medicine and Journal of American Medical
Association), communication and marketing periodicals
(Journal of Health Communication and Journal of Advertising
Research), public policy-related journal (Journal of Public
14
Policy & Marketing), and law-related periodical (American
Journal of Law & Medicine and Defense Counsel Journal). The
range of the listed p~riodicals roughly indicates the highly
controversial nature of the idea of promoting prescription
drugs directly to consumers.
Currently, New Zealand and the United States are the
only two economically advanced nations that permit OTC
advertising (Coney, 2002; Hoek & Genda1l, 2002). However,
the controversy has transcended the boundaries of these two
countries. It is now arising on the social agenda of the
European Union and Canada (Meek, 2001; Mintzes, Barer,
Kravitz, Kazanjian, Bassett, Lexchin, Evans, Pan, & Marion,
2002). Anecdotal accounts suggest that the rise has to do
with the transnational pharmaceutical industry's pushing for
changes to rules that prevent OTC advertising in Europe
(Jaderberg, 2002; Medawar, 2002).
The literature review reveals that OTC controversy
centers upon the following foci of concerns: policy and
regulatory issues; the content of OTC advertising; public
reaction; influences upon medical decision making and public
health; and OTC advertising' economic impact.
15
Po~icy and Regu~ato~ Issues
The 1962 amendments to the Food, Drug, and Cosmetic
Act (FDCA) authorize the FDA to regulate the development,
distribution, and promotion of pharmaceutical products
(Calfee, 2002) . Withdrawing the moratorium on DTC
advertising in 1985, FDA "announced that it would apply the
same standards to DTC advertisements as those in place for
advertisements directed to physicians, which must meet the
standards for fair balance and full disclosure" (Terzian,
1999, p. 152). More specifically, FDCA required print
executions of DTC advertising to include a "bri ef summary"
of risk information and broadcast executions to provide a
much shorter "major statement" o f risks and make "adequate
provision for viewers to obtain full FDA-approved
prescribing information. Pharmaceutical companies found it
impossible for broadcast advertising to satisfy the
conditions (Calfee, 2002).
Responding to the pharmaceutical industry's increasing
complaints, the FDA released the 1997 draft Industry
Guideline and its final version in 1999. The final Guideline
did not change the basic regulatory framework of 1962
amendments. Instea d, the Guideline clarified them and made
it easier for broadcast DTC advertising to meet the
requirements the FDCA stipulated. Specifically, the
16
Guideline stipulates that broadcast DTC advertising should
include: a toll-free number to contact the company; a
reference to its corr~sponding print executions; an Internet
web page address of the company; and a statement that
directs consumers to physicians for those who plan to seek
additional information about the product (Terzian, 1999, p.
150) .
DTC advertising is not inherently illegal, as the FDA
clearly stated in its 1982 moratorium. However, neither are
the FDA regulations without legal grounds, because 1962 FDCA
amendments transferred regulatory authority over
prescription drug advertising from Federal Trade Commission
(FTC) to the agency. The FDA regulations' legal authority is
further backed up by a recent ruling by The Supreme Court of
New Jersey in the case of Perez v. Wyeth Labs, Inc. The case
occurred because a patient was physically damaged by misuse
of a medical device made by the company. The patient
contended that the damage occurred because the manufacturer
failed in its duty to inform consumers fully of potential
misuses of the product and their effects on health. In the
case, the pharmaceutical company invoked the learned
intermediary thesis, i.e., the defense that "doctors who
prescribed and implanted the Norplant device [a
contraceptive] had sole duty to inform their patients of the
device's potential dangers and side effects" (Pateiro, 1999,
17
p. 575). However, the court held that pharmaceutical
companies engaging in DTC advertising are liable for the
failure to provide adequate product warnings to consumers
because "the physician's role in prescribing drugs does not
break the chain of causation" (Pateiro, 1999, p. 575).
Critics' positions on the regulation of DTC
advertising are largely polarized into supporters of tighter
FDA regulation and those advocating more relaxed policies,
such as New Zealand's self-regulation model. The latter
group contends that: consumers and even doctors reveal
increasingly positive attitudes toward DTC advertising. This
group contends that DTC advertising's informational value
induces more informed and meaningful doctor-patient
interaction and it drives the under-diagnosed public to
become more aware of their health conditions that
potentially need medical intervention. The group also
suggests that DTC advertising prevents the under-diagnosed
but minor diseases from developing into major health
problems; and it is not largely responsible for the
increasing drug expenditure (Bonaccorso & Sturchio, 2002;
Calfee, 2002; Holmer, 1999, 2002; Manning, & Keith, 2002;
Matthews, 2001).
Driven by the above arguments, supporters of more
relax FDA regulation argue that the current FDA regulations
are sufficient to protect the consumer. Furthermore, some
18
argue that DTC advertising is over-regulated. The following
statement by Calfee (2002) encapsulates this position:
Proposals to tighten regulation [e.g., mandatory pre clearance] are unlikely to increase consumer welfare, because they would increase costs and reduce the scope of DTC advertising and therefore limit its benefits. Conversely, the FDA should consider relaxing some of its rules. The context of FDA regulation virtually ensure that its advertising standards are too stringent and thus deprive the market of useful information. An obvious problem is the quantity of warning information required in broadcast advertisements (p. 188).
He further argues that an alternative system of regulation
will produce better consumer welfare.
United States should take advantage of the New Zealand experience ... [which has] demonstrated that selfregulation for DTC advertising can work well, providing substantial information to patients with litte harm, while also achieving support from the medical community ... many of the protections in the tightly regulated pharmaceutical information regimes of Europe and Canada are both unnecessary and costly to consumers (p. 189).
Critics of DTC advertising disagree. They argue that:
doctors are uncertain and often negative about the impact of
DTC advertising. They contend that information in DTC
advertising is unbalanced about risks and benefits of the
drug and therefore has the potential to mislead the public.
Further, they suggest that it leads patients to push doctors
into prescribing the drugs that they want but that do not
necessarily help. According to them, DTC advertising also
increases drug expenditure. It also medicalizes common life
problems and encourages drug use over other effective
treatment options (Bell, Wilkes, & Kravitz, 2000; Coney,
2002; Davis, 2000; Hoffman, 1999; Hollon, 1999; Kessler,
19
Rose, Temple, Schapiro, & Griffin, 1994; Kravitz, 2000;
Kravitz & Wilkes, 2000; Woloshin, et. al., 2001).
The following suggestions for the FDA regulations by
Bell and others (1999) largely represent the views of this
group of scholars.
The demonstrated ability of DTC advertisements to reach consumers and affect their behaviors raises concerns about the quality of information provided in these promotions. These come from an industry that has not always been above reproach_ Health professionals and the FDA need to monitor carefully and regularly DTC advertisements and be prepared to object when misleading claims are made. (p. 657).
They further suggest that "proactive efforts to improve the
educational value of DTC advertisements should also be
considered. For example, media organizations could be
encouraged to adopt guidelines that DTC advertisements must
meet for acceptance" (Bell, et. al., p. 657).
PubIic Reaction Issues
Regulators, advocates, and critics of DTC advertising
have conducted research on the public's reaction, especially
doctors' and consumers' attitudes to DTC advertising, to
inform and guide their positions. The most notable of their
attempts includes the two nation-wide surveys commissioned
by the FDA. According to the surveys, it is currently
unquestionable that consumers are highly aware of DTC
advertising. For example, "of FDA respondents in 2002, 81%
(up from 72% in 1999) recalled seeing a prescription drug
20
advertisement in the past three months, and most recalled
seeing several advertisements" (cited in Calfee, 2002, p.
181). This should come as no surprise, because health
information needs have been ascendant on a societal scale
for the past decades (Matthews, 2001). Other national scale
studies also confirm high levels of awareness (National
Consumers League, 1998; Rodale Publications, 1999, 2000).
The same is generally true of consumers' attitudes
towards DTC advertising. Several studies up until the early
1990s show that consumers generally have positive attitudes
toward DTC advertising (Everette, 1991; Morris, 1984; Perri
& Nelson, 1987; Williams & Hensel, 1995). These findings are
further supported by nation-wide surveys conducted mostly
around 2000. The 1999 FDA study, for example, reports that
respondents who like seeing DTC advertising outnumber those
who do not by two to one; 86% replied that DTC advertising
makes them aware of new drugs; and 62% said that it helps
them have better discussions with their physician about
their health (FDA, 1999).
These findings illustrate consumers' largely positive
attitudes toward DTC advertising and are largely undisputed
by critics. Supporters of DTC advertising tend to use this
point to argue that DTC advertising should remain legal and
the government should consider relaxing the regulations
(Calfee, 2002a). However, what critics consider problematic
21
is that consumers' positive attitudes, though an integral
part of the controversy, do not necessarily indicate that
DTe advertising actually benefits their health. A body of
research supports this alternative perspective.
For example, critics point out that the content of DTe
advertising often has ambiguous, unbalanced, and misleading
information regarding risks and benefits (Bell, et. al.,
2000; Kravitz & Wilkes, 2000). They also point out that it
often depends on emotional appeals, rather than rational
appeals (Roth, 1996). These findings are significant because
one can argue that DTe advertising makes patient-doctor
interaction neither more informed nor less informed. Instead,
it has the potential to make the interaction misinformed.
Therefore, consumers' largely positive attitudes may
indicate that DTe advertising may have negative, but often
unrecognized, impact on their health through its undesirable
influence on doctor-patient interaction.
Bell and others (1999) found that consumers have
serious misperceptions about the FDA's role in regulating
DTe advertising. For example:
approximately 50% [of respondents] thought that DTC advertisements had to be submitted to the government for prior approval, and 41% thought that only completely safe prescription drugs could be advertised directly to consumer" (Bell, et. al., 1999, p. 654-655).
Both the above points (the government enforces prior-
restriction and the complete safety of information in DTe
22
advertising) are false information. They were made up to
test if consumers have correct ideas about DTC advertising.
It is alarming that a considerable percentage of respondents
had serious misperceptions about such key aspects of DTC
advertising. More alarming is the finding that these
misperceptions significantly correlate with consumers'
positive attitudes toward DTC advertising. One can infer
that consumers may easily make these associations, which is
alarming.
Health policy experts and doctors seem to share
slightly more negative views than consumers. For example,
The American College of Physicians and the American Society
of Internal Medicine declared in a joint policy statement
that "[we] are concerned that [DTC] advertising will result
in increased consumption of these [highly advertised] drugs;
though their use may be neither appropriate nor necessary"
(Matthews, 2001, p. 15). Other studies further this concern.
In a survey with members of the American Academy of Family
Physicians, Lipsky and Taylor (1997) found that "80% of the
physician respondents believed that print DTC advertising
was not a good idea, while 84% expressed negative feelings
about television and radio advertising" (p. 495). In another
survey with the same organization, 84% held negative views
of television and radio advertisements, many seeing them as
biased and misleading (American Medical Association, 2001).
23
In short, physicians have considerably more negative
attitudes toward DTC advertising than do consumers.
Content Issues
During the past two decades, "patients have been
seeking much more medical information and are actively
participating in decisions affecting their health" (Wolfe,
2002, p. 524). Accordingly, debate over DTC advertising
often involves how much educational value its content has
for the consumer, rather than consumers understanding or
reaction to its content or appeals.
The 1962 amendments to FDCA still apply to the
regulation of DTC advertising. They require that DTC
advertising meet the following 4 basic conditions.
1. They cannot be false or misleading. 2. They must present a fair balance of informationabout
the risks and benefits of using the drug. 3. They must contain "facts" that are "material" to the
product's uses. 4. In general, the advertisemert' s "brief summary" of
the drug must include every risk fromthe product's approved labeling (KefauverHarris Act 21).
Critics debate over whether the content of DTC
advertising meets the above conditions and addresses
consumers' health information needs. Advocates of DTC
advertising argue that "a consumer-directed ad can be an
important educational tool in an era when patients want to
be more involved in their own health care" (Nordenberg, 1998,
24
p. 28). In fact, in a survey by FDA, 85% of respondents
replied that if they were especially interested in the
advertised drug, "they would read all or almost all of the
information" (FDA, 1999). This finding suggests that DTC
advertising receives considerable attention from the
consumer as an important source of medical information,
making content issues all the more crucial.
Researchers emphasizing the benefits of DTC
advertising always mention its educational value. They
suggest that it leads the public to be more informed
participants in the medical decision making with their
doctor (Calfee, 2002; Holmer, 1999, 2002; Matthews, 2001).
However, it is interesting to note that that there seems to
be no systematic research on the content of DTC advertising
that supports this position. Therefore, the educational
value thesis, often invoked without reference to empirical
evidence, can be potentially misleading strategies of
persuasion.
For example, to support the view that DTC advertising
contains and conveys balanced information on risks and
benefits, Calfee (2002, p. 183) cites the FDA finding that
90% of respondents said they saw risks and side effects
information. However, the finding does not address the issue
of content at all, because seeing and understanding are two
very different responses. In other words, it is one thing
25
that consumers report they saw risk information in an
advertisement, but it is another to use the finding to argue
that the advertisement carries balanced information risks
and benefits.
There are only three studies that systematically
analyze the content of DTC advertising from a moderately
critical of the position (Bell, et. al., 2000; Kravitz &
Wilkes, 2000; Roth, 1996). These studies generally conclude
that DTC advertising does not carry adequate information
that could educate patients about risk factors and "the
mechanism of action by which the drug treats a particular
condition, its success in doing so, alternative treatments,
and behavioral changes that could augment or supplant
treatment" (Bell, et. al., 2000, p. 1096). The studies also
point out that DTC advertising mostly omits the potential
for drug misuse and directions for proper usage. They also
point out that promotional inducements such as a monetary
incentive are offered to readers. Finally, the most alarming
finding is that about two fifths DTC advertisements make
potentially misleading claims of innovativeness, because
when it comes to drugs, "what is new is not necessarily
better" (Kravitz & Wilkes, 2000, p. 334). In summary,
studies that systematically analyze the content of DTC
advertising are critical of the contention that information
that pharmaceutical companies provide in DTC advertising is
26
truthful and balanced, implying that DTC advertising does
not necessarily help the consumer make better medical
decisions with their doctor.
Advocates further argue that DTC advertising serves
the consumers' needs for health information. However, this
is a questionable proposition because they do not discuss
specifically what types of information consumers may need
regarding their health and whether and/or how DTC
advertising satisfies them. In Britain, Coulter, Entwistle,
and Gilbert (1999) studied patient information needs through
focus groups. They came up with the following list of
patient information needs.
1. To understand what is wrong 2. To gain a realistic idea of prognosis 3. To make the most of consultations 4. To understand the processes and likely outcomes of
possible tests and treatments 5. To assist in sel~care 6. To learn about available services and sources of help 7. To provide reassurance and help to cope 8. To help others understand 9. To legitimize seeking help ffid their concerns 10. To learn how to prevent further illness 11. To identify further information and sel¥help groups 12. To identify the best health care providers (p.319)
As noted previously, the overall controversy over the
content issues is largely polarized. Yet, systematic inquiry
generally points out that DTC advertising often fails to
measure up to FDA-imposed conditions about balanced
information and also it often fails to meet patients' health
information needs. This perspective reflects the bitter
sentiment evident in the following criticism by Ingelfinger
(1972) about pharmaceutical advertising in general.
advertisements should be overtly recognized for what they are - an unabashed attempt to get someone to buy something, although some useful information may be provided in the process _. [advertising should be] divested of its "pseudo-educational character (p. 1319).
27
Content issues are inherently interlinked with how consumers
interact with information in DTC advertising. Consumers read
and use DTC advertising to respondent to their health
problems. Therefore, how consumers perceive DTC advertising
and process the information in it has the potential to
affect doctor-patient interaction, doctor's prescription,
and ultimately consumers' health. Therefore, one cannot
discuss DTC advertising's social impact without referring to
the aforementioned key aspects of its content.
SociaI ~act Issues 1: MedicaI Decision Making.
Concerns expressed by all parties engaged in the
debate over DTC advertising ultimately boil down to its
impact on public health. However, because prescription drugs
require doctor's intervention, DTC advertising has been
mostly conceptualized to affect public health, whether
positively or negatively, through its impact on doctor-
patient interaction.
Regarding DTC advertising's impact on public health,
advocates mostly contend that it has educational values.
They also suggest that it helps consumers to be better aware
28
of health problems that are otherwise not easily detectable.
Further, they posit that DTC advertising is a vehicle
through which consumers get additional information, and that
it helps turn consumers into more active and informed
participants in doctor-patient interaction, therefore
contributing to the overall improvement of public's health
(Bonaccorso & Sturchio, 2002; Calfee, 2002; Hoek & Gendall,
2002; Holmer, 1999, 2002; Matthews, 2001). The following
statement by Bonaccorso and Sturchio (2002) encapsulates
these points:
consumer surveys and other studies show tat DTC advertising provides valuable information on treatments (including risks and side effects); motivates consumers to seek additional information from doctors, pharmacists, and other sources; and increases adherence that leads to better health (p. 910).
Another integral proposition is the "learned
intermediary" thesis. It is the idea that doctors are the
"ultimate gatekeeper." It posits that even when patients
receive misleading ideas from DTC advertising, doctors help
correct them and prevent this misinformation from having
negative effects on public health. Holmer (2002) represents
the proposition in the following statement:
[DTC advertising] merely motivates patients to learn more about medical conditions and treatment options and to consult them. Cnce the dialogue is started, the physician's role is preeminent. The patient has been empowered with information, not prescribing authority. In the words of Harvard Medical School Professor Jerry Avorn, "there is no detail man or a pharmaceutical company or patient that points a gun to a doctots head to write a prescription. Ultimately, it isrrt the patient's signature on the prescription - it's the doctor'sU (p. 381).
29
Critics question the above proposition. For example,
Lyles (2002) argues that:
DTC advertising's blend of promotion and information has produced some prescription drug awareness than knowledge - it has been largely ineffective in educating patients with medical conditions about the medications for those conditions (p. 73).
In the same context, critics question the value of national
surveys by the FDA in supporting the contention that DTC
advertising has positive effects upon public health. In the
surveys, consumers report that they saw enough risk
information in DTC advertising. Using this information,
advocates of DTC advertising support the position that it
provides balanced information and therefore is educationally
valuable (Calfee, 2002). However, this position runs against
the aforementioned content analyses of DTC advertising,
which show that it is often unbalanced and potentially
misleading (Bell, et. al., 2000; Kravitz, et. al., 2000;
Roth, 1996; Woloshin, et. aI, 2001). If consumers think they
receive enough risk information from a source that medical
experts see as often unbalanced, one can argue that this
raises the possibility that DTC advertising poses a
potential threat to public health.
Critics also question the doctor's role as the
"ultimate gatekeeper." They suspect that patient requests
often pressure doctors. Mintzes and others (2002), for
example, found that doctors are twice as likely to prescribe
30
certain drugs when patients request them than when they do
not. They also revealed that when ambivalent about effective
treatment options, physicians are about three times more
likely to prescribe a certain drug requested by patients.
Further, Mintzes, et. al. found that physicians prescribe
three-fourths of all drugs that patients either initiated
conversation about or directly requested. In the same vein,
Lipski and Taylor (1997) found that 71% of family physicians
believe that DTC advertising pressures physicians into
prescribing drugs that they would not ordinarily prescribe.
Foote and Etheredge (2000) also confirm that 75% of
consumers who make requests for prescription drugs receive
the desired drug. In summary, the above studies strongly
question the thesis that physicians are the "ultimate
gatekeepers," protecting patients from being affected by
whatever misleading information they may receive from DTC
advertising.
A related body of research further questions the
physician's role as the gatekeeper. For example, Avorn, Chen,
and Hartlay (1982) revealed that physicians are more
dependent on doctor-targeted public relations communications
as an information source then physicians believe they are.
This finding weakens th~ "learned intermediate" thesis,
especially when combined with reports that doctor-targeted
advertising and promotional materials are often inaccurate,
31
misleading, and unbalanced (e.g., Wilkes, Doblin, & Shapiro,
1992) .
Socia~ ~act Issues 2: Economic ~act
The second social impact issue category relates DTC
advertising's impact on drug expenditure and prices. As
mentioned previously, because of the public concern about
the drastic increase in medical expenses, DTC advertising's
potential economic impact has become a political issue
(Teinowitz, 2003). Exactly how DTC advertising affects drug
expenditure, however, is widely unknown. Some researchers
such as Findlay (2002) provisionally conclude that "such
[DTC] ads are one element - and perhaps an increasingly
important one - driving expanded use of newer prescription
drugs and increase spending on pharmaceuticals" (p. 24),
implying that DTC advertising has potential economic effects
but the nature and amount of such effects are untraceable
yet. However, several other studies suggest that DTC
advertising does affect drug expenditure. For example,
Calfee (2002) states:
approximately three fourths of these [outpatient] drug expenditure increases have been ca~ed by expanded usage and switching to newer and more effective drugs, whereas price increases have accounted for only about one fourth" (p. 178).
Yet, one must consider that the above statement is
somewhat misleading. It fails to provide a clear categorical
32
definition of "newer and more effective drugs." The
statement also fails to consider the point that "newer" does
not necessarily mean "more effective" when it comes to drugs
(Drake & Uhlman, 1993; Kessler, et. al., 1994). Therefore,
the statement might mislead readers about the association
between the increasing drug expenditures and consumers'
increasing spending on their health by leaving the
impression that switching to new drugs necessarily
contributes to public health. Between 1989 and 1993, for
example, the Center for Drug Evaluation and Research (CDER)
of the FDA "approved 127 new molecular entities (excluding
generic drugs), but only a minority [about 16%] offered a
clear clinical advantage over existing therapies" (Kessler,
et. al., 1994, p. 1350). Findings such as this challenge the
contention that switching to newer and more expensive drugs
contributes to public health.
-Limitations With the Literature
This literature review reveals that the overall
conceptual horizon underlying and shaping the debate over on
DTC advertising share the following three limitations: lack.
of theory-guided models, focus on a narrow range of concepts
and variables, and one-dimensional view of impact that
33
largely fails to consider the ever increasing integration of
marketing communications.
Lack of Theo~-Guided Mode~s
Research on DTC advertising in general seems to be
theoretically devoid. It fails to take advantage of the rich
body of theoretical foundation on persuasion in general,
especially research on advertising. Gaining insights from
the literature on persuasion could lead to a deeper
understanding of DTC advertising and could provide models
that are applicable to a wider range of contexts. Currently,
research on DTC advertising often does no more than measure
a few select variables such as doctors' and consumers'
attitudes, beliefs and behaviors toward DTC advertising,
with minimum discussion on how they correlate. For example,
the widely cited FDA 1999 survey is mostly simple
description of consumers' awareness, recognition, and
attitudes toward DTC advertising, with some discussion on
how consumers process specific categories of information
(e.g., risk information). Within the current literature,
potentially vital associations between variables are missing,
such as the association between consumers' reported exposure
to sufficient risk and benefit information and the actual
balance and completeness of risk information in the
34
advertisement.
Some researchers do show an interest in exploring how
variables are associated. For example, Davis (2000) reveals
that "consumer's rate the safety and appeal of drugs
described with an incomplete risk statement significantly
more positively than comparable drugs described with a more
complete risk statement" (p. 349). Bell and others (1999)
show that the respondents' overestimation of FDA's control
of DTC advertising positively correlates with their positive
attitudes towards it.
However, one needs a more elaborate model that
incorporates a wider range of variables in order to gain
fuller insight into DTC advertising. Peyrot and others
(1998) provide a seemingly elaborate model that connects
demographic variables, exposure to the media, exposure to
drug advertising, etc. in order to explain consumers'
prescription drug knowledge and requests. However, their
research utterly lacks validity, because it fails to present
information such as measurement validity and reliability,
statistical significance of correlations, and strength of
correlations, even though it appears to be a quantitative
study.
35
Focus on a Narrow Range of VariabIes
Research on DTC advertising focuses on a narrow range
of dependent variables. From a consumer perspective, the
most integral part of research on DTC advertising is,
obviously, to answer the following question: exactly what
does DTC advertising do for doctors and consumers in their
experience of diseases, illness, and coping?
When one looks through the literature, s/he receives
the unmistakable impression that most impact studies often
exclusively attend to drug prices, drug expenditure, doctor
patient interaction, revenues for pharmaceutical companies,
patterns of prescription, consumer awareness, responsible
drug taking behavior, etc. Studies on the content of DTC
advertising also mostly focus on straightforwardly medical
information such as truth and balance in the statement of
risks and benefits.
The above issues undeniably need attention, but these
are certainly not the only issues that matter. A large body
of literature on advertising in general, for example, points
out that advertising unfavorably depicts certain categories
of people, especially women, older people, and minorities,
especially African Americans. There are indications that
this problem may carryover to DTC advertising. Hansen and
Osborne (1995), for example, point out that the carryover
36
occurs in pharmaceutical advertising in medical journals.
Driven from such findings, researchers can enrich scholarly
discourses on DTC advertising by investigating if
stereotyping carries over to DTC advertising, what impact
the stereotyping may have on self-image of people of the
targeted groups, how the carryover affects the way the
public thinks about the target groups, etc.
Furthermore, many researchers hold that certain
categories of drugs are almost exclusively associated with
specific social groups. For example, anti-depressants
advertising in medical journals have mostly depicted women
as expected recipients of the drugs (Lovdahl, & Riska, 2000;
Lovdahl, Riska, & Riska, 1999). Driven from these findings
in pharmaceutical advertising in medical journals,
researchers could enrich the literature on DTC by
investigating if the above phenomenon carries over to DTC
anti-depressants advertising, whether it affects the female
population's self-image, how it affects women's ideas about
depression, how it affects the public's ideas about women
and depression, etc. Still more fundamentally, researchers
should ask how DTC advertising affects people's ideas about
health, disease, and recovery. All these are examples of
socially significant questions that are completely missing
from the current literature on DTC advertising. Such
questions can arise only when researchers take advantage of
37
the rich theoretical grounds in persuasion research,
especially research in advertising.
One-Dimensiona~ Conceptua~ Mode~ of ~act
Most research on the effects of DTC advertising,
whether explicitly or implicitly, presuppose a lineal model
of communication flow. The flow starts from advertising,
moves through the consumer's reception and doctor-patient
interaction, and ends with the doctor's prescribing the drug.
However, there is considerable circumstantial evidence
suggesting that such an approach is a narrow and simplistic
conceptual framework and therefore can drastically
underestimate DTC advertising's effects.
First, professionals and critics in marketing
communications widely accept the idea that marketing
communications are now so highly organized and interlocked.
This approach, encapsulated by the term "integrated
marketing communications" (IMC), fundamentally characterizes
the current marketing landscape.
What marketing communications practitioners ultimately
want to achieve through the IMC approach is to maximize the
synergy effects among all available channels of marketing
communications.
"The distinction between marketing and public relations messages has become more blurred and the two main communication functions are beginning to overlap and
support each other' (Ranchhod, Gurau, & Lace, 2002, P. 6) •
Public relations have two major functions. First,
38
public relations enable an organization to control the way
in which the organization is presented, in order to
influence the way people think of it. Second, public
relations affect every aspect of the organization's
operations (Ranchod, et. al., 2002). Applying the concept of
IMC, one can reasonably assume that public relations of the
pharmaceutical industry can affect the way the public thinks
of the industry's business operations, which include DTC
advertising. The industry's public relations have the
potential to lead the public to consider the practice of DTC
advertising as more acceptable and as a result be more
receptive to the messages of DTC advertising.
As has been previously discussed, an organization
finds it necessary to manage social issues, especially when
it comes to the ones that affect their business operations.
In this respect, Buer (2002) states:
To be successful companies need to adopt a stakeholder view of how they interact with society- in short their communications need to be integrated. Rather than focusing purely on their consumer markets, advertisers should be aware of the impact of their messages on public opinion, pressure groups, politicians and others that build up the "political market" (p. 293).
Because of the social controversy that surrounds DTC
advertising, the new marketing practice may become an issue
that needs to be managed by the pharmaceutical industry.
39
Therefore, public relations professionals of the industry
will feel the need to defuse the public's criticism of DTC
advertising and promote the industry's position on the issue
to the public.
An organization can reach the public and promote their
policy position indirectly through delivering press releases
to the media. Reporters sometimes use such materials to
write news reports. Because public relations materials are
framed by the organization to promote its business interests,
the frames that characterize such press releases can
sometimes bias news reports in favor of the business
interests of the industry (Glascock, 2000). Organizations
can reach the public by other means. For example, the
Internet is arising as a new public relations channel that
enables organizations to reach the public directly (Ranchhod
et. al., 2002).
There is no research that discusses how pharmaceutical
public relations to promote DTC advertising interplay with
the public's perception of the new marketing practice.
Nevertheless a body of research indicates that public
relations can be an effective channel to mold consumers'
awareness and perception of a given issue. Stern (1994), for
example, implies that the manufacturer's multimedia campaign
to inform the general public and the medical profession of
an unlabeled use of tretinoin were responsible for "the
40
greatly increased attention to tretinoin (a derivative of
vitamin A used in the treatment of skin diseases) in the
medical and lay press and the substantial increase in the
number of visits possibly to discuss, and prescriptions
written for, this agent" apparently in order to use it for
treatments unapproved by FDA (p. 1348). These findings point
to the potential role of public relations practices in
causing the public's interest in and use of this drug.
Findings from other studies provide indirect support for
such a possibility. In 1999 FDA national survey, for
example:
21% [of respondents] said that they had seen or heard anything that made them want to ask a specific question in their last visit to a doctor ... Among sources that inspired their questions, advertisements (46%) ranked equally with news media (45%), and somewhat higher than friends (28%) and other doctors (23%) (Calfee, 2002, p. 184) .
Consumers use news media as an important source of
medical information. Media coverage is often influenced by
pharmaceutical companies' public relations activities
(Jamieson, 2000). Therefore, it is not without ground to
assume that news media can sometimes be conceptualized as a
potential public relations vehicle through which
pharmaceutical public relations efforts influence the public.
Valestein's (1998) Blaming the Brain provides a compelling.
summary of the complex network of channels through which
pharmaceutical companies' persuasion campaigns occur. His
41
work suggests that pharmaceutical companies, in addition to
advertising drugs to physicians and consumers, promote a
certain way of thinking about health, disease, and recovery.
That certain way is tightly controlled by the pharmaceutical
industry to serve its business interests. In sum,
Valenstine's work presents a critical overview of the
pharmaceutical industry's various marketing communications
activities and the way the industry integrates them gain a
maximum synergy effect among them and promote its business
interests.
Research also indicates that doctors are exposed to
inaccurate and misleading information provided by
advertising in medical journals (Stryer & Bero, 1996; Wilkes
et. al., 1992). Avorn et. al. (1982) reveal that doctors
often underestimate how much they are dependent on, and/or
influenced by, commercial sources of information.
All in all, the above findings suggest that treating
DTC advertising as separate from other marketing
communications can drastically underestimate its impact. For
example, the 1999 FDA survey shows that people are inspired
by information advertisements (46%), news media (45%),
friends (28%), and other doctors (21%) in asking questions
in their visits to a doctor (FDA, 1999). Researchers (e.g.,
Calfee, 2000), whether intentionally or unintentionally,
treat the listed information sources as mutually impervious.
42
These supposedly autonomous sources of information, however,
are all influenced by persuasion campaigns of pharmaceutical
companies. In order to enrich the literature on DTC
advertising, one should be able to use the concept of
multiple flow of information as a conceptual tool to explain,
for example, how information received from friends could
have been initiated by other sources such as media coverage,
driven by pharmaceutical companies' media relations
campaigns.
Another example of pharmaceutical marketing
communications with implications for research on DTC
advertising's effects is Blake and Early's (1995) finding
that gifts that pharmaceutical companies present to
physicians to promote drugs may undermine patient confidence
in the medical profession. In the same vein, Steinman (2000)
states:
Surveys show as many as 70% of patients believe that these gifts significantly impact prescribing, and as many as two thirds believe they increase overall costof medications for the pUblic. Furthermore, 24% of patients reported that their perception of the medical profession changed after learning about drug company gifts to physicians (p. 2243).
Studies suggest that "most physicians believe that gifts do
not influence their prescribing, but the same physicians
often believe that gifts influence their colleagues"
(Steinman, 2000, p. 2243). This is a clear example of third-
person effect. These findings strongly question the "learned
intermediary thesis," or the idea that doctors are the
"ultimate gatekeepers," safeguarding against DTC
advertising's potential adverse effects.
43
It comes as no surprise that the current research pays
little attention to the pharmaceutical industry's attempts
to influence the public's opinion about, and ultimately
public policy over, DTC advertising. The conceptual
framework that dominates the current literature does not
consider the multi-leveled nature of the industry's
persuasive communications that include, but are not limited
to: DTC advertising to promote drugs; doctor-targeted
advertising in medical journals; monetary incentives to
promote drugs; public relations to promote a certain way
(i.e., bio-chemical theory) of thinking about health,
disease, and recovery; and finally, creating and
distributing messages to create a marketing environment
conducive to their marketing practices.
All in all, the current literature on DTC advertising
is characterized by a few significant limitations. These
limitations are lack of theory-guided models; focus on a
narrow range of variables, and one-dimensional conceptual
model of impact. They block researchers from asking a wider
range of questions that can generate insights into various
aspects of DTC advertising. They also block researchers from
creating knowledge about DTC advertising's impact on public
44
health and more fundamentally, consumers' ideas about health,
disease, and recovery in the long term.
Chapter 3: Method
Data
To investigate how Pfizer attempts to frame the
overall issue of DTC advertising, news releases and other
public relations materials such as policy reports and
research papers were collected from Pfizer's main web site.
Pfizer was chosen for a number of reasons. First, the
company's expenditure on DTC advertising is the second
biggest in the industry, closely following GlaxoSmithKline,
a pharmaceutical company with the biggest spending on DTC
advertising (Branch, 2003). Second, even though Pfizer's
spending on DTC advertising is the second biggest in the
industry, the company produces 3 of the 10 DTC promoted
drugs with the strongest sales records (Anonymous, 2003).
This point roughly indicates the considerable vested
interests that Pfizer has in maintaining a favorable
marketing environment for DTC advertising. Finally, Pfizer
is the only company that most openly and continuously
expresses their position on the issue of DTC advertising.
Especially, only Pfizer makes available various public
relations materials to support its position on the issue
through its web site.
44
45
The collected materials will serve the overall
research purpose for a number of reasons. First, the
collected materials are the only available body of documents
that express Pfizer's official positions on public policy
issues in a thorough and detailed manner. More importantly,
this project is based upon the assumption that Pfizer
intends to persuade the public through framing the social
debate over DTC advertising in its favor and therefore
delivering the message that DTC advertising benefits society.
The web site offers a central place for Pfizer to control
public discourse on DTC advertising. The web site allows
Pfizer to present its position and show how the company's
policy dovetails with that of the FDA. In essence, the web
allows Pfizer to show that it is a good corporate citizen.
Therefore, one has good reason to assume that the company's
framing strategies will be reflected by the collected
official documents that Pfizer has made public to consumers
through its official web site. These reasons will be all the
more valid when one considers Pfizer's emphasis upon its
participation in the process of public policy making. To
that effect Pfizer states, "with political decisions
increasingly taking on greater importance, Pfizer needs to
ensure that our voice is heard when officials consider
crucial pieces of legislation" (Our Voice, 2004).
46
The site map of Pfizer's main website shows that under
the major heading "Who We Are," and its sub-heading "About
Pfizer," the company provides a page wholly for the purpose
of discussing Pfizer's position on diverse public policy
issues. Under the sub-heading is provided a news archive.
Phrases such as "DTC" or "direct-to-consumer" were typed
into the news archive's search engine to locate articles
that address direct-to-consumer advertising. Four relatively
short reports of 2 to 3 pages and eight relatively long
reports of 6 to 59 pages that directly address DTC
advertising were located through this process.
Also under "About Pfizer," is a sub-heading titled
"All Pfizer Web Sites." The latter provides a separate page
titled "Public Policy," which leads to a page titled
"PfizerForum.com: A World of Ideas on Public Policy."
PfizerForum.com explains that:
The PfizerForum "advertorial" series has featured articles by a wide variety of prominent individuals around the world _ The series has made a point of highlighting the contributions of public policy "think tanks" around the world (PfizerForum.com, 2004).
Three short reports were found on this web page and included
in the study. All in all, 15 articles were included in the
study. The total number of pages that the project analyzes
is 131.
In the process of data collection, every section of
Pfizer's main web site was explored to check if it carries
47
messages that address the issue of DTC advertising. The two
sections cited above, "news archive" and "who we are" were
the only two sections that have public relations articles
addressing DTC advertising. The news archive is a place
where general press releases are stored, while "who we are"
had two separate sub-sections that exclusively discuss the
issue of DTC advertising. More articles were found in "who
we are" (13 articles) than in news archive (6 articles), and
5 of these articles were found in both places. This means
Pfizer prefers to set aside exclusive space to promote its
position over DTC advertising, rather than to discuss the
issue together with other news releases in general. This
author believes this indirectly reveals the important Pfizer
puts upon participating in the social debate over DTC
advertising.
This project uses the resulting pool of public
relations materials as data set to investigate Pfizer's
strategies of framing the social debate over DTC
advertising2• To clearly differentiate between the collected
2 The website did not differentiate between such reports according to their intended audiences. Therefore, it was difficult to determine which articles were intended for the public to read, which ones for the media to cover, etc. These reports, long or short, and whoever they were intended to be read, nonetheless represent Pfizer's official positions on pubic policy issues, in this case, DTC advertising. Designators such as "policy report," "comments of Pfizer," and "executive summary" accompany these reports. Interestingly, the company apparently is publishing a
48
data and other articles covered in the literature review,
each of the collected pubic relations documents is assigned
a number. Each collected material will be addressed only
through the assigned number. This rule applies even when the
articles list the authors' names. Table 1 summarizes the
basic characteristics of the collected materials such as
length, authors' names, titles, and web address.
As illustrated in the table, articles mostly have named
authors. Additionally, articles with the listed publication
date were published after 2001. Regarding the articles
without a publication date, one can easily guess when they
were published. For example, Merill Matthew's article cites
the pharmaceutical industry's expenditure on OTC advertising
as of 1999. This reveals that it was written no sooner than
1999. Likewise, the article The Best of Both Worlds is an
overview of a 2003 volume of Economic Realities in Health
Care Policy, Pfizer's in-house publication. Therefore, the
article came no sooner than 2003. All in all, the collected
public relations materials mostly cover the time span
between 2001 and 2003. About half of them were published in
Pfizer's in-house periodical Economic Realities in Health
Care Policy. There are other types of materials, such as
Before the U.S. Food and Drug Administrations, which Pfizer
periodical titled "Economic Realities in Health Care Policy" that exclusively discuss their views on pharmaceutical marketing and promotion.
49
submitted to the FDA to express it position on the issue of
DTC advertising.
Reference
Number
Doc 1
Doc 2
Doc 3
Doc 4
Doc 5
Doc 6
Doc 7
Table 1 List of Collected Public Relations Materials
Title Authorship Year Length
(pages)
Before the US Bert Rein, Andrew2003
Food and Drug Krulwich, &
Administration Rosemary Harold
59
What is
Information
Worth?
Richard Manning, 2003 3
& Neal Masia
The Economics Paul Rubin
and Impact of
Pharmaceutical
Promotion
Pharmaceutical Neal Masia
Innovation,
Lowering the
Price of Good
Health
2003 13
2002 12
The Economic Frank Lichtenberg2002 6
Benefits of New
Drugs
The Economics Richard Manning &2001 7
of Direct-to- Alison Keith
Consumer
Advertising of
Prescription
drugs
What the FDA John Calfee
Survey Showed
About Direct
to-Consumer
Prescription
Advertising
2001 5
Location
About us
http://www.pfizer.c
om/download/public_
print_ads. pdf
About us
http://www.pfizer.c
om/download/public_
policy_pmp.pdf
About us
http://www.pfizer.c
om/download/public_
policy_pmp.pdf
About us & News
archive
http://www.pfizer.c
om/download/about e
r22.pdf
About us & News
archive
http://www.pfizer.c
om/download/about e
r22.pdf
About us
http://www.pfizer.c
om/download/about E
Rhealthcare.pdf
About us
http://www.pfizer.c
om/download/about E
Rhealthcare.pdf
Reference
Number
Doc 8
Doc 9
Doc 10
Doc 11
Doc 12
Doc 13
Doc 14
Doc 15
Table 1 - Continued
Title
Information
Matters: The
Consumer as the
Integrated Health
Care System
Pharmaceutical
Prices: What's
Missing in the
Public Discussion
Impact of DTC
Advertising
Relative to
Patient
Compliance
Advertising and
the Informed
Patient
Authorship Year
Alison Keith 2001
Alison Keith Not
& Richard Liste
Manning d
Length
(Pages)
4
9
Pfizer &
RxRemedy, No
Individual
Authors
2001 7
Merill
Matthews
Not 3
Liste
d
Direct-to- John Calfee Not 3
Consumer Drug Ads Liste
Benefit Patients d
The Best of Both Pfizer, No Not 3
Worlds: Today's Indi vidual Liste
Prescription
Drugs Help Save
Both Lives and
Money
Maximizing
Patient Choice
Direct-to
Consumer
Advertising
Author d
Jane Kolassa Not 3
Liste
Pfizer, No
Individual
Author
d
2002 3
50
About us
http://www.pfizer.
com/download/about
_ERhealthcare.pdf
News archive &
About us
http://www.pfizer.
com/are/about publ
ic/mn about econom
icrealities.html
News archive
http://www.pfizer.
com/are/about publ
ic/mn about dtcads
doc.html
About us
http://www.pfizerf
orum.com/english/m
atthews2.shtml
About us
http://www.pfizerf
orum.com/english/c
alfee2.shtml
News archive
http://www.pfizer.
com/download/best
of_both_worlds.pdf
About us
http://www.pfizerf
orum.com/english/k
olassa.shtml
About us
http://www.pfizer.
com/download/publi
c_policy_dtc.pdf
51
The term "public policy" designates such reports. The
collected public relations materials are preserved on the
web site apparently to represent the company's official
position on diverse pubic policy issues. These materials are
an available and appropriate data set, because they
represent a body of communication materials essentially
framed by the organization.
One should note that there might have been some public
relations materials that Pfizer presented to the media or
the public but were not included in the company's web site.
If this happened, it was anticipated that such documents
would not significantly differ from the ones located in the
web site in the way Pfizer addresses the issue of DTC
advertising. More importantly, as the purpose of this study
is to analyze how a debate is framed by materials publicly
maintained by Pfizer, officially posted materials are
clearly more pertinent to addressing its overall framing
strategies. The collected materials are documents open to
visitors to Pfizer's web site. Pfizer, as other
pharmaceutical companies do, invites investors and people
interested in the company and its brands to visit its
website.
52
Frame Ana1.ysis
Frame analysis has developed as a way of analyzing
arguments about complex social issues and their impact upon
the way people think about such issues. Frame analysis as a
method of analyzing the text is rooted in the concept of
"framing," initially suggested by Erving Goffman, the
cognitive psychologist who created the theory of framing. He
defines the theory of framing and frame analysis as the
following:
definitions of a situation are built up in accordance wi th principles of organization which govern events ... and our subjective involvement in them; frame is the word I use to refer ill such basic elements as I am able to identify ._ frame analysis is a slogan to refer to the examination in these terms of the organization of experience (1986, p. 10-11).
Framing theory refers to the idea that people process
incoming stimuli and interpret a particular object or
situation according to principles of organizing information.
Such principles of organization could both exist in the text
and be part of each individual's cognitive characteristics.
Frames built in a people's mind interact with the way a
particular object or situation is framed in the text. Frame
analysis could be either an act of exploring the frames that
constitute a given text or an investigation into the
interaction between the frames built in people's mind and
the frames in the text. In either case, frame analysis
"emphasizes how frames sort out and organize the complex
53
stimuli of everyday life" and how "individuals create and
rely on frames to make sense of daily interactions,
conventional rituals, discourse, advertising, and other
elements of social experience" (Creed, Langstraat, & Scully,
2002, p. 3).
Frame analysis has continued to gain popularity since
its introduction. Its application has been extended to
various social scientific traditions, including journalism
and mass communications. Researchers in journalism, for
example, started to use the theory to analyze how news media
frame social issues and induce the public to think about
them in a certain way. Likewise, researchers in public
relations use frame analysis to explore how pubic relations
professionals can use various strategies to frame issues of
public debate in favor of the organizations they represent.
At the same time, critics use the theory to analyze the
framing strategies public relations professionals use.
Frame Analysis in Journalism Research
In the context of journalism research, Gitlin (1980)
points out that one can use the concept of framing to
conduct research on how the media represent aspects of
social reality and influence the way public perceive and
react to them in a certain way. According to him, media
54
frames, "largely unspoken and unacknowledged, organize the
world both for journalists who report it and, in some
important degree, for us who rely on their reports" (p. 7).
The statement correctly prognosticated that subsequent
researchers would use frame analysis as a way of analyzing
both news coverage of social issues and its impact on the
way the public think about them.
For example, Entman (1991), analyzes how Time and
Newsweek frame similar airline incidents differently, with
significant social ramifications. According to Entman (1991),
the 1983 Soviet downing of Korean Air Line (KAL) Flight 007
and the 1988 u.S downing of Iran Air (IAR) Flight 655 shared
similar circumstances, such as:
"in both cases, military officials identified a property passenger plane as a possibly hostile target; in both cases, the perpetrating nations officials claimed the shooting was justifiable under the circumstanceg (p. 6)
However, through selective use of words and images, the two
magazines frame the IAR incident as a techni~al problem
while framing the KAL incident as evidence of Soviet Union's
moral bankruptcy. The two overarching frames (i.e., moral
bankruptcy vs. technical problem) consist of distinct
organizing principles of the text, such as agency (i.e.,
locating responsibility for the reported action) and
identification (i.e., inducing empathy towards victims of
the incidents).
55
Another example is Powers and Andsager's (1999)
analysis of how newspapers framed the silicone breast
implant controversy from 1992 through 1996. The study
discussed whether the selected newspapers provided the
public with a fair and balanced account of the controversy.
Through defining, locating, and analyzing the frames that
characterized news coverage of the issue, the study revealed
that "early coverage of the controversy focused upon the
health risks of silicone breast implant, while later
coverage focused on the financial situations of the implant
manufacturers" (p. 551). Interestingly, the study pointed
out that the implant manufacturers' public relations efforts
might have influenced such reporting patterns.
Frame Analysis in Public Relations Research
One of the key objectives of public relations is to
maintain a marketing environment in favor of an
organization's business interest. This is especially true
when a social issue arises with the potential to affect an
organization's business practices. The organization then
tries to manage the issue, lest it should have adverse
impact upon its interest.
Without question, the news media are a public forum
through which social issues emerge and are debated.
56
Therefore, organizations prepare and present to the news
media various forms of public relations materials with the
objective of presenting their view of a given issue and
ultimately influencing the news coverage of it. For example,
In Mediating the Message, Showmaker and Reese (1996) state:
Interest groups also conduct public relations campaigns that use the media to fOillS public attention. To the extent that these campaigns are successful, media content is affected directly (through the pUblication of the press releases) and indirectly (by calling the media's attention to the problem) (p. 186).
In the context of public relations, Hallahan (1999)
discusses framing as "a potentially useful paradigm for
examining the strategic creation of public relations
messages and audience responses" (p. 205). According to him,
one can create public relations materials to effectively
serve the interest of an organization by creating messages
that effectively frame situations, attributes,
responsibility, issues, etc.
The themes, messages, and perspectives that creators
of the text intend to convey to the readers about a given
topic are embedded in the frames they use. Framing comes to
life through a body of linguistic strategies that public
relations practitioners use, consciously or unconsciously,
to respond to social issues. Therefore, a large body of
literature uses frame analysis to explore how such
persuasive strategies constitute the frames in a give text
and what themes, messages, and perspectives are potentially
carried by the frames in the text. Such literature
ultimately investigates how the frames, themes, and
linguistic strategies interact to shape media coverage of
social issues. By investigating the linguistic strategies
and constructing frames
57
For example, Anderson (2001) conducted research on the
battle between two pharmaceutical companies, Merck and
Searle, to promote Celebrex and Vioxx (the two companies'
arthritis drugs). The study concludes that their public
relations may have influenced the press on "what" to cover,
but not "how" to cover it. In other words, public relations
of the two companies succeeded to call news media's
attention to the issues they raised, but failed to make the
media frame the issues the way the companies preferred.
Similarly, Glascock (2000) examined newspaper coverage
of the 1982 breakup of AT&T and the role that the company's
public relations campaign may have played in the way new
media reported the event. They used frame analysis to
determine the relationship between the company's public
relations and the press coverage of the incident. Using
statistical techniques to determine association, the study
exemplifies a quantitative application of the theory.
Esrock, Hart, Silva, and Werking (2002) used frame
analysis in a case study. Similar to Entman's (1991)
analysis of the way Time and Newsweek covered the KAL and
58
IRA incidents, the study exemplifies a qualitative way of
applying the theory. The underlying assumption of the study
is that "framing choices are among the most critical
strategic decisions in the public relations process" (p.
209). They further argue that:
public relations professimals inevitably are involved in the framing process _ By constructing social reality, framing influences the way people understand issues and events and therefore, is central to public relations (p. 212) .
The study explores a conflict between a business
organization and residents of an island involving the
company's decision to discontinue the production of a
product that apparently has cultural and historical
significance for the residents: a brand of crackers called
"Crown Pilot," which reportedly has become part of the
collective cultural identity of the residents of the island.
The authors conducted in-depth and probing interviews with
key figures (business representatives, journalists, and
protesters representing the island) in forming the climate
of opinion on the issue. The study provides an account of
how the public relations efforts of the protesters, coupled
with the initial inaction of the business organization, led
the media to cover the conflict with a sympathetic "Darvid
vs. Goliath" frame, not the "sound business" frame that the
company started to promote later.
59
strengths and Weaknesses of Frame Analysis
Critics point out that frame analysis has a number of
strengths and weaknesses. For example, discussing the
theory's weaknesses from a quantitative perspective, Scheufe
(1999) states:
Research on framing analysis is characterized by theoretical and empirical vagueness. This is due, in part, to the lack of commonly shared theoretical model underlying framing research. Conceptual problems translate into operational problems, limiting the comparability of instruments and results (p. 103).
However, some critics point out that the theory's
apparent conceptual flexibility is an important factor for
the success of Goffman's frame analysis. They point out that
framing theory is far more varied and extended than the one
Goffman originally created (D'Angelo, 2002; Fisher, 1997;
Maher, 2001, Scheufele, 1999). In other words, one can
consider frame analysis's apparent lack of coherence as an
indicator of its wide applicability. For example, as
indicated above, researchers have used the theory both
quantitatively (particularly in media effects research) and
qualitatively (as a method of in-depth analysis of media
coverage) .
Furthermore, unlike other traditions of analyzing the
text (for example, discourse analysis, semiotics, and
narrative analysis), framing analysis has a rich body of
literature that discusses the impact of framing (impact on
the way the public thinks about a certain issue, impact on
60
the way the news media cover a social issue, etc.). The body
of literature on the effects of framing does not authorize
one to use frame analysis to analyze the text and conclude
that the results suggest some type of social impact.
Nonetheless, it makes such an inference much more probable
and research findings much more meaningful.
App~ication to tbe Current Study
As noted, framing analysis is rooted in the
theoretical concept of framing. The theory of framing refers
to the idea that people process incoming stimuli and thus
understand a particular situation according to a number of
principles of organizing information, which could exist
either in people's mind or in the text. Accordingly, frame
analysis could be an act of exploring the frames that exist
in the text or the interaction between the frames in
people's mind and the frames in the text. This project uses
frame analysis in the first way, or as a method of analyzing
the text.
As described previously, Entman (1991) used frame
analysis to show how Times and Newsweek describe two similar
situations, the US downing of an Iranian airline and the
Soviet downing of a Korean airline, as two drastically
different events framing them in a consistently different
61
manner. In public relations research, Esrock, Hart, Silva,
and Werking (2002) used frame analysis to explore how two
different groups of people framed the same event (a
company's decision to discontinue the production of a
cracker) differently and tried to promote their own
interpretation of the event to get media coverage. In a much
similar fashion, this study uses frame analysis to explore
how Pfizer frames and interprets the social debate over the
issue of DTC advertising. This study investigates how Pfizer
potentially produces a set of meanings around the issue
conducive to the pharmaceutical industry's initiative to
create a favorable business environment and therefore
support their new business practice of DTC advertising. In
short, this project explores how the collected public
relations materials reflect Pfizer's initiative to lead the
public to believe that DTC advertising benefits American
society.
In addition, frame analysis can apply to public
relations research either quantitatively or qualitatively.
This project uses frame analysis qualitatively for a number
of reasons. First, the project collects all the available
data from a specific, highly relevant source and analyzes
them in an in-depth manner. Therefore, the findings of the
study do not have to generalize statistically to a larger
category. The findings admittedly indicate the strategies
62
that one pharmaceutical company (Pfizer) employs to frame
the public policy issues involving DTC advertising in favor
of its business practices. Therefore, one can view this
project as a case study in the sense that Entman's (1991)
and Esrock's (2002) works are. However, as previously noted,
Pfizer's considerable vested interests in the issue of DTC
advertising enable one to infer that the strategies the
company employs to frame the DTC debate potentially reflects
the pharmaceutical industry's overall position on the debate.
Second, the project attempts to employ an in-depth
approach to analyzing the text. It seeks to fully explore
the text and provide a thorough and contextualized
understanding of what strategies Pfizer uses to frame DTC
advertising. One can gain such depth only with fully
contextualized, "thick descriptions" of themes embedded in
the text, something that many critics call the hallmark of
qualitative research (see Denzin, & Lincoln, 2003). As noted
previously, Pfizer is the only pharmaceutical company that
provides a rich body of texts to express its view on the DTC
debate. The in-depth approach of this project fits the kind
of richness and depth of messages that characterize the
collected materials.
Third, and most importantly, the project purports to
explore the full range of Pfizer's framing strategies. It
does borrow insights from a literature review. Yet the
63
project does not start from a pre-determined, mutually
exclusive list of frames and end up presenting how they
emerge in the collected public relations materials. Such
deductive logic can produce findings that can generalize to
a larger entity and are comparable with findings from other
entities. However, to compare and generalize is not the
primary objective of this project. Instead, it begins
inductively without a predetermined set of frames. In
locating and representing frames, the project aims to cover
the fullest possible range of linguistic strategies. This
inductive logic of categorization constitutes a hallmark of
qualitative research (e.g., Denzin & Lincoln, 2003; Maykut &
Morehouse, 1994). In short, this study demonstrates a
context-bound, in-depth use of frame analysis in analyzing
the text.
Ana~ytic Procedure
The current project analyzes each public relations
piece from the data pool. It locates what strategies Pfizer
uses to frame such major issues on DTC advertising as
legality of the marketing practice, the public's perception
of DTC advertising, consumer's ability to process medical
information, etc.
64
In explaining how framing occurs in the text and also how
researchers conduct frame analysis, arguably no researcher
has presented a clearer itinerary than Entman (1991) in the
following account:
Frames reside in the specific properties of the news narrati ve ... News frames are constructed from and embodied in the keywords, metaphors, concepts, symbols, and visual images emphasized in a news narrative. Since the narrative finally consists of nothing more than words and pictures, frames can be detected by probing for particular words and visual images that consistently appear in a narrative and convey thematically consonant meanings across media and time (p. 8).
Framing techniques that receive attention in this
project included, but were not limited to: specific word
and/or image choice; selection of some pieces of information
over others; placement of and emphasis on some pieces of
information over others; employment of some ways of
interpreting given data and observed phenomena over
alternative ways; and emphasis upon some conceptual
dimension of an issue or concept over other conceptual
dimensions. The project intends to demonstrate how patterns
of language use and graphics occur in a repeated and
consonant manner across the collected public relations
materials.
To locate, categorize, compare and contrast,
contextualize, and represent frames and their thematic
constituents, the analysis consists of two overall reading
processes. Specifically, this study defines frame as
"underlying structures or organizing principles that hold
together and give coherence to a diverse array of symbols
and idea elements" (Creed, el. aI, 2002, p. 36). In the
first overall reading/analytic process, a single reading
deconstructed the content of each article to look for
potential frames running through the collected data and
potential linguistic strategies to support them.
65
The second overall reading/analytic process consists of
multiple processes of comparison and contrast of the frames
located in the first reading process. Units of information
coded into potential frames in the first reading are
compared against each other to check similarities and
differences across them. The frames that emerged in the
first reading were collapsed into a higher order category
when they shared similar properties enough to be grouped
under one theme and create a meaningful and coherent whole
in thematic terms, a process common to qualitative methods
of analyzing the text (Strauss & Corbin, 1994). The same
process occurred twice, and a final system of frames
resulted.
Through the two overall reading and analytic processes,
the following four frames emerged: DTC advertising is
information (frame 1), passive patients vs. empowered
consumers (frame 2), maximum benefits vs. minimum risks
(frame 3), no proven economic effects (frame 4). Each of
66
these four overall frames consists of a number of smaller
and more concrete themes, which were located in the first
reading process. These four overall frames and the way they
incorporate their constitutive idea elements are further
explained and described in the next chapter.
67
Chapter 4: Results
In a few reported occasions Pfizer lists the issues
that have great significance on its business interests. The
following statement by Chuck Hardwick, Senior Vice President
of Pfizer, reveals that DTC advertising is one such
significant public policy issue. The statement also reveals
that Pfizer finds it highly important to participate in the
public debate over the issue.
For the past several years, some candidates and elected officials have spent an enormous amount of time and money attacking our industry. Some attack the industry because they want to see government run health care, while others find us an inviting target because they feel we are unable to respond to their attacks. Patent protection, direct-to-consumer advertising, sup~emental
rebates, and personal injury lawsuits are just a few of the many issues debated in Congress and our state capitols across the country (Our Voice, 2004).
This project has previously illustrated a few similar
anecdotal accounts that reveal how Pfizer attempts to frame
the policy debate over DTC advertising.
To systematically analyze the framing strategies that
Pfizer uses to frame the social debate over DTC advertising,
the company's public relations documents that directly
address its position on the issue were collected. Multiple
reading processes revealed that four overall frames run
through the collected materials and a variety of strategies
were used to promote them. These frames include the
following. First, DTC advertising is information, providing
68
access to innovation. Second, the old, passive patient vs.
the new, empowered consumer. Third, maximum benefits vs.
minimum risks. Fourth, no proven economic impact on drug
prices and expenditure. These frames form relatively
discrete bundles of coherent information and incorporate the
full range of strategies that Pfizer employs.
Rooted in the rich theoretical soil of frame analysis,
this study assumes that the above frames are potential
windows through which the collected materials induce the
readers to perceive the public policy debate over DTC
advertising. What follows is full description of how the
four frames come to life through the strategies of
persuasion that Pfizer employs.
Previously this project provided an anecdotal example
of Pfizer's attempt to make less salient the promotional
nature of the messages in DTC advertising. Pat Kelly,
president of u.S. pharmaceuticals at Pfizer, proposes to the
pharmaceutical industry "changing the acronym [e.g., DTC
Advertising] to HIFC or Health Information for Consumers"
(Tosh, 2003, p. 8). This suggestion indicates the importance
of encouraging people to view DTC advertising as information,
rather than advertising. The first frame encapsulates this
strategy. Results of the project's frame analysis reveal
that this frame runs through the collected public relations
materials of Pfizer.
69
Frame 1: DTC Advertising is Infozmation
The first frame builds up the overarching theme that
DTC advertising benefits society because it enables "the
free flow of [health] information that is quite difficult to
convey to patients and physicians" (Doc 2). Across all
Pfizer materials, the following themes were located in the
first reading process. These themes constitute frame 1.
1. Information is a valuable economic prop~ty. 2. OTe advertising contributes to the betterment of
health care market because it induces the free flow of health information.
3. OTe advertising is an important information source through which doctors learn about new cures and treatments.
4. Patients become better informed about their health conditions and possible treatments.
5. Information in OTe advertising can hardly be misleading, because it serves each companys economic interest to keep the content of OTe advertising balanced.
6. OTe advertising maximizes consumer choice.
Elements of frame 1 appear in all documents except Doc 4,
Doc 5, Doc 9, and Doc 13. The ones that promote this frame
in the most powerful and elaborate manner include Doc 2, Doc
3, and Doc 11. Especially, Doc 2 allots most space to
promote the belief that DTC advertising is a neutral,
innocuous source of information.
A number of strategies are employed to convey the
above themes, which constitute the first frame. First, the
frame takes full advantage of the fa9ade of neutrality that.
the term "information" connotes. It concurrently downplays
the profit-making motivation that underlies the production
70
of DTC advertising. For example, the collected public
relations article What Is Information Worth? (Doc 2) begins
with the following rhetorical question:
If you were asked to name the most valuable commodity in existence - one that makes economies go; one that allows people to move from one decision to another with speed and accuracy; one that helps people buy what they nee, helps them get a job, make more money, live a more satisfying life; one that lowers a business cost of manufacturing and distribution, and moreover, one without which essentially all economic activity would grind to halt - what would you choose? (p. 3).
The answer is, obviously, information. In this way, they set
the overall tone of their argumentation by discussing how
valuable information is in modern economy.
Also cited is the economic principle that in the
"perfect market," information is not only available but also
free to achieve (Doc 2). However, the authors of the above
article point out that, in the real word, "people do not
know ... what they need ... to fill their wants and needs" (p.
3) for lack of information. From the above account of the
role of information in general as part of a modern global
economy, the article draw the conclusion that DTC
advertising makes the same contribution to the health care
market. It leads towards the perfect health care market. The
authors argue that the marketing of health services directly
to consumers is "a less time-consuming way to get free
healthcare information" (p. 3) than other information
sources, such as the Internet.
71
All in all, this frame conceptualizes DTC advertising
as "free information." Directly in parallel with discussion
of the general values of information in a modern global
economy, DTC advertising is supposed to perform the same
functions that the ideal-type concept "information" does
through society.
Entman (1991) argues that "the essence of framing is
sizing - magnifying or shrinking elements of the depicted
reality to make them more or less salient" (p. 9). This
study similarly reveals that selective use and placement of
words functions to support the first frame and corne to the
fore, while evidence to the contrary is downplayed.
For example, because article titles get the most
immediate attention from readers (similar to headlines in
newspaper articles), they effectively connote the sense that
a certain piece of information is important. As illustrated
in Table 1, titles such as What Is Information Worth? (Doc
2) and Information Matters: The Consumer as the Integrated
Health Care System (Doc 8) highlight the "DTC advertising as
information" frame.
Use of specific words also deserves attention. Linked
with the word "information" repeatedly used to designate DTC
advertising, are words such as "free," "learn," "knowledge,"
"informed," "choice," and "education." These words are
repeated throughout the collected documents, with minimum
attention paid to the profit making motivation that
underlies DTC advertising. Especially, the summary article
Direct-to-Consumer (2002) lists all the above words in the
most compact manner.
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Similarly, the collected materials present ample space
for evidence that supports the "DTC advertising as
information" frame, while they sometimes give minimum space
to discussing evidence to the contrary. Understandably, the
collected materials fully elaborate on the views that
support the frame. However, when it comes to research
findings and arguments that run counter to the frame, they
either do not mention them or provide minimum space for
discussing them in a rather haphazard manner.
For example, even though the issues of balance, truth,
and bias in the content of DTC advertisements should
obviously be a central concern in discussing the
"informational" aspect of DTC advertising, findings that the
content of DTC advertising is sometimes unfair, unbalanced
and therefore misleading (e.g., Bell, et. al., 2000; Kravitz
& Wilkes, 2000; Roth, 1996) hardly appear in the collected
data. When they appear, they are stated in the briefest
manner, with minimum reference to evidence to support them.
In sum, the collected articles frame DTC advertising
as a neutral source of information and downplay the idea
that the first priority of the new adverting is to promote
73
the business interests of the company that employs it.
Mostly promoted by citing a number of the context-free
discussion of the role advertising in general plays in the
modern economy, this frame has the potential to lead the
public to believe that DTC advertising helps make a good
medical decision. Pfizer argues that a patient-friendly,
free access to medical information makes the physician-
patient interaction more equal and efficient.
Frame 2: Passive Patients vs. Empowered Consumers
The second frame suggests that in contrast to the
"passive patients" (receivers of health care service in the
past), today's receivers are "empowered consumers."
Empowered with information, these consumers equally
participate in the decision-making process with their doctor.
This frame incorporates the following themes, located in the
first reading process.
1. Passivity used to characterize patients in the past. 2. Patients used to h~e minimum understanding of their
wants and needs, passively receiving information from their doctors.
3. Patients were unequal participants in the decision making process.
4. Today's receivers of health care service are "empowered consumers."
5. Empowered consumers understand their right to seek health information.
6. Empowered consumers take responsibility for their health.
7. Empowered consumers have relatively sophisticated skills of processing health care information.
8. Information "empowers" consumers, enabling them to participate in the decision making process on an equal basis with their doctor.
9. Empowerment benefits both providers and receivers of health care service.
Elements of frame 2 appear in all collected documents
Doc 4, Doc 5, Doc 9, and Doc 10. The ones that embody the
74
frame in the most powerful, elaborate, and consistent manner
include Doc 8, Doc 10, Doc 11, and Doc 14. Especially, Doc 8
allots most space in defining and explicating the new,
empowered consumers as "the integrated health care system."
Frame 2 puts the "passive patient" and the "empowered
consumer" in conceptual contrast. The two concepts of
consumers exhibit two contrasting sets of characteristics in
terms of health behavior. The following statement by Keith
(Doc 8) exemplifies this framing strategy.
Most health care systems seem to have the patient at the center. But in fact, the patient has been the relatively powerless recipient of wel~intentioned care rather than a powerful center from which criteria for the patien's own health care and the shape of the overall system radiate, with decisions made as full partners with health care (p. 16).
As the passage shows, words such as "powerful," "center,"
and "full partner" accrue in describing today's "empowered"
consumers to emphasize that they are active and
knowledgeable. In contrast, "powerless" and "recipients,"
both of which convey an overall sense of passivity,
accompany the description of patients in the past. In short,
the concept of "empowered consumer" is pitted against that
of "passive patient," making the concept of empowerment and
the role of information all the more salient.
75
The article takes the empowerment frame one step
further when it presents the concept of "consumer as the co-
maker of medical decision" in the following statement:
Given sufficient and accurate information- greatly enhanced by DTC advertising- a consumer knows better than anyone else whether he or she would prefer a product with fewer unpleasant side effects even at a slightly higher risk of some serious event ... the ideal -and the emerging model - is a full partnership between patient and health care professional (Doc 8, p. 17).
Other similar concepts appear, such as "consumer as
integrator" theme. This theme posits that "the consumer may
be the best integrator of care received across various
elements of the health care system" (Doc 8, p. 17). The
theme boils down to the corollary that information empowers
consumers, enabling them to actively and equally participate
in the medical decision making process with their doctor.
Therefore, consumers are raised to nearly equal standing to
physicians, as the phrase "full partnership" may connote in
the above passage (Doc 8). One may further argue that the
medical training of doctors is downplayed where Pfizer
states "a consumer knows better than anyone else whether he
or she prefers a product with fewer unpleasant side effects
" (Doc 8, p. 17) in the same passage.
In addition to the fact that "passive patients" and
"informed consumers" are pitted against each other, the
collected data promote this frame through selective use of
research findings. For example, in order to argue that DTC
76
advertising leads to more informed doctor-patient
interaction, without the "empowered consumers" pressuring
their doctor, the article Direct-to-Consumer Drug Ads
Benefit Patients (Doc 12) cites an FDA survey and contends
that "asked whether DTC ads make it seem like the doctor is
not needed to decide whether a drug is right for me, 70% [of
the respondents] disagreed" (p. 15). However, the article
fails to mention that a large body of research findings
point out that patients are pressuring their doctors into
prescribing drugs they see in DTC advertisements (Foote &
Etheredge, 2000; Lipski & Taylor, 1997; Mintzes, et. al.,
2002) .
Similarly, the collected public relations materials do
not mention the body of literature on how consumers have
serious misunderstandings about DTC advertising. The
following account is one such finding that potentially
disrupts the empowered consumer frame.
[A]pproximately 50% [of respondents] thought that DTC advertisements had to be submitted to the government for prior approval, and 41% thought that only completely safe prescription drugs could be advertised directly to consumer" (Bell, et. al., 1999, p. 654--655).
Research findings such as the above are not addressed at all.
Titles of collected materials also emphasize the
vision of the informed and powerful consumer. Such titles
include Information Matters: The Consumer as the Integrated
Health Care System (Doc 8), Maximizing Patient Choice (Doc
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14), and Advertising and the Informed Patient (Doc 11). The
"empowered consumer" theme consistently runs through the
titles, potentially leading to the frame's reinforcement.
Finally, one should note the interlocked nature of the
relationship between the first frame (DTC advertising is
information) and the second (passive patients vs. empowered
consumers). The following statement encapsulates this point.
DTC advertising empowers consumers. Oneof the primary economic principles underlying all advertising is the value of information. DTC advertising is part of a larger trend towards consumer empowerment over healthcare decision-making and greater consumer access to healthcare information (Doc l5~
DTC advertising empowers consumers because it is, more than
anything else, information and therefore shares the same
range of benefits that information holds within the overall
modern economy. In turn, today's empowered (i.e., active,
sophisticated, and knowledgeable) consumers feel more
responsible for their health and therefore seek more health
information. The following account describes the vision of
empowered and responsible consumers that Pfizer provides.
Consumers shape their own health through dEt and exercise and prudent (and occasionally no~so-prudent) risk-taking and a panoply of other behaviors ... They decide whether and when to approach the formal health care system. They have a great deal of information about themselves - symptoms, experiences, behaviors, preferences. They share or withhold this information from health care practitioners. Actually, the consumer may be the best, or even only, integrator of care received across various elements of the health care system (Doc 8, p. 17).
The two frames are both sides of the same coin in the
sense that they reinforce each other. It is impossible for
78
one to be effective without the other.
In sum, frame 2 presents a vision of the active,
responsible consumer, which is then pitted against the
vision of the passive, non-inquisitive recipient of health
care service in the past. This frame has the potential to
make DTC advertising appear more desirable to American
people by appealing to their preference for individualism,
which is known to be one of the cultural values that
fundamentally characterize American culture (Steel & Redding,
1962) .
Frame 3: Maximum Benefits & Minimum Risks
Understandably, in the center of DTC advertising
controversy is the debate over whether it has beneficial or
harmful effects, potential or actual, upon pubic health. The
third frame directly touches upon this dimension of the
controversy.
The "maximum benefits & minimum risks" frame posits
that DTC advertising is socially beneficial because it has
more benefits than risks. This frame most directly supports
the policy position that it should remain legal. It also
lends itself to the argument that the FDA should relax its
regulations over DTC advertising. The frame incorporates the
following themes, which were located in the first reading
process.
1. DTC advertising makes the largely underdiagnosed population more aware of their health problems.
2. DTC advertising leads patients to better conform to their physician's advice.
3. DTC advertising makes patients more aware of a drug's side effects.
4. In contrast to the actual positive effects of DTC advertising, its negative effects are minimal and therefore can be ignored.
Elements of frame 3 emerge in all collected documents. The
frame's high prevalence comes as no surprise because the
fundamental message Pfizer intends to convey to the public
about DTC advertising is that the new marketing practice
79
benefits public health. Of all the documents, Doc 5, Doc 10,
and Doc 12 allot the most space to promote frame 3.
Strategies that support this frame are relatively
simple. Health benefits and risks of prescription drugs, by
the very nature of the product category, are discussed
mostly in scientific terms. Therefore, arguably the
essential, if not the only, strategy to promote the frame is
to highlight "new research studies, data, and analyses
focused on measuring the impact of promotion and marketing
on physician behavior, patient behavior, and the public's
health" (Doc 2, p. 5).
However, the above self-evident approach can be
slightly misleading. The essence of the strategies to
promote this frame lies in how they "select" studies and the
relevant literature to define the focus and represent the
80
studies' findings, and how they silence, or make less
salient, other research findings that counter the frame. In
this sense, one could reasonably argue that Pfizer frames
the strategies it uses to promote frame 3 by depicting them
as neutral and devoid of promotional intention.
The collected article What FDA Survey Showed About
Direct-to-Consumer Prescription Drug Advertising (Doc 7)
exemplifies how advocates select and represent a study in an
attempt to support the frame. Before citing the study's
major findings, which apparently reveal the benefits of DTC
advertising, the author sets up a lengthy context in which
the research was conducted:
The FDA has an intense interest in direc~to-consumer advertising. It is the agency designated by Congress to regulate all prescription drug advertising, and it has done so with a level of rigor seldom achieved for any other form of advertising. The FDA also monitors a pharmaceutical's safety and side-effect profile after FDA approval. The FDA is deeply concerned with the accuracy and balance of direc~to-consumer advertisings effects on consumers, particularly with respect to information about potential side effects and other harms from prescription drugs, as well as its effects on relations among patients and physicians (Doc 7, p. 11).
The passage sets the credibility of the research first,
before the author introduces its major findings. Because the
FDA study is depicted as most credible and its findings most
believable, the document has the potential to lead the
readers to believe that DTC advertising gives more benefits.
than harms. Further, for the same reason the readers may
become resistant to other research findings that counter
frame 3 and the FDA study's findings, that is, research
findings that suspect DTC advertising's social benefits.
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After the lengthy presentation of the context of the
study, the article summarizes the study's major findings,
such as: consumers are very much aware of DTC ads; DTC ads
are similarly influential with friends, news stories, etc.
in making respondents go to their physicians with a specific
question, etc. (Doc 1; Doc 15; Doc 7). Again, the initial
setting of the study's context can make the findings all the
more credible.
Repetitive use of specific words and phrases, similar
to the previous two frames, is an effective strategy to
promote this frame. "Serve the public," "public interests,"
"consumer welfare," "public health interests," "surveys
show," and "research indicates" are examples of the phrases
running through the collected materials to convey the
overall benefits of DTC advertising to society. Statements
such as "DTC advertising is in the best interests of public
health" (Doc 15) are generally placed before specific health
benefits are mentioned.
To convey messages upon DTC advertising's specific
health benefits, mostly scientific words are used, such as
"increased compliance," "increased risk-awareness," etc. The
following passage is a typical way of presenting DTC'
advertising's health benefits.
The high levels of awareness of and attention to DTe ads also strongly suggest that consumers gain informatin about the core topics of these ads [such as] symptoms of medical conditions, potential therapies, alternative dosages _. in particular, ads remind consumers take their medications and refill their prescriptions (Doc 12).
Overall, frame 3 conveys the message that DTC
advertising presents more benefits than risks to the
American public in term of their health. Dealing with an
essential part of the social debate over the new marketing
82
practice, the collected materials confer maximum credibility
upon the body of research that approves DTC advertising
while ignoring or giving an ignorable amount of space to
research that questions DTC advertising's value for society.
Frame 4: No Proven Economic Effects
Economic effects of DTC advertising are a major issue
in the overall controversy. The aforementioned example about
the race for the 2004 Democratic presidential nomination, in
which candidate Howard Dean called for a ban on DTC
advertising, indicates the seriousness of this issue.
A cursory look at Pfizer's public relations materials
will reveal that it takes this issue seriously. For example,
the Pfizer-published periodical on public policy is titled
Economic Realities in Health Care Policy, indicating that
economic issues assume a priority in Pfizer's position
building on health care issues.
83
Most collected materials incorporate the issue of DTC
advertising's economic effects either intensely or
tangentially. Against the criticism that DTC advertising
increases health care expenditure by increasing drug prices,
Pfizer consistently uses the "no proven economic effects"
frame. This is a frame that takes full advantage of the fact
that there is no known research that proves the role of DTC
advertising in boosting up drug expenditure or prices. The
frame incorporates the following themes. These themes were
located in the first reading process.
1. No research proves that DTC advertising increases drug prices for consumers.
2. Increases in drugs expenditure potentially contributes to public health because they imply that the under-diagnosed population are becoming more concerned about their health.
3. No research proves that the increase in drug expenditure is driven by increases drug prices.
4. The spending on DTC advertising can be recouped by increased sales volu~, hence no effects on drug prices.
5. Advertising in general has potential to decrease product prices.
All the collected documents except Doc 11 incorporate
elements of this frame. Two articles, The Economics of
Direct-to-Consumer Advertising of Prescription Drugs (Doc 6),
The Economics and Impact of Pharmaceutical Promotion (Doc 3),
almost exclusively deal with economic issues of DTC
advertising. These titles suggest the importance Pfizer puts
on applying basic rules of economics when expressing its
position on DTC advertising's economic impact.
84
Pfizer takes this frame one step further. It nearly
suggests the possibility that DTC advertising may have an
effect of decreasing health care expenditure, because it can
make consumers convert to "new and more effective" drugs and
therefore prevent their health conditions from developing
into more serious diseases. The following statement is an
example of such stance.
An assessment of advertisings impact on spending [on health care], however, requires consideratbn of the other factors that drive pharmaceutical use_. Many studies have demonstrated the value of new and existing pharmaceuticals in terms of health improvement and avoidance of more costly treatment (Doc 6).
In fact, the aforementioned periodical Economic
Realities in Health Care Policy has an issue entirely
dedicated to furthering the belief that newer drugs are more
effective and therefore can have positive economic impact.
The titles in the issue are Pharmaceutical Innovation:
Lowering the Price of Good Health (Doc 4) and The Economic
Benefits of New Drugs (Doc 5). In summary, Pfizer promotes
the position that DTC advertising potentially lowers the
public's expenditure to maintain good health by providing
access to pharmaceutical innovation.
Citing basic principles of advertising can be an
effective strategy to support the above position, similar to
the way Pfizer uses the discussion of the value of
information in general in modern economy to argue that DTC
advertising makes the same contribution to society. The
followings are examples of such strategy.
While advertising presumably will increase demand for a product, the cost of that advertising would usually be recouped through increased sales volume rather than through higher prices ... Advertising is an important catalyst for price and quality competition (Doc 6).
Fundamental economic principles suggest that, as a general rule, product advertising enhances competition, decreases profit margins and lowers consumer prices. Americans are spending more ffi health in general and drugs in particular, but DTC advertising is not the leading reason why (Doc 15).
In much the same way that the basic role information plays
in the modern economy is addressed to deceptively spin DTC
advertising as information rather than promotion, the
discussion of the basic function of advertising in the
modern economy is used in the above excerpts to insinuate
the impression that DTC advertising may have the potential
to decrease the American public's health care spending.
A number of words, phrases, and concepts are employed
to convey this overall frame. They include "economic
principles," "information society," "economy of scale,"
85
"efficiency," and "enhances competition," which are used to
apply the basic rules of economics to imply DTC advertising
has the potential to decrease drug prices. To emphasize that
no research has found the link between the increase in drug
expenditure and DTC advertising, argumentation generally
begins with phrases such as "no research yet" and "no
objective study," as noticeable in the following statement:
While this assumption [that DTC advertising increases drug prices] has a certain intuitive appeal, the
available evidence suggests that the story is more complicated and that in fact the opposite migt be true ._ More generally, economic theory suggests that there is no clear link between advertising for a product and the price of that product (Doc 15).
Overall, frame 3 starts with the defensive position
that there is no proven link between the rise of DTC
86
advertising and the increase in drug prices and the American
public's health care spending. This frame is taken one step
further where Pfizer implies that DTC advertising has the
potential to decrease drug prices. The "fundamental rules"
of economics were cited and applied to imply that DTC
advertising can perform the same positive roles in American
society as advertising does in general in modern economy, a
strategy similar to the way Pfizer promoted frame 1.
The Overa~~ Frame
The study concludes that there are four frames in the
131 pages of collected public relations materials published
primarily between 2001 and 2003. Pfizer organizes their
rhetoric to support the practice of DTC advertising along
the following four frames.
1. DTC advertising is information, rather than advertising, for access to medical innovation.
2. Instead of passivity that used to characterize patients in the past, the contemporary consumers, empowered with information, actively involve in the medical decision making process with their doctor.
3. DTC advertising has maximum benefits and ignorable potential risks.
4. No research exists that links DTC advertising to the overall increase in drug prices and health care expenditure. Instead, DTC advertising has potential
87
to decrease the cost of healthy living.
Together, the above four frames convey the overall message
that DTC advertising benefits society because it empowers
consumers with information, enabling them to be more active
and responsible caretakers of their own health, or
"integrated health care systems," in the emerging health
care market.
Each of the four overall frames appeared in most of
the collected materials. This means that even though the
collected documents have one or two foci of concern, they
generally do not fail to weave together the 4 overall frames.
This point was especially true of frame 1, 2, and 3. Frame 4
tended to be treated separately from other frames. This
appears to be because discussing economic issues involves
highly theoretical and complex concepts and ideas derived
from basic theories of economics.
One particular point that calls attention is that
there are no clear-cut divisions between these four overall
frames. A number of words, concepts, and phrases and
persuasive strategies can be categorized as more than one
frame. For example, concepts such as "informed consumer" and
"educated consumer" are the backbone of frame 2. However,
one can reasonably argue that the concept of "informed
consumer" necessarily incorporates the position that DTC
88
advertising should be treated as information, rather than
promotion. In the second reading process, "informed
consumer" was not categorized as frame 1, because it formed
a more coherent and meaningful whole with other concepts
such as consumer's reading capability," "passive patients,"
and "equal participation with physicians," rather than with
"OTe advertising is information."
This kind of judgment was conducted in the second
reading process, which compared, contrasted, and collapsed
the frames that had emerged in the first reading process.
This "compare and contrast" reading process is arbitrary to
a certain degree, but one must admit that a degree of
arbitrary categorization cannot be completely avoided in the
qualitative use of frame analysis, or the inductive approach
to breaking up the text into discrete frames. The following
short excerpt is just one of many examples that reveal the
interconnected nature of the four frames. In the excerpt,
one will easily notice that messages that pertain to frame 1,
frame 2, and frame 3 concurrently emerge.
Without these activities, many physicians would not know about new medicines, or new uses for existing medicines. In general, physicians do not readily seek out new therapies, and they have no requirement b inform themselves about new medicines. Marketing activities of drug firms are virtually the only means by which physicians learn about new drugs (Drug 14).
This project explored and illustrated how Pfizer
builds their strategies along the above four frames. Public
89
relations practitioners cannot and should not ignore their
business imperative to further the economic interests of the
organization they represent. However, building their
persuasive messages on sound and ethical principles should
not be ignored either. Therefore, looking over Pfizer's
strategies to support the four frames, public relations
practitioners will have a chance to question if the company
uses sound and valid argumentation to represent and support
its policy position. However, more importantly, the findings
of this study have important implications for consumers. By
understanding Pfizer's framing strategies revealed through
this study, consumers will have an opportunity to distance
themselves from the persuasive messages to contemplate the
messages' implications for their welfare and public health
as well.
90
Chapter 5: Conclusion & Discussion
DTC advertising is an increasingly popular way of
promoting prescription drugs. The new marketing vehicle,
however, has been a cause of concern since its inception
among physicians, politicians, and members of the public. In
the center of the social controversy is the fact that
prescription drugs are directly related to public health,
and that consumers have limited ability to process
information properly in DTC advertising.
Current practitioners of marketing communications
stress that it is just as important to create a favorable
marketing environment as promoting products to consumers.
This position reflects the general trend of marketing toward
a more integrated approach to marketing communications. The
approach also applies to pharmaceutical marketing
communications (Schreiber, 1997).
Pfizer apparently assimilates the above IMC approach
in that it actively addresses the social debate over DTC
advertising. Throughout its web site, Pfizer makes it clear
that it will be an active participant in the policy making
process when it comes to the issues that directly involve
the company's business interests. Pfizer clarifies that
together with regulation of drug prices and patent
91
restrictions, it considers DTC advertising as a social issue
it needs to actively resolve (Our Voice, 2004).
This participatory approach also fits Pfizer's sense of
corporate citizenship. Pfizer defines its sense of corporate
citizenship as:
Citizenship defines our role in local and global communities and how we strive to conduct business responsibly in a changing world. Being a good corporate citizen includes listening to, understanding, and responding to our stakeholders about their needs regarding Pfizer's policies and operations. Stakeholders are people or groups who affect, or are affected by, Pfizer's business activities. Our relationship with them is at the heart of our citizenship because they define what it means for Pfizer to create value (What is corporate citizenship, 2004).
Pfizer also defines its role in the pharmaceutical industry
in the following statement:
As the world's largest biomedical research and pharmaceutical company, with 122,000 employees in over 150 countries, Pfizer has a unique opportunity to be a good corporate citizen (Our role, 2004).
In sum, one can reasonably assume that Pfizer's
participation in the pubic discourse on DTC advertising
reflects both the company's application of the IMC approach
and its will to listen to, understand, and respond to their
stakeholders to define its role in local and global
communities as a leader in the pharmaceutical industry (What
is corporate citizenship, 2004). As a result, Pfizer has
prepared, stored, made available a number of public
relations documents to promote its vision of the social
debate over DTC advertising.
92
Through an in-depth, qualitative analysis of Pfizer's
public relations documents, this project reveals how the
company tries to frame the public policy debate over DTC
advertising. In the process Pfizer also frames the
overarching concept of who it is, thus setting the tone to a
controlled public discourse. The results indicate that
Pfizer's public relations materials have the potential to
lead consumers to approach the issue of DTC advertising
through a number of Pfizer-initiated perspectives,
encapsulated by the following four frames: DTC advertising
is information, passive patients vs. empowered consumers,
maximum benefits & minimum risks, and no proven economic
effects upon drug expenditure. Through these four frames,
Pfizer ultimately conveys the fundamental message that DTC
advertising benefits society.
One can understand the message as reflecting both the
company's IMC initiative to create a favorable marketing
environment and Pfizer's willingness to fulfill its own
sense of good corporate citizenship as a leader in the
pharmaceutical industry. This enables one to infer that the
findings of this project could reflect the perspective and
interests of both Pfizer and the pharmaceutical industry.
As has been briefly mentioned, the findings of this
project have implications for society from a number of
perspectives. First, understanding Pfizer's framing
93
strategies will help public relations professionals judge
the strategies in terms of ethics as well as effectiveness.
More importantly, for consumers, the findings will lead them
to critically contemplate what the framing strategies imply
for public health.
The fundamental reason for which public relations
exists is to serve the business interests of the
organizations they represent. However, building their
persuasive communications on ethical principles should not
be ignored, as without these principles, business is not
well served. The most uncontroversial, if not the most
appropriate, way of judging the ethics of a public relations
campaign is obviously to investigate if the campaign
measures up to the standards established by the public
relations industry itself.
Public Relations Society of America (PRSA) has a code
of ethics. According to Johannesen (2002), the "core
principles and specific guidelines for each principle serve
as starting points for professional and public scrutiny of
ethical issues in public relations" (p. 189). Further, the
PRSA's membership statement speaks of professional values.
"These values are the fundamental beliefs that guide our
behaviors and decision-making process. We believe our
professional values are vital to the integrity of the
profession as a whole" (Johannesen, p. 190). Of all the
values, the following two are the most appropriate for
application to this study.
1. Advocacy a) We serve the public interest by acting as responsible
advocates for those we represent. b) We provide a voice in the marketplace of ideas, facts,
and viewpoints to aid informed public debate.
2. Honesty a) We adhere to the highest standards of accuracy and
truth in advancing the interests of those we represent and in communicating with the public.
3. Fairness a) We deal fairly with clients, employers, competitors,
peers, vendors, the media, and the general pblic. b) We respect all opinions and support the right of free
expression (Johannesen, 2002, p. 190).
First, in terms of fairness, Pfizer uses some
questionable rhetorical strategies. The most salient of
these strategies is that Pfizer provides such a limited
space to criticisms of OTe advertising that the company is
in no position to rebut these criticisms in a fair manner.
Regarding many issues, the company presents only position
statements and does not cover any opposing perspectives In
94
any comprehensive manner at all. In other words, the company
attacks critic's points without ever fully explaining them.
The following passage represents one such strategy.
Critics of DTC advertising contend that [DTC] ads prompt consumers to demand that their doctors isue prescriptions for specific drugs - and that those physicians comply without regard to either their professional judgment or knowledge of alternatives. The empirical record contains no meaningful evidence to substantiate this contention ... Multiple studies corroborate that most consumers who consult their doctor about advertised drugs are seekingmore information about underlying condition and available treatment (Doc 1, p. 28).
Why critics are concerned about how patients might pressure
95
their doctor is never explained in any comprehensive manner.
Instead, the article criticizes the critics' concern in a
single-handed manner in the statement that the "empirical
record contains no meaningful evidence to substantiate this
contention" (p. 28). Pfizer does not provide any standards
about when and how one can consider a body of evidence as
meaningful or not. Therefore, one may argue that the passage
makes the wealth of literature (e.g., Bell, et. al., 1999;
Kravitz, 2000)running against Pfizer's position appear
meaningless without actually citing them or explaining why
they are meaningless. Certainly, Pfizer should introduce and
explore major arguments from critics more thoroughly. Only
then will the company find itself in a legitimate position
for counterattack.
Second, a related problem is that Pfizer's public
relations materials often present false, or at best
misleading, information. For example, Manning and Masia
state "only a product's scientifically proven capabilities,
verified by strict regulatory agencies, can be used in its
marketing" (Doc 2, p. 4).
The statement is not true. The FDA does not have legal
authority to screen the content of DTC advertisements before
they reach consumers, a point that many consumers do not
understand (Bell, et. al., 1999). In fact, many
pharmaceutical advertisements receive warning letters from
96
FDA each year for the reason that they misrepresent and
exaggerate drug effects and therefore could mislead
consumers. Some advertisements have been forced to withdraw
from the market after they reach consumers (Bell, et. al.,
1999) .
Third, use of truism also appeared to be somewhat
misleading. For example, discussing how DTC advertising can
lead to increase in the quality of health care, the article
The Economics of Direct-to-Consumer Advertising of
Prescription Drugs (2001) quotes the following excerpt from
a statement by the FDA: "We believe that truthful and non
deceptive DTC advertising can contribute to consumers'
health information environment and consumer welfare" (p. 8)
Most critics express their concerns about DTC advertising
because they see many DTC advertisements as deceptive and
misleading. In this context, the point that "truthful and
non-deceptive advertisements can contribute consumer
welfare" not only lacks any type of substance but also is
misleading.
Fourth, there is a serious logical gap between
enumerating general values of information and arguing that
DTC advertising helps the pubic because it is information.
One can summarize the position as the following misleading
syllogism that Manning and Masia (What is Information Worth?
2003) use.
1. Information presents a number of benefits to society. 2. OTC advertising is also information. 3. Therefore OTC advertising presents the same range of benefits to society.
The article's discussion of the general values of
information in a modern economy does not have any specific
97
social and cultural context. In other words, the concept of
"information" that they constantly take advantage of is held
within the most pristine condition. One can never use the
ideal-type, context-less, neural concept of "information" to
insinuate that a certain type of advertising is good because
it also is information.
One can argue that DTC advertising is not so much
information per se as promotion of drugs through a series of
strategic and selective presentation of information. One
should incorporate such contextual aspects of a type of
releasing information to be in a legitimate position discuss
its effects on society.
Ethical considerations help ascertain if a certain
public relations campaign is acceptable or unacceptable from
the industry's collective and agreed-upon set of standards.
However, discussions of ethics do not encourage a full range
of discourses upon the practice's social implications. A
communication campaign's social ramifications can move
beyond the scope of the industry's professional ethics or a
campaign's success from a business perspective.
98
A message, just because it is constructed as open and
fair, (which are values of proper ethics) does not guarantee
that it will not have questionable social implications.
Truth and fairness are necessary, but not sufficient
conditions for a message's positive impact. This point
becomes more apparent especially when one places Pfizer's
rhetorical strategies to frame DTC advertising amongst the
complex network of public communications that the
pharmaceutical industry employs to sell drugs and to create
a more favorable marketing.
Pharmaceutical companies employ a wide spectrum of
marketing communications, including advertising and public
relations, to promote their drugs. At the "short-term" end
of the spectrum, they advertise their drugs to doctors and
also directly to consumers.
However, consumption is not the only thing
pharmaceutical companies promote through their marketing
communications. Around the mid-point of the spectrum of the
persuasion network, to better promote their drugs, the
industry ultimately has to sell the idea that drugs are
potentially more effective and efficient treatments than
others for various health conditions. They achieve this goal
through public relations campaigns.
At the "long-term" end of the wide spectrum of
persuasive communications, one can place Pfizer's rhetorical
99
strategies to promote the idea that DTC adverting benefits
society and therefore influence public policy over the new
marketing practice in their favor. Through such
communications, the industry wants to make the public more
receptive to their drug promotions and the way the industry
communicates such promotional messages.
The important notion that one has to keep in mind is
that all the above three levels of pharmaceutical marketing
communication occur concurrently. Altogether, about the
overall issue of health, disease, and recovery, the
communications can combine and potentially induce a "drug-
oriented frame of thinking" in people's mind. This study
conceptualizes that frame of thinking as the following:
1. Drugs are more effective and efficient ways of treating diseases.
2. It benefits and empowers consumers to have information on drugs, wherever such information may come from.
3. DTe advertising is one channel to get such information.
Without question, this frame of thinking is more
conducive to the idea that DTC advertising should remain
legal and unregulated. Through the wide range of
communications, the pharmaceutical industry has the
potential to drive American society toward the predominance
of such drug-centered frame of reference in thinking about
issues of health, disease, and recovery.
100
A number of critics have expressed concerned, directly
or indirectly, with the ways the aforementioned different
levels of promotional communications may combine to create
synergistic effects on society. An example, anti-depressants,
will help explain why critics question the way the
pharmaceutical industry promote psychotropic drugs.
Along with advertising for other drug categories, DTC
advertisements for anti-depressants often appear in popular
consumer magazines such as Time, Newsweek, and Reader's
Digest. Concurrent with the public communications to promote
specific drugs, the pharmaceutical industry attempts to
induce the idea that drugs are more effective and efficient,
both health-wise and cost-wise, than other treatment options.
Valenstein (1998), for example, presents an account of how
the pharmaceutical industry's public relations campaign
promotes not only drugs but also bio-chemical theories of
mental illnesses to both doctors and consumers.
The truth is that we still do not know what causes any mental disorder or how drugs sometimes help patients get better. Yet, despite this, the theory that mental disorder arises from biochemical imbalance is widely accepted. I believe this is partly because few people, including mental he~th professionals, have the time, inclination, or background to critically examine the [biochemical] evidence and partly because powerful special interest groups have influenced the way people think about drug treatment and mental disordersThe pharmaceutical industry spends enormous sums to influence the opinions and behavior of both physicians and the public, and the effectiveness of their marketing strategies cannot be overestimated (Valenstein, 1998, p.165) .
101
Along with such public relations to promote the bio-
chemical theory of mental disorders, the pharmaceutical
industry also promotes the message that it benefits
consumers to be more receptive to the industry's persuasive
messages, including DTC advertising. The four overall frames
that Pfizer employs to promote the marketing practice of DTC
advertising consistently conveys the message that it
benefits consumers to be more receptive. In other words, the
ideas that DTC adverting is neutral information (frame 1)
and that consumers have enough sophistication to process
medical information in DTC advertising for better decision-
making (frame 2) persuade the public to be more receptive to
pharmaceutical promotion. Likewise, the ideas that DTC
advertising has maximum benefits with ignorable risks and
that its economic impact is largely unproven are conducive
to the message that it benefits consumers to be more
receptive. Concurrently, the content of DTC advertising may
reinforce, directly or indirectly, the bio-chemical theory
to sell anti-depressants.
Of potential consequences of the synergy of such
multi-leveled pharmaceutical marketing communications,
Gardner (2001) presents the following statement:
consumers are led toward bi~psychiatric treatment -especially antidepressants - by depression treatment propaganda (made available to them through doctors and consumer depression sources) suggesting that depression in general should be treated with bi~psychiatric therapies _. numerous studies, including the most recent
large scale NIH study, contend that thoughmajor depression is best treated with a combined treatment of anti-depressants and therapy for many, minor depression is well-treated by psychotherapy alone. In most cases of diagnosed depression, however, ant~depressants are prescribed as part of the treatment package (pp.12-13)
The above account is only one of many examples of the
potential social implications of the integrated
pharmaceutical marketing communications. In addition, to
fully understand the persuasive messages' potential
102
influences one should also consider the fact that consumers
in the contemporary American society are more and more
interested in seeking health information. For example,
numerous studies conclude that American consumers often
refer to advertising as a source of health information,
especially since pharmaceutical companies started to heavily
engage in DTC advertising for prescription drugs from the
late 1990s (Bell, Wilkes, Kravitz, 2000; Calfee, 2002;
Sorofman, 1992; Terzian, 1999).
All in all, today's marketing landscape is
characterized by integrated marketing communication, which
also appear to apply to pharmaceutical marketing
communication. At the other end of the spectrum, consumers'
feel increasingly more responsible for their own health and
as a result, they are more actively pursuing health
information. The two phenomena imply that it is now time for
critics and consumers to keep a critical distance from the
contemporary burst of medical information, including the
103
growth of DTC advertising, and contemplate what messages the
pharmaceutical industry's convey to society about health,
disease, and recovery. For example, through a frame analysis
of public relations materials produced by Pfizer, this
project suggests that the company's strategies to support
DTC advertising have the potential to propel and perpetuate
the predominance of drug-oriented frame of thinking in the
public's thinking about health, disease, and recovery.
Considering the importance of public health as a social
issue, more research has to come to critically analyze the
messages about health and disease that the pharmaceutical
industry conveys to society through a variety of its profit
motivated communications.
Suggestions for Future Research
Based on the literature review on DTC advertising, the
following suggestions are made to enrich future research.
First, DTC advertising research should consider a wider
range of concepts and variables. Research should include not
only people's rational processing of medical information but
also their reaction to the emotional appeals use in DTC
advertising. Research should incorporate not only impact on
doctors' and consumers' perception of DTC advertising and
specific drugs and drug categories, but also more
fundamental beliefs about health, disease, recovery, and
alternative modes of treatment. Future research should
investigate how consumers' reaction to DTC advertising is
mediated by demographic variables, as well as their
preexisting attitudes and beliefs about medical profession
and pharmaceutical marketing communications. In addition,
critical scholars should question how DTC advertising
depicts social groups and how these depictions affect the
public's beliefs and expectations about the disease
categories and the targeted social groups.
104
Second, simple reporting of the measurements of
variables (e.g., simply measuring and reporting how
correctly consumers retain information DTC advertising)
deserves attention, because it is equally, if not more,
important to generate a model that incorporates how these
variables are associated to explain their relationship to
each other and predict possible important phenomena. Such
models, preferably guided by generic theories of persuasion,
can contribute to a more comprehensive understanding of DTC
advertising.
Last, future research should conceptualize DTC
advertising that pays attention to the complex persuasion
networks that the pharmaceutical industry engages in to
promote drugs, which they create and manage within a
marketing environment conducive to advancing their profit
105
margins. Current marketing communications are characterized
by the integrated communications landscape. Therefore,
researchers should note that consumer-targeted advertising,
doctor-targeted advertising, doctor-targeted sales promotion,
and public relations practices, including its efforts to
influence public policy over DTC advertising, all interact
to produce multiple social consequences.
The current project exemplifies an attempt to enrich
scholarly discourses on DTC advertising by dealing with a
topic that the current literature fails to incorporate. It
explored the rhetorical strategies Pfizer uses to frame the
public debate over DTC advertising in favor of its business
interests. It concluded by discussing the rhetorical
strategies' potential to interact with other pharmaceutical
communications and instill a drug-centered frame of thinking
in people's mind in the matter of health, disease, and
recovery.
Despite a meaningful attempt to enrich social
discourses on DTC advertising, this project has a number of
significant limitations. First, it derives Pfizer's
rhetorical strategies to frame DTC advertising from various
public relations materials located in the company's main
website. Pfizer invites consumers to visit their website in
their DTC advertising. Thus one can reasonably expect that
consumers have an opportunity to Pfizer's rhetoric to
106
promote DTC advertising. However, exactly how many consumers
are exposed to the messages and how they respond to them are
untraceable. Second, more importantly, posting their
position on the issue of DTC advertising on their website is
only one of many possible public relations efforts to
promote DTC advertising. To investigate if Pfizer's messages
actually reach a large number of consumers, one may have to
analyze the company's media relations activities. An
especially important issue in this aspect is what kind of
media relations techniques Pfizer employs to get the media's
attention. How the media respond to the way Pfizer frames
the public debate over DTC advertising is also an important
issue. Future research on the pharmaceutical industry's
campaign to promote DTC advertising should incorporate the
above points in its research agenda.
90
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