DTC: European Style

Frank Hone and Rob Benson are executive vice-presidents in the Global Business Group at Healthworld Communications Group. Hone can be reached in New York at frank.hone@healthworld.com. Benson can be reached in London at rob.benson@healthworld.co.uk.

In 1996, Sandoz (now Novartis) decided to brave new waters to create consumer demand for the antifungal Lamisil (terbinafine) in the United Kingdom. But with European law forbidding pharma companies to conduct brand-name advertising, Sandoz needed to find another way to encourage patients to talk with their doctors about onychomycosis and its treatment options. So the company re-named the condition the more consumer-friendly "fungal infection" and took out newspaper ads asking readers to call or write to "Step Wise" for a free brochure on foot care.

By creating a consumer-relevant name for their patient education program, Sandoz branded the solution, without naming the prescription product in the ad. They also effectively articulated the unmet needs of many people and created a way for sufferers to make an informed choice and take action. This first foray into direct-to-consumer (DTC) advertising in Europe drew protests from some physician groups who filed legal protests claiming the campaign would improperly influence prescribing. But the courts overruled the protests, paving the way for other pharma marketers to reach out to consumers.

And they did. Despite the perception that DTC is illegal in Europe, pharma companies have been conducting—and refining—consumer-targeted campaigns since the Sandoz test case. Although many US marketers believe that those European initiatives are DTC's poor stepchild, European legal restrictions on brand-name promotion have, in effect, encouraged a significant level of integrated marketing. The net result is an approach to marketing that addresses attitude and behavior change in addition to awareness building. While DTC focuses mainly on advertising to mass audiences to drive new prescriptions, the European initiatives take a more strategic approach by targeting patients who are likely to use the medication. The approach lends itself to tactics—executed in collaboration with healthcare professionals and with the support of other influencers—that build brand loyalty and improve compliance because they help patients gain a deeper understanding of the disease and therapeutic options.

This article discusses the emergence of patient mobilization strategies in Europe and explains how to develop and deploy them. It also illustrates how US and European marketing platforms—which aren't as radically different as they may seem—are actually converging.

Patient Mobilization

In Europe, regulations stipulate that companies can disseminate only unbranded information in their promotional initiatives to consumers. The European Council Directive 92/28/EEC "prohibits the advertising to the general public of medicinal products which are on medical prescription only." However, "statements relating to human health or diseases, provided there is no reference, even indirectly, to medicinal products" are permitted. In other words, disease education is allowed. Also, the European Union marketplace, as it relates to healthcare, is far more conservative. European patients are less accepting of in-your-face branded ads than the US audience, and European physicians feel more strongly than US physicians about their traditional role as the gatekeepers of health information and prescribing decision makers. So companies realize that an effective way to reach commercial goals is to cultivate long-term patients through education, rather than acquiring new consumers through brand-awareness advertising.

Patient mobilization strategies rely heavily on public relations and a wide range of marketing communications vehicles to build an environment favorable to a brand's prescribing and long-term usage. European marketers' approach is subtler than DTC and ensures that patient groups and other stakeholders buy into, and participate in, the dissemination of patient education and disease information. Patient mobilization also depends on the effective delivery of messages and favors vehicles that closely target the intended audience—such as brochures, booklets, advertorials, and testimonials, in addition to targeted advertising—and the Internet. That contrasts with DTC, which primarily uses television advertising aimed at a broad consumer audience.

Bladder banter: Pharmacia (now Pfizer) launched a patient mobilization campaign on behalf of its incontinence treatment Detrusitol. Magazine advertising included a quiz that patients could take to determine whether they should speak with their doctors. Other elements included a phone number patients could call to receive information about bladder problems specifically tailored to their needs.

Strategy at Work

An example of patient mobilization in action is the disease awareness campaign mounted by Pharmacia (now Pfizer) on behalf of its incontinence treatment Detrusitol (tolterodine) in the UK. Working closely with groups such as the Royal College of Nursing and the Patients Association, Pharmacia rolled out an educational advertising campaign called "Greater Freedom from Bladder Problems." The campaign aimed to break down the stigma of incontinence, partly by replacing the medical term "incontinence" with the more consumer-friendly phrase "bladder problems." It included a symptom quiz that patients could take to determine whether they should speak with their doctors. It also featured direct-response elements, such as a phone number patients could call to receive an information booklet tailored to their needs. Pharmacia also informed all general practitioners of the campaign by mail and held a series of accredited workshops for physicians.

That orchestrated approach, first communicating with physicians and then with patients, is a trademark of patient mobilization. Because European marketers can't direct consumers to talk to their doctors about a specific product, marketers must coordinate their branded communications to health professionals and unbranded disease information to consumers to build an "ownable" point of view about the disease that leads to a discussion of the promoted brand's benefits.

Patient mobilization also relies heavily on public relations to get the buzz out to consumers. Typically, health news raises disease awareness, but it can sometimes even introduce consumers to a brand.

The power of PR varies, depending on editorial interest. For example, the media largely shaped end-user interest and ultimate demand for erectile dysfunction products. In France, the most conservative of European markets, journalists began referring to Lilly's Cialis (tadalafil), which has a 36-hour therapeutic action, as "Le Weekend." The term, now part of the vernacular, can be used by the brand owner as a surrogate branded communicational vehicle working essentially within the letter of the law.

Long-Term Effects

Patient mobilization has an advantage over DTC because the promotion extends well beyond the promotional peaks of launch, ensuring a continuity of brand performance and building an enduring relationship with customers, instead of focusing on the return of a single media investment.

Stabilizing sales: Roche created ads such as this one that ran in women's magazines in Germany, which more closely targeted patients and promoted persistency and compliance programs.; French connection: In 2002, Sanofi-Synthélabo distributed this poster in France to increase awareness of several neurological diseases in support of its products Solian, Stilnox, and Tranxene.

The story of Xenical (orlistat) illustrates this. Roche spent heavily on its US DTC launch campaign, which focused on creating demand through branded TV commercials. However, the campaign didn't effectively convey to US consumers the need for lifestyle modification along with the therapy. It also had difficulty articulating the drug's potential side effects—including the excretion of unabsorbed fats—in a consumer-friendly way. Although the company was successful in achieving new patient starts, low rates of persistence and compliance hurt overall sales.

Roche decided to launch its consumer campaign in Europe based on lessons learned in the United States. The company worked with healthcare professionals to establish self-help and support programs for patients and launched a series of ad campaigns across Europe. This time, it more rigorously defined and targeted prospective patients. Telephone help lines offered consultations and advice from qualified nurses. The nurses weren't there to encourage patients to ask their doctor for the product; rather, they screened callers to ensure that only appropriate patients were asking physicians for information about prescription diet therapies. Those help lines also captured callers' data, which were used, with permission, for future support programs.

Published case studies in key European markets have since indicated that not only did this more considered and concentrated marketing approach help stabilize brand sales volatility, but its focus on encouraging longer-term use and appropriate diet and lifestyle adjustment created a new level of physician confidence in the role the brand could play in addressing weight-related disorders.

Building Blocks

The campaigns for Pfizer's Viagra (sildenafil) and Lilly's Cialis show that patient mobilization takes a complete view of the promotional mix and fosters patients' long-term relationships with brands. There are three basic building blocks to patient mobilization campaigns:

1. Environment enhancement. This phase sets the stage for brand launch. In its market preparation, Pfizer created the term "erectile dysfunction," which helped condition the emerging market for Viagra by de-stigmatizing male impotence and establishing a need for treatment. The company worked with the Impotence Association and the Men's Health Forum to foster discussions about the disease and set the stage for the brand with discussion aids such as a list of questions for patients to ask their doctors.

Similarly, Lilly created its own association called ManMatters before it launched Cialis in Europe. Lilly built on Pfizer's market-conditioning activities by segmenting the audience, targeting those for whom Viagra wasn't fully effective and those who still had unmet expectations and a propensity to take further action. This approach illustrates the value of using segmentation based on both demographics and psychographics to more closely align a brand's performance benefits with its most appropriate (and potentially most loyal and profitable) users.

In effect, Lilly sought to mobilize an unmet aspirational need by focusing its campaigns less on the medical problem of erectile dysfunction and more on the emotional dimension of sexual relationships. The company carved out that aspect, so that even when patients viewed unbranded information, they knew it wasn't Viagra, but rather something new, prompting associative beliefs that it was potentially better and worth checking out with their physicians.

Both Pfizer and Lilly used campaign branding to tie in patient education with the sales force efforts and targeted physicians with complimentary messages. This wasn't organized just to link all communication around the brand name, it also provided a necessary educational vehicle to inform, guide, and motivate physicians themselves to recognize and address both the medical condition and patient needs within the context of modern primary care.

2. Enabled interface. During the launch phase, consumer communications encourage patients to have productive dialogues with their physicians. Pfizer, like many other companies in Europe, now places a heavy focus on implementing customer relationship management (CRM) programs within this phase of patient mobilization campaigns, in part so it can obtain patient information to enable post-prescribing communications.

Pfizer built CRM into its national media campaign, using coupons consumers could mail in to receive information packets about erectile dysfunction. Pfizer responded to consumers with follow-up questionnaires, which not only created an information platform reinforcing the value and benefits of the brand, but also assisted the company in refining future communication and content.

In another campaign, Pfizer built up its brand-related imagery and value associations by using the soccer legend Pele a front man for its 2002 campaign for erectile dysfunction. By using a well-respected athlete with the problem, it helped consumers overcome the myth that erectile dysfunction doesn't happen to macho guys.

In its promotion, Lilly used print advertising with a variety of direct-response mechanisms such as patient help lines, direct-response booklets, and dedicated website support. The company focused on generating a new level of patient physician discussion based on informed choice and picking the right therapy for the patient. The campaign featured materials with headlines such as "Why Treating Erection Problems Is All About Choice" and introduced personal-style testimonials such as: "The first treatment I tried wasn't right for me. However, after going back to see my doctor and talking further about all the options available, we did find a treatment that was right for me. My life has been completely transformed." Thus, even in unbranded situations, Lilly was able to drive competitive differentiation. Cialis now controls 20-30 percent of the European erectile dysfunction market.

Pelé speaks to patients: Pfizer has used patient mobilization to drive consumer demand for Viagra. Pfizer built up its brand-related imagery and value associations by using the soccer legend Pelé as a front man for its 2002 campaign for erectile dysfunction. By using a well-respected athlete with the problem, it helped consumers overcome the myth that erectile dysfunction doesn't happen to macho guys.

3. Enduring engagement. This third phase is the most important commercially because patient compliance and loyalty determine long-term brand profitability after launch. Many brand managers now recognize this. For example, in the UK, Pfizer is currently using the "voice" of the third-party Men's Health Forum to run targeted radio ads that encourage men to talk about erectile dysfunction with their doctors. This message is backed by facts on the number of men who have already taken the first step toward treatment assistance and a "better love life." The ads help reinforce the confidence and loyalty of existing patients while adding further endorsement to encourage potential new Viagra users to step forward and see their physician.

Other programs, such as Lilly's ManMatters, offer a range of web-based pre- and post-prescribing services and information content that includes not just advice on erectile dysfunction but detailed insight into specific treatment options, as well as access to patient case studies and relationship guidance advice.

Companies are increasingly using physician-supplied patient starter packs containing user leaflets, tips, FAQ advice, and patient diaries at the initial prescribing consultation to help ensure the right patient/brand compliance from the start. Those packs create the basis of initial patient expectations with resulting patient treatment outcomes fostering repeat brand loyalty in terms of prescribing decision making and user preference.

Less is more: Recently, Pfizer introduced ChoLESSterol,a consumer initiative that aims to create a call to action about cholesterol control and heart health. The company launched the campaign in support of Lipitor's market-leading position in cardiovascular, the planned launch of Caduet, and the likelihood that Europe will switch statins over the counter in the near future.

In 2003, Pfizer launched another multiplatform consumer initiative that further illustrated the enduring relevance and logic behind the three patient mobilization building blocks. Taking a wider category position, Pfizer introduced "ChoLESSterol," a campaign that used targeted press advertising and public relations to create a consumer call to action about cholesterol control and heart health. Various copy treatments targeted "at risk" groups such as diabetic patients and those who had suffered a heart attack in the past.

Pfizer used follow-through direct-marketing programs and "opt-in" CRM activities endorsed by patient groups to deepen and develop patient interest, understanding, and involvement.

Pfizer's commercial rationale for the campaign rests on its strength in the cardiovascular category with Lipitor (atorvastatin), the planned launch of Caduet (amlodipine besylate/atorvastatin calcium), as well as the untapped business potential of major undertreatment in that area. Alongside such growth ambition, it was also a smart pre-emptive and protective initiative, as the likelihood of statins switching to over the counter in European markets moves closer toward reality in 2004 and 2005.

Can DTC Overcome Challenges?

As the European market develops patient mobilization campaigns, US-style DTC has also significantly evolved. The days of explosive DTC spending that began in 1997 with FDA's relaxation of broadcast regulations have become more cautious. Marketers are feeling the pressure against aggressive DTC campaigns from critics as well as cost-cutting managers, and have slowed their DTC spend.

Brands like Claritin (loratadine) and Prilosec (omeprazole) that once defined the era of massive DTC campaigns are now OTCs, while marketers working on others like Propecia (finasteride), Meridia (sibutramine), and Xenical have shifted their media schedule away from television advertising because of the difficulty in effectively communicating a positive brand message in the face of extensive or difficult fair balance.

Even for the most successful brands, there are real questions as to whether DTC is worth it. Recently, the US Congress proposed restrictions against DTC; several state legislatures took up bills; large employers focused on generics—like General Motors with its Generics First campaign to workers and retirees; and managed-care plans have stepped up their reimbursement penalties on advertised brands with tiered co-pays.

Convergence Is Coming

Although the evolution toward an era of less television advertising and more cautious marketing won't rapidly transform the US DTC market, it may create an advertising paradigm more similar to the European system. The United States will always be more aggressive in execution, but marketers that recognize that the quality of communication and depth of patients' relationship with a brand may solve one significant problem in their marketing plan—the lack of patient persistence on chronic therapies.

Some US companies have started to address the problem by replacing aggressive branded awareness messages on television with more targeted and education-based campaigns. For example, Pfizer is spending money on promoting its glaucoma disease awareness site instead of its product site supporting Xalatan (latanoprost). And it makes sense: After all, the more patients understand their condition and the relevance of their medical treatment to managing their health, the stronger their adherence is. That opportunity should be incentive enough for marketers to shift their priority from scooping up new patients to building brand loyalty and advocacy to retain existing customers.

New FDA guidelines will also encourage US marketers to take steps along that path. In time, many companies will replace promotional messages with educational content.

Marketers who are shifting their perspective are placing a new emphasis on long-form television documercials, video on demand, targeted print advertising, interactive online campaigns, in-office communications, relevant sponsorships, and appropriate direct-marketing approaches. Abbott, for example, is using an unbranded disease education campaign to communicate with US consumers about rheumatoid arthritis. Much of the campaign's focus can be found on the website www.controlRA.com, which offers consumers targeted information. It also offers an unbranded reply card in its advertising that allows users to receive free information about new treatment options—a big departure from competitors such as Celebrex (celecoxib) and Vioxx (rofecoxib).

With Internet growth, globalization, and the rise of patient empowerment, a phenomenon may soon take shape: US DTC advertising may start to mellow at the same time that pharma marketers are stepping up their efforts to drive the most appropriate consumer demand in European markets.

As a result, in Europe, as in the United States, patient mobilization can be seen in new brand launches, category management initiatives, and life-cycle planning processes, particularly among the world's top 15 pharma companies who have launched campaigns in Europe and who can now increasingly share best practices within their international affiliates.