Media Spend Trends: Change the Channel

It's not closing time, but it does seem like the nine-year, direct-to-consumer (DTC) advertising happy hour is winding down. PhRMA's new Guiding Principles are dimming the lights, and television, the most glamorous and visible media channel for DTC, will have to turn down the volume.

"Reminder ads are gone," says Ken Johnson, senior vice president, PhRMA. Reminder ads—quickie TV spots urging viewers to ask their doctor about a drug—are an early casualty of PhRMA's decision to encourage member companies to make big voluntary changes in the way they advertise prescription drugs. These changes, called Guiding Principles on Direct-to-Consumer Advertising, were announced at the American Legislative Council's annual meeting last August, and went into effect in January. Twenty-seven of PhRMA's 34 members have signed on so far.

Flatlining

Why the change? Johnson says it was, in part, a case of "govern or be governed." Legislative efforts to curtail DTC marketing efforts were increasing at both the state and federal levels (see "50 5 2005," Pharm Exec, September 2005). Senate Majority Leader Bill Frist (R-TN) was poised to call for a DTC moratorium for all prescription drugs less than two years old.

"Politics certainly figured into it," says Johnson, "but we were also listening to consumer and healthcare professionals who wanted DTC to be more educational. Ads are already taking on a more serious tone and tenor, and there are less critical rumblings as well."

Beyond the demise of reminder ads, David Gascoigne, head of promotion management at IMS Management Consulting, predicts DTC will be less reliant on TV.

"The days of the 100-million-dollar television campaign are gone," Gascoigne says. "Where DTC was once heavily skewed toward television and mass media campaigns, we're now seeing a greater emphasis on print advertising and a greater focus on disease education, medication adherence, and consistency. Mass media adverting brought consumers in, now marketers have to concentrate on keeping them."

Keeping patients on their prescribed drugs continues to vex pharmaceutical marketers. It's a challenge no mass marketing campaign, no matter how costly, has been able to adequately address thus far.

"Mass marketing is all about reaching your target as frequently as possible," says Elizabeth Boehm, principal analyst at Forrester Research's Health Care and Science division. "You can buy your way in. When you're doing compliance marketing, you can buy impressions but can't buy your way into participation."

Script Trip

A funny thing happens on the way to the pharmacist, according to industry analysts: The prescription and the patient often don't get there. "Part of the challenge is to do research up front," Boehm says. "Pharmaceutical companies have less data on what happens between obtaining a prescription and actually taking the medication. We need to find this out without becoming too intrusive."

Pfizer on Top

One approach, Boehm suggests, is to shift more dollars from mass media to micromedia campaigns. "You're dealing with a smaller universe when you're doing compliance marketing," she says. "This is an area requiring experimentation in order to make an impact down the road."

Devising an effective medication-compliance campaign often starts with one question: Why aren't patients taking their medications? "There are some approaches that have been known to work," Boehm says. "If the challenge is medication cost, coupons may work. If it's disease denial, education may be in order. If it's forgetfulness, reminders may help. Marketers have to determine what the right mix is for the right set of consumers."

What effect on compliance, if any, will innovative mechanisms of drug delivery have for chronic diseases like diabetes? Pfizer's Exubera (human insulin [rDNA origin]), for example, an inhalable insulin for type 1 and type 2 diabetes, just received FDA approval and is expected to hit the market soon. Will patients be more receptive to inhaled insulin than to injections or pills? Yes, according to at least one investigator on the Exubera team.

"Many people who could benefit from insulin are fearful of injections, so they delay treatment five years or 10 years, placing them at risk for serious complications," says William Cefalu, MD, an investigator from Pennington Biomedical Research Center who worked on Exubera. Cefalu feels the draw of fewer—or no—injections will bring more diabetics into treatment sooner. Will the same principle apply to fast-acting medicines that melt under the tongue, such as allergy medicines, or inhaled through the nose, like migraine treatments? Marketers will be watching very carefully.

Unforgettable: Lexapro and Effexor

It's Not What You Say...

The media that deliver pharmaceutical marketing messages also affect their impact.

"Even though awareness is high in several specific therapeutic categories, the messages are not serving the purpose of the information," says Sue Ramspacher, senior vice president of GFK Market Measures. "When asked where they get the most helpful information, people rate their doctors high. Advertisements are really down at the bottom."

This perception, thus far, has not been measurably affected by PhRMA's sweeping guidelines. "Despite messages being delivered in a more somber, education-type format, DTC ads are still not being viewed as a big information source," Ramspacher says. "It's a fact [that] magazine and newspaper DTC can be more helpful than TV and radio."

Digitize Me

Electronic media—primarily Internet communications—continue to gain credibility in DTC messaging. Spending for the top-10 products in this channel took a dip in 2005, although AstraZeneca's heartburn medication, Nexium (esomeprazole magnesium), and Novartis' toenail antifungal, Lamasil (terbinafine HCl), remain among the top-three spenders. Pfizer's Viagra (sildenafil citrate) jumped into third place, up from seventh last year. Notable new entries to the top-10 Internet spenders in 2005 included Sanofi-Aventis' insomnia-med, Ambien (zolpidem tartrate), and Eli Lilly's Cymbalta (duloxetene), for depression.

Are these Internet spends early signs of the new PhRMA guidelines at work? "I can't say I've seen a whole rash of solutions come out on the Internet," Boehm says. But she thinks Lilly, with its combination TV and Web site campaign for Cymbalta (www.depressionhurts.com), may be on to something.

"When you see the Depression Hurts TV commercial, they're talking about a Web site, not a medication," Boehm says. "They're telling the viewer, 'Look, depression is a bigger problem than we can explain in a TV ad, so go to this Web site, where we have more of your time and attention.'"

"Six or eight years ago you may have just done a Web site with a little more information than your print or TV ad gave," says Richard Campbell, partner of healthcare marketing agency Regan Campbell Ward (RCW). "People are doing a much better job of making information work for them as opposed to viewing Web sites as something you just have to do."

Well beyond early invitations to simply "Visit us at www dot," the Web offers chatrooms, blogs, listservs, message boards, groups, and instant messaging—many of which can be accessed from wireless hand-held devices. Some pharmaceutical marketers are eager to embrace these newer, sophisticated tools—but only if they don't risk opening a can of worms.

"More often than not, pharma is keeping its involvement with blogs and public Web sites at arms length," Boehm says. Unfettered online chatter can leave a pharmaceutical company open to a host of liability issues, says Campbell. "If I put up a Web site and allow anyone to contribute, it's still my Web site," he says. "I have a legal responsibility to report side effects if they're discussed, and to try to control the conversation to stay within the drug's FDA-approved indication."

But something like search-engine optimization is another matter. Weaving key search terms into pharmaceutical Web sites to bump up their ranking in popular Internet search engines—increasing the likelihood of a visit—is an evolving art.

"We used search-engine optimization and placement strategies for one of our clients, Bioval, which markets Zovirax [acyclovir], a treatment for oral and genital herpes," says Maureen Regan, CEO at RCW. "Visitor activity on the Zovirax site was linked directly to our own, enabling us to, for example, ascertain how many hits the site got and capture visitors' names. This media is ideal for reaching smaller markets with a very targeted audience."

Cyber Awareness

Shaking Things Up

Last year's Spend Trends Report ("Changing Lanes," Pharm Exec, May 2005) predicted a shift in DTC spending from big branded campaigns to more disease awareness and medication compliance efforts. Those predictions appear to be on target, although the change may seem subtle at first.

"The shift will be taking place behind the scenes, and it will take time," Boehm says. "This year [2006] is an infrastructure-building year, and we'll see the results two or three years down the road. When change is intelligence-driven, you see less extreme shifts, based not on fashion or whim. Most of the things pharmaceutical companies try, do work." Intelligence, says Boehm, will provide information about the extent to which pharma companies' tactics work, and in what combination.

Additionally, adds Gascoigne, DTC marketers should bear in mind that the regulatory environment is less friendly than it once was. "I think the question DTC marketers must ask, if we want to keep it as a viable form of communication, is: Does what we're doing adhere to the regulatory guidelines?"

Guidelines Hit Home at Pfizer

Perhaps the biggest change suggested by PhRMA's Guiding Principles calls for pharmaceutical companies to spend "an appropriate amount of time" educating health professionals about new medicines or therapeutic indications, before beginning a new DTC campaign.

"What we've suggested is allowing an appropriate amount of time for doctors and other health professionals to be educated about the medication," says PhRMA's Ken Johnson. "This will vary from product to product—a breakthrough cancer drug would take longer than an athlete's foot cream, for example."

Pfizer, however, has decided to put a minimum time period on all products slotted for promotion. "Pfizer has committed to educating physicians for a minimum of six months before beginning TV and print product-branded advertising to consumers," says Jim Maffezzoli, team leader for Pfizer's consumer strategy team. "[This] applies to newly approved products where doctors have expressed a desire to have time to become more familiar with the medicine."

Broadcast advertising

PhRMA has asked its members to submit print and broadcast ads to FDA before they are released, and to assure that advertisements identifying a product by name clearly state the condition it is approved for and the major risks associated with its use. In response, Pfizer is running unbranded reminder ads.

"Pfizer will no longer create 'Go ask your doctor about a medicine' TV and print advertisements that do not include the benefits and risks associated with the advertised medicine," a company statement said. Pfizer will, however, air "dedicated, nationwide TV and print advertising promoting Pfizer Helpful Answers, assistance programs which may help under insured people to pay for medications.

Television and print

TV and print ads should be designed to achieve a balanced presentation of a drug's benefits and risks. Specifically, risks and safety information should be clear, understandable, and presented in a manner supportive of dialogue between patients and physicians, according to PhRMAs Principles. Pfizer says it has already made changes to meet these goals.

"The new consumer-friendly brief summary currently appearing in Lipitor [atorvastatin] print advertising is designed to more effectively communicate risk and benefit information in an accessible way," Maffezzoli says. "And to support the doctor-patient dialogue, we are implementing improvements, such as including alternative treatment language in our advertising. For example, the new campaign for Zyrtec [cetirizine] includes an example of what the doctor may suggest, such as ways to first remove or avoid allergens using a dehumidifier, as well as medication options like Zyrtec."

Other changes afoot at Pfizer in 2006, according to a company statement, include a vow to "invest a meaningful amount—on par with what it spends on a branded advertisement campaign" to create more unbranded disease awareness ads (such as the "Why Live With Depression" ad starring Sopranos actress Lorraine Bracco). The company also plans to take a closer look at ad placement "to avoid audiences that are not age appropriate." In particular, the company says ads for erectile dysfunction drugs like Viagra (sildenafil citrate) will be aired during programs with a primarily adult viewership.

"Our hope," Maffezzoli says, "is that these changes will result in making consumer advertising more effective at encouraging more valuable patient-healthcare professional dialog, helping consumers better understand the risks and benefits of prescription medicines, and motivating people to overcome significant barriers to better health."