Although the public health impact of direct-to-consumer (DTC) pharmaceutical advertising remains a subject of great controversy, such promotion is typically understood as a recent phenomenon permitted only by changes in federal regulation of print and broadcast advertising over the past two decades. But today's omnipresent ads are only the most recent chapter in a longer history of DTC pharmaceutical promotion (including the ghostwriting of popular articles, organization of public-relations events, and implicit advertising of products to consumers) stretching back over the twentieth century. We use trade literature and archival materials to examine the continuity of efforts to promote prescription drugs to consumers and to better grapple with the public health significance of contemporary pharmaceutical marketing practices. DIRECT-TO-CONSUMER (DTC) advertising of prescription drugs has mushroomed from a few isolated and relatively sensational cases in the early 1980s to an omnipresent feature of American consumer society, powered in 2005 by $4.2 billion in promotional dollars. 1 This explosive growth—most intense in the past decade—has inverted the role of physician as learned intermediary in the flow of information about prescription drugs and replaced it with what is, in theory, a more egalitarian consumerist model of health information. Considerable controversy persists, however, about the impact of DTC advertising on American public health and the doctor–patient relationship. 2 Whereas some argue that advertising has indeed democratized access to important new medications, 3 others decry the coarsening of medical discourse, the diminution of physicians' authority, and the risks of overprescription and inappropriate prescription by the manipulation of consumer awareness and consequent pressure on prescribers. 4 The lively debate among scholars and policymakers about consumer-oriented pharmaceutical promotion has, for the most part, focused on the explicit regulation of prescription drug advertisements in print and broadcast media,5 following a series of Food and Drug Administration (FDA) guidances in 1985, 1997, and 1999. However, as revealed by recent scholarship, 6 tort litigation, 7 and congressional hearings regarding pharmaceutical promotion to physicians, 8 explicitly regulated promotional practices such as advertisements and sales visits have long been flanked by such unregulated, implicit forms of promotion as the ghostwriting of scientific articles and control of the content of continuing medical education. 9 We present new historical evidence to demonstrate that such “shadow” marketing has also been employed in the DTC promotion of prescription drugs for over a half century. These proto-DTC campaigns flourished at the boundaries of acceptable self-regulation by the pharmaceutical industry as it negotiated attempts at external regulation by the medical profession and the regulatory state. The vitality and persistence of DTC pharmaceutical promotion in the twentieth century suggest that contemporary DTC advertising is not merely a recent aberration that can be fixed by returning to an earlier and better time, and that attempts to wrestle with the consequences of popular marketing would do best to focus on managing, not eradicating, this longstanding element of public life.
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