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Cigarette advertising and adolescent experimentation with smoking.

The extent to which cigarette advertising contributes to increases in smoking has been debated by public health professionals and the tobacco industry. One aspect of this debate has been the degree to which advertising influences smoking among adolescents. Previous research suggests that there are significant relationships between measures of advertising and smoking. However, potential simultaneous relationships between these measures have not been addressed. Observed correlations may arise from the effects of advertising on smoking or from smokers' selective exposure to advertisements. This study examined relationships between cigarette advertising and smoking experimentation. Using environmental and psychological measures of advertising exposure, it was demonstrated that adolescents who experimented with cigarettes were better able to recognize advertised products than those who had not, a selective exposure effect. Conversely, subjects who were better at recognizing advertised brands were more likely to have experimented with cigarettes, an effect due to their exposure to cigarette advertising.

Adolescent↗

The extent and nature of televised food advertising to New Zealand children and adolescents.

OBJECTIVE: There has been international concern over the balance of television advertising for healthy and less-healthy foods to which children and adolescents are exposed. This study examined the extent to which 9-17 year old New Zealanders were exposed to advertising for different food groups over a year and compared New Zealand rates of advertising with a 13-country study. METHOD: 'People meter' data collected over three months--May and September 1995 and February 1996--and food advertising from a sample week of television during hours when children were likely to be watching were also examined. Comparison was made with a similar 1989 South Australian study and an international study covering 13 countries. RESULTS: Both the exposure estimated for a year and the opportunities for exposure during the sample week were highest for sweet snacks, drinks, fast food/takeaways and breakfast cereals. There were very low levels for fruit, vegetables, and meat/fish/eggs. Water was not advertised in any sample month. Comparisons with the 13-country study showed New Zealand had the third-highest rate of food advertising, the highest rate of confectionery and drinks advertising, and the second-highest rate of restaurant advertising which included fast food restaurants. CONCLUSION: Current patterns of food advertising pose a conflict of interest between public health and commercial interests. Regulation of food advertising may be needed to address this in order to improve future health.

Adolescent↗

Do drug advertisements provide therapeutic information?

In this study of advertisements appearing in medical periodicals and by direct mail advertising to general practitioners, Dr. Stimson, a sociologist, concludes that from what is intended to provide therapeutic information hardly any therapeutic information is provided. He reminds the reader of the safeguards which surround all drug advertising by law and by the code of practice of the Association of the British Pharmaceutical Industry but these safeguards do not appear to control real or potential sins of omission. Frequently in these advertisements the literature relating to the drug is quoted but Dr. Stimson found that it was difficult to trace all the papers quoted in different types of medical library. (Some references quoted were to unpublished papers but surely the blame should be shared in this situation?) Dr. Stimson also gives a vivid and fascinating glimpse of what he calls the 'images and stereotypes' of the patients who, it is claimed, would benefit from the drug being advertised. Certainly most general practitioners must be aware that when they prescribe that image is displaced by an individual but the portrait gallery is indeed depressing. However, to balance these advertisements drug companies issue data sheets which must be more informative than advertisements and conform to regulations in their format. Unfortunately data sheets are only issued every 15 months whereas the 'average general practitioner is potentially exposed to 1,300 advertisements every month'. In other words, the data sheet and not the advertisement should be the guideline but it arrives too infrequently to offset the lack of therapeutic information contained in advertisements.

Advertising↗

A longitudinal study of externally visible cigarette advertising on retail storefronts in Massachusetts before and after the Master Settlement Agreement.

OBJECTIVES: To assess the effect of the Master Settlement Agreement (MSA) on the amount of cigarette advertisements visible from outside of over-the-counter tobacco retailers, for five specific premium brands and an "all other" category, for five types of establishments, and in three areas (windows/doors, building/other detached areas, and sidewalks); to assess the relation of total exterior retail cigarette advertising to illegal sales to youth. METHODS: Observations were conducted on the number of cigarette advertisements visible from outside tobacco retail establishments in a paired convenience sample (n = 556) in Massachusetts before and after the MSA. Archival databases containing information on merchant compliance with age related sales laws during the time period were used to assess the relation of total cigarette advertising with sales to underage youth. Paired sample t tests assessed planned comparisons pre- to post-MSA; Spearman's rho tested associations for dichotomous variables. RESULTS: Significant post-ban increases were observed in the prevalence of exterior cigarette advertising on gas (petrol) stations and gas mini/marts (gasoline retailers) buildings, windows, and doors. Significant declines were observed on windows of liquor stores. Winston advertising declined overall, while advertisements of the "all other" brand category increased. Correlations between advertising and illegal sales, while modest, were significant. CONCLUSIONS: These pre- to post-MSA increases suggest the tobacco industry may be shifting expenditures selectively from billboard advertising to retailer exteriors more favoured by youth. Greater amount of cigarette advertising visible from outside over-the-counter tobacco retailers is associated with greater cigarette sales to minors.

Advertising↗

Newspaper advertising by health maintenance organizations during the reform of healthcare services in Israel.

BACKGROUND: On 1 January 1995 a new mandatory National Health Insurance Law was enacted in Israel. The new law fostered competition among the four major Israeli healthcare providers (HMOs or sick funds) already operating in the market due to the possibility that an unlimited number of patients and the relative budget share would shift among the HMOs. This led them to launch advertising campaigns to attract new members. OBJECTIVES: To examine newspaper advertising activities during the early stages of healthcare market reform in Israel. METHODS: Advertising efforts were reviewed during a study period of 24 months (July 1994 to June 1996). Advertisements were analyzed in terms of marketing strategy, costs and quality of information. RESULTS: During the study period 412 newspaper advertisements were collected. The total advertising costs by all HMOs was approximately US$4 million in 1996 prices. Differences were found in marketing strategy, relative advertising costs, contents and priorities among the HMOs. CONCLUSIONS: The content of HMOs' newspaper advertising was consistent with their marketing strategy. The messages met the criteria of persuasive advertising in that they cultivated interest in the HMOs but did not provide meaningful information about them. Future developments in this area should include consensus guidelines for advertising activities of HMOs in Israel, instruction concerning the content of messages, and standardization of criteria to report on HMO performance.

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Pharmaceutical advertising as a consumer empowerment device.

Pharmaceutical companies have greatly increased their level of "direct-to-consumer" (DTC) advertising in recent years. For 1998, estimates are that over $1.1 billion was spent on this form of advertising, increased from $850 million in 1997 and $600 million in 1996. In 1998, 84 separate drugs were advertised to consumers. The impetus was a decision in August of 1997 by the Food and Drug Administration to reduce the restrictions on DTC advertising on television. As a result, such ads have become very common on TV, and 32 products were advertised on TV in 1998. Pharmaceutical companies advertise because they think that advertising will make money for them. But how will this make money? It will make money by providing consumers with the information they need to make proper decisions about medication. That is, DTC advertising is profitable exactly because it empowers consumers and enables them to purchase useful drugs. The goals of advertising companies and consumers are both for consumers to have information about the most beneficial drug for particular conditions, and so advertising is beneficial both to manufacturers and to consumers. This article describes emerging trends in DTC within the context of the life sciences sector.

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How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA.

BACKGROUND: Direct-to-consumer advertising (DTCA) of prescription drugs has increased rapidly in the United States during the last decade, yet little is known about its effects on prescribing decisions in primary care. We compared prescribing decisions in a US setting with legal DTCA and a Canadian setting where DTCA of prescription drugs is illegal, but some cross-border exposure occurs. METHODS: We recruited primary care physicians working in Sacramento, California, and Vancouver, British Columbia, and their group practice partners to participate in the study. On pre- selected days, patients aged 18 years or more completed a questionnaire before seeing their physician. We asked these patients' physicians to complete a brief questionnaire immediately following the selected patient visit. By pairing individual patient and physician responses, we determined how many patients had been exposed to some form of DTCA, the frequency of patients' requests for prescriptions for advertised medicines and the frequency of prescriptions that were stimulated by the patients' requests. We measured physicians' confidence in treatment choice for each new prescription by asking them whether they would prescribe this drug to a patient with the same condition. RESULTS: Seventy-eight physicians (Sacramento n = 38, Vancouver n = 40) and 1431 adult patients (Sacramento n = 683, Vancouver n = 748), or 61% of patients who consulted participating physicians on pre-set days, participated in the survey. Exposure to DTCA was higher in Sacramento, although 87.4% of Vancouver patients had seen prescription drug advertisements. Of the Sacramento patients, 7.2% requested advertised drugs as opposed to 3.3% in Vancouver (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.2-4.1). Patients with higher self- reported exposure to advertising, conditions that were potentially treatable by advertised drugs, and/or greater reliance on advertising requested more advertised medicines. Physicians fulfilled most requests for DTCA drugs (for 72% of patients in Vancouver and 78% in Sacramento); this difference was not statistically significant. Patients who requested DTCA drugs were much more likely to receive 1 or more new prescriptions (for requested drugs or alternatives) than those who did not request DTCA drugs (OR 16.9, 95% CI 7.5-38.2). Physicians judged 50.0% of new prescriptions for requested DTCA drugs to be only "possible" or "unlikely" choices for other similar patients, as compared with 12.4% of new prescriptions not requested by patients (p < 0.001). INTERPRETATION: Our results suggest that more advertising leads to more requests for advertised medicines, and more prescriptions. If DTCA opens a conversation between patients and physicians, that conversation is highly likely to end with a prescription, often despite physician ambivalence about treatment choice.

Adult↗

Using paid radio advertisements to promote physical activity among Arkansas tweens.

INTRODUCTION: The level of physical activity among children is a growing concern. Evidence shows that many children aged 9 to 13 years (tweens) do not participate in any organized physical activity during their nonschool hours, and some do not engage in any free-time physical activity. Physical inactivity is associated with a host of chronic diseases such as diabetes and cardiovascular disease. Paid media advertisements have been an effective method of promoting physical activity. METHODS: From March 10, 2003, through June 29, 2003, we aired paid radio advertisements in six major Arkansas metropolitan areas to promote physical activity among tweens. In September 2003, we surveyed 295 Arkansas tweens by telephone to assess their exposure to the advertisements and the impact of the advertisements on their intent to participate in physical activity. In the same telephone survey, we also asked questions about the respondents' physical activity level. The data were weighted so that the results would be representative of the areas surveyed. The statistical analysis was performed using SPSS, version 11.5 (SPSS Inc, Chicago, Ill). RESULTS: Of the tweens surveyed, 56.4% (95% confidence interval [CI], 50.7%-62.1%) reported hearing the radio advertisements. Of the tweens who heard the advertisement messages, 76.1% (95% CI, 69.4%-82.8%) said the messages made them more likely to get involved in physical activity. Younger tweens (aged 9 and 10 years) were less likely to have heard the advertisements than older tweens (aged 11 to 13 years). However, the advertisements were more likely to cause younger tweens to want to get involved in physical activity (odds ratio [OR] = 6.89, P = .003) than older tweens. Of the tweens surveyed, 74.9% (95% CI, 70.0%-79.8%) reported that they were involved in nonschool-sponsored sports, and 45.3% (95% CI, 39.6%-51.0%) were involved in school-sponsored sports. CONCLUSION: Paid media advertisements may be an effective way to promote physical activity among tweens. More rigorous evaluations of the impact of paid media advertisements among tweens, with larger samples and additional media markets, are needed. Future physical activity promotion efforts should focus on encouraging participation in school-sponsored sports and creating community environments conducive to physical activity.

Adolescent↗

Youth exposure to alcohol advertising on radio--United States, June-August 2004.

In the United States, more underage youth drink alcohol than smoke tobacco or use illicit drugs. Excessive alcohol consumption leads to many adverse health and social consequences and results in approximately 4,500 deaths among underage youth each year. Recent studies have emphasized the contribution of alcohol marketing to underage drinking and have demonstrated that a substantial proportion of alcohol advertising appears in media for which the audience composition is youth-oriented (i.e., composed disproportionately of persons aged 12-20 years). To determine the proportion of radio advertisements that occurred on radio programs with audiences composed disproportionately of underage youth and the proportion of total youth exposure to alcohol advertising that occurs as a result of such advertising, researchers at the Center on Alcohol Marketing and Youth (Health Policy Institute, Georgetown University, District of Columbia) evaluated the placement of individual radio advertisements for the most advertised U.S. alcohol brands and the composition of audiences in the largest 104 markets in the United States. This report summarizes the results of that study, which indicate that alcohol advertising is common on radio programs which have disproportionately large youth audiences and that this advertising accounts for a substantial proportion of all alcohol radio advertising heard by underage youth. These results further indicate that 1) the current voluntary standards limiting alcohol marketing to youth should be enforced and ultimately strengthened, and 2) ongoing monitoring of youth exposure to alcohol advertising should continue.

Adolescent↗

Regulating firearm advertisements that promise home protection. A public health intervention.

Firearms are a consumer product responsible for 38500 deaths in the United States in 1994. Like other products, firearms are advertised. In the absence of rules governing the design of firearms, regulating the way guns are advertised may be a useful public health intervention. Some gun advertisements include messages suggesting that bringing a handgun into the home is generally protective for the occupants of the home. The best available scientific information contradicts this message. Given this disjunction, regulating those advertisements may be an appropriate response. Under federal law, the Federal Trade Commission (FTC) has authority to prohibit advertisements that are "deceptive" or "unfair." Under the FTC's deception analysis, the focus is on whether consumers are misled by an advertisement. For a finding of unfairness, the FTC looks for advertisements that may cause substantial injury to consumers. Under either analysis, a strong argument can be made that firearm advertisements promising home protection are unlawful. On February 14, 1996, several organizations sent separate petitions to the FTC asking it to consider the issues raised by firearm advertisements that promise home protection. The FTC is still reviewing the information presented. There are no First Amendment or Second Amendment impediments to FTC regulation of deceptive firearm advertising under the US Constitution.

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Advertising by academic medical centers.

BACKGROUND: Many academic medical centers have increased their use of advertising to attract patients. While the content of direct-to-consumer pharmaceutical advertisements (ads) has been studied, to our knowledge, advertising by academic medical centers has not. We aimed to characterize advertising by the nation's top academic medical centers. METHODS: We contacted all 17 medical centers named to the US News & World Report 2002 honor roll of "America's Best Hospitals" for a semistructured interview regarding their advertising practices. In addition, we obtained and systematically analyzed all non-research-related print ads placed by these institutions in their 5 most widely circulating local newspapers during 2002. RESULTS: Of the 17 institutions, 16 reported advertising to attract patients; 1 stated, "We're just word of mouth." While all 17 centers confirmed the presence of an institutional review board process for approving advertising to attract research subjects, none reported a comparable process for advertising to attract patients. We identified 127 unique non-research-related print ads for the 17 institutions during 2002 (mean, 7.5; range, 0-39). Three ads promoted community events with institution sponsorship, 2 announced genuine public services, and 122 were aimed at attracting patients. Of the latter group, 36 ads (29.5%) promoted the medical center as a whole, while 65 (53.3%) promoted specific clinical departments and 21 (17.2%) promoted single therapeutic interventions or diagnostic tests. The most commonly used marketing strategies included appealing to emotions (61.5%), highlighting institution prestige (60.7%), mentioning a symptom or disease (53.3%), and promoting introductory lectures or special offers likely to lead to further business (47.5%). Of the 21 ads for single interventions, most were for unproved (38.1%) or cosmetic (28.6%) procedures. While more than half of these ads presented benefits, none quantified their positive claims and just 1 mentioned potential harms. CONCLUSIONS: Advertising to attract patients is common among top academic medical centers but is not subjected to the oversight standard for clinical research. Many of the ads seemed to place the interests of the medical center before the interests of the patients.

Academic Medical Centers↗

Recognition and liking of tobacco and alcohol advertisements among adolescents: relationships with susceptibility to substance use.

BACKGROUND: Exposure to tobacco and alcohol advertising has been associated with adolescent substance use. However, it is not clear whether favorable reactions to advertising are an antecedent to or a consequence of substance use. This study investigated relationships between adolescents' levels of susceptibility to substance use and their recognition and liking of tobacco and alcohol advertising. METHOD: Eighth-grade students viewed pictures of tobacco and alcohol advertisements with brand names and identifying information obscured, attempted to identify the brand name and type of product being advertised, and rated their liking of the advertisements. Subjects were divided into three substance use status groups: nonsusceptible nonusers (have never used and do not intend to do so), susceptible nonusers (have not used but have not made a firm commitment not to experiment in the future), and users (have tried the substance). RESULTS: Susceptible nonusers liked the tobacco advertisements at a level that was significantly greater than that of the nonsusceptible nonsmokers and comparable to that of the users. Liking of the alcohol advertisements generally increased with alcohol use status. CONCLUSIONS: These results suggest that tobacco advertisements ostensibly targeted to adult smokers may have the effect of recruiting new adolescent smokers.

Adolescent↗

Exposure to brand-specific cigarette advertising in magazines and its impact on youth smoking.

BACKGROUND: Despite the potential influence of cigarette advertising on youth smoking, few studies have characterized brand-specific magazine advertising exposure among youths or examined its impact on youth smoking behavior. METHODS: A longitudinal youth survey was conducted to assess baseline exposure to brand-specific cigarette advertising in magazines and to measure subsequent smoking behavior. The sample comprised 1,069 Massachusetts youths, ages 12-15 years at baseline in 1993, and 627 of these youths who were interviewed after 4 years. RESULTS: Five brands accounted for 81.8% of the gross impressions for magazine advertising among Massachusetts youths. These same brands accounted for 88.4% of the brand market share among 12- to 15-year-old smokers nationally in 1993. The levels of brand-specific advertising exposure in the sample were highly correlated with these national brand market shares (r = 0.96, P = 0. 0002). Among the cohort, baseline brand-specific exposure to cigarette advertising in magazines was highly correlated with brand of initiation among new smokers (r = 0.93, P = 0.0001), brand smoked by current smokers (r = 0.86, P = 0.0004), and brand whose advertisements attracted attention the most (r = 0.87, P = 0.0002). CONCLUSION: By documenting a relationship between brand-specific magazine advertising exposure and brand of smoking initiation among new smokers, this study provides strong new evidence that cigarette advertising influences youth smoking.

Adolescent↗

Prescription drug advertising: trends and implications.

Prescription drug advertisements which appeared in two leading American medical journals in 1972, 1977 and 1982 were analyzed to discover possible trends in advertising. The 5016 ads examined showed that ads for the diuretic-cardiovasculars, especially the beta-adrenergic blocking agents and the slow channel inhibitors, as well as the analgesics, had increased, while ads for the anti-infectives and tranquilizers had diminished. The average amount of space allocated for each ad had increased. On the average, most ads (69%) depicted neither male nor female patients in their graphics, and a trend of increased neutrality was observed. When the hormones were excluded, an average of 21% of the ads showed male patients and 10% showed females. Since a relationship was discerned between the leading drugs advertised and the leading prescriptions filled, it was concluded that advertising does have some effect on the prescribing behavior of practitioners. The findings suggest that great investment in advertising is necessary in order to achieve high levels of sales for such drugs as Valium (diazepam) which do not have a clear-cut ameliorative effect on a specific physiological condition. On the other hand, it was suggested that saturation advertising would not significantly enhance the sales of such drugs as Dyazide (triamterene and hydrochlorothiazide) because of its well established therapeutic value in the control of hypertension. Ten advertising companies, on the average, had purchased 67% of all advertising space and five had purchased almost half (47%). The same two pharmaceutical companies were among the top five advertisers and the same five were among the top ten for the three years studied.

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Dermatology Internet Yellow Page advertising.

BACKGROUND: Patients may use Internet Yellow Pages to help select a physician. OBJECTIVE: We sought to describe dermatology Internet Yellow Page advertising. METHODS: Dermatology advertisements in Colorado, California, New York, and Texas at 3 Yellow Page World Wide Web sites were systematically examined. RESULTS: Most advertisements (76%; 223/292) listed only one provider, 56 listed more than one provider, and 13 listed no practitioner names. Five advertisements listed provider names without any credentialing letters, 265 listed at least one doctor of medicine or osteopathy, and 9 listed only providers with other credentials (6 doctors of podiatric medicine and 3 registered nurses). Most advertisements (61%; 179/292) listed a doctor of medicine or osteopathy claiming board certification, 78% (139/179) in dermatology and 22% (40/179) in other medical specialties. Four (1%; 4/292) claims of board certification could not be verified (one each in dermatology, family practice, dermatologic/cosmetologic surgery, and laser surgery). Board certification could be verified for most doctors of medicine and osteopathy not advertising claims of board certification (68%; 41/60; 32 dermatology, 9 other specialties). A total of 50 advertisements (17%) contained unverifiable or no board certification information, and 47 (16%) listed a physician with verifiable board certification in a field other than dermatology. LIMITATIONS: All Internet Yellow Page World Wide Web sites and all US states were not examined. CONCLUSION: Nonphysicians, physicians board certified in medical specialties other than dermatology, and individuals without verifiable board certification in any medical specialty are advertising in dermatology Internet Yellow Pages. Many board-certified dermatologists are not advertising this certification.

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Methodological challenges surrounding direct-to-consumer advertising research--the measurement conundrum.

OBJECTIVES: Numerous studies have focused on the impact of direct-to-consumer (DTC) prescription drug advertising on consumer behavior and health outcomes. These studies have used various approaches to assess exposure to prescription drug advertising and to measure the subsequent effects of such advertisements. The objectives of this article are to (1) discuss measurement challenges involved in DTC advertising research, (2) summarize measurement approaches commonly identified in the literature, and (3) discuss contamination, time to action, and endogeneity as specific problems in measurement design and application. METHODS: We conducted a review of the professional literature to identify illustrative approaches to advertising measurement. Specifically, our review of the literature focused on measurement of DTC advertising exposure and effect. We used the hierarchy-of-effects model to guide our discussion of processing and communication effects. Other effects were characterized as target audience action, sales, market share, and profit. RESULTS: Overall, existing studies have used a variety of approaches to measure advertising exposure and effect, yet the ability of measures to produce a valid and reliable understanding of the effects of DTC advertising can be improved. Our review provides a framework for conceptualizing DTC measurement, and can be used to identify gaps in the literature not sufficiently addressed by existing measures. CONCLUSIONS: Researchers should continue to explore correlations between exposure and effect of DTC advertising, but are obliged to improve and validate measurement in this area.

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A 3-stage model for assessing the probable economic effects of direct-to-consumer advertising of pharmaceuticals.

BACKGROUND: The pharmaceutical industry employs a variety of marketing strategies that have previously been directed primarily toward physicians. However, mass media direct-to-consumer (DTC) advertising of prescription drugs has emerged as a ubiquitous promotional strategy. OBJECTIVE: This article explores the economics of DTC advertising in greater depth than has been done in the past by using a 3-stage economic model to assess the pertinent literature and to show the probable effects of DTC advertising in the United States. METHODS: Economics literature on the subject was searched using the Journal of Economic Literature. Health services literature was searched using computer callback devices. RESULTS: Spending on DTC advertising in the United States increased from $17 million in 1985 to $2.5 billion in 2000. Proponents of DTC advertising claim that it provides valuable product-related information to health care professionals and patients, may contribute to better use of medications, and helps patients take charge of their own health care. Opponents argue that DTC advertising provides misleading messages rather than well-balanced, evidence-based information. The literature is replete with opinions about the effects of prescription drug advertising on pharmaceutical drug prices and physician-prescribing patterns, but few studies have addressed the issues beyond opinion surveys. The economic literature on advertising effects in other markets, however, may provide insight. CONCLUSION: DTC advertising indirectly affects the price and the quantity of production of pharmaceuticals via its effect on changes in consumer demand.

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A survey of the advertising of nine new drugs in the general practice literature.

OBJECTIVE: To undertake a survey of the advertising of new drugs in the general practice literature as part of a larger study investigating the factors which influence the introduction of new drugs into clinical practice. METHOD: The advertisements for nine new drugs from a range of therapeutic groups were monitored for 30 months in 12 journals, which are received by most GPs. The amount of prescribing, in defined daily doses, of each new drug by 50 GPs, selected as regular users of a teaching hospital, was also recorded during this period. RESULTS: Of the journals, 798 issues were surveyed (93% of the total published). The total number of advertisements was almost 33 000, of which 2163 (6.6%) were for the study drugs. The pattern of advertising of each study drug was very complex and varied from month to month and between journals. There was no consistent pattern in the way the drugs were advertised, with large variations in the amount and timing of advertisements. The prescribing data showed wide variations in the number of GPs prescribing each drug and in the amount prescribed. CONCLUSION: There was no clear relationship between the extent of the advertising of a drug and the amount of prescribing by the GPs. This suggests that advertising in journals is only one of many factors which are important in influencing GPs to prescribe new drugs. However, the study may have been insufficiently comprehensive to capture complex relationships between advertising and prescribing.

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