APPENDIX 33 (PI 125)|
Memorandum by the University of Stirling
Dealing in Drugs: An Analysis of the
Pharmaceutical Industry's Marketing Documents
As part of their investigation into the conduct
of the UK pharmaceutical industry, the House of Commons Health
Select Committee obtained access to internal documents from various
pharmaceutical companies relating to their marketing activity
for specified products or programmes. The Institute for Social
Marketing (ISM), at the University of Stirling and the Open University,
was asked to analyse these documents and prepare a report.
The committee obtained documents from five pharmaceutical
companies: GlaxoSmithKline, AstraZeneca, Pfizer, Eli Lilly and
Wyeth. Each company was instructed to provide all promotional
and product support material for specific brands or programmes
(see Table 1 below). On the ISM's advice, the Committee requested
a range of documents, including: contact reports between clients
and agency/agencies, client briefs, creative briefs, media briefs,
market research reports, details of public relations activity
and any other documents relating to promotion and product support.
A total of 49 boxes were obtained.
SUMMARY OF DOCUMENTS OBTAINED
|Eli Lilly||Zyprexa (Well being support programme) Cialis|
(36 hours of freedom)
The Association of the British Pharmaceutical Industry (ABPI)
Code of Practice, 2003, covers all forms of promotional activity
by the UK pharmaceutical industry. Although the code itself is
self-regulatory, it was designed to reflect the requirements of
the Medicines Act and the European Advertising Directives, which
are legally binding. The Code states that promotional activity
by the pharmaceutical industry for prescription-only (PO) medicines
should only target members of the health professions and not the
general public, and in doing so should abide by the code in "both
spirit and letter" and such promotion should be carried out
"in a responsible, ethical and professional manner".
The documents obtained were analysed around four key themes taken
from the Code of Practice.
Targeting patients and general public.
Servicing the emotional needs of health professionals
and the use of branding.
The use of public relations and building relationships
to counteract negative publicity.
Disguised marketing to the health professionals.
In each area, examples were found that contravened the spirit
if not the letter of the Code of Practice. This is of particular
concern because the analysis is based on a small number of documents
as three of the five companies provided a very limited set of
papers. For this reason the results have been anonymised.
2.1 Targeting Patients and General Public
The Code of Practice states that as far as targeting patients
and the general public is concerned:
"Medicines must not be advertised to the general public
if they are prescription only medicines."
Code of Practice, Clause 20.1
"Statements must not be made for the purpose of encouraging
members of the general public to ask their doctors to prescribe
a specific medicine."
Code of Practice, Clause 20.2
"A company may conduct a disease awareness or public health
campaign provided that the purpose is to encourage members of
the public to seek treatment for their symptoms while in no way
promoting the use of a specific medicine."
Code of Practice, Clause 20.2
Thus, beyond the simple provision of information, the pharmaceutical
industry is prohibited from targeting patients and the general
public with marketing and promotional activity relating to prescription-only
(PO) medicines. In many of the documents, however, patients and
the general public emerge as key targets for direct and indirect
communications that go beyond the simple provision of information.
Detailed and continuous market research, for example, is conducted
with the public to uncover their emotional drivers and motivations,
which are then exploited to encourage presentation to the medical
services. Public relations activity is also used to encourage
media coverage with the clear intention of targeting patients,
patient groups and the general public. This activity is then tied
into specific brands and their performance in the market place.
There is clear evidence that the industry is concerned with
identifying populations who are not currently presenting to the
medical services for diagnosis and prescription of medicines.
This population, dubbed "the missing millions",
are estimated to include almost 2 million people in the UK:
"Through their strategic planning process, Company
X have identified a population of patients . . . that do not currently
present to their GP or take prescription medications." .
. ."This population provides a significant opportunity for
Research is then conducted with the aim of understanding
what barriers exist to prevent these people from presenting and
to identify factors, both rational and emotional, that will overcome
these barriers and encourage presentation:
To understand how to target these patients and overcome
their barriers to presentation.
To understand the segments of patients that do not currently
present to GPs
To explore their rationale/belief systems that inhibit
them from presenting
Identify hooks and drivers to encourage them to seek advice
both emotional and rational."
The documents make it clear that the pharmaceutical industry
is concerned with using the results of such research to design
strategies that are able to `target these customers' and goes
as far as identifying which of these customers will be most `receptive'
to their communications:
"Evaluate and communicate channels that could be used
to target these customers. Identify which segments are likely
to be most receptive."
This demonstrates that the pharmaceutical industry are concerned
with targeting members of the general public, particularly those
who are most likely to respond to their messagesand the
fact that they refer to them as customers suggests that this is
not just motivated by an interest in public health.
The documents also demonstrate that the pharmaceutical industry
employs sophisticated marketing principles, such as segmentation,
targeting channel choice and source effects to maximise their
Thus, their research is used to segment the population into
smaller, more homogenous groups, and targeting strategies are
employed to meet the specific and unique needs of each group.
In one research paper, for example, segmentation principles are
employed to identify various patient types based on their involvement
with the condition and the impact their condition has on their
life, including segments called "endurers", "sceptics"
and "deniers". Figure 1 overleaf outlines all
the segments identified.
 The research
then goes on to identify the most appropriate ways in which to
target these groups to encourage them to present to the medical
services. Figure 2 below outlines how they propose to target one
group: "hard working heroes". This highlights that the
main barrier to presentation for this group is a lack of perceived
time and the research then suggests providing information on "how
little time improvement requires" and suggests providing
the incentive of prolonging their "working career" by
The research also profiles all of the identified patient
groups according to ease of targeting (see Figure 3 overleaf).
The majority of the "missing millions" are identified
as "easier targets" in terms of their "willingness
to take medication", although it is recognised that even
this group "may still have reservations re prescribed
`symptom relief' that needs to be taken continuously".
"Prescribed symptom relief" can only be interpreted
as prescription medicines.
Given these reservations, a clear need is identified to "reframe
perspectives" and "raise expectations re normality"
among these "missing millions" and the documents
highlight that "patients will need to be provided with
hooks to make them `open to change beliefs'" and once
belief patterns are changed, behaviour should follow suit".
Again this must refer to their willingness to take medication,
and a desire to make them more favourably inclined to do so.
Research is also conducted with the general public which
aims to "evaluate and communicate channels that could
be used to target customers" and highlights more general
communication principles the industry consider when targeting
such general public groups. For example, the outcomes of the research
suggest that the perceived source of the message is vital to the
target audience's receptiveness to the communication.
"Strong perception exists amongst missing millions that
any communication or information provided needs to be from credible
source, eg. GP, `medical organisation', patient groupNOT
outwardly a drug companystigma attached to pharmaceutical
companies that they'd just be doing it to sell drugs', not seen
to be patient focussed."
Similarly, other more "credible" channels
of communication are outlined:
"Patient leaflets left on the counter in pharmacies/GPs
surgeriesperceived to be more `credible' source than, eg
at end of supermarket aisle."
Advertising and Public Relations
There are also occasions within the documents when overt
references are made to "direct consumer advertising"
and again there is a desire that this advertising should be "not
obviously from a pharmaceutical company". Potential routes
are outlined, including "PR activities" in the
form of "articles in lay press", "TV
documentaries" and "soap operas"which
being indirect and unattributed are potentially more powerful
than conventional advertising.
Furthermore, the campaign is clearly aimed at those who will
be "most likely to take action" which suggests
that the campaign is primarily concerned with those who are most
likely to benefit the company rather than those who may arguably
be more legitimate targets, but more resistant to change. In a
similar vein, concerns are raised in the conclusions and recommendations
that some of the target audience are presenting to pharmacies
rather than GPs or hospitals which "results in fewer scripts".
This is clearly viewed as a threat and is described as "something
to be monitored". More specifically, calculations are
made regarding the number of people who are prescribed the company's
brand. The clear aim of the campaign is to "be effective
in attracting these people" which again makes it clear
that the ultimate aim of the campaign is to increase sales of
the company's brand.
Public relations activity is also used to target "patients",
"patient groups", "consumers"
and "consumer journalists".
This PR activity aims, among other things, to promote awareness
of specific diseases, the need to seek treatment and the benefits
of specific brands.
"Create a positive media and press environment for
brand X. ` `Positive articles on brand X generating a positive
"Generate a positive risk: benefit of brand X."
"Strengthen relationships with target journalists
to ensure brand X possesses a greater share of voice in the future."
"Utilisation of real-life data to demonstrate the
critical role of brand X".
The documents also provide examples of research being conducted
with members of the general public to evaluate the effectiveness
of an "advertising campaign run in the national press".
Although the Code of Practice allows pharmaceutical companies
to run "disease awareness or public health campaigns",
these are only permitted if the goal is to "encourage
members of the public to seek treatment for their symptoms while
in no way promoting the use of a specific medicine".
However, the documents show that such campaigns are evaluated
according to the impact on "future behaviour, information
sought and treatments received" and there is a clear
desire from the company who ran the advertising campaign to "provide
a return on investment calculation", rather than evaluate
it in terms of changes in the target audience's general knowledge,
attitudes and behaviours concerning a specific condition.
In summary, this section shows that the public are the target
for sophisticated promotional activity by pharmaceutical companies;
that this activity exploits emotional drivers and marketing principles
that go way beyond the simple provision of information and that
its ultimate effectiveness is directly tied in to specific brands.
In our view this breaches both the letter and the spirit of the
2.2 Servicing the Emotional Needs of Health Professionals
and the Use of Branding
The Code of Practice states:
"Information, claims and comparisons must be accurate,
balanced, fair, objective and unambiguous and must be based on
an up-to-date evaluation of all the evidence and reflect that
Code of Practice, Clause 7.2
An important theme to emerge from many of the documents was
the importance not only of creating products, but the creation
of strong and powerful brands. An extract from one document describes
brands as "existing only in the mind of consumers"
and as something that the pharmaceutical industry "manipulate[d]".
|"What is a brand?||
What is stripped of all its
Constructed by manufacturing
What it becomes with all its
emotional baggage intact
Exits only in the mind of consumers
understood, measured and manipulated by us."
Figure 4 overleaf outlines the equal importance attached
by the pharmaceutical industry to the role of "rational"
and "emotional" elements in the development of
strong brands. For example, emotional elements such as "how
does using the brand make the customer feel?" and "how
would others view users of the brand?" appear to be given
as much importance as "what are the physical features
of the product?" and "how do the features benefit
This role of "emotion" is recognised as growing
in importance given that there are "less clear rational
differences" between different products within the pharmaceutical
industry and therefore in order to "find further competitive
advantage" products must be "differentiate [ed]
on an emotional basis as well". One-document estimates
that this can lead to a "50% increase in sales".
Consistently throughout the documents, brands are deliberately
associated with attributes that can not be described as "objective"
as required by the Code of Practice, such as "energetic",
"passionate", "desirable", "sexy",
"romantic", "intimate" "relaxed",
"effortless", "freedom" and
Not only are brands deliberately associated with such attributes
and designed and marketed to satisfy emotional as well as rational
benefits, but there is a clear desire by the industry to exploit
health professional's emotional needs and vulnerabilities. For
example, the pressure GPs are under when prescribing and the difficulties
they face on a daily basis including the pressure associated with
prescribing the right medication, perceived difficulties in patient
compliance and the risk of being judged by peers.
Brands and marketing activity are designed accordingly to
tap into "customer insight of hassle of how difficult
the patients will be to treat", "likelihood of
compliance" and to tap into their "emotional
button of risk". Another document demonstrates that campaigns
are deliberately designed to "give the perception that
brand X is a trusted brand" and to "give the
customer the confidence to prescribe Brand X first line for new
patients". Similarly, marketing activity is designed
to make GPs feel "unburdened, confident, no more heart
sink moments, rebelling and responsible" by prescribing
certain brands and to "provide reassurance that a large
proportion of doctors are using brand X" and as a "decision
The documents go into detail about how best to communicate
these messages, including the desired "tone of voice".
For example, one document describes it as "important to
convey confidence, reassurance" through the "tone
of voice" of the communication. Figure 5 below outlines
diagrammatically how one company identified the "need"
of prescribers and devised strategies such as "differentiate
brand X" through the use of slogans in order to provide
prescribers with the "confidence" to prescribe
their brand and to "commit customer[s] to increase brand
X prescribing from current level".
In our view all this is far from the "accurate, balanced,
fair, objective and unambiguous" communication required
by clause 7.2.
2.3 The Use of Public Relations and Building Relationships
to Counteract Negative Publicity
On public relations activity and the payment of honoraria,
the Code of Practice states:
"Companies are responsible for information about their
products which is issued by their public relations agencies."
Code of Practice, Clause 20.5
"The payment of reasonable honoraria and reimbursement
of out of pocket expenses, including travel, for speakers, is
Code of Practice, Clause 19.1
It is clear from the documents that public relations activity
forms a key and integral element of marketing activity within
the pharmaceutical industry. It emerges as a popular method of
communication to both patients and the general public (see Section
2.1) and to members of the health professions. PR activity appears
to be particularly important and relevant for countering times
of negative publicity, particularly when the safety of products
is called into question.
The pharmaceutical industry conduct "extensive media
monitoring" to identify coverage of their brands and
there are various examples within the documents of negative publicity
concerning the safety of certain brands, for example "[Publication]
calls for brand X ban". Strategies to deal with such
publicity are devised, including proactive discussion and press
releases: "discussion regarding proactive response",
"developing proactive releases and rationale",
and responding to unplanned coverage through planning exercises:
"setting the Record Straight plan", "developing
reactive statements based on Company X messages" and
utilising media contacts to monitor coverage: "initiating
an early warning system for the Lancet via media contacts".
Building long-term, sustainable relationships with various
stakeholders, including journalists, key opinion leaders (KOL)
and well respected medics and academics emerges as pivotal in
dealing with such negative publicity and when conducting PR activities
generally. These relationships are developed to influence media
"To build relationships with national journalists."
"To build advocacy with consumer press to secure a
greater share of voice."
Specifically, these relationships are leveraged to have an
impact on the coverage relating to certain brands:
"Development of a group of KOLs who will be advocates
for Brand X on varying levels through proactive and reactive media
"The media spokespeople will be advocates and prescribers
of Brand X who will be involved in issues management and with
whom all brand X data is shared."
Another interesting finding to emerge from the documents
is the payment of considerable "honorarium" for
such stakeholders to attend meetings organised by the pharmaceutical
companies. One document states "In terms of honorarium,
I can confirm that we will pay you a total of £10,000 for
four meetings plus travel expenses".
In a similar vein, relationships were also used in order
to "maximise sales of brand X in 2004". For example,
one company sought to identify "the most critical people
to influence" such as "policy making customers"
in order to "persuade these customers to endorse brand
X over other . . . brands". As emerged from Section 2.2,
explicit attempts are made to understand the "emotive
drivers of these policy making customers".
"It has been identified that a better understanding
of the rational and emotional drivers of these customers, their
attitudes and priorities would enable Company X to develop a better
approach and communication tools tailored to their specific needs."
Similar examples were found within a hospital context:
"Drive hospital endorsement and usage of brand X."
"The development of key advocates and speakers for
brand X in order that this hospital support can be taken out to
In our view this is again a long way from objective and balanced
treatment of important issues such as safety required by the code.
It is also extremely debatable that a fee of £10,000 can
be described as a "reasonable honorarium".
2.4 Disguised Marketing
The Code of Practice states that:
"Certain types, styles and methods of promotion, even
where they might be acceptable for the promotion of products other
than medicines, are unacceptable. These include: "Teaser"
advertising whereby promotional material is intended to "tease"
the recipient by eliciting interest in something which will be
following or will be available at a later date without providing
any actual information about it."
Code of Practice, Clause 9.1, 9.2
"Promotional material and activities must not be disguised."
Code of Practice, Clause 10.1
An important, and worrying, theme to emerge from the documents
is the desire of the pharmaceutical industry to strategically
"create the need" among health professionals
for new brands before their launch, while not being explicit about
the nature of their communication.
One company, for example, devised a six-staged mail-out over
a two year period to health professionals for the launch of a
new brand. The first two stages of the mail-out were solely designed
to communicate that "patients are being targeted with
[treatment] but not hitting required targets" and that
"there is a need for a more effective [treatment]".
The aim is to "establish current underachievement"
and as a "call for new treatments". At no point
in these two stages is the new brand mentioned or is product branding
used, nor is the ultimate aim of the campaignto "create
the need" for the new brandrevealed. In short,
the promotional aim is being disguised.
Only after five months is the brand finally introduced in
a further mail-out. At this point the purpose is to "establish
brand X brand values at launchefficacy, freedom"
and to "reinforce brand X efficacy and safety".
Added to this is the need to "encompass a certain degree
of education feel" in the mail-out, while the brand image
is designed to achieve "freedom and peace of mind for
all (controlled power)".
Figure 6: New brand mail-out strategy
||50% CV Brand
|Patients are being treated with [treatment] but not hitting required targets
||50% CV Brand|
|New study shows that in UK patients still not hitting target. There is a need for a more effective [treatment] to help get patients to target.
||25% CV Brand|
75% Brand X
|Brand X is the most effective [treatment] for lowering [condition] to target. It has a safety profile to all other treatments
|Months 5-14||Rep activated
||100% Brand X||Brand X is the most effective [treatment] for lowering [condition] to target. It has a safety profile to all other treatments
||100% Brand X||Brand X is a safe [treatment]
Patient volumes in the UK
|100% Brand X||Supporting campaign refinement and resulting data
||Evidence Item||Access Item
|Month 1||To establish current underachievement of treatment goals in condition
|To be advised|
|Month 2||To reinforce UK Study findings that calls for new treatments to address non titration of patients to guideline targets|
PFL published November 2002)
|Copy of article||To be advised
|Month 5||To establish Brand X Brand values at launch|
Brand X Launch March 2003)
|[clinical] Trial||To be advised
|Month 5-14||To reinforce Brand X efficacy and safety message
(Pooled data 24-26
|To be advised|
|Month 15||To reinforce Brand X is a safe [treatment] that is being prescribed widely
||[Trial] Publication||To be advised
Prescription-only medicines are promoted using a combination
of advertising, public relations, promotional and scientific meetings,
branding and the construction of long-term and mutually beneficial
relationships with key stakeholders. This activity is guided by
detailed market research along with careful segmentation and targeting.
This analysis shows that, on occasions, this marketing transgresses
the Association of the British Pharmaceutical Industry (ABPI)
Code of Practice, 2003. Specifically, despite clear rules to the
contrary, it is apparent that:
The general public and patients are seen as key
targets for marketing communication campaigns on prescription-only
medicines, and clever use is made of such phenomena as channel
and source effects and emotional drivers to maximise audience
susceptibility. These campaigns are tied in to the performance
of specific brands.
Campaigns targeting health professionals use emotional
drivers, irrational constructs and branding strategies that are
very far removed from the codes requirement for communications
to be "accurate, balanced, fair, objective and unambiguous".
Public relations and paid "key opinion
leaders" are used to counter bad publicity, especially
about product safety. Again the treatment of these issues is frequently
neither objective nor balanced.
Brand marketing is disguised and the need for
new brands is artificially created prior to launch.
These findings are especially disappointing as the Code emphasises
the need for companies to carry out their marketing "in
a responsible, ethical and professional manner" that
follows "both the spirit and letter" of the Code.
At the same time, it is apparent that the code has to tackle
some complex and ambiguous concepts. Words like "objective"
and "balanced" sit uncomfortably with marketing
efforts that are by definition partial and techniques like branding
which play on patently subjective feelings and emotions.
This suggests a need, not just for a fundamental reappraisal
of current pharmaceutical marketing, but of the code itself.
Gerard Hastings, Elinor Devlin and Susan Anderson
Although all of the figures presented in this analysis have been
taken from the pharmaceutical industry's own documents some have
been adapted slightly to ensure the findings remain anonymous. Back