Healthy Skepticism’s new AdWatch: understanding drug promotion

The quality of care delivered by doctors and our consequent incomes depend on our decision-making skills in the face of information and promotion of variable quality. However, few doctors have much training in the basic sciences for decision-making, such as logic and psychology. A database of 2178 references on drug promotion compiled by the World Health Organization provides evidence that many doctors are more vulnerable to being misled than they realise.2

Healthy Skepticism is an international organisation based in Australia that aims to improve health by reducing harm from misleading drug promotion. In October 2003, Healthy Skepticism launched AdWatch, a monthly webpage that explains the techniques used in drug advertisements.3 The story of Healthy Skepticism’s predecessor, MaLAM (the Medical Lobby for Appropriate Marketing), was told in the 1997 Christmas issue of the Journal.4 This update describes the ideas behind the transition from MaLAM to Healthy Skepticism and the launch of AdWatch.

In the 1980s, open letters from MaLAM achieved improvements in advertising and some drugs were withdrawn.5 During the 1990s, there were fewer obviously inappropriate drugs to target. Although many serious problems with misleading promotion persist,6 they are more subtle and thus less amenable to open-letter campaigns. To understand these problems better, we developed a stronger multidisciplinary team with expertise in medicine, marketing, psychology, pharmacy, pharmacology, statistics and logic.7

We were inspired to change our name to Healthy Skepticism by a 1963 speech from drug advertising executive Pierre Garai.8 Garai urged doctors to stop blaming drug companies for misleading drug promotion and argued that the quality of drug promotion depends on the quality of medical decision-making; “. . . indeed, [if] candor, accuracy, scientific completeness, and a permanent ban on cartoons came to be essential for the successful promotion of [prescription] drugs, advertising would have no choice but to comply”. Garai challenged doctors to accept responsibility for improving their decision-making and to develop healthy scepticism.

We accept that effective promotion is a mirror to our souls, reflecting how we really make decisions. The image it reveals differs from what we would prefer to believe about ourselves. However, accepting our human limitations is the best first step towards improved medical care. Consequently, we accept Garai’s challenge, but we feel that blaming the targets of promotion for human vulnerability to promotional techniques is not helpful. Many techniques have been effective in fooling many of the people much of the time for centuries;9 others are products of recent sophisticated research on ways to increase sales.10,11 We prefer to focus on changing the current system in which misleading promotion leads to inappropriate prescribing and higher profits for drug companies, thus funding more misleading promotion. This vicious cycle harms patients and may reduce incomes for doctors and drug companies in the long run.

There were two schools of extreme scepticism in ancient Greece. The Pyrrhonian Sceptics suspended judgement on all claims, including the Academic Sceptics’ claim that nothing could be known for certain. Moderate healthy scepticism started with the 16th century theologian Castellio, who advocated accepting reasonable beliefs rather than aiming for certainty.12

In the 1990s, a US business academic developed a questionnaire for measuring scepticism.13 She characterised sceptics as slow to accept claims or form judgements, but keen to ask questions in pursuit of knowledge and understanding, and found that sceptical auditors were more effective and efficient at detecting problems in company accounts.

Thus, healthy scepticism involves selectively accepting claims that are justified by good evidence or argument, while resisting those that are not.

From Aristotle onward, logicians have observed many types of misleading arguments, which are now called fallacies.9 Psychologists have studied similar concepts, calling them heuristics, biases and influence techniques.14,15 We prefer the term shortcuts. These are quick and easy processes for reaching conclusions that are correct only when common assumptions are justified. For example, “newer is better” is usually a reliable shortcut for choosing the best vegetables or computers, but often unreliable when choosing drugs. It is common to assume that most new drugs are superior, but only about 3% of new drugs offer real advances.16 It is normal to use shortcuts when faced with inadequate time, skills or resources to examine the evidence fully, or when the evidence required is not available. Some common shortcuts are listed in the Box.

Drug companies are skilled at influencing prescribing by triggering the shortcuts that doctors rely on. For example, the “experts know best” shortcut underpins company-funded education. Drug companies also carefully choose visual and verbal images that appeal to our normal desires for power, respect, wealth, speed, simplicity, security and sex.10

There is evidence that advertising can be effective at influencing behaviour despite being given little attention.11 Subtle messages that might be rejected if carefully considered can sneak “under the radar” to create links between the indication, the product and the motivation. Repetition strengthens these links so that the product moves up the mental agenda to be the first to come to mind during decision-making.

Promotional techniques are tools for good or ill depending on how they are used and what they are used for. Shortcuts often lead to correct conclusions, and desires can be appropriate. It is not possible to advance good causes without using promotion. To be successful at advancing the aims of Healthy Skepticism, we have to use the same techniques that we want people to be more sceptical about. However, we aim to use promotion honestly. This article uses all the shortcuts listed in the Box and appeals to most of the desires listed above.

Healthy scepticism is difficult to promote because most people are confident that they already have an optimal amount. It is common to believe that only other people are susceptible to being misled. Dispelling this illusion of unique invulnerability is the key to improving discrimination between misleading and justified claims.15 One effective method for dispelling this illusion is to mislead people and then show them how they have been deceived. In one study, hospital pharmacists used the techniques of drug company representatives to mislead medical students and then explained the techniques.17 After the intervention, the students were less certain about the value of interactions with drug company representatives.

We hope AdWatch will produce similar benefits by explaining the logical, psychological and pharmacological techniques used in drug advertisements. We will also use feedback from visitors to the AdWatch section of the Healthy Skepticism website (www.healthyskepticism.org/adwatch.asp) for dialogue with the companies responsible for the advertisements, the Medicines Australia Code of Conduct Committee and the government regulatory agencies.

We have started with advertisements targeting Australian general practitioners but hope to develop editions for specialists and for other countries. Initial feedback to AdWatch from general practitioners, specialists, pharmacists and members of the public worldwide has been positive. An Australian doctor commented: “Unfortunately [the advertisement] had me sucked in for a period, but no longer.”