Earlier this year, two industry-sponsored advertising campaigns for cholesterol awareness that target the general public were launched in Australia.
These campaigns aimed to alert the public to the risks associated with having high cholesterol and encouraged cholesterol testing for wider groups than those specified by the National Heart Foundation.
General practitioners should be aware of the potential for the two campaigns to confuse the general public as to who should be tested, and where.
The campaign sponsors (Unilever Australasia and Pfizer) each have the potential to benefit by increased market share for their products, and increased profits.
These disease awareness campaigns are examples of what is increasingly being termed “condition branding” by pharmaceutical marketing experts.
Earlier this year, general practitioners were informed about two new campaigns to inform the Australian public about cholesterol: “Test the Nation”, sponsored by Unilever Australasia, and the “National Cholesterol Awareness Campaign”, sponsored by Pfizer.
The Unilever campaign was identified as a “national cholesterol education campaign”1 and was held in conjunction with the National Cholesterol Education Program of Australia (NCEPA), also funded by Unilever.2 Unilever Australasia manufactures Flora pro-activ, a margarine spread containing plant sterols that have been found to reduce cholesterol absorption.
Unilever’s sponsorship of the campaign was evident by the branding of both the campaign flyer3 and the website (http://www.testthenation.com.au)4 with the Flora pro-activ logo. Also involved, according to the NCEPA website, were program partners the Commonwealth Scientific and Industrial Research Organisation (CSIRO), the Australian Atherosclerosis Society, the Royal Australian College of General Practitioners, and the Dietitians Association of Australia.2
According to a letter sent to GPs prior to the campaign by Megan Cobcroft, Unilever’s Corporate Nutritionist, Australian adults would be given the opportunity to receive a free heart-risk assessment and total cholesterol-level check at testing sites located near major supermarkets nationally for a 1-week period in April 2008. The letter stated that those found to have elevated blood cholesterol levels or other risk factors for heart disease would be advised to consult their health care professional.
The campaign name Test the Nation, while informing the public of its intended action (getting cholesterol levels tested), implies that the entire nation needs to be tested. No target group for testing was identified on the campaign brochure or website.3,4 However, in an article published in The Australian, David Sullivan, President of the Australian Atherosclerosis Society, was quoted as saying that “the aim of the campaign was to encourage people over 45, and all adults whose families had a history of early heart disease, to see their GP for a cholesterol test”.1
This creates two obvious points of confusion for the general public. First, are they being encouraged to make use of the testing facilities provided by Unilever, or should they see their GP — or both? Second, if adults over 45 and those with a family history are the target group, why is the campaign called Test the Nation? This has potentially serious ramifications, in that people outside of the target group could present for unnecessary testing, potentially at the expense of the government rather than Unilever.
Another issue with the campaign is that the information about cholesterol and its management, as well as the testing facilities, are provided by a for-profit company that manufactures a product that reduces cholesterol absorption (Flora pro-activ). For this company, the more people found to have high cholesterol levels, the larger the market potential for their product.
This campaign also demonstrates the growing “wellbeing” movement in food and drink manufacturing, where products are marketed as “nutraceuticals” because they contain compounds with purported medicinal effect. Had this been a disease awareness campaign sponsored by a pharmaceutical company that manufactures prescription cholesterol-lowering medicine, the company would have been prevented from using the name of its product by the Therapeutic Goods Advertising Code 2007, under the Therapeutic Goods Act 1989 (Cwlth).5
In March 2008, Pfizer notified GPs via full-page advertisements in Medical Observer and Australian Doctor of the launch of the National Cholesterol Awareness Campaign, including television and newspaper advertisements and a website.6 The Pfizer campaign is also being conducted in conjunction with the Australian Atherosclerosis Society, through its Familial Hypercholesterolaemia Sub-Committee, which was established to help people with inherited cholesterol disorders.7
The campaign website (http://www.cholesteroltest.com.au) features an attractive woman standing in a spotlight, who presents some alarming statistics about cholesterol, heart attacks and stroke.6 The website repeatedly refers to research that has found that one in two Australians over 25 years of age have cholesterol levels of 5.5 mmol/L or higher. One of the website pages, titled “How do I know if I have high cholesterol?”, contains a section discussing who should talk to their doctor about having a cholesterol test. This section states that “High cholesterol can affect anyone [sic] of us, even those who are relatively young and look and feel fit”.6 It also states that it is particularly important for people with other health issues (including smoking, overweight, high blood pressure, and diabetes, among others) to talk with their doctor. However, subsequent pages within the website refer to the National Heart Foundation guidelines that recommend cholesterol screening for adults 45 years and older.6
Hyperlipidaemia is generally an asymptomatic condition. It is considered important because it can contribute to the risk of future cardiovascular disease (CVD), particularly if there are other risk factors present.8 In the National Heart Foundation’s Lipid management guidelines 20019 and Position statement on lipid management — 2005,8 cholesterol screening is only recommended for adults less than 45 years old if they are at risk of a CVD event due to other risk factors. The groups at higher absolute risk of a CVD event, according to the 2005 position statement, are those shown in the Box.
The National Heart Foundation’s guidelines are endorsed by the Cardiac Society of Australia and New Zealand and are generally recognised as the “gold standard”, as they summarise current evidence from clinical trials and encourage best clinical practice for practitioners, as well as consistency of care, in an effort to prevent coronary heart disease.9 Practitioners can refer to these guidelines before making a decision on whether their patients require cholesterol screening, and they may also wish to consult the Australian Government’s General statement for lipid-lowering drugs prescribed as pharmaceutical benefits.10
In considering Pfizer’s campaign and its statements regarding who is at risk of high cholesterol and who should be tested, it must be considered that this multinational company manufactures a prescription drug (atorvastatin) designed to treat high cholesterol. Pfizer’s campaign is an example of what is increasingly being termed “condition branding” among pharmaceutical marketing specialists. Parry describes condition branding as useful in increasing prescriptions (and profits) for pharmaceutical manufacturers because “if you can define a particular condition and its associated symptoms in the minds of physicians and patients, you can also predicate the best treatment for that condition”.11
Others have described how condition branding can increase profits and brand share for pharmaceutical products — especially when the company already has a large share of the market for that condition.12 Interestingly, Pfizer report that they make the most-prescribed cholesterol-lowering medication in the world;13 it was also the most-prescribed medicine dispensed by Australian community pharmacies in 2002.14
Consumer groups have voiced concern about the potential for industry-sponsored disease awareness advertising and condition branding to exaggerate the risk or prevalence of a condition, which may result in increased community fear and anxiety and unnecessary visits to doctors.15 These marketing practices have also been criticised as “disease mongering”, where the industry promotes disease via the mass media in order to expand markets for pharmaceutical products.16
A recent example of a disease awareness campaign — albeit for a very different health issue — occurred in the Netherlands, where a Novartis-sponsored campaign created awareness and heightened the importance of onychomycosis. A study found that, as a result of the campaign, prescription rates for terbinafine (to treat onychomycosis) made by Novartis and onychomycosis-related consultations increased, while prescriptions for the competitor product decreased. The study authors were critical of the campaign and its impact on the workload of doctors, and described how the Dutch Society of General Practitioners opposed the campaign as “an unnecessary focus on an unimportant health problem”,17 potentially at the expense of more important health issues.
The Unilever and Pfizer cholesterol awareness campaigns do have some potential benefit for public health, but also some potential for creating considerable public confusion over who should have their cholesterol levels tested. This in turn may cause unnecessary public anxiety about cholesterol and unnecessary visits to Australia’s already pressured GPs. With their focus predominantly on cholesterol levels, these campaigns also potentially underplay broader issues in CVD causation. While it will be difficult to determine the longer-term educational effects on consumers, it will be interesting to see how sales of Flora pro-activ and prescriptions for atorvastatin fare as a result of these campaigns.
National Heart Foundation guidelines — groups at higher absolute risk of a cardiovascular disease (CVD) event8
Those with clinical evidence of:
Aboriginal and Torres Strait Islander peoples
Those with an absolute risk of ≥ 15% risk of a CVD event in the next 5 years using the 1991 Framingham equation (eg, New Zealand CVD absolute risk calculator)
Those with an absolute risk of 10%–15% of a CVD event in the next 5 years when any of the following is present:
Comment: Elevated blood cholesterol is one of several important risk factors for cardiovascular disease. The mean blood cholesterol concentration in the Australian adult population is high compared with other countries1 and is responsible for almost 12% of all Australian deaths.2 Recognition of the importance of lowering the mean blood cholesterol level in the population has shaped the recommendations for saturated and polyunsaturated fats in the Dietary guidelines for Australian adults.3 However, the mean blood cholesterol level in Australian adults remains the same as it was when first assessed nationally in 1980,4,5 suggesting that the importance of lowering cholesterol is underestimated by the general public, or the dietary means of achieving it is poorly understood or implemented.
Food manufacturer Unilever is a supplier of plant sterol-enriched foods, which have been clinically shown to reduce low-density lipoprotein cholesterol levels in the order of 10%.6 Plant sterols have been approved for addition to certain foods under the Australia New Zealand Food Standards Code. The advent of plant sterol-enriched foods has effectively doubled the potential of diet to lower blood cholesterol levels.7
Unilever is committed to helping lower the mean blood cholesterol level of Australian adults, and so initiated and supports the National Cholesterol Education Program of Australia. This is a coalition of independent, respected health care organisations with a common goal to raise awareness of cholesterol and its management through diet and lifestyle. The program was developed in consultation with lipid experts, general practitioners and accredited practising dietitians. The response to the program has been so positive that reprinting of educational material has been required to meet requests from practitioners for their patients.
Separately, Unilever undertook a specific cholesterol awareness campaign, “Flora pro-activ Test the Nation”, during April 2008, offering Australian adults a free cardiovascular disease-risk screen, including a finger-prick test for total cholesterol level, at over 300 locations around the country. More than 64 000 people were screened. Participants received comprehensive, evidence-based information on dietary and lifestyle measures to help manage cholesterol and promote overall heart health, and were encouraged to monitor their cholesterol and heart health with their GP.
Referral of participants to GPs was an integral component of the program, as GPs are best placed to consider patients’ true risk of cardiovascular disease in the context of their overall health and medical history.
At a time of increased national focus on preventive health, it is incumbent upon all parties to play their part in reducing modifiable risk factors for cardiovascular disease — the nation’s leading cause of premature death.
Comment: Pfizer Australia’s cholesterol campaign aims to raise people’s awareness of high cholesterol and its links with cardiovascular disease, and to encourage Australians who may have high cholesterol to talk to their doctor.
The campaign’s statement that “one in two Australians over 25 have high cholesterol” is based on published data from the Australian Institute of Health and Welfare,1 and, far from being alarmist, highlights an important public health issue.
High cholesterol is an important modifiable risk factor for cardiovascular disease, which is the leading cause of death in Australia.2 As such, comparison with the Novartis-sponsored campaign highlighting onychomycosis — an “unimportant health problem” — is inappropriate.
In developing the campaign, we have taken particular care to ensure our messages are aligned with national recommendations. The visual representation of seemingly fit middle-aged people underscores statements made by the Royal Australian College of General Practitioners that there are no obvious physical features or symptoms of high cholesterol; only a test can diagnose high cholesterol.3
Hall expresses concern that our campaign might generate public anxiety and confusion over who should be tested. The only recommendation made throughout the campaign is for people to speak with their doctor about a cholesterol test. The decision to test is left to the doctor as part of an overall cardiovascular risk assessment.
Hall’s view that the campaign “may cause unnecessary public anxiety about cholesterol and unnecessary visits to Australia’s already pressured GPs” is unfounded. The “silent” nature of high cholesterol suggests that such GP visits could identify a previously undiagnosed patient with dyslipidaemia who is at risk of cardiovascular disease. Additionally, National Heart Foundation guidelines have identified a treatment gap caused by, among other reasons, patients not visiting doctors.4
It is also important to clarify that the prescribing of statins is governed by the Pharmaceutical Benefits Scheme (PBS), which is based on rigorous cost-effectiveness evaluations.5 This ensures that GPs only prescribe statins to eligible patients who meet the criteria outlined in the PBS.
Pfizer Australia is committed to the quality use of medicines and the appropriate management of cardiovascular risk in patients. Our consumer awareness materials discuss the need for patients to modify their diet and undertake an exercise regimen before being prescribed lipid-lowering medicines.
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