Framing Analysis of Pfizer's Strategies to Manage Public Policy Issues Regarding Direct-to-Consumer Advertising

by

Jin Seong Park, B.A.

A Thesis submitted to the Faculty of the Graduate School, Marquette University, in Partial Fulfillment of the Requirements for the Degree of Master of Arts

Milwaukee, Wisconsin

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Preface

Working as a research assistant for Dr. Jean Grow at

Marquette University, I had an opportunity to investigate how pharmaceutical companies promote anti-depressants.

Through an in-depth analysis of direct-to-consumer advertising for anti-depressants, Dr . Grow and I tried to reveal what messages the pharmaceutical industry conveys to the public regarding health, mental illness, and recovery in society.

Reviewing the literature for the project, I received the unmistakable impression that while pharmaceutical companies promote their drugs directly to the public through advertising campaigns, at the same time the industry launches another layer of campaigns with the aim of making DTC advertising appear more acceptable to the public and therefore creating a favorable marketing environment. This inspiration also fits the perspective that today's marketing communications are being heavily integrated in order to make them support each other. With this train of insights, I planned a study to explore what messages the pharmaceutical industry conveys to the public through their public relations documents about health, disease, and society while it attempts to support

DTC advertising. iii

This study attempts to investigate the persuasive strategies that Pfizer is using to frame the issues regarding public policy over DTC advertising in its favor and therefore create' a favorable marketing environment.

Under the assumption that the company's framing strategies will emerge throughout their public relations documents, news releases and other public relations materials that directly address the issue of DTC advertising were collected from Pfizer's main web site.

Through an in-depth, qualitative frame analysis of the collected documents, this project reveals how the company tries to frame the public policy debate over DTC advertising. The study also investigates how Pfizer also frames the overarching concept of who the company is, thus setting the tone to a controlled public discourse.

The results indicate that Pfizer's public relations materials have the potential to lead consumers to approach the issue of DTC advertising through a number of

Pfizer-initiated perspectives, encapsulated by the following four frames: DTC advertising is information, passive patients vs. empowered consumers, maximum benefits & minimum risks, and no proven economic effects upon drug expenditure. Through these four frames, Pfizer ultimately conveys the fundamental message that DTC advertising benefits society. One can understand the message as reflecting both the company's IMC initiative iv to create a favorable marketing environment and Pfizer's willingness to fulfill its own sense of good corporate citizenship as a leader in the pharmaceutical industry.

I The findings of this project will have significance for society for a number of reasons. First, the project will help enrich the social discourses on OTe advertising, because it deals with a potentially significant topic of which scholarly discourses have lost sight. Second, understanding Pfizer's framing strategies to promote OTC advertising will help public relations practitioners to judge if the company uses sound and valid argumentation to represent and support its policy position. Most importantly, for consumers, understanding Pfizer's strategies to frame OTC advert-ising will lead them to distance themselves from the pharmaceutical industry's persuasive messages to contemplate the messages' implications for public health. v

Acknowledgements

This thesis is a collaborative work for a number of reasons. First, a considerable portion of this project is grounded in the works that I completed for the classes that I have taken at Marquette. Interaction with my class instructors and colleagues through numerous occasions has been a great source of inspiration and advice. These people include, but are not limited to, Dr. Lawrence

Soley, Dr. Joyce Wolburg, Dr. Steve Goldzwig, Robert

Griffin, Dr. Ana Garner, and Dr. Karen Slattery.

Second, the thesis committee members, Dr. Jean Grow,

Dr. Ana Garner, and Dr. Daradirek "Gee" Ekachai, have been more co-workers than supervisors throughout the process of completing the thesis, because they actively participated in conceptualizing the research design, constructing research questions, etc. Without their critical and helpful comments, this thesis would be much different. In addition, when I suffered from lethargy and sagging motivation, the committee members showed their vi patience to wait for me to regain my morale. I cannot appreciate their understanding, patience, and tolerance enough.

Third, I especially thank Dr. Jean Grow and Dr. Ana

Garner for their listening to me when I needed them most.

Throughout the two years at Marquette, I visited their office whenever I felt like sharing my personal problems, creative ideas, and pure curiosity. Their sincere and genuinely open-minded attitudes made my days at Marquette much more meaningful and productive. Interacting with them, I could internalize how to generate new ideas and turn them into meaningful research projects.

Last but not the least, I especially thank my best friend and life partner Jeong Ei Park for being with me for the past one year. Since I met her an year ago, she has stayed with me and tried to listen to my innermost voice in the most difficult times. A shy and easily depressed person, I cannot imagine how I could have completed the master's program at Marquette with this kind of success, if it had not been for her staying with vii me.

I thank all of these people for what I am today and what I could achieve at Marquette. viii

Table of Contents

PREFACE ii

ACKOWLEDGEMENTS v

CHAPTER 1: INTRODUCTION 1

CHAPTER 2: THE LITERATURE ON DTC ADVERTISING 13 Policy & Regulatory Issues 15 Public Reaction Issues 19 Content Issues 23 Social Impact Issues 1 27 Social Impact Issues 2 31 Limitations With the Literature 32 Lack of Theory-Guided Models 33 Focus on a Narrow Range of Variables 35 One-Dimensional Conceptual Model of Impact 37

CHAPTER 3: METHOD 44 Data 44 Frame Analysis 52 Frame Analysis in Journalism Research 53 Frame Analysis in Public Relations Research 55 Strengths & Weaknesses of Frame Analysis 59 Application to the Current Study 60 Analytic Procedure 63

CHAPTER 4: RESULTS 67 Frame 1: Advertising is Information 69 Frame 2: Passive Patients vs. Empowered 73 Consumers Frame 3: Maximum Benefits vs. Minimum Risks 78 Frame 4: No Proven Economic Impact 82 The Overall Frame 86

CHAPTER 5: CONCLUSION & DISCUSSION 90 Suggestions for Future Research 103

BIBLIOGRAPHY 107 1

Chapter l:Introduction

Advertising prescription drugs directly to consumers

(DTC advertising) has been around for decades. For example, the first American advertisement of prescription drugs directly targeted to consumers appeared in Reader's Digest in 1981. The subsequent years witnessed a slow increase in

DTC advertising until the mid-1990s, when the new type of marketing rapidly became popular (Pine, 1999).

Since the recent growth in DTC advertising, the public has become interested in the potential role DTt advertising plays in contemporary society. However, relatively little is known about DTC advertising's effects on public health. To this effect, Roth (2003) states, "two things are well known about direct-to-consumer (DTC) advertising of prescription drugs--annual expenditures keep going up and the debate over the merits and effectiveness of DTC drug advertising continues" (p. 180).

Even though critics have not generally agreed upon DTC advertising's social impact, "the pharmaceutical industry, other private and public sectors have continued to issue opinions" (Allison-Ottey, Ruffin, Allison, & Ottey, 2003, p ~

120). In today's integrated marketing communications (IMC), all channels of communication are systematically mobilized 2

to promote products and create a favorable marketing environment as well. In this context, pharmaceutical marketing professiona+s can consider governmental regulations and the public's perception of OTe advertising as an important factor in the pharmaceutical industry's business environment. The following statement by Pfizer attests to this point:

"Every day, state and federal governments make decisions that affect Pfizer and our business operations. Patent restrictions, importation, ant~DTC and marketing regulations, supplemEntal rebates, and preferred drug lists are just a few examples of the challenges that we are facing (Our Voice, 2004).

The above statement leads one to assume that pharmaceutical companies might feel the need to frame the public debate over OTe advertising in favor of their business interests.

Based upon the above assumption, this thesis explores the strategies that Pfizer, a pharmaceutical company with the second largest expenditure on OTe advertising, uses to frame the social debate over OTe advertising. To achieve this overall research purpose, public relations materials in which Pfizer directly expresses its polity position upon the new marketing practice will be collected. Frame analysis will be employed to analyze the strategies Pfizer uses to spin the public debate over OTe advertising.

OTe advertising refers to "any advertisement developed by the pharmaceutical industry including radio, print, and/or television of prescription medication that targets 3

the consumers/patients" (Allison-Ottey et. aI, 2003, p. 121).

Regarding potential contributors to the rise of DTC advertising, some allyde to the possibility that the Food and Drug Administration (FDA)'s 1997 provision of the draft

Guideline for Industry and the 1999 final Guidance were major driving forces (Calfee, 2002; Kravitz & Wilkes, 2000;

Wechsler, 1999). However, commentators seem to consider the proliferation of managed care organizations and the resulting erosion of physicians' authority to prescribe drugs (represented by the term "preferred drug lists") as the leading propeller of DTC advertising's rapid growth

(Bell, Kravitz, & Wilkes, 1999; Kravitz, 2000; Matthews,

2001; Morris & Griffin, 1992; Pinto, Pinto, & Barber, 1998;

Terzian, 1999).

The FDA, a government agency charged with regulating the promotion of prescription drugs, initially expressed the position that the new advertising practice is not inherently in violation of FDA regulations. Nevertheless, in September

1982, the FDA initiated a moratorium on DTC advertising, because it became worried about DTC advertising's potential adverse influences on the public (Calfee, 2002). In 1985, however, the FDA lifted the moratorium because of concerns about freedom of speech, regardless of its previous position that DTC advertising is not necessarily in the public interest. 4

Reflecting the consensus at that time, it was thought that regulations already in place to monitor doctor-targeted advertising were sufficient to protect the public. The FDA required that DTC advertising meet the same standards as those applied to advertising aimed at doctors (FDA, 1985).

Specifically, the FDA required that the content of DTC advertising include a "brief summary" of risk information for print executions, a "major statement" of risks, and

"adequate provision" for viewers to obtain full FDA-approved prescribing information. The above requirements were potential constraints on the growth of the new marketing practice. However, DTC advertising expenditure gradually increased from $12 million in 1989 through $55 million in

1991 and $579 million in 1996 (Nordenberg, 1998; Pines,

1999) to $2.4 billion in 2000 (Rosenthal, Ernst, Berndt,

Donohue, Frank, & Epstein, 2002).

The overall increase in expenditure on DTC advertising becomes more salient when compared with expenditure on pharmaceutical advertising in medical journals, which had been the main advertising venue before DTC advertising came.

In 1999, the pharmaceutical industry spent four times as much on DTC advertising compared to its spending on medical journal advertising. In 2000, the ratio increased to five to one (Rosenthal, et. al., 2002; Woloshin, Schwartz, Tremmel,

& Welch, 2001). DTC advertising still does not constitute a 5

major share in the pharmaceutical industry's total expenditure for promotion (Rosenthal, et. al., 2002).

However, the shift of , weight between the two advertising venues illustrates the importance the pharmaceutical industry increasingly puts on the new marketing channel.

The idea of promoting prescription drugs directly to consumers is a cause for concern, driven by the fact that the product category is directly related to public health.

Regarding DTC advertising's social impact and regulatory issues, critics' positions are largely polarized into the following two groups: those who view it as socially beneficial and propose that FDA should relax its current regulation; and those who attend to its potential harm on the public and press for more intense regulation by the government agency.

The polarization of opinion among critics reflects the highly sensitive nature of the new marketing development, i.e., promoting directly to consumers a product category with impact, actual or potential, on public health. Since the beginning of the new marketing practice in the mid-1980s, and especially with DTC advertising's rapid growth in the late 1990s, politicians, academics, and physicians have incessantly expressed concerns about DTC advertising's potential adverse influences on public health. 6

Some physicians, for example, have attacked DTC advertising because they believe information provided in DTC advertising is unbalaqced about benefits and risks of the drug and therefore could mislead the public. They suggest that it leads patients to push doctors into prescribing the drugs they want. Further, it increases drug prices and expenditure; and it medicalizes common life problems and encourages drug use over other effective treatment options

(Bell, Wilkes, & Kravitz, 2000; Coney, 2002 ; Davis, 2000 ;

Hoffman, 1999; Hollon, 1999; Kessler, Rose, Temple, Schapiro,

& Griffin, 1994; Kravitz, 2000 ; Kravitz & Wilkes, 2000;

Woloshin, Schwartz, Tremme l, & Welch, 2001).

The criticism that DTC advertising increases drug prices and expenditure and therefore presents a bigger economic burden t o the public has become a political issue.

For example, in the race for the 2004 Democratic presidential nomination, candidate Howard Dean called for a ban on DTC advertising as an element of his six-point plan to reduce prescription drug costs. Two other candidates,

Richard Gephardt and John Edwards, expressed similar, though less harsh, criticisms (Teinowitz , 2003).

Anecdotal accounts suggest that there have been attempts from the pharmaceutical industry and advertising and public relations interest groups to defuse public concerns about DTC advertising's potential adverse effects 7

upon public health. For example, Pfizer admits that it considers "anti-OTC and marketing regulations," along with patent restrictions i~portation and preferred drugs lists, as an example of "the challenges that the company is facing

" ... because federal and state legislation and regulation directly impact the financial well being of our company"

(Our Voice, 2004). When candidate Howard Dean's pledge to ban OTC advertising received media coverage, Dan Jaffe, executive vice president of the Association for National

Advertisers, called the candidate's plan "a prescription for disaster" and argued that:

there is compelling evidence that this advertising often provides consumers [with] extremely valuable in~rmation that can save lives, often avoids seriou s health problems and in so doing often lowers health costs (Teinowitz, 2003, p. 1).

In the same vein, at the 2003 annual OTC National Conference,

keynote speaker Pat Kelly, president of U.S. pharmaceuticals at Pfizer, "challenged marketers to make OTC represent more than mere advertising and ... proposed changing the acronym to

HIFC or Health Information for Consumers" (Tosh, 2003, p. 8).

The above anecdotal accounts illustrate Pfizer's public relations efforts to address the public policy issue concerning OTC advertising. This series of attempts comes as no surprise, because professionals and executives in the pharmaceutical industry increasingly point out that public

relations must be strategically integrated into the 8

decision-making process, "more aligned with long-term business objectives, and able to meet the new challenges of a highly regulated ... health care marketplace" (Schreiber,

1997, p. 338). This approach is an extension of the principle of I MC advertising. Given the controversy over DTC advertising, it is not surprising that pharmaceutical companies continue to fight back to defuse criticisms and create a favorable market environment through a variety of marketing communications. Without question, an important part of the overall marketing communications objective is to add an alternative vision of DTC advertising to the nation­ wide debate and mo ld public perception and government policy regarding DTC advertising.

The current literature on DTC advertising focuses only on the new marketing practice's short-term impact on public health and the way the public responds to it. Specifically, the current research, mostly based upon quantitative methods, focuses upon a limited range of variables such as consumer attitudes, recall, recognition, and certain behavioral concepts such as compliance with the regiment. Research that conceptualizes DTC advertising as an integral part of the complex persuasion network employed by the pharmaceutical industry is missing from the current literature. The dearth of such research runs against the current marketing environment , in which the distinction between advertising 9

and public relations is being increasingly blurred.

Accordingly, the current literature largely ignores the pharmaceutical in~ustry's efforts to influence public policy over DTC advertising. However, this ignored research area has a few significant social implications. First, the pharmaceutical industry and public relations professionals can have an opportunity to evaluate their issues management approaches in terms of ethics as well as effectiveness.

Second, and more importantly, it is also a significant topic for the public, because it deals with a marketing practice with potential effects upon public health. Marketing communications that directly address public health but target consumers with allegedly limited ability to understand medical information can potentially have adverse consequences. Furthermore, one may reasonably assume that in their attempt to influence national controversy over DTC advertising, pharmaceutical companies are conveying, with long-term cultural ramifications for society, more fundamental messages about health, disease, and recovery in people's lives.

Because of the significant potential consequences of

DTC advertising, this study touches upon the above uncharted area of research. Particularly, it will explore how Pfizer frames the social debate over DTC advertising. Of all the

companies in the pharmaceutical industry, Pfizer is chosen 10

for a number of reasons. First, the company's expenditure on

DTC advertising is the second biggest in the industry, closely following Gla ~ oSmithKline (Branch, 2 003). Second,

Pfizer excels over other companies in producing drugs with the strongest sales records. Pfizer produces 3 of the 10 DTC promoted drugs with the strongest sales records (Anonymous,

2003). This point roughly indicates the considerable vested interests that Pfizer has in maintaining a favorable marketing environment for DTC advertising. Finally, Pfizer is the only company that most openly and continuously expresses their position over the issue of DTC advertising.

More specifically, only Pfizer makes available various public relations materials to support its position on the issue through its web site.

Specifically, this project addresses the following t wo research questions.

RQ 1: What frames does Pfizer1 use to spin the

public policy controversy over DTC

advertising in favor of its business

1 This study originally attempted to collect data from ten leading pharmaceutical companies with heaviest expenditures on DTA advertising. Interestingly, however, of the ten companies, only Pfizer, with its second biggest expenditure on DTC advertising in the industry (Branch, 2003), had public relations materials that directly deal with public policy issues over DTC advertising. Therefore, this project changed from its original plan to discussing Pfizer's rhetorical strategies of issues management, rather than those of the enti re industry. 11

interests?

RQ 2: What is the overarching message of DTC

advertising ,that Pfizer promotes through

the frames?

In short, this study attempts to investigate the persuasive strategies that Pfizer is using to frame the issues regarding public policy over DTC advertising in its favor and therefore create a favorable marketing environment.

To achieve this overall research purpose, news releases and other public relations materials such as policy reports and research papers that directly address the issue of DTC advertising will be collected from Pfizer's main web page. If the company intends to persuade the public to accept its policy position, one has good reason to believe that the company's framing strategies will emerge throughout the collected public relations materials, because such materials are official documents that Pfizer makes public to consumers.

The findings of this project will have significance for society for a number of reasons. First, the project will help enrich the social discourses on DTC advertising, because it deals with a potentially significant topic of which scholarly discourses have lost sight. Second, understanding Pfizer's framing strategies to promote DTC advertising will help public relations practitioners to 12

judge if the company uses sound and valid argumentation to represent and support its policy position. Most importantly, for consumers, unders~anding Pfizer's strategies to frame

DTC advertising will lead them to distance themselves from the pharmaceutical industry's persuasive messages to contemplate the messages' implications for public health. 13

Chapter 2: The Literature on DTC Advertising

There is a large body of literature on OTe advertising.

However, the current literature focuses on OTe advertising's short-term impact upon public health and the public's response to it. As stated earlier, regarding OTe advertising's social impact and regulatory issues, critics' positions are largely polarized into the following two groups: those who attend to its potential harm on the public and argue for more intensified regulation by the FDA; and those who view it as socially beneficial and propose that the FDA should relax its current regulation.

Although general positions on policy and social issues are largely polarized, a literature review reveals that the overall controversy is harder to grasp than one might expect.

Discourses on DTe advertising are multifaceted, with a wide range of topics entangled within each other. This point will surface when one looks through the titles of academic periodicals that publish articles on the controversy. These periodicals include the medical journals (New England

Journal of Medicine and Journal of American Medical

Association), communication and marketing periodicals

(Journal of Health Communication and Journal of Advertising

Research), public policy-related journal (Journal of Public 14

Policy & Marketing), and law-related periodical (American

Journal of Law & Medicine and Defense Counsel Journal). The range of the listed p~riodicals roughly indicates the highly controversial nature of the idea of promoting prescription drugs directly to consumers.

Currently, New Zealand and the United States are the only two economically advanced nations that permit OTC advertising (Coney, 2002; Hoek & Genda1l, 2002). However, the controversy has transcended the boundaries of these two countries. It is now arising on the social agenda of the

European Union and Canada (Meek, 2001; Mintzes, Barer,

Kravitz, Kazanjian, Bassett, Lexchin, Evans, Pan, & Marion,

2002). Anecdotal accounts suggest that the rise has to do with the transnational pharmaceutical industry's pushing for changes to rules that prevent OTC advertising in Europe

(Jaderberg, 2002; Medawar, 2002).

The literature review reveals that OTC controversy centers upon the following foci of concerns: policy and regulatory issues; the content of OTC advertising; public reaction; influences upon medical decision making and public health; and OTC advertising' economic impact. 15

Po~icy and Regu~ato~ Issues

The 1962 amendments to the Food, Drug, and Cosmetic

Act (FDCA) autho rize the FDA to regulate the development, distribution, and promotion of pharmaceutical products

(Calfee, 2002) . Withdrawing the moratorium on DTC advertising in 1985, FDA "announced that it would apply the same standards to DTC advertisements as those in place for advertisements directed to physicians, which must meet the standards for fair balance and full disclosure" (Terzian,

1999, p. 152). More specifically, FDCA required print executions of DTC advertising to include a "bri ef summary" of risk information and broadcast executions to provide a much shorter "major statement" o f risks and make "adequate provision for viewers to obtain full FDA-approved prescribing information. Pharmaceutical companies found it impossible for broadcast advertising to satisfy the conditions (Calfee, 2002).

Responding to the pharmaceutical industry's increasing complaints, the FDA released the 1997 draft Industry

Guideline and its final version in 1999. The final Guideline did not change the basic regulatory framework of 1962 amendments. Instea d, the Guideline clarified them and made it easier for broadcast DTC advertising to meet the requirements the FDCA stipulated. Specifically, the 16

Guideline stipulates that broadcast DTC advertising should include: a toll-free number to contact the company; a reference to its corr~sponding print executions; an Internet web page address of the company; and a statement that directs consumers to physicians for those who plan to seek additional information about the product (Terzian, 1999, p.

150) .

DTC advertising is not inherently illegal, as the FDA clearly stated in its 1982 moratorium. However, neither are the FDA regulations without legal grounds, because 1962 FDCA amendments transferred regulatory authority over prescription drug advertising from Federal Trade Commission

(FTC) to the agency. The FDA regulations' legal authority is further backed up by a recent ruling by The Supreme Court of

New Jersey in the case of Perez v. Wyeth Labs, Inc. The case occurred because a patient was physically damaged by misuse of a medical device made by the company. The patient contended that the damage occurred because the manufacturer failed in its duty to inform consumers fully of potential misuses of the product and their effects on health. In the case, the pharmaceutical company invoked the learned intermediary thesis, i.e., the defense that "doctors who prescribed and implanted the Norplant device [a contraceptive] had sole duty to inform their patients of the device's potential dangers and side effects" (Pateiro, 1999, 17

p. 575). However, the court held that pharmaceutical companies engaging in DTC advertising are liable for the failure to provide adequate product warnings to consumers because "the physician's role in prescribing drugs does not break the chain of causation" (Pateiro, 1999, p. 575).

Critics' positions on the regulation of DTC advertising are largely polarized into supporters of tighter

FDA regulation and those advocating more relaxed policies, such as New Zealand's self-regulation model. The latter group contends that: consumers and even doctors reveal increasingly positive attitudes toward DTC advertising. This group contends that DTC advertising's informational value induces more informed and meaningful doctor-patient interaction and it drives the under-diagnosed public to become more aware of their health conditions that potentially need medical intervention. The group also suggests that DTC advertising prevents the under-diagnosed but minor diseases from developing into major health problems; and it is not largely responsible for the increasing drug expenditure (Bonaccorso & Sturchio, 2002;

Calfee, 2002; Holmer, 1999, 2002; Manning, & Keith, 2002;

Matthews, 2001).

Driven by the above arguments, supporters of more relax FDA regulation argue that the current FDA regulations are sufficient to protect the consumer. Furthermore, some 18

argue that DTC advertising is over-regulated. The following

statement by Calfee (2002) encapsulates this position:

Proposals to tighten regulation [e.g., mandatory pre clearance] are unlikely to increase consumer welfare, because they would increase costs and reduce the scope of DTC advertising and therefore limit its benefits. Conversely, the FDA should consider relaxing some of its rules. The context of FDA regulation virtually ensure that its advertising standards are too stringent and thus deprive the market of useful information. An obvious problem is the quantity of warning information required in broadcast advertisements (p. 188).

He further argues that an alternative system of regulation will produce better consumer welfare.

United States should take advantage of the New Zealand experience ... [which has] demonstrated that self­ regulation for DTC advertising can work well, providing substantial information to patients with litte harm, while also achieving support from the medical community ... many of the protections in the tightly regulated pharmaceutical information regimes of Europe and Canada are both unnecessary and costly to consumers (p. 189).

Critics of DTC advertising disagree. They argue that:

doctors are uncertain and often negative about the impact of

DTC advertising. They contend that information in DTC

advertising is unbalanced about risks and benefits of the

drug and therefore has the potential to mislead the public.

Further, they suggest that it leads patients to push doctors

into prescribing the drugs that they want but that do not

necessarily help. According to them, DTC advertising also

increases drug expenditure. It also medicalizes common life

problems and encourages drug use over other effective

treatment options (Bell, Wilkes, & Kravitz, 2000; Coney,

2002; Davis, 2000; Hoffman, 1999; Hollon, 1999; Kessler, 19

Rose, Temple, Schapiro, & Griffin, 1994; Kravitz, 2000;

Kravitz & Wilkes, 2000; Woloshin, et. al., 2001).

The following suggestions for the FDA regulations by

Bell and others (1999) largely represent the views of this group of scholars.

The demonstrated ability of DTC advertisements to reach consumers and affect their behaviors raises concerns about the quality of information provided in these promotions. These come from an industry that has not always been above reproach_ Health professionals and the FDA need to monitor carefully and regularly DTC advertisements and be prepared to object when misleading claims are made. (p. 657).

They further suggest that "proactive efforts to improve the educational value of DTC advertisements should also be considered. For example, media organizations could be encouraged to adopt guidelines that DTC advertisements must meet for acceptance" (Bell, et. al., p. 657).

PubIic Reaction Issues

Regulators, advocates, and critics of DTC advertising have conducted research on the public's reaction, especially doctors' and consumers' attitudes to DTC advertising, to inform and guide their positions. The most notable of their attempts includes the two nation-wide surveys commissioned by the FDA. According to the surveys, it is currently unquestionable that consumers are highly aware of DTC advertising. For example, "of FDA respondents in 2002, 81%

(up from 72% in 1999) recalled seeing a prescription drug 20

advertisement in the past three months, and most recalled seeing several advertisements" (cited in Calfee, 2002, p.

181). This should come as no surprise, because health information needs have been ascendant on a societal scale for the past decades (Matthews, 2001). Other national scale studies also confirm high levels of awareness (National

Consumers League, 1998; Rodale Publications, 1999, 2000).

The same is generally true of consumers' attitudes towards DTC advertising. Several studies up until the early

1990s show that consumers generally have positive attitudes toward DTC advertising (Everette, 1991; Morris, 1984; Perri

& Nelson, 1987; Williams & Hensel, 1995). These findings are further supported by nation-wide surveys conducted mostly around 2000. The 1999 FDA study, for example, reports that respondents who like seeing DTC advertising outnumber those who do not by two to one; 86% replied that DTC advertising makes them aware of new drugs; and 62% said that it helps them have better discussions with their physician about their health (FDA, 1999).

These findings illustrate consumers' largely positive attitudes toward DTC advertising and are largely undisputed by critics. Supporters of DTC advertising tend to use this point to argue that DTC advertising should remain legal and the government should consider relaxing the regulations

(Calfee, 2002a). However, what critics consider problematic 21

is that consumers' positive attitudes, though an integral part of the controversy, do not necessarily indicate that

DTe advertising actually benefits their health. A body of research supports this alternative perspective.

For example, critics point out that the content of DTe advertising often has ambiguous, unbalanced, and misleading information regarding risks and benefits (Bell, et. al.,

2000; Kravitz & Wilkes, 2000). They also point out that it often depends on emotional appeals, rather than rational appeals (Roth, 1996). These findings are significant because one can argue that DTe advertising makes patient-doctor interaction neither more informed nor less informed. Instead, it has the potential to make the interaction misinformed.

Therefore, consumers' largely positive attitudes may indicate that DTe advertising may have negative, but often unrecognized, impact on their health through its undesirable influence on doctor-patient interaction.

Bell and others (1999) found that consumers have serious misperceptions about the FDA's role in regulating

DTe advertising. For example:

approximately 50% [of respondents] thought that DTC advertisements had to be submitted to the government for prior approval, and 41% thought that only completely safe prescription drugs could be advertised directly to consumer" (Bell, et. al., 1999, p. 654-655).

Both the above points (the government enforces prior- restriction and the complete safety of information in DTe 22

advertising) are false information. They were made up to test if consumers have correct ideas about DTC advertising.

It is alarming that a considerable percentage of respondents had serious misperceptions about such key aspects of DTC advertising. More alarming is the finding that these misperceptions significantly correlate with consumers' positive attitudes toward DTC advertising. One can infer that consumers may easily make these associations, which is alarming.

Health policy experts and doctors seem to share slightly more negative views than consumers. For example,

The American College of Physicians and the American Society of Internal Medicine declared in a joint policy statement that "[we] are concerned that [DTC] advertising will result in increased consumption of these [highly advertised] drugs; though their use may be neither appropriate nor necessary"

(Matthews, 2001, p. 15). Other studies further this concern.

In a survey with members of the American Academy of Family

Physicians, Lipsky and Taylor (1997) found that "80% of the physician respondents believed that print DTC advertising was not a good idea, while 84% expressed negative feelings about television and radio advertising" (p. 495). In another survey with the same organization, 84% held negative views of television and radio advertisements, many seeing them as biased and misleading (American Medical Association, 2001). 23

In short, physicians have considerably more negative attitudes toward DTC advertising than do consumers.

Content Issues

During the past two decades, "patients have been seeking much more medical information and are actively participating in decisions affecting their health" (Wolfe,

2002, p. 524). Accordingly, debate over DTC advertising often involves how much educational value its content has for the consumer, rather than consumers understanding or reaction to its content or appeals.

The 1962 amendments to FDCA still apply to the regulation of DTC advertising. They require that DTC advertising meet the following 4 basic conditions.

1. They cannot be false or misleading. 2. They must present a fair balance of informationabout the risks and benefits of using the drug. 3. They must contain "facts" that are "material" to the product's uses. 4. In general, the advertisemert' s "brief summary" of the drug must include every risk fromthe product's approved labeling (KefauverHarris Act 21).

Critics debate over whether the content of DTC advertising meets the above conditions and addresses consumers' health information needs. Advocates of DTC advertising argue that "a consumer-directed ad can be an important educational tool in an era when patients want to be more involved in their own health care" (Nordenberg, 1998, 24

p. 28). In fact, in a survey by FDA, 85% of respondents replied that if they were especially interested in the advertised drug, "they would read all or almost all of the information" (FDA, 1999). This finding suggests that DTC advertising receives considerable attention from the consumer as an important source of medical information, making content issues all the more crucial.

Researchers emphasizing the benefits of DTC advertising always mention its educational value. They suggest that it leads the public to be more informed participants in the medical decision making with their doctor (Calfee, 2002; Holmer, 1999, 2002; Matthews, 2001).

However, it is interesting to note that that there seems to be no systematic research on the content of DTC advertising that supports this position. Therefore, the educational value thesis, often invoked without reference to empirical evidence, can be potentially misleading strategies of persuasion.

For example, to support the view that DTC advertising contains and conveys balanced information on risks and benefits, Calfee (2002, p. 183) cites the FDA finding that

90% of respondents said they saw risks and side effects information. However, the finding does not address the issue of content at all, because seeing and understanding are two very different responses. In other words, it is one thing 25

that consumers report they saw risk information in an advertisement, but it is another to use the finding to argue that the advertisement carries balanced information risks and benefits.

There are only three studies that systematically analyze the content of DTC advertising from a moderately critical of the position (Bell, et. al., 2000; Kravitz &

Wilkes, 2000; Roth, 1996). These studies generally conclude that DTC advertising does not carry adequate information that could educate patients about risk factors and "the mechanism of action by which the drug treats a particular condition, its success in doing so, alternative treatments, and behavioral changes that could augment or supplant treatment" (Bell, et. al., 2000, p. 1096). The studies also point out that DTC advertising mostly omits the potential for drug misuse and directions for proper usage. They also point out that promotional inducements such as a monetary incentive are offered to readers. Finally, the most alarming finding is that about two fifths DTC advertisements make potentially misleading claims of innovativeness, because when it comes to drugs, "what is new is not necessarily better" (Kravitz & Wilkes, 2000, p. 334). In summary, studies that systematically analyze the content of DTC advertising are critical of the contention that information that pharmaceutical companies provide in DTC advertising is 26

truthful and balanced, implying that DTC advertising does not necessarily help the consumer make better medical decisions with their doctor.

Advocates further argue that DTC advertising serves the consumers' needs for health information. However, this is a questionable proposition because they do not discuss specifically what types of information consumers may need regarding their health and whether and/or how DTC advertising satisfies them. In Britain, Coulter, Entwistle, and Gilbert (1999) studied patient information needs through focus groups. They came up with the following list of patient information needs.

1. To understand what is wrong 2. To gain a realistic idea of prognosis 3. To make the most of consultations 4. To understand the processes and likely outcomes of possible tests and treatments 5. To assist in sel~care 6. To learn about available services and sources of help 7. To provide reassurance and help to cope 8. To help others understand 9. To legitimize seeking help ffid their concerns 10. To learn how to prevent further illness 11. To identify further information and sel¥help groups 12. To identify the best health care providers (p.319)

As noted previously, the overall controversy over the content issues is largely polarized. Yet, systematic inquiry generally points out that DTC advertising often fails to measure up to FDA-imposed conditions about balanced information and also it often fails to meet patients' health information needs. This perspective reflects the bitter sentiment evident in the following criticism by Ingelfinger 27

(1972) about pharmaceutical advertising in general.

advertisements should be overtly recognized for what they are - an unabashed attempt to get someone to buy something, although some useful information may be provided in the process _. [advertising should be] divested of its "pseudo-educational character (p. 1319).

Content issues are inherently interlinked with how consumers interact with information in DTC advertising. Consumers read and use DTC advertising to respondent to their health problems. Therefore, how consumers perceive DTC advertising and process the information in it has the potential to affect doctor-patient interaction, doctor's prescription, and ultimately consumers' health. Therefore, one cannot discuss DTC advertising's social impact without referring to the aforementioned key aspects of its content.

SociaI ~act Issues 1: MedicaI Decision Making.

Concerns expressed by all parties engaged in the debate over DTC advertising ultimately boil down to its impact on public health. However, because prescription drugs require doctor's intervention, DTC advertising has been mostly conceptualized to affect public health, whether positively or negatively, through its impact on doctor- patient interaction.

Regarding DTC advertising's impact on public health, advocates mostly contend that it has educational values.

They also suggest that it helps consumers to be better aware 28

of health problems that are otherwise not easily detectable.

Further, they posit that DTC advertising is a vehicle through which consumers get additional information, and that it helps turn consumers into more active and informed participants in doctor-patient interaction, therefore contributing to the overall improvement of public's health

(Bonaccorso & Sturchio, 2002; Calfee, 2002; Hoek & Gendall,

2002; Holmer, 1999, 2002; Matthews, 2001). The following statement by Bonaccorso and Sturchio (2002) encapsulates these points:

consumer surveys and other studies show tat DTC advertising provides valuable information on treatments (including risks and side effects); motivates consumers to seek additional information from doctors, pharmacists, and other sources; and increases adherence that leads to better health (p. 910).

Another integral proposition is the "learned intermediary" thesis. It is the idea that doctors are the

"ultimate gatekeeper." It posits that even when patients receive misleading ideas from DTC advertising, doctors help correct them and prevent this misinformation from having negative effects on public health. Holmer (2002) represents the proposition in the following statement:

[DTC advertising] merely motivates patients to learn more about medical conditions and treatment options and to consult them. Cnce the dialogue is started, the physician's role is preeminent. The patient has been empowered with information, not prescribing authority. In the words of Harvard Medical School Professor Jerry Avorn, "there is no detail man or a pharmaceutical company or patient that points a gun to a doctots head to write a prescription. Ultimately, it isrrt the patient's signature on the prescription - it's the doctor'sU (p. 381). 29

Critics question the above proposition. For example,

Lyles (2002) argues that:

DTC advertising's blend of promotion and information has produced some prescription drug awareness than knowledge - it has been largely ineffective in educating patients with medical conditions about the medications for those conditions (p. 73).

In the same context, critics question the value of national surveys by the FDA in supporting the contention that DTC advertising has positive effects upon public health. In the surveys, consumers report that they saw enough risk information in DTC advertising. Using this information, advocates of DTC advertising support the position that it provides balanced information and therefore is educationally valuable (Calfee, 2002). However, this position runs against the aforementioned content analyses of DTC advertising, which show that it is often unbalanced and potentially misleading (Bell, et. al., 2000; Kravitz, et. al., 2000;

Roth, 1996; Woloshin, et. aI, 2001). If consumers think they receive enough risk information from a source that medical experts see as often unbalanced, one can argue that this raises the possibility that DTC advertising poses a potential threat to public health.

Critics also question the doctor's role as the

"ultimate gatekeeper." They suspect that patient requests often pressure doctors. Mintzes and others (2002), for example, found that doctors are twice as likely to prescribe 30

certain drugs when patients request them than when they do not. They also revealed that when ambivalent about effective treatment options, physicians are about three times more likely to prescribe a certain drug requested by patients.

Further, Mintzes, et. al. found that physicians prescribe three-fourths of all drugs that patients either initiated conversation about or directly requested. In the same vein,

Lipski and Taylor (1997) found that 71% of family physicians believe that DTC advertising pressures physicians into prescribing drugs that they would not ordinarily prescribe.

Foote and Etheredge (2000) also confirm that 75% of consumers who make requests for prescription drugs receive the desired drug. In summary, the above studies strongly question the thesis that physicians are the "ultimate gatekeepers," protecting patients from being affected by whatever misleading information they may receive from DTC advertising.

A related body of research further questions the physician's role as the gatekeeper. For example, Avorn, Chen, and Hartlay (1982) revealed that physicians are more dependent on doctor-targeted public relations communications as an information source then physicians believe they are.

This finding weakens th~ "learned intermediate" thesis, especially when combined with reports that doctor-targeted advertising and promotional materials are often inaccurate, 31

misleading, and unbalanced (e.g., Wilkes, Doblin, & Shapiro,

1992) .

Socia~ ~act Issues 2: Economic ~act

The second social impact issue category relates DTC advertising's impact on drug expenditure and prices. As mentioned previously, because of the public concern about the drastic increase in medical expenses, DTC advertising's potential economic impact has become a political issue

(Teinowitz, 2003). Exactly how DTC advertising affects drug expenditure, however, is widely unknown. Some researchers such as Findlay (2002) provisionally conclude that "such

[DTC] ads are one element - and perhaps an increasingly important one - driving expanded use of newer prescription drugs and increase spending on pharmaceuticals" (p. 24), implying that DTC advertising has potential economic effects but the nature and amount of such effects are untraceable yet. However, several other studies suggest that DTC advertising does affect drug expenditure. For example,

Calfee (2002) states:

approximately three fourths of these [outpatient] drug expenditure increases have been ca~ed by expanded usage and switching to newer and more effective drugs, whereas price increases have accounted for only about one fourth" (p. 178).

Yet, one must consider that the above statement is somewhat misleading. It fails to provide a clear categorical 32

definition of "newer and more effective drugs." The statement also fails to consider the point that "newer" does not necessarily mean "more effective" when it comes to drugs

(Drake & Uhlman, 1993; Kessler, et. al., 1994). Therefore, the statement might mislead readers about the association between the increasing drug expenditures and consumers' increasing spending on their health by leaving the impression that switching to new drugs necessarily contributes to public health. Between 1989 and 1993, for example, the Center for Drug Evaluation and Research (CDER) of the FDA "approved 127 new molecular entities (excluding generic drugs), but only a minority [about 16%] offered a clear clinical advantage over existing therapies" (Kessler, et. al., 1994, p. 1350). Findings such as this challenge the contention that switching to newer and more expensive drugs contributes to public health.

-Limitations With the Literature

This literature review reveals that the overall conceptual horizon underlying and shaping the debate over on

DTC advertising share the following three limitations: lack. of theory-guided models, focus on a narrow range of concepts and variables, and one-dimensional view of impact that 33

largely fails to consider the ever increasing integration of marketing communications.

Lack of Theo~-Guided Mode~s

Research on DTC advertising in general seems to be theoretically devoid. It fails to take advantage of the rich body of theoretical foundation on persuasion in general, especially research on advertising. Gaining insights from the literature on persuasion could lead to a deeper understanding of DTC advertising and could provide models that are applicable to a wider range of contexts. Currently, research on DTC advertising often does no more than measure a few select variables such as doctors' and consumers' attitudes, beliefs and behaviors toward DTC advertising, with minimum discussion on how they correlate. For example, the widely cited FDA 1999 survey is mostly simple description of consumers' awareness, recognition, and attitudes toward DTC advertising, with some discussion on how consumers process specific categories of information

(e.g., risk information). Within the current literature, potentially vital associations between variables are missing, such as the association between consumers' reported exposure to sufficient risk and benefit information and the actual balance and completeness of risk information in the 34

advertisement.

Some researchers do show an interest in exploring how variables are associated. For example, Davis (2000) reveals that "consumer's rate the safety and appeal of drugs described with an incomplete risk statement significantly more positively than comparable drugs described with a more complete risk statement" (p. 349). Bell and others (1999) show that the respondents' overestimation of FDA's control of DTC advertising positively correlates with their positive attitudes towards it.

However, one needs a more elaborate model that incorporates a wider range of variables in order to gain fuller insight into DTC advertising. Peyrot and others

(1998) provide a seemingly elaborate model that connects demographic variables, exposure to the media, exposure to drug advertising, etc. in order to explain consumers' prescription drug knowledge and requests. However, their research utterly lacks validity, because it fails to present information such as measurement validity and reliability, statistical significance of correlations, and strength of correlations, even though it appears to be a quantitative study. 35

Focus on a Narrow Range of VariabIes

Research on DTC advertising focuses on a narrow range of dependent variables. From a consumer perspective, the most integral part of research on DTC advertising is, obviously, to answer the following question: exactly what does DTC advertising do for doctors and consumers in their experience of diseases, illness, and coping?

When one looks through the literature, s/he receives the unmistakable impression that most impact studies often exclusively attend to drug prices, drug expenditure, doctor­ patient interaction, revenues for pharmaceutical companies, patterns of prescription, consumer awareness, responsible drug taking behavior, etc. Studies on the content of DTC advertising also mostly focus on straightforwardly medical information such as truth and balance in the statement of risks and benefits.

The above issues undeniably need attention, but these are certainly not the only issues that matter. A large body of literature on advertising in general, for example, points out that advertising unfavorably depicts certain categories of people, especially women, older people, and minorities, especially African Americans. There are indications that this problem may carryover to DTC advertising. Hansen and

Osborne (1995), for example, point out that the carryover 36

occurs in pharmaceutical advertising in medical journals.

Driven from such findings, researchers can enrich scholarly discourses on DTC advertising by investigating if stereotyping carries over to DTC advertising, what impact the stereotyping may have on self-image of people of the targeted groups, how the carryover affects the way the public thinks about the target groups, etc.

Furthermore, many researchers hold that certain categories of drugs are almost exclusively associated with specific social groups. For example, anti-depressants advertising in medical journals have mostly depicted women as expected recipients of the drugs (Lovdahl, & Riska, 2000;

Lovdahl, Riska, & Riska, 1999). Driven from these findings in pharmaceutical advertising in medical journals, researchers could enrich the literature on DTC by investigating if the above phenomenon carries over to DTC anti-depressants advertising, whether it affects the female population's self-image, how it affects women's ideas about depression, how it affects the public's ideas about women and depression, etc. Still more fundamentally, researchers should ask how DTC advertising affects people's ideas about health, disease, and recovery. All these are examples of socially significant questions that are completely missing from the current literature on DTC advertising. Such questions can arise only when researchers take advantage of 37

the rich theoretical grounds in persuasion research, especially research in advertising.

One-Dimensiona~ Conceptua~ Mode~ of ~act

Most research on the effects of DTC advertising, whether explicitly or implicitly, presuppose a lineal model of communication flow. The flow starts from advertising, moves through the consumer's reception and doctor-patient interaction, and ends with the doctor's prescribing the drug.

However, there is considerable circumstantial evidence suggesting that such an approach is a narrow and simplistic conceptual framework and therefore can drastically underestimate DTC advertising's effects.

First, professionals and critics in marketing communications widely accept the idea that marketing communications are now so highly organized and interlocked.

This approach, encapsulated by the term "integrated marketing communications" (IMC), fundamentally characterizes the current marketing landscape.

What marketing communications practitioners ultimately want to achieve through the IMC approach is to maximize the synergy effects among all available channels of marketing communications.

"The distinction between marketing and public relations messages has become more blurred and the two main communication functions are beginning to overlap and 38

support each other' (Ranchhod, Gurau, & Lace, 2002, P. 6) •

Public relations have two major functions. First, public relations enable an organization to control the way in which the organization is presented, in order to influence the way people think of it. Second, public relations affect every aspect of the organization's operations (Ranchod, et. al., 2002). Applying the concept of

IMC, one can reasonably assume that public relations of the pharmaceutical industry can affect the way the public thinks of the industry's business operations, which include DTC advertising. The industry's public relations have the potential to lead the public to consider the practice of DTC advertising as more acceptable and as a result be more receptive to the messages of DTC advertising.

As has been previously discussed, an organization finds it necessary to manage social issues, especially when it comes to the ones that affect their business operations.

In this respect, Buer (2002) states:

To be successful companies need to adopt a stakeholder view of how they interact with society- in short their communications need to be integrated. Rather than focusing purely on their consumer markets, advertisers should be aware of the impact of their messages on public opinion, pressure groups, politicians and others that build up the "political market" (p. 293).

Because of the social controversy that surrounds DTC advertising, the new marketing practice may become an issue that needs to be managed by the pharmaceutical industry. 39

Therefore, public relations professionals of the industry will feel the need to defuse the public's criticism of DTC advertising and promote the industry's position on the issue to the public.

An organization can reach the public and promote their policy position indirectly through delivering press releases to the media. Reporters sometimes use such materials to write news reports. Because public relations materials are framed by the organization to promote its business interests, the frames that characterize such press releases can sometimes bias news reports in favor of the business interests of the industry (Glascock, 2000). Organizations can reach the public by other means. For example, the

Internet is arising as a new public relations channel that enables organizations to reach the public directly (Ranchhod et. al., 2002).

There is no research that discusses how pharmaceutical public relations to promote DTC advertising interplay with the public's perception of the new marketing practice.

Nevertheless a body of research indicates that public relations can be an effective channel to mold consumers' awareness and perception of a given issue. Stern (1994), for example, implies that the manufacturer's multimedia campaign to inform the general public and the medical profession of an unlabeled use of tretinoin were responsible for "the 40

greatly increased attention to tretinoin (a derivative of vitamin A used in the treatment of skin diseases) in the medical and lay press and the substantial increase in the number of visits possibly to discuss, and prescriptions written for, this agent" apparently in order to use it for treatments unapproved by FDA (p. 1348). These findings point to the potential role of public relations practices in causing the public's interest in and use of this drug.

Findings from other studies provide indirect support for such a possibility. In 1999 FDA national survey, for example:

21% [of respondents] said that they had seen or heard anything that made them want to ask a specific question in their last visit to a doctor ... Among sources that inspired their questions, advertisements (46%) ranked equally with news media (45%), and somewhat higher than friends (28%) and other doctors (23%) (Calfee, 2002, p. 184) .

Consumers use news media as an important source of medical information. Media coverage is often influenced by pharmaceutical companies' public relations activities

(Jamieson, 2000). Therefore, it is not without ground to assume that news media can sometimes be conceptualized as a potential public relations vehicle through which pharmaceutical public relations efforts influence the public.

Valestein's (1998) Blaming the Brain provides a compelling. summary of the complex network of channels through which pharmaceutical companies' persuasion campaigns occur. His 41

work suggests that pharmaceutical companies, in addition to advertising drugs to physicians and consumers, promote a certain way of thinking about health, disease, and recovery.

That certain way is tightly controlled by the pharmaceutical industry to serve its business interests. In sum,

Valenstine's work presents a critical overview of the pharmaceutical industry's various marketing communications activities and the way the industry integrates them gain a maximum synergy effect among them and promote its business interests.

Research also indicates that doctors are exposed to inaccurate and misleading information provided by advertising in medical journals (Stryer & Bero, 1996; Wilkes et. al., 1992). Avorn et. al. (1982) reveal that doctors often underestimate how much they are dependent on, and/or influenced by, commercial sources of information.

All in all, the above findings suggest that treating

DTC advertising as separate from other marketing communications can drastically underestimate its impact. For example, the 1999 FDA survey shows that people are inspired by information advertisements (46%), news media (45%), friends (28%), and other doctors (21%) in asking questions in their visits to a doctor (FDA, 1999). Researchers (e.g.,

Calfee, 2000), whether intentionally or unintentionally, treat the listed information sources as mutually impervious. 42

These supposedly autonomous sources of information, however, are all influenced by persuasion campaigns of pharmaceutical companies. In order to enrich the literature on DTC advertising, one should be able to use the concept of multiple flow of information as a conceptual tool to explain, for example, how information received from friends could have been initiated by other sources such as media coverage, driven by pharmaceutical companies' media relations campaigns.

Another example of pharmaceutical marketing communications with implications for research on DTC advertising's effects is Blake and Early's (1995) finding that gifts that pharmaceutical companies present to physicians to promote drugs may undermine patient confidence in the medical profession. In the same vein, Steinman (2000) states:

Surveys show as many as 70% of patients believe that these gifts significantly impact prescribing, and as many as two thirds believe they increase overall costof medications for the pUblic. Furthermore, 24% of patients reported that their perception of the medical profession changed after learning about drug company gifts to physicians (p. 2243).

Studies suggest that "most physicians believe that gifts do not influence their prescribing, but the same physicians often believe that gifts influence their colleagues"

(Steinman, 2000, p. 2243). This is a clear example of third- person effect. These findings strongly question the "learned 43

intermediary thesis," or the idea that doctors are the

"ultimate gatekeepers," safeguarding against DTC advertising's potential adverse effects.

It comes as no surprise that the current research pays little attention to the pharmaceutical industry's attempts to influence the public's opinion about, and ultimately public policy over, DTC advertising. The conceptual framework that dominates the current literature does not consider the multi-leveled nature of the industry's persuasive communications that include, but are not limited to: DTC advertising to promote drugs; doctor-targeted advertising in medical journals; monetary incentives to promote drugs; public relations to promote a certain way

(i.e., bio-chemical theory) of thinking about health, disease, and recovery; and finally, creating and distributing messages to create a marketing environment conducive to their marketing practices.

All in all, the current literature on DTC advertising is characterized by a few significant limitations. These limitations are lack of theory-guided models; focus on a narrow range of variables, and one-dimensional conceptual model of impact. They block researchers from asking a wider range of questions that can generate insights into various aspects of DTC advertising. They also block researchers from creating knowledge about DTC advertising's impact on public 44

health and more fundamentally, consumers' ideas about health, disease, and recovery in the long term. 44

Chapter 3: Method

Data

To investigate how Pfizer attempts to frame the overall issue of DTC advertising, news releases and other public relations materials such as policy reports and research papers were collected from Pfizer's main web site.

Pfizer was chosen for a number of reasons. First, the company's expenditure on DTC advertising is the second biggest in the industry, closely following GlaxoSmithKline, a pharmaceutical company with the biggest spending on DTC advertising (Branch, 2003). Second, even though Pfizer's spending on DTC advertising is the second biggest in the industry, the company produces 3 of the 10 DTC promoted drugs with the strongest sales records (Anonymous, 2003).

This point roughly indicates the considerable vested interests that Pfizer has in maintaining a favorable marketing environment for DTC advertising. Finally, Pfizer is the only company that most openly and continuously expresses their position on the issue of DTC advertising.

Especially, only Pfizer makes available various public relations materials to support its position on the issue through its web site. 45

The collected materials will serve the overall research purpose for a number of reasons. First, the collected materials are the only available body of documents that express Pfizer's official positions on public policy issues in a thorough and detailed manner. More importantly, this project is based upon the assumption that Pfizer intends to persuade the public through framing the social debate over DTC advertising in its favor and therefore delivering the message that DTC advertising benefits society.

The web site offers a central place for Pfizer to control public discourse on DTC advertising. The web site allows

Pfizer to present its position and show how the company's policy dovetails with that of the FDA. In essence, the web allows Pfizer to show that it is a good corporate citizen.

Therefore, one has good reason to assume that the company's framing strategies will be reflected by the collected official documents that Pfizer has made public to consumers through its official web site. These reasons will be all the more valid when one considers Pfizer's emphasis upon its participation in the process of public policy making. To that effect Pfizer states, "with political decisions increasingly taking on greater importance, Pfizer needs to ensure that our voice is heard when officials consider crucial pieces of legislation" (Our Voice, 2004). 46

The site map of Pfizer's main website shows that under the major heading "Who We Are," and its sub-heading "About

Pfizer," the company provides a page wholly for the purpose of discussing Pfizer's position on diverse public policy issues. Under the sub-heading is provided a news archive.

Phrases such as "DTC" or "direct-to-consumer" were typed into the news archive's search engine to locate articles that address direct-to-consumer advertising. Four relatively short reports of 2 to 3 pages and eight relatively long reports of 6 to 59 pages that directly address DTC advertising were located through this process.

Also under "About Pfizer," is a sub-heading titled

"All Pfizer Web Sites." The latter provides a separate page titled "Public Policy," which leads to a page titled

"PfizerForum.com: A World of Ideas on Public Policy."

PfizerForum.com explains that:

The PfizerForum "advertorial" series has featured articles by a wide variety of prominent individuals around the world _ The series has made a point of highlighting the contributions of public policy "think tanks" around the world (PfizerForum.com, 2004).

Three short reports were found on this web page and included in the study. All in all, 15 articles were included in the study. The total number of pages that the project analyzes is 131.

In the process of data collection, every section of

Pfizer's main web site was explored to check if it carries 47

messages that address the issue of DTC advertising. The two sections cited above, "news archive" and "who we are" were the only two sections that have public relations articles addressing DTC advertising. The news archive is a place where general press releases are stored, while "who we are" had two separate sub-sections that exclusively discuss the issue of DTC advertising. More articles were found in "who we are" (13 articles) than in news archive (6 articles), and

5 of these articles were found in both places. This means

Pfizer prefers to set aside exclusive space to promote its position over DTC advertising, rather than to discuss the issue together with other news releases in general. This author believes this indirectly reveals the important Pfizer puts upon participating in the social debate over DTC advertising.

This project uses the resulting pool of public relations materials as data set to investigate Pfizer's strategies of framing the social debate over DTC

2 advertising • To clearly differentiate between the collected

2 The website did not differentiate between such reports according to their intended audiences. Therefore, it was difficult to determine which articles were intended for the public to read, which ones for the media to cover, etc. These reports, long or short, and whoever they were intended to be read, nonetheless represent Pfizer's official positions on pubic policy issues, in this case, DTC advertising. Designators such as "policy report," "comments of Pfizer," and "executive summary" accompany these reports. Interestingly, the company apparently is publishing a 48

data and other articles covered in the literature review, each of the collected pubic relations documents is assigned a number. Each collected material will be addressed only through the assigned number. This rule applies even when the articles list the authors' names. Table 1 summarizes the basic characteristics of the collected materials such as length, authors' names, titles, and web address.

As illustrated in the table, articles mostly have named authors. Additionally, articles with the listed publication date were published after 2001. Regarding the articles without a publication date, one can easily guess when they were published. For example, Merill Matthew's article cites the pharmaceutical industry's expenditure on OTC advertising as of 1999. This reveals that it was written no sooner than

1999. Likewise, the article The Best of Both Worlds is an overview of a 2003 volume of Economic Realities in Health

Care Policy, Pfizer's in-house publication. Therefore, the article came no sooner than 2003. All in all, the collected public relations materials mostly cover the time span between 2001 and 2003. About half of them were published in

Pfizer's in-house periodical Economic Realities in Health

Care Policy. There are other types of materials, such as

Before the U.S. Food and Drug Administrations, which Pfizer periodical titled "Economic Realities in Health Care Policy" that exclusively discuss their views on pharmaceutical marketing and promotion. 49

submitted to the FDA to express it position on the issue of

DTC advertising.

Table 1 List of Collected Public Relations Materials

Reference Title Authorship Year Length Location Number (pages) Doc 1 Before the US Bert Rein, Andrew2003 59 About us Food and Drug Krulwich, & http://www.pfizer.c Administration Rosemary Harold om/download/public_ print_ads. pdf Doc 2 What is Richard Manning, 2003 3 About us Information & Neal Masia http://www.pfizer.c Worth? om/download/public_ policy_pmp.pdf Doc 3 The Economics Paul Rubin 2003 13 About us and Impact of http://www.pfizer.c Pharmaceutical om/download/public_ Promotion policy_pmp.pdf Doc 4 Pharmaceutical Neal Masia 2002 12 About us & News Innovation, archive Lowering the http://www.pfizer.c Price of Good om/download/about e Health r22.pdf Doc 5 The Economic Frank Lichtenberg2002 6 About us & News Benefits of New archive Drugs http://www.pfizer.c om/download/about e r22.pdf Doc 6 The Economics Richard Manning &2001 7 About us of Direct-to- Alison Keith http://www.pfizer.c Consumer om/download/about E Advertising of Rhealthcare.pdf Prescription drugs Doc 7 What the FDA John Calfee 2001 5 About us Survey Showed http://www.pfizer.c About Direct­ om/download/about E to-Consumer Rhealthcare.pdf Prescription Advertising 50

Table 1 - Continued

Reference Title Authorship Year Length Number (Pages) Doc 8 Information Alison Keith 2001 4 About us Matters: The http://www.pfizer. Consumer as the com/download/about Integrated Health _ERhealthcare.pdf Care System Doc 9 Pharmaceutical Alison Keith Not 9 News archive & Prices: What's & Richard Liste About us Missing in the Manning d http://www.pfizer. Public Discussion com/are/about publ ic/mn about econom icrealities.html Doc 10 Impact of DTC Pfizer & 2001 7 News archive Advertising RxRemedy, No http://www.pfizer. Relative to Individual com/are/about publ Patient Authors ic/mn about dtcads Compliance doc.html Doc 11 Advertising and Merill Not 3 About us the Informed Matthews Liste http://www.pfizerf Patient d orum.com/english/m atthews2.shtml Doc 12 Direct-to- John Calfee Not 3 About us Consumer Drug Ads Liste http://www.pfizerf Benefit Patients d orum.com/english/c alfee2.shtml Doc 13 The Best of Both Pfizer, No Not 3 News archive Worlds: Today's Indi vidual Liste http://www.pfizer. Prescription Author d com/download/best Drugs Help Save of_both_worlds.pdf Both Lives and Money Doc 14 Maximizing Jane Kolassa Not 3 About us Patient Choice Liste http://www.pfizerf d orum.com/english/k olassa.shtml Doc 15 Direct-to­ Pfizer, No 2002 3 About us Consumer Individual http://www.pfizer. Advertising Author com/download/publi c_policy_dtc.pdf 51

The term "public policy" designates such reports. The

collected public relations materials are preserved on the web site apparently to represent the company's official position on diverse pubic policy issues. These materials are

an available and appropriate data set, because they

represent a body of communication materials essentially

framed by the organization.

One should note that there might have been some public

relations materials that Pfizer presented to the media or

the public but were not included in the company's web site.

If this happened, it was anticipated that such documents

would not significantly differ from the ones located in the

web site in the way Pfizer addresses the issue of DTC

advertising. More importantly, as the purpose of this study

is to analyze how a debate is framed by materials publicly maintained by Pfizer, officially posted materials are

clearly more pertinent to addressing its overall framing

strategies. The collected materials are documents open to

visitors to Pfizer's web site. Pfizer, as other

pharmaceutical companies do, invites investors and people

interested in the company and its brands to visit its

website. 52

Frame Ana1.ysis

Frame analysis has developed as a way of analyzing arguments about complex social issues and their impact upon the way people think about such issues. Frame analysis as a method of analyzing the text is rooted in the concept of

"framing," initially suggested by Erving Goffman, the cognitive psychologist who created the theory of framing. He defines the theory of framing and frame analysis as the following:

definitions of a situation are built up in accordance wi th principles of organization which govern events ... and our subjective involvement in them; frame is the word I use to refer ill such basic elements as I am able to identify ._ frame analysis is a slogan to refer to the examination in these terms of the organization of experience (1986, p. 10-11).

Framing theory refers to the idea that people process incoming stimuli and interpret a particular object or situation according to principles of organizing information.

Such principles of organization could both exist in the text and be part of each individual's cognitive characteristics.

Frames built in a people's mind interact with the way a particular object or situation is framed in the text. Frame analysis could be either an act of exploring the frames that constitute a given text or an investigation into the interaction between the frames built in people's mind and the frames in the text. In either case, frame analysis

"emphasizes how frames sort out and organize the complex 53

stimuli of everyday life" and how "individuals create and rely on frames to make sense of daily interactions, conventional rituals, discourse, advertising, and other elements of social experience" (Creed, Langstraat, & Scully,

2002, p. 3).

Frame analysis has continued to gain popularity since its introduction. Its application has been extended to various social scientific traditions, including journalism and mass communications. Researchers in journalism, for example, started to use the theory to analyze how news media frame social issues and induce the public to think about them in a certain way. Likewise, researchers in public relations use frame analysis to explore how pubic relations professionals can use various strategies to frame issues of public debate in favor of the organizations they represent.

At the same time, critics use the theory to analyze the framing strategies public relations professionals use.

Frame Analysis in Journalism Research

In the context of journalism research, Gitlin (1980) points out that one can use the concept of framing to conduct research on how the media represent aspects of social reality and influence the way public perceive and react to them in a certain way. According to him, media 54

frames, "largely unspoken and unacknowledged, organize the world both for journalists who report it and, in some

important degree, for us who rely on their reports" (p. 7).

The statement correctly prognosticated that subsequent researchers would use frame analysis as a way of analyzing both news coverage of social issues and its impact on the way the public think about them.

For example, Entman (1991), analyzes how Time and

Newsweek frame similar airline incidents differently, with

significant social ramifications. According to Entman (1991),

the 1983 Soviet downing of Korean Air Line (KAL) Flight 007

and the 1988 u.S downing of Iran Air (IAR) Flight 655 shared

similar circumstances, such as:

"in both cases, military officials identified a property passenger plane as a possibly hostile target; in both cases, the perpetrating nations officials claimed the shooting was justifiable under the circumstanceg (p. 6)

However, through selective use of words and images, the two magazines frame the IAR incident as a techni~al problem

while framing the KAL incident as evidence of Soviet Union's moral bankruptcy. The two overarching frames (i.e., moral

bankruptcy vs. technical problem) consist of distinct

organizing principles of the text, such as agency (i.e.,

locating responsibility for the reported action) and

identification (i.e., inducing empathy towards victims of

the incidents). 55

Another example is Powers and Andsager's (1999) analysis of how newspapers framed the silicone breast implant controversy from 1992 through 1996. The study discussed whether the selected newspapers provided the public with a fair and balanced account of the controversy.

Through defining, locating, and analyzing the frames that characterized news coverage of the issue, the study revealed that "early coverage of the controversy focused upon the health risks of silicone breast implant, while later coverage focused on the financial situations of the implant manufacturers" (p. 551). Interestingly, the study pointed out that the implant manufacturers' public relations efforts might have influenced such reporting patterns.

Frame Analysis in Public Relations Research

One of the key objectives of public relations is to maintain a marketing environment in favor of an organization's business interest. This is especially true when a social issue arises with the potential to affect an organization's business practices. The organization then tries to manage the issue, lest it should have adverse impact upon its interest.

Without question, the news media are a public forum through which social issues emerge and are debated. 56

Therefore, organizations prepare and present to the news media various forms of public relations materials with the objective of presenting their view of a given issue and ultimately influencing the news coverage of it. For example,

In Mediating the Message, Showmaker and Reese (1996) state:

Interest groups also conduct public relations campaigns that use the media to fOillS public attention. To the extent that these campaigns are successful, media content is affected directly (through the pUblication of the press releases) and indirectly (by calling the media's attention to the problem) (p. 186).

In the context of public relations, Hallahan (1999) discusses framing as "a potentially useful paradigm for examining the strategic creation of public relations messages and audience responses" (p. 205). According to him, one can create public relations materials to effectively serve the interest of an organization by creating messages that effectively frame situations, attributes, responsibility, issues, etc.

The themes, messages, and perspectives that creators of the text intend to convey to the readers about a given topic are embedded in the frames they use. Framing comes to life through a body of linguistic strategies that public relations practitioners use, consciously or unconsciously, to respond to social issues. Therefore, a large body of literature uses frame analysis to explore how such persuasive strategies constitute the frames in a give text and what themes, messages, and perspectives are potentially 57

carried by the frames in the text. Such literature

ultimately investigates how the frames, themes, and

linguistic strategies interact to shape media coverage of

social issues. By investigating the linguistic strategies

and constructing frames

For example, Anderson (2001) conducted research on the

battle between two pharmaceutical companies, Merck and

Searle, to promote Celebrex and Vioxx (the two companies'

arthritis drugs). The study concludes that their public

relations may have influenced the press on "what" to cover,

but not "how" to cover it. In other words, public relations

of the two companies succeeded to call news media's

attention to the issues they raised, but failed to make the media frame the issues the way the companies preferred.

Similarly, Glascock (2000) examined newspaper coverage

of the 1982 breakup of AT&T and the role that the company's

public relations campaign may have played in the way new media reported the event. They used frame analysis to

determine the relationship between the company's public

relations and the press coverage of the incident. Using

statistical techniques to determine association, the study

exemplifies a quantitative application of the theory.

Esrock, Hart, Silva, and Werking (2002) used frame

analysis in a case study. Similar to Entman's (1991)

analysis of the way Time and Newsweek covered the KAL and 58

IRA incidents, the study exemplifies a qualitative way of

applying the theory. The underlying assumption of the study

is that "framing choices are among the most critical

strategic decisions in the public relations process" (p.

209). They further argue that:

public relations professimals inevitably are involved in the framing process _ By constructing social reality, framing influences the way people understand issues and events and therefore, is central to public relations (p. 212) .

The study explores a conflict between a business

organization and residents of an island involving the

company's decision to discontinue the production of a

product that apparently has cultural and historical

significance for the residents: a brand of crackers called

"Crown Pilot," which reportedly has become part of the

collective cultural identity of the residents of the island.

The authors conducted in-depth and probing interviews with

key figures (business representatives, journalists, and

protesters representing the island) in forming the climate

of opinion on the issue. The study provides an account of

how the public relations efforts of the protesters, coupled with the initial inaction of the business organization, led

the media to cover the conflict with a sympathetic "Darvid

vs. Goliath" frame, not the "sound business" frame that the

company started to promote later. 59

strengths and Weaknesses of Frame Analysis

Critics point out that frame analysis has a number of strengths and weaknesses. For example, discussing the theory's weaknesses from a quantitative perspective, Scheufe

(1999) states:

Research on framing analysis is characterized by theoretical and empirical vagueness. This is due, in part, to the lack of commonly shared theoretical model underlying framing research. Conceptual problems translate into operational problems, limiting the comparability of instruments and results (p. 103).

However, some critics point out that the theory's apparent conceptual flexibility is an important factor for the success of Goffman's frame analysis. They point out that framing theory is far more varied and extended than the one

Goffman originally created (D'Angelo, 2002; Fisher, 1997;

Maher, 2001, Scheufele, 1999). In other words, one can consider frame analysis's apparent lack of coherence as an indicator of its wide applicability. For example, as indicated above, researchers have used the theory both quantitatively (particularly in media effects research) and qualitatively (as a method of in-depth analysis of media coverage) .

Furthermore, unlike other traditions of analyzing the text (for example, discourse analysis, semiotics, and narrative analysis), framing analysis has a rich body of literature that discusses the impact of framing (impact on the way the public thinks about a certain issue, impact on 60

the way the news media cover a social issue, etc.). The body

of literature on the effects of framing does not authorize

one to use frame analysis to analyze the text and conclude

that the results suggest some type of social impact.

Nonetheless, it makes such an inference much more probable

and research findings much more meaningful.

App~ication to tbe Current Study

As noted, framing analysis is rooted in the

theoretical concept of framing. The theory of framing refers

to the idea that people process incoming stimuli and thus

understand a particular situation according to a number of

principles of organizing information, which could exist

either in people's mind or in the text. Accordingly, frame

analysis could be an act of exploring the frames that exist

in the text or the interaction between the frames in

people's mind and the frames in the text. This project uses

frame analysis in the first way, or as a method of analyzing

the text.

As described previously, Entman (1991) used frame

analysis to show how Times and Newsweek describe two similar

situations, the US downing of an Iranian airline and the

Soviet downing of a Korean airline, as two drastically

different events framing them in a consistently different 61

manner. In public relations research, Esrock, Hart, Silva, and Werking (2002) used frame analysis to explore how two different groups of people framed the same event (a company's decision to discontinue the production of a cracker) differently and tried to promote their own interpretation of the event to get media coverage. In a much similar fashion, this study uses frame analysis to explore how Pfizer frames and interprets the social debate over the issue of DTC advertising. This study investigates how Pfizer potentially produces a set of meanings around the issue conducive to the pharmaceutical industry's initiative to create a favorable business environment and therefore support their new business practice of DTC advertising. In short, this project explores how the collected public relations materials reflect Pfizer's initiative to lead the public to believe that DTC advertising benefits American society.

In addition, frame analysis can apply to public relations research either quantitatively or qualitatively.

This project uses frame analysis qualitatively for a number of reasons. First, the project collects all the available data from a specific, highly relevant source and analyzes them in an in-depth manner. Therefore, the findings of the study do not have to generalize statistically to a larger category. The findings admittedly indicate the strategies 62

that one pharmaceutical company (Pfizer) employs to frame the public policy issues involving DTC advertising in favor of its business practices. Therefore, one can view this project as a case study in the sense that Entman's (1991) and Esrock's (2002) works are. However, as previously noted,

Pfizer's considerable vested interests in the issue of DTC advertising enable one to infer that the strategies the company employs to frame the DTC debate potentially reflects the pharmaceutical industry's overall position on the debate.

Second, the project attempts to employ an in-depth approach to analyzing the text. It seeks to fully explore the text and provide a thorough and contextualized understanding of what strategies Pfizer uses to frame DTC advertising. One can gain such depth only with fully contextualized, "thick descriptions" of themes embedded in the text, something that many critics call the hallmark of qualitative research (see Denzin, & Lincoln, 2003). As noted previously, Pfizer is the only pharmaceutical company that provides a rich body of texts to express its view on the DTC debate. The in-depth approach of this project fits the kind of richness and depth of messages that characterize the collected materials.

Third, and most importantly, the project purports to explore the full range of Pfizer's framing strategies. It does borrow insights from a literature review. Yet the 63

project does not start from a pre-determined, mutually exclusive list of frames and end up presenting how they emerge in the collected public relations materials. Such deductive logic can produce findings that can generalize to a larger entity and are comparable with findings from other entities. However, to compare and generalize is not the primary objective of this project. Instead, it begins inductively without a predetermined set of frames. In locating and representing frames, the project aims to cover the fullest possible range of linguistic strategies. This inductive logic of categorization constitutes a hallmark of qualitative research (e.g., Denzin & Lincoln, 2003; Maykut &

Morehouse, 1994). In short, this study demonstrates a context-bound, in-depth use of frame analysis in analyzing the text.

Ana~ytic Procedure

The current project analyzes each public relations piece from the data pool. It locates what strategies Pfizer uses to frame such major issues on DTC advertising as legality of the marketing practice, the public's perception of DTC advertising, consumer's ability to process medical information, etc. 64

In explaining how framing occurs in the text and also how researchers conduct frame analysis, arguably no researcher has presented a clearer itinerary than Entman (1991) in the following account:

Frames reside in the specific properties of the news narrati ve ... News frames are constructed from and embodied in the keywords, metaphors, concepts, symbols, and visual images emphasized in a news narrative. Since the narrative finally consists of nothing more than words and pictures, frames can be detected by probing for particular words and visual images that consistently appear in a narrative and convey thematically consonant meanings across media and time (p. 8).

Framing techniques that receive attention in this project included, but were not limited to: specific word and/or image choice; selection of some pieces of information over others; placement of and emphasis on some pieces of information over others; employment of some ways of interpreting given data and observed phenomena over alternative ways; and emphasis upon some conceptual dimension of an issue or concept over other conceptual dimensions. The project intends to demonstrate how patterns of language use and graphics occur in a repeated and consonant manner across the collected public relations materials.

To locate, categorize, compare and contrast, contextualize, and represent frames and their thematic constituents, the analysis consists of two overall reading processes. Specifically, this study defines frame as 65

"underlying structures or organizing principles that hold together and give coherence to a diverse array of symbols and idea elements" (Creed, el. aI, 2002, p. 36). In the first overall reading/analytic process, a single reading deconstructed the content of each article to look for potential frames running through the collected data and potential linguistic strategies to support them.

The second overall reading/analytic process consists of multiple processes of comparison and contrast of the frames located in the first reading process. Units of information coded into potential frames in the first reading are compared against each other to check similarities and differences across them. The frames that emerged in the first reading were collapsed into a higher order category when they shared similar properties enough to be grouped under one theme and create a meaningful and coherent whole in thematic terms, a process common to qualitative methods of analyzing the text (Strauss & Corbin, 1994). The same process occurred twice, and a final system of frames resulted.

Through the two overall reading and analytic processes, the following four frames emerged: DTC advertising is information (frame 1), passive patients vs. empowered consumers (frame 2), maximum benefits vs. minimum risks

(frame 3), no proven economic effects (frame 4). Each of 66

these four overall frames consists of a number of smaller and more concrete themes, which were located in the first reading process. These four overall frames and the way they incorporate their constitutive idea elements are further explained and described in the next chapter. 67

Chapter 4: Results

In a few reported occasions Pfizer lists the issues that have great significance on its business interests. The following statement by Chuck Hardwick, Senior Vice President of Pfizer, reveals that DTC advertising is one such significant public policy issue. The statement also reveals that Pfizer finds it highly important to participate in the public debate over the issue.

For the past several years, some candidates and elected officials have spent an enormous amount of time and money attacking our industry. Some attack the industry because they want to see government run health care, while others find us an inviting target because they feel we are unable to respond to their attacks. Patent protection, direct-to-consumer advertising, sup~emental rebates, and personal injury lawsuits are just a few of the many issues debated in Congress and our state capitols across the country (Our Voice, 2004).

This project has previously illustrated a few similar anecdotal accounts that reveal how Pfizer attempts to frame the policy debate over DTC advertising.

To systematically analyze the framing strategies that

Pfizer uses to frame the social debate over DTC advertising, the company's public relations documents that directly address its position on the issue were collected. Multiple reading processes revealed that four overall frames run through the collected materials and a variety of strategies were used to promote them. These frames include the following. First, DTC advertising is information, providing 68

access to innovation. Second, the old, passive patient vs. the new, empowered consumer. Third, maximum benefits vs. minimum risks. Fourth, no proven economic impact on drug prices and expenditure. These frames form relatively discrete bundles of coherent information and incorporate the full range of strategies that Pfizer employs.

Rooted in the rich theoretical soil of frame analysis, this study assumes that the above frames are potential windows through which the collected materials induce the readers to perceive the public policy debate over DTC advertising. What follows is full description of how the four frames come to life through the strategies of persuasion that Pfizer employs.

Previously this project provided an anecdotal example of Pfizer's attempt to make less salient the promotional nature of the messages in DTC advertising. Pat Kelly, president of u.S. pharmaceuticals at Pfizer, proposes to the pharmaceutical industry "changing the acronym [e.g., DTC

Advertising] to HIFC or Health Information for Consumers"

(Tosh, 2003, p. 8). This suggestion indicates the importance of encouraging people to view DTC advertising as information, rather than advertising. The first frame encapsulates this strategy. Results of the project's frame analysis reveal that this frame runs through the collected public relations materials of Pfizer. 69

Frame 1: DTC Advertising is Infozmation

The first frame builds up the overarching theme that

DTC advertising benefits society because it enables "the free flow of [health] information that is quite difficult to convey to patients and physicians" (Doc 2). Across all

Pfizer materials, the following themes were located in the first reading process. These themes constitute frame 1.

1. Information is a valuable economic prop~ty. 2. OTe advertising contributes to the betterment of health care market because it induces the free flow of health information. 3. OTe advertising is an important information source through which doctors learn about new cures and treatments. 4. Patients become better informed about their health conditions and possible treatments. 5. Information in OTe advertising can hardly be misleading, because it serves each companys economic interest to keep the content of OTe advertising balanced. 6. OTe advertising maximizes consumer choice.

Elements of frame 1 appear in all documents except Doc 4,

Doc 5, Doc 9, and Doc 13. The ones that promote this frame in the most powerful and elaborate manner include Doc 2, Doc

3, and Doc 11. Especially, Doc 2 allots most space to promote the belief that DTC advertising is a neutral, innocuous source of information.

A number of strategies are employed to convey the above themes, which constitute the first frame. First, the frame takes full advantage of the fa9ade of neutrality that. the term "information" connotes. It concurrently downplays the profit-making motivation that underlies the production 70

of DTC advertising. For example, the collected public relations article What Is Information Worth? (Doc 2) begins with the following rhetorical question:

If you were asked to name the most valuable commodity in existence - one that makes economies go; one that allows people to move from one decision to another with speed and accuracy; one that helps people buy what they nee, helps them get a job, make more money, live a more satisfying life; one that lowers a business cost of manufacturing and distribution, and moreover, one without which essentially all economic activity would grind to halt - what would you choose? (p. 3).

The answer is, obviously, information. In this way, they set the overall tone of their argumentation by discussing how valuable information is in modern economy.

Also cited is the economic principle that in the

"perfect market," information is not only available but also free to achieve (Doc 2). However, the authors of the above article point out that, in the real word, "people do not know ... what they need ... to fill their wants and needs" (p.

3) for lack of information. From the above account of the role of information in general as part of a modern global economy, the article draw the conclusion that DTC advertising makes the same contribution to the health care market. It leads towards the perfect health care market. The authors argue that the marketing of health services directly to consumers is "a less time-consuming way to get free healthcare information" (p. 3) than other information sources, such as the Internet. 71

All in all, this frame conceptualizes DTC advertising

as "free information." Directly in parallel with discussion

of the general values of information in a modern global economy, DTC advertising is supposed to perform the same

functions that the ideal-type concept "information" does through society.

Entman (1991) argues that "the essence of framing is

sizing - magnifying or shrinking elements of the depicted

reality to make them more or less salient" (p. 9). This

study similarly reveals that selective use and placement of words functions to support the first frame and corne to the

fore, while evidence to the contrary is downplayed.

For example, because article titles get the most

immediate attention from readers (similar to headlines in

newspaper articles), they effectively connote the sense that

a certain piece of information is important. As illustrated

in Table 1, titles such as What Is Information Worth? (Doc

2) and Information Matters: The Consumer as the Integrated

Health Care System (Doc 8) highlight the "DTC advertising as

information" frame.

Use of specific words also deserves attention. Linked

with the word "information" repeatedly used to designate DTC

advertising, are words such as "free," "learn," "knowledge,"

"informed," "choice," and "education." These words are

repeated throughout the collected documents, with minimum 72

attention paid to the profit making motivation that underlies DTC advertising. Especially, the summary article

Direct-to-Consumer (2002) lists all the above words in the most compact manner.

Similarly, the collected materials present ample space for evidence that supports the "DTC advertising as information" frame, while they sometimes give minimum space to discussing evidence to the contrary. Understandably, the collected materials fully elaborate on the views that support the frame. However, when it comes to research findings and arguments that run counter to the frame, they either do not mention them or provide minimum space for discussing them in a rather haphazard manner.

For example, even though the issues of balance, truth, and bias in the content of DTC advertisements should obviously be a central concern in discussing the

"informational" aspect of DTC advertising, findings that the content of DTC advertising is sometimes unfair, unbalanced and therefore misleading (e.g., Bell, et. al., 2000; Kravitz

& Wilkes, 2000; Roth, 1996) hardly appear in the collected data. When they appear, they are stated in the briefest manner, with minimum reference to evidence to support them.

In sum, the collected articles frame DTC advertising as a neutral source of information and downplay the idea that the first priority of the new adverting is to promote 73

the business interests of the company that employs it.

Mostly promoted by citing a number of the context-free discussion of the role advertising in general plays in the modern economy, this frame has the potential to lead the public to believe that DTC advertising helps make a good medical decision. Pfizer argues that a patient-friendly, free access to medical information makes the physician- patient interaction more equal and efficient.

Frame 2: Passive Patients vs. Empowered Consumers

The second frame suggests that in contrast to the

"passive patients" (receivers of health care service in the past), today's receivers are "empowered consumers."

Empowered with information, these consumers equally participate in the decision-making process with their doctor.

This frame incorporates the following themes, located in the first reading process.

1. Passivity used to characterize patients in the past. 2. Patients used to h~e minimum understanding of their wants and needs, passively receiving information from their doctors. 3. Patients were unequal participants in the decision making process. 4. Today's receivers of health care service are "empowered consumers." 5. Empowered consumers understand their right to seek health information. 6. Empowered consumers take responsibility for their health. 7. Empowered consumers have relatively sophisticated skills of processing health care information. 8. Information "empowers" consumers, enabling them to participate in the decision making process on an equal basis with their doctor. 74

9. Empowerment benefits both providers and receivers of health care service.

Elements of frame 2 appear in all collected documents

Doc 4, Doc 5, Doc 9, and Doc 10. The ones that embody the frame in the most powerful, elaborate, and consistent manner include Doc 8, Doc 10, Doc 11, and Doc 14. Especially, Doc 8 allots most space in defining and explicating the new, empowered consumers as "the integrated health care system."

Frame 2 puts the "passive patient" and the "empowered consumer" in conceptual contrast. The two concepts of consumers exhibit two contrasting sets of characteristics in terms of health behavior. The following statement by Keith

(Doc 8) exemplifies this framing strategy.

Most health care systems seem to have the patient at the center. But in fact, the patient has been the relatively powerless recipient of wel~intentioned care rather than a powerful center from which criteria for the patien's own health care and the shape of the overall system radiate, with decisions made as full partners with health care (p. 16).

As the passage shows, words such as "powerful," "center," and "full partner" accrue in describing today's "empowered" consumers to emphasize that they are active and knowledgeable. In contrast, "powerless" and "recipients," both of which convey an overall sense of passivity, accompany the description of patients in the past. In short, the concept of "empowered consumer" is pitted against that of "passive patient," making the concept of empowerment and the role of information all the more salient. 75

The article takes the empowerment frame one step further when it presents the concept of "consumer as the co- maker of medical decision" in the following statement:

Given sufficient and accurate information- greatly enhanced by DTC advertising- a consumer knows better than anyone else whether he or she would prefer a product with fewer unpleasant side effects even at a slightly higher risk of some serious event ... the ideal - and the emerging model - is a full partnership between patient and health care professional (Doc 8, p. 17).

Other similar concepts appear, such as "consumer as integrator" theme. This theme posits that "the consumer may be the best integrator of care received across various elements of the health care system" (Doc 8, p. 17). The theme boils down to the corollary that information empowers consumers, enabling them to actively and equally participate in the medical decision making process with their doctor.

Therefore, consumers are raised to nearly equal standing to physicians, as the phrase "full partnership" may connote in the above passage (Doc 8). One may further argue that the medical training of doctors is downplayed where Pfizer states "a consumer knows better than anyone else whether he or she prefers a product with fewer unpleasant side effects

" (Doc 8, p. 17) in the same passage.

In addition to the fact that "passive patients" and

"informed consumers" are pitted against each other, the collected data promote this frame through selective use of research findings. For example, in order to argue that DTC 76

advertising leads to more informed doctor-patient interaction, without the "empowered consumers" pressuring their doctor, the article Direct-to-Consumer Drug Ads

Benefit Patients (Doc 12) cites an FDA survey and contends that "asked whether DTC ads make it seem like the doctor is not needed to decide whether a drug is right for me, 70% [of the respondents] disagreed" (p. 15). However, the article fails to mention that a large body of research findings point out that patients are pressuring their doctors into prescribing drugs they see in DTC advertisements (Foote &

Etheredge, 2000; Lipski & Taylor, 1997; Mintzes, et. al.,

2002) .

Similarly, the collected public relations materials do not mention the body of literature on how consumers have serious misunderstandings about DTC advertising. The following account is one such finding that potentially disrupts the empowered consumer frame.

[A]pproximately 50% [of respondents] thought that DTC advertisements had to be submitted to the government for prior approval, and 41% thought that only completely safe prescription drugs could be advertised directly to consumer" (Bell, et. al., 1999, p. 654--655).

Research findings such as the above are not addressed at all.

Titles of collected materials also emphasize the vision of the informed and powerful consumer. Such titles include Information Matters: The Consumer as the Integrated

Health Care System (Doc 8), Maximizing Patient Choice (Doc 77

14), and Advertising and the Informed Patient (Doc 11). The

"empowered consumer" theme consistently runs through the titles, potentially leading to the frame's reinforcement.

Finally, one should note the interlocked nature of the relationship between the first frame (DTC advertising is information) and the second (passive patients vs. empowered consumers). The following statement encapsulates this point.

DTC advertising empowers consumers. Oneof the primary economic principles underlying all advertising is the value of information. DTC advertising is part of a larger trend towards consumer empowerment over healthcare decision-making and greater consumer access to healthcare information (Doc l5~

DTC advertising empowers consumers because it is, more than anything else, information and therefore shares the same range of benefits that information holds within the overall modern economy. In turn, today's empowered (i.e., active, sophisticated, and knowledgeable) consumers feel more responsible for their health and therefore seek more health information. The following account describes the vision of empowered and responsible consumers that Pfizer provides.

Consumers shape their own health through dEt and exercise and prudent (and occasionally no~so-prudent) risk-taking and a panoply of other behaviors ... They decide whether and when to approach the formal health care system. They have a great deal of information about themselves - symptoms, experiences, behaviors, preferences. They share or withhold this information from health care practitioners. Actually, the consumer may be the best, or even only, integrator of care received across various elements of the health care system (Doc 8, p. 17).

The two frames are both sides of the same coin in the sense that they reinforce each other. It is impossible for 78

one to be effective without the other.

In sum, frame 2 presents a vision of the active, responsible consumer, which is then pitted against the vision of the passive, non-inquisitive recipient of health care service in the past. This frame has the potential to make DTC advertising appear more desirable to American people by appealing to their preference for individualism, which is known to be one of the cultural values that fundamentally characterize American culture (Steel & Redding,

1962) .

Frame 3: Maximum Benefits & Minimum Risks

Understandably, in the center of DTC advertising controversy is the debate over whether it has beneficial or harmful effects, potential or actual, upon pubic health. The third frame directly touches upon this dimension of the controversy.

The "maximum benefits & minimum risks" frame posits that DTC advertising is socially beneficial because it has more benefits than risks. This frame most directly supports the policy position that it should remain legal. It also lends itself to the argument that the FDA should relax its regulations over DTC advertising. The frame incorporates the following themes, which were located in the first reading 79

process.

1. DTC advertising makes the largely underdiagnosed population more aware of their health problems. 2. DTC advertising leads patients to better conform to their physician's advice. 3. DTC advertising makes patients more aware of a drug's side effects. 4. In contrast to the actual positive effects of DTC advertising, its negative effects are minimal and therefore can be ignored.

Elements of frame 3 emerge in all collected documents. The frame's high prevalence comes as no surprise because the fundamental message Pfizer intends to convey to the public about DTC advertising is that the new marketing practice benefits public health. Of all the documents, Doc 5, Doc 10, and Doc 12 allot the most space to promote frame 3.

Strategies that support this frame are relatively simple. Health benefits and risks of prescription drugs, by the very nature of the product category, are discussed mostly in scientific terms. Therefore, arguably the essential, if not the only, strategy to promote the frame is to highlight "new research studies, data, and analyses focused on measuring the impact of promotion and marketing on physician behavior, patient behavior, and the public's health" (Doc 2, p. 5).

However, the above self-evident approach can be slightly misleading. The essence of the strategies to promote this frame lies in how they "select" studies and the relevant literature to define the focus and represent the 80

studies' findings, and how they silence, or make less salient, other research findings that counter the frame. In this sense, one could reasonably argue that Pfizer frames the strategies it uses to promote frame 3 by depicting them as neutral and devoid of promotional intention.

The collected article What FDA Survey Showed About

Direct-to-Consumer Prescription Drug Advertising (Doc 7) exemplifies how advocates select and represent a study in an attempt to support the frame. Before citing the study's major findings, which apparently reveal the benefits of DTC advertising, the author sets up a lengthy context in which the research was conducted:

The FDA has an intense interest in direc~to-consumer advertising. It is the agency designated by Congress to regulate all prescription drug advertising, and it has done so with a level of rigor seldom achieved for any other form of advertising. The FDA also monitors a pharmaceutical's safety and side-effect profile after FDA approval. The FDA is deeply concerned with the accuracy and balance of direc~to-consumer advertisings effects on consumers, particularly with respect to information about potential side effects and other harms from prescription drugs, as well as its effects on relations among patients and physicians (Doc 7, p. 11).

The passage sets the credibility of the research first, before the author introduces its major findings. Because the

FDA study is depicted as most credible and its findings most believable, the document has the potential to lead the readers to believe that DTC advertising gives more benefits. than harms. Further, for the same reason the readers may become resistant to other research findings that counter 81

frame 3 and the FDA study's findings, that is, research findings that suspect DTC advertising's social benefits.

After the lengthy presentation of the context of the study, the article summarizes the study's major findings, such as: consumers are very much aware of DTC ads; DTC ads are similarly influential with friends, news stories, etc. in making respondents go to their physicians with a specific question, etc. (Doc 1; Doc 15; Doc 7). Again, the initial setting of the study's context can make the findings all the more credible.

Repetitive use of specific words and phrases, similar to the previous two frames, is an effective strategy to promote this frame. "Serve the public," "public interests,"

"consumer welfare," "public health interests," "surveys show," and "research indicates" are examples of the phrases running through the collected materials to convey the overall benefits of DTC advertising to society. Statements such as "DTC advertising is in the best interests of public health" (Doc 15) are generally placed before specific health benefits are mentioned.

To convey messages upon DTC advertising's specific health benefits, mostly scientific words are used, such as

"increased compliance," "increased risk-awareness," etc. The following passage is a typical way of presenting DTC' advertising's health benefits. 82

The high levels of awareness of and attention to DTe ads also strongly suggest that consumers gain informatin about the core topics of these ads [such as] symptoms of medical conditions, potential therapies, alternative dosages _. in particular, ads remind consumers take their medications and refill their prescriptions (Doc 12).

Overall, frame 3 conveys the message that DTC advertising presents more benefits than risks to the

American public in term of their health. Dealing with an essential part of the social debate over the new marketing practice, the collected materials confer maximum credibility upon the body of research that approves DTC advertising while ignoring or giving an ignorable amount of space to research that questions DTC advertising's value for society.

Frame 4: No Proven Economic Effects

Economic effects of DTC advertising are a major issue in the overall controversy. The aforementioned example about the race for the 2004 Democratic presidential nomination, in which candidate Howard Dean called for a ban on DTC advertising, indicates the seriousness of this issue.

A cursory look at Pfizer's public relations materials will reveal that it takes this issue seriously. For example, the Pfizer-published periodical on public policy is titled

Economic Realities in Health Care Policy, indicating that economic issues assume a priority in Pfizer's position building on health care issues. 83

Most collected materials incorporate the issue of DTC advertising's economic effects either intensely or tangentially. Against the criticism that DTC advertising increases health care expenditure by increasing drug prices,

Pfizer consistently uses the "no proven economic effects" frame. This is a frame that takes full advantage of the fact that there is no known research that proves the role of DTC advertising in boosting up drug expenditure or prices. The frame incorporates the following themes. These themes were located in the first reading process.

1. No research proves that DTC advertising increases drug prices for consumers. 2. Increases in drugs expenditure potentially contributes to public health because they imply that the under-diagnosed population are becoming more concerned about their health. 3. No research proves that the increase in drug expenditure is driven by increases drug prices. 4. The spending on DTC advertising can be recouped by increased sales volu~, hence no effects on drug prices. 5. Advertising in general has potential to decrease product prices.

All the collected documents except Doc 11 incorporate elements of this frame. Two articles, The Economics of

Direct-to-Consumer Advertising of Prescription Drugs (Doc 6),

The Economics and Impact of Pharmaceutical Promotion (Doc 3), almost exclusively deal with economic issues of DTC advertising. These titles suggest the importance Pfizer puts on applying basic rules of economics when expressing its position on DTC advertising's economic impact. 84

Pfizer takes this frame one step further. It nearly suggests the possibility that DTC advertising may have an effect of decreasing health care expenditure, because it can make consumers convert to "new and more effective" drugs and therefore prevent their health conditions from developing into more serious diseases. The following statement is an example of such stance.

An assessment of advertisings impact on spending [on health care], however, requires consideratbn of the other factors that drive pharmaceutical use_. Many studies have demonstrated the value of new and existing pharmaceuticals in terms of health improvement and avoidance of more costly treatment (Doc 6).

In fact, the aforementioned periodical Economic

Realities in Health Care Policy has an issue entirely dedicated to furthering the belief that newer drugs are more effective and therefore can have positive economic impact.

The titles in the issue are Pharmaceutical Innovation:

Lowering the Price of Good Health (Doc 4) and The Economic

Benefits of New Drugs (Doc 5). In summary, Pfizer promotes the position that DTC advertising potentially lowers the public's expenditure to maintain good health by providing access to pharmaceutical innovation.

Citing basic principles of advertising can be an effective strategy to support the above position, similar to the way Pfizer uses the discussion of the value of information in general in modern economy to argue that DTC advertising makes the same contribution to society. The 85

followings are examples of such strategy.

While advertising presumably will increase demand for a product, the cost of that advertising would usually be recouped through increased sales volume rather than through higher prices ... Advertising is an important catalyst for price and quality competition (Doc 6).

Fundamental economic principles suggest that, as a general rule, product advertising enhances competition, decreases profit margins and lowers consumer prices. Americans are spending more ffi health in general and drugs in particular, but DTC advertising is not the leading reason why (Doc 15).

In much the same way that the basic role information plays in the modern economy is addressed to deceptively spin DTC advertising as information rather than promotion, the discussion of the basic function of advertising in the modern economy is used in the above excerpts to insinuate the impression that DTC advertising may have the potential to decrease the American public's health care spending.

A number of words, phrases, and concepts are employed to convey this overall frame. They include "economic principles," "information society," "economy of scale,"

"efficiency," and "enhances competition," which are used to apply the basic rules of economics to imply DTC advertising has the potential to decrease drug prices. To emphasize that no research has found the link between the increase in drug expenditure and DTC advertising, argumentation generally begins with phrases such as "no research yet" and "no objective study," as noticeable in the following statement:

While this assumption [that DTC advertising increases drug prices] has a certain intuitive appeal, the 86

available evidence suggests that the story is more complicated and that in fact the opposite migt be true ._ More generally, economic theory suggests that there is no clear link between advertising for a product and the price of that product (Doc 15).

Overall, frame 3 starts with the defensive position that there is no proven link between the rise of DTC advertising and the increase in drug prices and the American public's health care spending. This frame is taken one step further where Pfizer implies that DTC advertising has the potential to decrease drug prices. The "fundamental rules" of economics were cited and applied to imply that DTC advertising can perform the same positive roles in American society as advertising does in general in modern economy, a strategy similar to the way Pfizer promoted frame 1.

The Overa~~ Frame

The study concludes that there are four frames in the

131 pages of collected public relations materials published primarily between 2001 and 2003. Pfizer organizes their rhetoric to support the practice of DTC advertising along the following four frames.

1. DTC advertising is information, rather than advertising, for access to medical innovation. 2. Instead of passivity that used to characterize patients in the past, the contemporary consumers, empowered with information, actively involve in the medical decision making process with their doctor. 3. DTC advertising has maximum benefits and ignorable potential risks. 4. No research exists that links DTC advertising to the overall increase in drug prices and health care expenditure. Instead, DTC advertising has potential 87

to decrease the cost of healthy living.

Together, the above four frames convey the overall message that DTC advertising benefits society because it empowers consumers with information, enabling them to be more active and responsible caretakers of their own health, or

"integrated health care systems," in the emerging health care market.

Each of the four overall frames appeared in most of the collected materials. This means that even though the collected documents have one or two foci of concern, they generally do not fail to weave together the 4 overall frames.

This point was especially true of frame 1, 2, and 3. Frame 4 tended to be treated separately from other frames. This appears to be because discussing economic issues involves highly theoretical and complex concepts and ideas derived from basic theories of economics.

One particular point that calls attention is that there are no clear-cut divisions between these four overall frames. A number of words, concepts, and phrases and persuasive strategies can be categorized as more than one frame. For example, concepts such as "informed consumer" and

"educated consumer" are the backbone of frame 2. However, one can reasonably argue that the concept of "informed consumer" necessarily incorporates the position that DTC 88

advertising should be treated as information, rather than promotion. In the second reading process, "informed consumer" was not categorized as frame 1, because it formed a more coherent and meaningful whole with other concepts such as consumer's reading capability," "passive patients," and "equal participation with physicians," rather than with

"OTe advertising is information."

This kind of judgment was conducted in the second reading process, which compared, contrasted, and collapsed the frames that had emerged in the first reading process.

This "compare and contrast" reading process is arbitrary to a certain degree, but one must admit that a degree of arbitrary categorization cannot be completely avoided in the qualitative use of frame analysis, or the inductive approach to breaking up the text into discrete frames. The following short excerpt is just one of many examples that reveal the interconnected nature of the four frames. In the excerpt, one will easily notice that messages that pertain to frame 1, frame 2, and frame 3 concurrently emerge.

Without these activities, many physicians would not know about new medicines, or new uses for existing medicines. In general, physicians do not readily seek out new therapies, and they have no requirement b inform themselves about new medicines. Marketing activities of drug firms are virtually the only means by which physicians learn about new drugs (Drug 14).

This project explored and illustrated how Pfizer builds their strategies along the above four frames. Public 89

relations practitioners cannot and should not ignore their business imperative to further the economic interests of the organization they represent. However, building their persuasive messages on sound and ethical principles should not be ignored either. Therefore, looking over Pfizer's strategies to support the four frames, public relations practitioners will have a chance to question if the company uses sound and valid argumentation to represent and support its policy position. However, more importantly, the findings of this study have important implications for consumers. By understanding Pfizer's framing strategies revealed through this study, consumers will have an opportunity to distance themselves from the persuasive messages to contemplate the messages' implications for their welfare and public health as well. 90

Chapter 5: Conclusion & Discussion

DTC advertising is an increasingly popular way of promoting prescription drugs. The new marketing vehicle, however, has been a cause of concern since its inception among physicians, politicians, and members of the public. In the center of the social controversy is the fact that prescription drugs are directly related to public health, and that consumers have limited ability to process information properly in DTC advertising.

Current practitioners of marketing communications stress that it is just as important to create a favorable marketing environment as promoting products to consumers.

This position reflects the general trend of marketing toward a more integrated approach to marketing communications. The approach also applies to pharmaceutical marketing communications (Schreiber, 1997).

Pfizer apparently assimilates the above IMC approach in that it actively addresses the social debate over DTC advertising. Throughout its web site, Pfizer makes it clear that it will be an active participant in the policy making process when it comes to the issues that directly involve the company's business interests. Pfizer clarifies that together with regulation of drug prices and patent 91

restrictions, it considers DTC advertising as a social issue

it needs to actively resolve (Our Voice, 2004).

This participatory approach also fits Pfizer's sense of

corporate citizenship. Pfizer defines its sense of corporate citizenship as:

Citizenship defines our role in local and global communities and how we strive to conduct business responsibly in a changing world. Being a good corporate citizen includes listening to, understanding, and responding to our stakeholders about their needs regarding Pfizer's policies and operations. Stakeholders are people or groups who affect, or are affected by, Pfizer's business activities. Our relationship with them is at the heart of our citizenship because they define what it means for Pfizer to create value (What is corporate citizenship, 2004).

Pfizer also defines its role in the pharmaceutical industry

in the following statement:

As the world's largest biomedical research and pharmaceutical company, with 122,000 employees in over 150 countries, Pfizer has a unique opportunity to be a good corporate citizen (Our role, 2004).

In sum, one can reasonably assume that Pfizer's participation in the pubic discourse on DTC advertising

reflects both the company's application of the IMC approach

and its will to listen to, understand, and respond to their

stakeholders to define its role in local and global

communities as a leader in the pharmaceutical industry (What

is corporate citizenship, 2004). As a result, Pfizer has

prepared, stored, made available a number of public

relations documents to promote its vision of the social

debate over DTC advertising. 92

Through an in-depth, qualitative analysis of Pfizer's

public relations documents, this project reveals how the

company tries to frame the public policy debate over DTC

advertising. In the process Pfizer also frames the overarching concept of who it is, thus setting the tone to a

controlled public discourse. The results indicate that

Pfizer's public relations materials have the potential to

lead consumers to approach the issue of DTC advertising

through a number of Pfizer-initiated perspectives,

encapsulated by the following four frames: DTC advertising

is information, passive patients vs. empowered consumers, maximum benefits & minimum risks, and no proven economic

effects upon drug expenditure. Through these four frames,

Pfizer ultimately conveys the fundamental message that DTC

advertising benefits society.

One can understand the message as reflecting both the

company's IMC initiative to create a favorable marketing

environment and Pfizer's willingness to fulfill its own

sense of good corporate citizenship as a leader in the

pharmaceutical industry. This enables one to infer that the

findings of this project could reflect the perspective and

interests of both Pfizer and the pharmaceutical industry.

As has been briefly mentioned, the findings of this

project have implications for society from a number of

perspectives. First, understanding Pfizer's framing 93

strategies will help public relations professionals judge

the strategies in terms of ethics as well as effectiveness.

More importantly, for consumers, the findings will lead them

to critically contemplate what the framing strategies imply

for public health.

The fundamental reason for which public relations

exists is to serve the business interests of the

organizations they represent. However, building their

persuasive communications on ethical principles should not

be ignored, as without these principles, business is not

well served. The most uncontroversial, if not the most

appropriate, way of judging the ethics of a public relations

campaign is obviously to investigate if the campaign

measures up to the standards established by the public

relations industry itself.

Public Relations Society of America (PRSA) has a code

of ethics. According to Johannesen (2002), the "core

principles and specific guidelines for each principle serve

as starting points for professional and public scrutiny of

ethical issues in public relations" (p. 189). Further, the

PRSA's membership statement speaks of professional values.

"These values are the fundamental beliefs that guide our

behaviors and decision-making process. We believe our

professional values are vital to the integrity of the

profession as a whole" (Johannesen, p. 190). Of all the 94 values, the following two are the most appropriate for application to this study.

1. Advocacy a) We serve the public interest by acting as responsible advocates for those we represent. b) We provide a voice in the marketplace of ideas, facts, and viewpoints to aid informed public debate.

2. Honesty a) We adhere to the highest standards of accuracy and truth in advancing the interests of those we represent and in communicating with the public.

3. Fairness a) We deal fairly with clients, employers, competitors, peers, vendors, the media, and the general pblic. b) We respect all opinions and support the right of free expression (Johannesen, 2002, p. 190).

First, in terms of fairness, Pfizer uses some questionable rhetorical strategies. The most salient of these strategies is that Pfizer provides such a limited space to criticisms of OTe advertising that the company is in no position to rebut these criticisms in a fair manner.

Regarding many issues, the company presents only position statements and does not cover any opposing perspectives In any comprehensive manner at all. In other words, the company attacks critic's points without ever fully explaining them.

The following passage represents one such strategy.

Critics of DTC advertising contend that [DTC] ads prompt consumers to demand that their doctors isue prescriptions for specific drugs - and that those physicians comply without regard to either their professional judgment or knowledge of alternatives. The empirical record contains no meaningful evidence to substantiate this contention... Multiple studies corroborate that most consumers who consult their doctor about advertised drugs are seekingmore information about underlying condition and available treatment (Doc 1, p. 28).

Why critics are concerned about how patients might pressure 95

their doctor is never explained in any comprehensive manner.

Instead, the article criticizes the critics' concern in a

single-handed manner in the statement that the "empirical record contains no meaningful evidence to substantiate this contention" (p. 28). Pfizer does not provide any standards about when and how one can consider a body of evidence as meaningful or not. Therefore, one may argue that the passage makes the wealth of literature (e.g., Bell, et. al., 1999;

Kravitz, 2000)running against Pfizer's position appear meaningless without actually citing them or explaining why

they are meaningless. Certainly, Pfizer should introduce and

explore major arguments from critics more thoroughly. Only

then will the company find itself in a legitimate position

for counterattack.

Second, a related problem is that Pfizer's public

relations materials often present false, or at best misleading, information. For example, Manning and Masia

state "only a product's scientifically proven capabilities,

verified by strict regulatory agencies, can be used in its marketing" (Doc 2, p. 4).

The statement is not true. The FDA does not have legal

authority to screen the content of DTC advertisements before

they reach consumers, a point that many consumers do not

understand (Bell, et. al., 1999). In fact, many

pharmaceutical advertisements receive warning letters from 96

FDA each year for the reason that they misrepresent and exaggerate drug effects and therefore could mislead consumers. Some advertisements have been forced to withdraw from the market after they reach consumers (Bell, et. al.,

1999) .

Third, use of truism also appeared to be somewhat misleading. For example, discussing how DTC advertising can lead to increase in the quality of health care, the article

The Economics of Direct-to-Consumer Advertising of

Prescription Drugs (2001) quotes the following excerpt from a statement by the FDA: "We believe that truthful and non­ deceptive DTC advertising can contribute to consumers' health information environment and consumer welfare" (p. 8)

Most critics express their concerns about DTC advertising because they see many DTC advertisements as deceptive and misleading. In this context, the point that "truthful and non-deceptive advertisements can contribute consumer welfare" not only lacks any type of substance but also is misleading.

Fourth, there is a serious logical gap between enumerating general values of information and arguing that

DTC advertising helps the pubic because it is information.

One can summarize the position as the following misleading

syllogism that Manning and Masia (What is Information Worth?

2003) use. 97

1. Information presents a number of benefits to society. 2. OTC advertising is also information. 3. Therefore OTC advertising presents the same range of benefits to society.

The article's discussion of the general values of information in a modern economy does not have any specific social and cultural context. In other words, the concept of

"information" that they constantly take advantage of is held within the most pristine condition. One can never use the ideal-type, context-less, neural concept of "information" to insinuate that a certain type of advertising is good because it also is information.

One can argue that DTC advertising is not so much information per se as promotion of drugs through a series of strategic and selective presentation of information. One should incorporate such contextual aspects of a type of releasing information to be in a legitimate position discuss its effects on society.

Ethical considerations help ascertain if a certain public relations campaign is acceptable or unacceptable from the industry's collective and agreed-upon set of standards.

However, discussions of ethics do not encourage a full range of discourses upon the practice's social implications. A communication campaign's social ramifications can move beyond the scope of the industry's professional ethics or a campaign's success from a business perspective. 98

A message, just because it is constructed as open and

fair, (which are values of proper ethics) does not guarantee

that it will not have questionable social implications.

Truth and fairness are necessary, but not sufficient

conditions for a message's positive impact. This point

becomes more apparent especially when one places Pfizer's

rhetorical strategies to frame DTC advertising amongst the

complex network of public communications that the

pharmaceutical industry employs to sell drugs and to create

a more favorable marketing.

Pharmaceutical companies employ a wide spectrum of marketing communications, including advertising and public

relations, to promote their drugs. At the "short-term" end

of the spectrum, they advertise their drugs to doctors and

also directly to consumers.

However, consumption is not the only thing

pharmaceutical companies promote through their marketing

communications. Around the mid-point of the spectrum of the

persuasion network, to better promote their drugs, the

industry ultimately has to sell the idea that drugs are

potentially more effective and efficient treatments than

others for various health conditions. They achieve this goal

through public relations campaigns.

At the "long-term" end of the wide spectrum of

persuasive communications, one can place Pfizer's rhetorical 99 strategies to promote the idea that DTC adverting benefits society and therefore influence public policy over the new marketing practice in their favor. Through such communications, the industry wants to make the public more receptive to their drug promotions and the way the industry communicates such promotional messages.

The important notion that one has to keep in mind is that all the above three levels of pharmaceutical marketing communication occur concurrently. Altogether, about the overall issue of health, disease, and recovery, the communications can combine and potentially induce a "drug- oriented frame of thinking" in people's mind. This study conceptualizes that frame of thinking as the following:

1. Drugs are more effective and efficient ways of treating diseases. 2. It benefits and empowers consumers to have information on drugs, wherever such information may come from. 3. DTe advertising is one channel to get such information.

Without question, this frame of thinking is more conducive to the idea that DTC advertising should remain legal and unregulated. Through the wide range of communications, the pharmaceutical industry has the potential to drive American society toward the predominance of such drug-centered frame of reference in thinking about issues of health, disease, and recovery. 100

A number of critics have expressed concerned, directly or indirectly, with the ways the aforementioned different levels of promotional communications may combine to create synergistic effects on society. An example, anti-depressants, will help explain why critics question the way the pharmaceutical industry promote psychotropic drugs.

Along with advertising for other drug categories, DTC advertisements for anti-depressants often appear in popular consumer magazines such as Time, Newsweek, and Reader's

Digest. Concurrent with the public communications to promote specific drugs, the pharmaceutical industry attempts to induce the idea that drugs are more effective and efficient, both health-wise and cost-wise, than other treatment options.

Valenstein (1998), for example, presents an account of how the pharmaceutical industry's public relations campaign promotes not only drugs but also bio-chemical theories of mental illnesses to both doctors and consumers.

The truth is that we still do not know what causes any mental disorder or how drugs sometimes help patients get better. Yet, despite this, the theory that mental disorder arises from biochemical imbalance is widely accepted. I believe this is partly because few people, including mental he~th professionals, have the time, inclination, or background to critically examine the [biochemical] evidence and partly because powerful special interest groups have influenced the way people think about drug treatment and mental disordersThe pharmaceutical industry spends enormous sums to influence the opinions and behavior of both physicians and the public, and the effectiveness of their marketing strategies cannot be overestimated (Valenstein, 1998, p.165) . 101

Along with such public relations to promote the bio-

chemical theory of mental disorders, the pharmaceutical industry also promotes the message that it benefits consumers to be more receptive to the industry's persuasive messages, including DTC advertising. The four overall frames that Pfizer employs to promote the marketing practice of DTC

advertising consistently conveys the message that it benefits consumers to be more receptive. In other words, the

ideas that DTC adverting is neutral information (frame 1)

and that consumers have enough sophistication to process medical information in DTC advertising for better decision- making (frame 2) persuade the public to be more receptive to

pharmaceutical promotion. Likewise, the ideas that DTC

advertising has maximum benefits with ignorable risks and

that its economic impact is largely unproven are conducive

to the message that it benefits consumers to be more

receptive. Concurrently, the content of DTC advertising may

reinforce, directly or indirectly, the bio-chemical theory

to sell anti-depressants.

Of potential consequences of the synergy of such multi-leveled pharmaceutical marketing communications,

Gardner (2001) presents the following statement:

consumers are led toward bi~psychiatric treatment - especially antidepressants - by depression treatment propaganda (made available to them through doctors and consumer depression sources) suggesting that depression in general should be treated with bi~psychiatric therapies _. numerous studies, including the most recent 102

large scale NIH study, contend that thoughmajor depression is best treated with a combined treatment of anti-depressants and therapy for many, minor depression is well-treated by psychotherapy alone. In most cases of diagnosed depression, however, ant~depressants are prescribed as part of the treatment package (pp.12-13)

The above account is only one of many examples of the potential social implications of the integrated pharmaceutical marketing communications. In addition, to fully understand the persuasive messages' potential influences one should also consider the fact that consumers in the contemporary American society are more and more interested in seeking health information. For example, numerous studies conclude that American consumers often refer to advertising as a source of health information, especially since pharmaceutical companies started to heavily engage in DTC advertising for prescription drugs from the late 1990s (Bell, Wilkes, Kravitz, 2000; Calfee, 2002;

Sorofman, 1992; Terzian, 1999).

All in all, today's marketing landscape is characterized by integrated marketing communication, which also appear to apply to pharmaceutical marketing communication. At the other end of the spectrum, consumers' feel increasingly more responsible for their own health and as a result, they are more actively pursuing health information. The two phenomena imply that it is now time for critics and consumers to keep a critical distance from the contemporary burst of medical information, including the 103

growth of DTC advertising, and contemplate what messages the

pharmaceutical industry's convey to society about health,

disease, and recovery. For example, through a frame analysis

of public relations materials produced by Pfizer, this project suggests that the company's strategies to support

DTC advertising have the potential to propel and perpetuate

the predominance of drug-oriented frame of thinking in the

public's thinking about health, disease, and recovery.

Considering the importance of public health as a social

issue, more research has to come to critically analyze the messages about health and disease that the pharmaceutical

industry conveys to society through a variety of its profit­ motivated communications.

Suggestions for Future Research

Based on the literature review on DTC advertising, the

following suggestions are made to enrich future research.

First, DTC advertising research should consider a wider

range of concepts and variables. Research should include not

only people's rational processing of medical information but

also their reaction to the emotional appeals use in DTC

advertising. Research should incorporate not only impact on

doctors' and consumers' perception of DTC advertising and

specific drugs and drug categories, but also more 104

fundamental beliefs about health, disease, recovery, and alternative modes of treatment. Future research should investigate how consumers' reaction to DTC advertising is mediated by demographic variables, as well as their preexisting attitudes and beliefs about medical profession and pharmaceutical marketing communications. In addition, critical scholars should question how DTC advertising depicts social groups and how these depictions affect the public's beliefs and expectations about the disease categories and the targeted social groups.

Second, simple reporting of the measurements of variables (e.g., simply measuring and reporting how correctly consumers retain information DTC advertising) deserves attention, because it is equally, if not more, important to generate a model that incorporates how these variables are associated to explain their relationship to each other and predict possible important phenomena. Such models, preferably guided by generic theories of persuasion, can contribute to a more comprehensive understanding of DTC advertising.

Last, future research should conceptualize DTC advertising that pays attention to the complex persuasion networks that the pharmaceutical industry engages in to promote drugs, which they create and manage within a marketing environment conducive to advancing their profit 105 margins. Current marketing communications are characterized by the integrated communications landscape. Therefore, researchers should note that consumer-targeted advertising, doctor-targeted advertising, doctor-targeted sales promotion, and public relations practices, including its efforts to influence public policy over DTC advertising, all interact to produce multiple social consequences.

The current project exemplifies an attempt to enrich scholarly discourses on DTC advertising by dealing with a topic that the current literature fails to incorporate. It explored the rhetorical strategies Pfizer uses to frame the public debate over DTC advertising in favor of its business interests. It concluded by discussing the rhetorical strategies' potential to interact with other pharmaceutical communications and instill a drug-centered frame of thinking in people's mind in the matter of health, disease, and recovery.

Despite a meaningful attempt to enrich social discourses on DTC advertising, this project has a number of significant limitations. First, it derives Pfizer's rhetorical strategies to frame DTC advertising from various public relations materials located in the company's main website. Pfizer invites consumers to visit their website in their DTC advertising. Thus one can reasonably expect that consumers have an opportunity to Pfizer's rhetoric to 106

promote DTC advertising. However, exactly how many consumers

are exposed to the messages and how they respond to them are

untraceable. Second, more importantly, posting their position on the issue of DTC advertising on their website is

only one of many possible public relations efforts to promote DTC advertising. To investigate if Pfizer's messages

actually reach a large number of consumers, one may have to

analyze the company's media relations activities. An

especially important issue in this aspect is what kind of media relations techniques Pfizer employs to get the media's

attention. How the media respond to the way Pfizer frames

the public debate over DTC advertising is also an important

issue. Future research on the pharmaceutical industry's

campaign to promote DTC advertising should incorporate the

above points in its research agenda. 90

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