SYLVIE DOUGLIS, BYLINE: This is PLANET MONEY from NPR.
SARAH GONZALEZ, HOST:
So a few months ago, a bunch of people in England tuned in to some good old live, complete with commercials U.S. TV.
PETRA DIAZ: Obviously, it was the royal interview with Prince Harry and Meghan.
MARY CHILDS, HOST:
Petra Diaz (ph) is in South Hampshire, England, where the Meghan Markle-Prince Harry-Oprah interview was going to air the day after it aired in the U.S.
GONZALEZ: So Petra and a bunch of other Brits tuned into U.S. TV so that they could get all the royal tea in real time.
(SOUNDBITE OF TV SHOW, "OPRAH WITH MEGHAN AND HARRY")
OPRAH WINFREY: Wait, hold, hold up. Wait a minute. Your family cut you off?
HARRY: Yeah, in the first half - the first quarter of 2020.
GONZALEZ: And aside from all the royal palace bombshells, there was this one thing that really stood out to Brits about U.S. television - the commercials. They were not like commercials in England.
DIAZ: Very, very pushy, very salesy, you know, buy this, do it now, whereas here it's like they tend to be a bit more sort of jokey.
CHILDS: Petra remembers seeing an ad for some kind of medicine, and she was like, OK, that's a little odd. But then there was another one.
DIAZ: It was for sort of an ailment that would have been really serious, so either, like, chronic something pain or whatever it was, but it was a very in-depth commercial about it. And I thought, this is dramatic, yeah.
GONZALEZ: All over Twitter during this Oprah interview, British people are saying the same thing. What is the deal with all of these medicine ads in the U.S.? Because England doesn't allow commercials for prescription drugs.
DIAZ: And it never even crossed my mind that medicine was for - like, was promoted. I didn't - it did not even cross my mind that that was a thing.
CHILDS: Brits were like, you lot get bombarded like this daily? And American medical adverts are some real dystopian [expletive]. And like, how is the cream for your joints going to give you cancer? These are all real tweets.
GONZALEZ: Yeah. Brits had a lot of fun with the side effects.
CHILDS: Petra was tweeting too, and she couldn't tell who the ads were even for, really.
DIAZ: So I didn't understand if the adverts are to sell the medicine to the public. And somebody replied to a tweet saying it's not to sell it. It's so that you go to your doctor and convince them to give that to you, which is the strangest, strangest thing I could think of.
GONZALEZ: One of the tweets was like, hold on, hold on, hold on. You are supposed to go to your doctor and tell them what you need? Like, that is weird.
DIAZ: Yeah, no, people had no idea.
GONZALEZ: So many people outside of the United States were like, what the heck is going on over there in America? Because while there are ads for over-the-counter drugs in most of the world, the U.S. and New Zealand are the only two countries that allow drug companies to advertise prescription drugs directly to consumers.
(SOUNDBITE OF MUSIC)
GONZALEZ: Hello, and welcome to PLANET MONEY. I'm Sarah Gonzalez.
CHILDS: And I'm Mary Childs. Commercials for prescription drugs do not exist in Europe or South America or Asia or Africa or Mexico or Australia, just in the U.S. and New Zealand, which is a much smaller market. And we are just not going to get in to New Zealand.
GONZALEZ: Today on the show, how the U.S. got here and what all these ads do to us as consumers.
(SOUNDBITE OF MUSIC)
GONZALEZ: It wasn't too long ago that TV in the U.S. was like the rest of the world, completely free of prescription drug ads. The '60s, the '70s, most of the '80s, there are no ads like this.
LOU MORRIS: There was no advertising to the public, I mean, not for prescription drugs.
CHILDS: Lou Morris worked on drug advertising for two decades at the Bureau of Drugs at the FDA, the Food and Drug Administration.
GONZALEZ: And drugs have always been heavily advertised, but back then, this is how drug companies got the word out about new prescription drugs. Salesmen would knock on a doctor's door like, have you heard of Motrin? - this is back when Motrin was prescription only - please allow me to tell you about it. Drug companies could also put ads in medical journals, so if you looked at a medical journal, you'd see a regular-looking ad for, like, Motrin. Maybe the ad's in color. But behind the ad was pages and pages of science and risks and disclaimers about the drug.
MORRIS: The mechanism of action, the indications, the side effects, the warnings, the precautions, you know, the toxicology.
CHILDS: Lou says this disclaimer was euphemistically called a drug's brief summary. It was mandatory, required by the FDA, so the doctors would understand all the science behind a drug before prescribing it to anyone.
GONZALEZ: By the '80s, though, Lou says drug companies started saying, we don't want to advertise our drugs just to doctors and pharmacists anymore. We want to market our drugs directly to consumers. So they start approaching Lou and others at the FDA to try to feel out what the rules might be for them.
CHILDS: Lou says, they had all kinds of concerns. He remembers this one pharmaceutical company, Ciba-Geigy, that wanted to make an ad for a new drug for high blood pressure.
MORRIS: Yeah, pitching an advertisement. And we - I mean - and we didn't like it at all (laughter).
GONZALEZ: What didn't you like about it?
MORRIS: Oh, it was terrible (laughter). It was - I don't know if I - I'm not sure...
GONZALEZ: Can you give me, like, a general sense?
MORRIS: I'm not sure I can disclose that. But I mean, it was - it really - it really pissed off the commissioner.
GONZALEZ: You - I wish so badly that you could tell me what this commercial was like.
GONZALEZ: Lou's going to be back in a bit. But Lou was not going to spill the beans, so I found Lou's old boss at the FDA, Peter Reinstein.
PETER REINSTEIN: Let's see. Can you still hear me?
GONZALEZ: Yes, I can.
Peter was also in the pitch meeting for this ad for the high blood pressure drug. And Peter says the most common drugs for high blood pressure at the time, when given to men, had a known side effect of impotence. And Ciba-Geigy wanted to be like, our drug doesn't do that - not as much.
REINSTEIN: As I recall, the would-be Ciba-Geigy ad had a tagline that went something like - and Dolores likes it, too.
GONZALEZ: And Dolores likes it, too?
REINSTEIN: It was something like that. Don't quote me on that being the exact words. But Dolores was the name.
GONZALEZ: That - Dolores, that was the big state secret that Lou just couldn't get out.
CHILDS: OK. Peter says there were mixed reactions at the FDA about this proposed ad.
REINSTEIN: People found it amusing. The commissioner did not.
GONZALEZ: He thinks this is just, like, tacky, not tasteful. Or do you have a sense of why he didn't like this?
REINSTEIN: Art Hayes was...
GONZALEZ: A prude?
REINSTEIN: He was quite a religious man.
REINSTEIN: It just, I think, offended him.
GONZALEZ: OK, back to Lou. It wasn't just that the ad was too suggestive. Lou says the FDA was worried that ads targeted directly to consumers would trivialize prescription drugs.
MORRIS: They treat them like candy and not be as respectful as they needed to be or concerned about the drug's side effects and risks - and this ad was in that vein.
CHILDS: The FDA was also concerned that drug companies would start promising, like, miracle cures.
MORRIS: You know, that - take this drug, and all of a sudden, you'll be great. It'll make you better, you know, and that's not the way drugs work.
CHILDS: And the FDA was worried about how commercials would impact demand for drugs - misuse, overuse, all kinds of things. But there were compelling reasons to go directly to consumers.
GONZALEZ: Like, right around this time, Merck had developed this new pneumonia vaccine. And they were like, listen; the people who need this pneumonia vaccine are healthy people over the age of 65. But healthy people over 65 might not be going to see their doctors that much, so they have no way of finding out about this vaccine. We need to go directly to them.
CHILDS: So in 1981, the first direct-to-consumer ad runs in print in Reader's Digest. And just like in ads in medical journals, the print ad needed to include a long, thorough list of disclaimers.
GONZALEZ: And this disclaimer rule is kind of what kept TV commercials from happening because if you were running a 30-second TV ad, how could you possibly squeeze in all of this extra disclaimer information?
CHILDS: Enter Liz Moench, a Brit, actually, and the first person to finally get a drug ad on U.S. television - when she was just 23.
GONZALEZ: So young.
LIZ MOENCH: Yeah. Looking back, I didn't feel young. I felt very sure of myself.
CHILDS: Liz was working for a British drug company called Boots that had a U.S. office.
GONZALEZ: Boots had discovered this fancy new drug called ibuprofen, also prescription-only back then. And Boots had let this other company sell ibuprofen in the U.S. under the brand name Motrin. Motrin was really successful, so Boots decided to sell their own version in the U.S. under the brand name Rufen.
CHILDS: Selling Rufen through a TV ad was Liz's big project.
MOENCH: Oh, right from Day 1, it was to be charged with looking at going direct to consumer.
CHILDS: She's looking at FDA regulations like, OK, what can I do here? There must be a way.
MOENCH: And there wasn't anything that said you could not go advertise to patients.
GONZALEZ: Now, OK, yes, there were FDA rules about how to advertise prescription drugs. You know, the risks, the side effects - you have to disclose them. But those rules had only ever really been applied to ads targeted to doctors, not to consumers, except for that pneumonia vaccine ad. No one had applied the rules to a TV ad because no one wanted to get dinged by the FDA. But Liz and Boots, they were like, we're going to take that chance.
CHILDS: On May 19, 1983, Liz and Boots run their ad on a few stations in Florida. There was actually a Wall Street Journal article about the whole thing.
MOENCH: That's where we told the entire world, today these ads are airing in Florida. And we knew that the FDA would be reading this at exactly the same time.
GONZALEZ: Oh, the FDA was reading this. And the next day, they told Boots, pull the ad.
CHILDS: At the time, the FDA said that the ad made false and misleading claims.
GONZALEZ: Liz says the FDA was opposed to a line in the ad that called Rufen the original ibuprofen because it implied that Rufen was superior to Motrin when they were chemically equivalent. Also, the original ad had flashed a long list of ibuprofen's side effects across the screen really quickly, and the FDA said there was no way the consumer would be able to read all those side effects.
CHILDS: So the ad came down. But Liz and Boots had anticipated this. They had a backup ad, a modified version that the FDA couldn't say no to.
GONZALEZ: The CEO of Boots is standing by a chalkboard in a suit, very not amusing, very non-Dolores-likes-it-too vibes.
MOENCH: On camera, he says, if you're one of the many people who take the prescription drug Motrin, you should ask your physician or pharmacist about Rufen.
(SOUNDBITE OF AD)
UNIDENTIFIED PERSON #1: You should ask your physician or pharmacist about Rufen. They will tell you that both Motrin 400-milligram tablets and Rufen 400-milligram tablets are different brand names for the same drug, ibuprofen.
MOENCH: ...Are different brand names for the same drug, ibuprofen.
(SOUNDBITE OF AD)
UNIDENTIFIED PERSON #1: There is only one important difference. Rufen can cost you considerably less.
MOENCH: Rufen can cost you considerably less.
CHILDS: That was the ad.
MOENCH: That was the ad.
CHILDS: For Liz, it was a big moment.
MOENCH: Oh, euphoric.
GONZALEZ: And here was the brilliance of this boring ad. The problem with making a TV ad had always been those mandatory disclaimers. But under FDA rules, drug companies had always been able to do these reminder ads to doctors where they just said, hey, remember Motrin? We're still here. We don't need to tell you anything about the drug. It's just a reminder ad.
CHILDS: And if you do one of these reminder ads where you don't say what a drug is for, you actually don't have to include the disclaimers, and the people taking Motrin already knew what they were taking Motrin for.
MOENCH: So they knew what it was for. We didn't have to explain all the side effects and all of that information.
CHILDS: At this point, drug makers, the FDA, everyone can see that more of these ads are coming. And Lou - Lou who was at the FDA - he says a lot of the big drug companies actually didn't want ads like this.
MORRIS: I mean, it costs a lot of money to advertise products on television, so they were concerned that if your competitor did it, then you would have to and it would cost them a hell of a lot of money.
GONZALEZ: But it was kind of hard for the FDA to stand in the way of these ads because of our whole freedom of speech thing.
CHILDS: Which actually, at the time, was becoming even more of a thing - because in the 1970s, courts were starting to protect commercial speech in ruling after ruling.
MORRIS: And we thought, given the First Amendment, that companies did have the right to advertise unless there was a strong public interest or view that it would be harmful. And we couldn't come up with that determination.
CHILDS: But Lou says they do decide to study TV ads so they can give drug companies some clear guidance about what the ads could say. So they make a series of fake TV commercials to see how consumers would respond.
GONZALEZ: Lou says that what the industry wanted was for the ads to just include some general disclaimer like, talk to your doctor about potential risks - simple.
MORRIS: But we found out when we developed these test ads, that wasn't interpreted as risk information. It was interpreted as a reassurance that, oh, I don't have to worry about the drug because my doctor will take care of me.
GONZALEZ: Saying ask your doctor about whatever drug apparently just confirmed to people that the drug was safe.
MORRIS: And that's not the interpretation we wanted.
GONZALEZ: Lou says he and the FDA decide these commercials need to say, out loud, the major risks of a drug.
So are you the reason why TV ads for drugs have that long list of, like...
MORRIS: Yeah, blame me. You can blame me.
GONZALEZ: ...All the side effects. OK.
MORRIS: It's my fault. I did it.
CHILDS: Lou and the FDA basically decided that the rules that had applied to advertising to doctors should also apply to consumer ads. Lou's old boss remembers this resulting in commercials with really long, slow scrolls of side effects, which kept TV ads from taking off. But then, in 1997, the rules get clarified. Now it was pretty clear that you just had to include the major risks of a drug, along with places where consumers could get more information about the drug, like a phone number or a website or a recommendation just to talk to your doctor. And this is what really opens the TV ad floodgates.
(SOUNDBITE OF MONTAGE)
UNIDENTIFIED PERSON #2: Side effects may include dry mouth and difficulty sleeping...
UNIDENTIFIED PERSON #3: Notice swelling of face, mouth, throat or a rash...
UNIDENTIFIED PERSON #4: Abdominal pain and yellowing of the skin or eyes...
CHILDS: In 1997, drug companies spent $300 million on TV ads. By '98, it was double that - 600 million. And by 2000, we were in the billions - $1.57 billion on TV drug ads.
(SOUNDBITE OF MONTAGE)
UNIDENTIFIED PERSON #5: Inability to move while falling asleep or waking up.
UNIDENTIFIED PERSON #6: Ulcers, which can occur without warning and may cause damage.
UNIDENTIFIED PERSON #7: Serious, sometimes fatal bleeding.
UNIDENTIFIED PERSON #8: Can lead to coma or death.
UNIDENTIFIED PERSON #9: And may be fatal, risk of death or stroke, increased risk of death.
CHILDS: So how do these ads affect the cost of drugs, and did all of this make the U.S. prescribe more drugs? That is after the break.
(SOUNDBITE OF NIKLAS ROLD EDBERGER'S "GRAFITTI GRIN")
CHILDS: After 1997, when the direct-to-consumer pharma ads floodgates opened, a bunch of people, economists and public health people, all wanted to study the effects of these ads. One of those people was Julie Donohue at the University of Pittsburgh.
JULIE DONOHUE: I was just fascinated by the rise of this new kind of promotion and the debate that ensued about whether or not it was appropriate.
GONZALEZ: One of the biggest questions was, do ads make us take more drugs?
DONOHUE: I think it's clear that we are using more medicine because of direct consumer advertising. And in fact, that's what it's designed to do.
CHILDS: Right. Like, that's what ads do. They encourage us to buy things, and we do. So there are actually studies that back this up, that show that doctors have changed their prescribing behavior, that they are prescribing us more drugs. This is one of the things that the FDA was looking into 40 years ago.
GONZALEZ: But people like Liz Mensch, who got the first drug ad on TV, they say, listen; if a doctor feels bullied into prescribing a drug to someone, that's a problematic doctor. They should be the gatekeepers.
CHILDS: And Julie says prescribing more medicine isn't universally bad. Say you're depressed. But maybe this was 20 years ago, and we weren't really talking about depression, and you're not getting any treatment for it. You see that commercial with the cute, little sad blob blobbing all around. And you're like, oh, maybe I'm sad. Maybe this is a thing. Maybe I should ask my doctor about it.
DONOHUE: I think advertising can both exacerbate problems with overmedication or overtreatment and help problems with undertreatment. We have both things going on at the same time.
GONZALEZ: Another big question - do ads drive up prices? 'Cause, like, if drug companies are spending billions of dollars on TV ads, are we the ones paying for those ads every time we get a prescription?
CHILDS: Julie says there is some evidence that the ads increase prices.
DONOHUE: Although not in the way that people usually think about it - advertising shapes perceptions around the benefit of a drug.
CHILDS: Drug companies don't just blow a ton of money on advertising and then pass the cost to consumers. It's more subtle. It's more us. When we see an ad for some brand-name drug, the ad makes us value that brand name. And when we value something, we will pay more for it - or at least we will ask our insurance company to pay more for it.
DONOHUE: All of the economic evidence, both theoretical and empirical evidence, on how prescription drug prices are set is that they're a function of what consumers or payers are willing to pay.
CHILDS: So we go into our doctor's, and we ask for the fancy drug when sometimes, often, there's an actual identical, cheaper drug under a different name.
GONZALEZ: And if you think about it, in the rest of the world, where these prescription drug ads are banned, consumers do not hear drug names every time they turn on the TV. So brands don't have the same power to get consumers to pay more.
CHILDS: OK. So these direct-to-consumer ads, they are in our faces all the time, and they definitely change some things about our behavior. But the people we talked to say the ads that we don't see affect us way more.
GONZALEZ: Because the old way of advertising, the someone knocking on a doctor's doorway, that kind of advertising still goes on today - and those conversations are all behind closed doors.
CHILDS: Pharma companies spent $6 billion on TV drug ads in 2016, but they spent $20 billion advertising directly to doctors, pushing drugs that we don't see on TV, like the addictive ones. This is how those drugs get sold.
(SOUNDBITE OF JAMES ROBERT JOHNSON KIRK AND JAMIE WESTGARTH SHIELD'S "AFTER HOURS")
GONZALEZ: Today's show was produced by Dave Blanchard and edited by Molly Messick.
CHILDS: It was mastered by Isaac Rodrigues, and our supervising producer is Alex Goldmark. Huge thank-you to Meredith Rosenthal at Harvard and a big thank-you to Dylan Scott at STAT News. He wrote a great article on Liz a few years ago. I'm Mary Childs.
GONZALEZ: And I'm Sarah Gonzalez. This is NPR. Thanks for listening.
(SOUNDBITE OF JAMES ROBERT JOHNSON KIRK AND JAMIE WESTGARTH SHIELD'S "AFTER HOURS")
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