4 questions | Applied Sciences homework help

1. Barrett S. The unhealthy alliance: Crusaders for “health free- dom.” New York, 1988, American Council on Science and Health.

Advertising And Other PrOmOtiOnAl Activities The public is constantly being bombarded by those who wish to pro- mote their own views, sell a bill of goods, convert others to a cause, or convince us that they have discovered a special truth or have found a unique road to salvation. Paul Kurtz, Ph.D.1 All things should be laid bare so that the buyer may not be in any way ignorant of anything the seller knows. CiCero Freedom of speech doesn’t give a person the right to shout “fire” in a crowded theater. . . . Nor should it give con artists the right to promote health frauds through ads in print or on the air. Yet, health fraud lives and thrives . . . because of successful advertising. roger Miller2 FDA Consumer, 1985 © medical economics, 1985 “I like it, Blitherington. Now come up with a product.” Chapter Four Part One Dynamics of the Health Marketplace46 The prevailing philosophy of our free-enterprise system is based on the profit motive. It permits sellers to supply what consumers want and buyers to select the products they believe will be advantageous. In the health marketplace, consumers should regard promotional activities cautiously. Although advertising can supply useful information, intelligent consumers should follow the principle of caveat emptor (let the buyer beware). Business leaders view promotion in different ways. Some say that advertising has the obligation to commu- nicate messages clearly, accurately, honestly, and with interest and impact. Others have said that “the solution to marketing problems is not one of giving consumers what they want, but rather to make consumers want what we, the marketers, want them to want” and that advertis- ers are “concerned not with finding an audience to hear their message, but rather with finding a message to hold their audience.” William Lutz,3 author of Doublespeak, states that “the job of advertising is to make something out of nothing.” Mainstream physicians and hospitals tend to market their services more conservatively than the business community, but abuses exist among them also. Advertisements are not the only form of promotion. Many sellers spread their messages through the news and entertainment media. Some entrepreneurs host their own talk shows. Multilevel marketers spread their ideas from person to person. Many people hawk their wares through books, lectures, Web sites, computer newsgroups, and press conferences. This chapter describes how advertising and other marketing activities can mislead consumers. It also examines problems with the advertising of mail-order health products, professional services, drug products, foods, dietary supplements, homeopathic products, exercise and fitness products, weight-control products and services, and tobacco products. PsychOlOgic mAniPulAtiOn The business world uses insights from psychology and other social sciences to manipulate consumer behavior. Many companies base their marketing strategies on re- search that determines what governs people’s choices. Armed with such knowledge, advertisers can often persuade people to buy things in a predictable manner. Cosmetics manufacturers, for example, are not sell- ing merely lanolin, but fantasies involving attractiveness. Women who normally would pay less than $1 for a bar of soap might be willing to pay much more for a skin cream they hope will make them more attractive (see Chapter 18). Purchasers of a cosmetic alleged to remove wrinkles are seeking everlasting youth and social ac- ceptance. Shampoo buyers may be hoping for romance. For decades, cigarette ads used images of youth, health, vigor, and social acceptance to convey the op- posite of what cigarette smoking will do to smokers. A widely aired series of television ads has portrayed coffee as a valuable aid to friendship and romance. Many ads link alcoholic beverages to success, sociability, elegance, relaxation, romance, and adventure. Many ads offer simple answers to people’s hopes, and fears. Ads suggest products to enhance sexual performance or provide relief from a boring or lonely life. Many offer quick, simple, painless solutions. They encourage pill-taking for insomnia, tension, and lack of energy. Ads for baldness remedies, weight-control products, deodorants, impotence cures, bust enhanc- ers, and penis enlargers exploit feelings of inferiority and suggest that using these products will bring social success. Vitamin ads picture energetic people. Many ads falsely suggest that dietary supplements boost im- munity. Ads for “ergogenic aids” feature bodybuilding champions without indicating that the primary ingredi- ent of athletic success is hard work. Table 4-1 illustrates common persuasive techniques.

• The main purpose of advertising is to sell rather than to inform. Many ads that are not blatantly false do not tell the whole truth.
• Many ads for products are designed to distract attention from the risks involved in using them.
• Many health professionals who advertise do not represent their services accurately or comprehensively.
• The vast majority of health-related products marketed primarily by mail, by telephone, through infomercials, through the Internet, and from person to person are worthless, overpriced, or both.
• Misleading advertising is so widespread that government agencies cannot stop most law violators they detect.

KeeP these POints in mind As yOu study this chAPter Key Concepts Chapter Four Advertising and Other Promotional Activities 47 Visual imagery is sometimes used to exaggerate the truth. For example, Crest toothpaste has shown a “fluo- ride eraser” rubbing out a substantial black carious area on a tooth. Fluoridated toothpaste is valuable because it helps prevent decay, but it does not cure cavities. Prat- kanis and Aronson4 have noted that appeals to fear are most effective when they terrify the recipient and offer a specific solution. Television ads for headache remedies often use soothing background music to promote their par- ticular brand of pain reliever. Many ads encourage self-diagnosis and self-treatment. Consumers who are Technique Power words to gain attention “Strengthens immune system” “Fights . . .” “Free,” “Money back guarantee” “It’s natural” “Amazing breakthrough” “Ask your doctor” “FDA-approved” “Used by millions” “Scientifically tested” “Contains twice as much . . .” “Wrinkle eraser” “Isn’t it time you tried . . .” “Contains X” “Up to 8-hour relief” “Provides relief three times longer” “Less salt, fat, calories” “Fast-acting,” “Inexpensive” “Guaranteed purity, potency, and quality” “Clinically proven safe and effective” Imagery to appeal to emotion “Quiet world is like taking a vacation from tension” “Beautiful people, places, things” “The Marlboro man” “Look younger instantly” “Created by research scientist (or special ist)” “Miracle beauty secret, no surgery” “Used extensively in Europe” “Before-and-after pictures” Weasel words “Helps . . .” “Virtually . . .” “New and improved” techniques used in Advertising Table 4-1

Questions to Raise

Is this possible? Will it prevent infections? Will it harm people with diseases for which the immune system is overactive? How? Is it effective? What is free? Is this a come-on? What do you pay for? Will the company honor its pledge? What is “natural?” Is it better? More expensive? Who says? What evidence? How effective? Do doctors generally recommend this product? Is it actually approved? For what purpose? Is it really? Is popularity a good measure of effectiveness? How? By whom? Were studies well-designed? Is it better than taking twice as much of another product? Does it really erase? Or cover temporarily? Why? Because everybody does? What is X? What does it do? Is it better than the ingredient(s) of competing products? What is “up to”? How long is the relief typically? Longer than what? Why not four times? Less than what? Is it still high? How does it compare to other products? Does the product work? What’s the evidence? Will it help you escape from problems? The real world? Will the product help you achieve this? Is smoking macho? Or is it foolish and unhealthy? How quickly? Possible? Temporary? Aren’t most products? Qualifications? What is? Why secret? Does it work? Why not in the United States? Not FDA-approved? Do they depict typical results? Were they faked? Does it? In what way? How much? Does it or doesn’t it do what surrounding words imply? How was it changed? Is it more effective? Misleading comparisons to encourage consumers to jump to conclusions Part One Dynamics of the Health Marketplace48 interested in self-care (Chapter 14) are targets for decep- tive advertising. Many companies plug health-related products by issuing press releases or canned video news reports. The resultant press coverage may have greater impact and cost the manufacturer less than regular ads. Prescription drug manufacturers and supplement companies often use this method to call public attention to new products or preliminary scientific reports. Print ads are sometimes formatted to look like news reports. Puffery, WeAsel WOrds, And hAlf-truths In many ads the primary technique is puffery, which Preston defines as praise that includes opinions, super- latives, exaggerations, or generalities, but no specific facts. Preston5 states: “Puffery lies to you and it deceives you, but the law says it doesn’t.” In The Great American Blow-Up, he provides this illustration: The book you are about to read is a superior piece of work. It demonstrates the sheerest true excellence in its treatment of one of the outstanding important topics of our time. You will find every moment informative and entertaining to a degree you have never before encountered in the world of fine literature. This much-applauded volume has earned for its author a rightful place as one of the top writers on the contemporary scene.

He then states:

The paragraph you have just read is the purest baloney. . . . It is puffery. It is the pretentious opinion of salesmen and ad- vertisers exaggerating their wares, magnifying value, quality and attractiveness to the limits of plausibility and beyond. It is false, and I know it is false. I do not believe it. If you had believed it, and had bought this book because you relied upon the belief, you would have gotten less than you had bargained for in the marketplace. You would have been cheated. Puffery is often used to promote nonprescription drugs. For example, Bayer aspirin has been said to “work wonders,” and Pepto-Bismol has been touted as having “the famous coating action.” Many pain relievers, vitamins, and other products are identified as “advanced formulas.” The word “revolutionary” is liberally used to describe dietary supplement formulas and diet books. In July 2011, a Google search for the phrase “amazing health secrets” found more than 340,000 links. Another selling trick is the use of “weasel words.” These create the illusion of a promise but permit the advertiser to “weasel” out of the deal later. Here is an example from the catalog of a laboratory that supplies “glandular” products to chiropractors. These products are composed of dehydrated animal organs but contain no hormone or other pharmacologically active ingredi- ent. They are mainly ordinary proteins made into pills or capsules. But according to the catalog (the weasel words are italicized for the purposes of this textbook): These glandular concentrates reportedly go directly to the aid of the gland of the same name . . . liver to liver, eye to eye, prostate to prostate, and so forth. Theoretically, the nutrients found in glands may contain essential factors, and when taken as a supplement, will help the body’s glands reach and maintain proper functioning levels. Despite the illusion that the products are useful, the ad actually promises nothing. Another example would be a promised weight loss of “up to 20 pounds in 30 days.” Many statements in advertising, although literally true, could be misunderstood by consumers to mean things that are not true. For example, a claim that one food product has more “food energy” than that of its competitors may be literally true because “food energy” is simply a synonym for calories. Yet the consuming public may relate “food energy” to feeling energetic and interpret the claim to mean something that is untrue. Many ad claims have multiple meanings, one of which may be false or unsubstantiated. To some consumers a “better” product should be better than competing prod- ucts. To others, “better” may mean superior to previous versions of the product itself. If a product is claimed to be better, consumers should ask, “Better than what?” Boush and others7 have noted that deceit-minded marketers want the target consumer to notice and process only favorable message parts and to ignore disclosures or suggestions of drawbacks, risks, and limitations. Many advertisers believe they have license to mis- lead people as long as nothing explicitly false is said. √ Consumer Tip Consumptive Behavior 101 • Human behavior is purposive: to maintain and enhance one’s self-concept. • Human behavior is learned behavior; that which is rewarded is repeated, and that which is punished or ignored becomes extinct.

• People buy only two things: good feelings and solu- tions to problems.
• People make decisions with their emotions then justify with logic.
• People use a lot of shortcuts in decision-making because of the increasing tendency for cognitive overload.

Nabil Y. Razzouk, Ph.D.6 Chapter Four Advertising and Other Promotional Activities 49 Years ago, a Harvard Business Review poll of 2700 executives found that two out of three believed that ad- vertising failed to present a true picture of the product advertised. They were uneasy about the truthfulness and the social impact of ads.8 A similar poll of business school deans rated honesty in advertising to be 13%.9 mArKeting Outlets The number of marketing outlets is enormous. There are tens of thousands of daily and weekly newspapers, magazines, and radio and television stations. Many sell- ers obtain publicity through the use of public relations agencies, press releases, and public appearances. Prod- ucts are also marketed through direct mail, by telephone, by word of mouth, and through the Internet. It has been estimated that the average American is exposed to 1500 advertising messages a day. The cost of advertising depends mainly on the size of the audience it can reach. Ads can cost anywhere from a few dollars for a 30-second radio spot on a small station to tens of thousands of dollars for ads in popular magazines to more than $2 million for a 30-second nationwide televi- sion ad aired during the Super Bowl. The Internet probably enables advertisers to deliver more information at lower cost per view than any other medium. In addition to obvious ads, consumers should also be wary of claims made in press releases they en- counter through Web searches. Many people believe that advertising must be rea- sonably truthful or it would somehow not be permitted. However, standards for advertising acceptability vary greatly. Some outlets do their best not to carry mislead- ing ads, whereas others care very little about truth in advertising. Government regulation curbs some decep- tive promotions, but it cannot stop most of them. The impact of advertising extends beyond the ads themselves. Many advertising outlets will not convey news or viewpoints that would place their advertisers in an unfavorable light. Some outlets deliberately promote their advertisers’ wares. Radio talk shows sponsored by health-food stores, for example, interview a steady stream of guests who promote the types of products sold in the stores. Health-food industry and bodybuild- ing publications invariably boost the types of products marketed by their advertisers.10 The integrity of advertising is unlikely to improve unless our government finds a way to penalize the media that profit from distributing misleading ads. The nature and extent of health-related advertis- ing raise serious questions about its effect on people’s health. What kind of society is being produced by the information transmitted? Is the selling of more health products and services a good thing for consumers? Does a belief in caveat emptor absolve the seller who encourages behavior detrimental to health? Is it right to profit by playing on people’s hopes, fears, and anxieties? Regardless, consumers should still protect themselves by intelligently analyzing the ads they encounter. PrOfessiOnAl Advertising Medical and dental societies traditionally have frowned on the use of advertising to solicit patients. Years ago, members who advertised might be expelled, and many state laws banned or severely restricted advertising by health professionals. However, court decisions and pres- sure by the Federal Trade Commission (FTC) forced professional societies to abolish their ethical restraints on advertising. The FTC is legally responsible for helping to foster competition and prevent price-fixing. In 1978 an FTC adminitrative law judge ruled that the American Medical Association (AMA) could no longer forbid advertising by its members. After the U.S. Supreme Court upheld this order (in 1982) the AMA Council on Ethical and Judicial Affairs removed all restrictions on advertising “except those that can be specifically justified to protect the public from deceptive practices. . . . . The key issue is whether advertising or publicity, regardless of format or content, is true and not materially misleading.” How- ever, the Council cautions that statements relating to the quality of medical services may be a problem because they may be difficult or impossible to measure by objec- tive standards.11 The American Dental Association also changed its guidelines. The FTC believes that advertising lowers prices by increasing competition and provides consumers with ad- ditional information that will help them make appropriate decisions. However, advertising by health professionals can have serious consequences that FTC policy does not address: (a) advertising enables the least qualified practitioners to try to lure patients through salesman- ship rather than demonstrations of competence, and (b) advertising does not lower medical fees because it tends to increase both the demand for services and the cost of delivering them. The amount of professional advertis- ing has increased greatly since the 1982 Supreme Court decision. The most appropriate approach in health-care ad- vertising is one that accurately informs the public of facilities and useful services offered. Figure 4-1 shows a Part One Dynamics of the Health Marketplace50 clever message that calls attention to appropriate preven- tive care. Figure 4-2 shows a responsible ad that attempts to attract patients by offering a discount coupon for a dental examination. Ads by medical and dental societies tend to be useful and informative. Flamboyant advertising is probably a sign of low- quality, mass-production service. For example, the Lasik Vision Institute (LVI), which operates facilities in many states, has widely advertised fees of $299 or $499 per eye for refractive surgery. But regulatory actions and media investigations suggest that this number was intended to lure patients into consultations at which much higher prices are quoted.12 In 2003 LVI signed an FTC consent agreement to settle charges that the company failed to substantiate claims that its Lasik operations would eliminate the need for glasses and contact lenses for life and eliminate the need for reading glasses or bifocals.13 Page 427 has additional details about LVI. Ads for questionable screening tests have also been a matter of concern. A study14 of 60 advertisements and brochures for self-referred computed tomography (CT) and magnetic resonance imaging (MRI) screening tests found that many of them were misleading. Noting that the marketers emphasized potential benefits but almost never mentioned real risks (such as the ultimate cost of false-positive tests), the researchers concluded: Direct-to-consumer marketing of self-referred imaging ser- vices . . . fails to provide prospective consumers with compre- hensive balanced information vital to informed autonomous decision making. Professional guidelines and oversight for advertising and promotion of these services are needed. The largest number of ads in the study came from HealthScan America, Inc., which did business in Cali- fornia under the name of AmeriScan. About 14 months before the study was published, the San Francisco District Attorney and the Medical Board of California jointly filed suit against the company and the doctor who founded it. The suit sought to halt advertising claims that the company’s MRI BreastScreen was “the absolute most accurate technology available for the early detection of breast cancer” and had been “proven to find nearly 100% of all breast cancers.” The regulators believed that the ads were intended to scare women away from mammog- raphy in order to sell them a $2,000 MRI BreastScreen. Soon after the suit was filed, the AmeriScan centers were closed. Telephone directory publishers have shown little or no interest in preventing unqualified individuals from misrepresenting their credentials. In Allentown, Pennsyl- vania, for example, an anesthesiologist with an interest in hypnosis for pain relief was permitted to advertise himself as a psychiatrist despite protests made to both the directory publisher and the state medical board. To counter this type of problem, the American Board of Medical Specialties places lists of board-certified phy- sicians in many of the Yellow Pages. However, many board-certified physicians do not participate because they do not wish to pay the required fee. Many people advertising under the heading “Nutritionists” are un- qualified (see Chapter 11). Many chiropractic ads are misleading; the “free” spinal examinations or postural screening they offer nearly always result in a recommendation for lengthy treatment.15 Figure 4-3 illustrates one such solicitation. mArKeting by hOsPitAls Rising overhead costs have placed many hospitals in a precarious financial position. In many communities, hospitals are engaged in extensive marketing plans intended to ensure that they fill their beds. These may include ads for emergency services; outpatient clinics; programs for alcoholism, drug addiction, and chronic pain; fitness programs; smoking-cessation courses; medical referral services; community lectures; and other activities designed to boost community awareness of the hospital and its facilities. Some hospitals offer Saturday surgery (for convenience), gourmet food, newsletters to former patients, and free transportation. A few have used figure 4-2. Straightforward ad with discount for first visit.figure 4-1. Innovative ad alluding to auto maintenance. . Chapter Four Advertising and Other Promotional Activities 51 gimmicks such as a “$10 off” coupon for emergency room services. Many hospital marketing campaigns anticipate consumer needs and offer useful services. On the other hand, many hospitals have “integrative medi- cine” clinics that claim to offer the best of both standard and “alternative” medical services. As Chapter 8 notes, adding ineffective services to effective ones raises costs without benefit to the patients. In many hospitals, even though science-based staff members object, hospital administrators maintain these programs for marketing purposes. The American Hospital Association’s guidelines for ethical advertising state16: Advertising may be used to advance the health care organiza- tion’s goals and objectives and should, in all cases, support the mission of the health care organization. Advertising may be used to educate the public, to report to the community, to increase awareness of available services, to increase sup- port for the organization, and to recruit employees. Health care advertising should be truthful, fair, accurate, complete, and sensitive to the health care needs of the public. False or misleading statements, or statements that might lead the uninformed to draw false conclusions about the health care facility, its competitors, or other health care providers are unacceptable and unethical. Figure 4-4 shows a straightforward ad for people experiencing symptoms related to anxiety. PrescriPtiOn drug mArKeting Prescription drug marketing traditionally has been di- rected toward physicians, dentists, and other health-care personnel in professional and technical magazines. The FDA regulates this and requires ads and package inserts to include full information about dosage, effective- ness, side effects, adverse reactions, precautions, and contraindications. Promotion to Physicians Pharmaceutical companies spend several billion dollars a year promoting prescription drugs to physicians. This promotion has included not only advertising but also individual visits by sales representatives, free samples and gifts, continuing education courses, dinner presenta- tions, and other perquisites. During the past few years, however, many medical training centers and profes- sional groups have taken steps to ban or discourage perks and other interactions with drug companies or their representatives that might unduly influence what doctors prescribe. Direct-to-Consumer Advertising For many years the FDA opposed the advertising of prescription drugs to the public because the informa- tion needed to make intelligent decisions about them is generally too complex to place in a brief advertisement. But in 1999 the agency issued guidelines that it believed would safeguard consumers.17 figure 4-4. Straightforward ad for a hospital program that includes a free evaluation of anxiety-related symptoms. figure 4-3. “Danger signal” ad from a phone book. It is misleading because: (a) the listed symptoms are not usually caused by “pinched nerves,” (b) most cases involving such symptoms are not serious, and (c) some of the symptoms are likely to be appropriate for medical rather than chiropractic evaluation. Respondents to ads like these are almost always told they have a spinal problem that needs prolonged care—often between 50 and 100 visits! Part One Dynamics of the Health Marketplace52 Manufacturers now spend several billions of dollars per year to advertise prescription products in magazines and newspapers, on television, and through Web sites. It has been estimated that American television viewers see as many as 16 hours of drug ads per year.18 Some ads mention a product by name, whereas others encour- age people with certain health problems to seek further medical advice. Most drugs in the latter category are either the only drug or the market leader in a category of drugs for the advertised problem. Figures 4-5 and 4-6 show ads that provided helpful, informative messages. Ads that mention a prescription drug by name must include “adequate directions for use.” This includes full product information of the type found in package inserts and the Physicians’ Desk Reference. This amount of information is often too technical for laypersons to understand. Less information is required in ads that do not name a specific product.19 Although prescription drug ads call attention to useful products, their primary purpose is to sell them. Some observers believe that direct advertising educates patients, alerts consumers to new treatments, encourages people to seek medical advice for conditions that would otherwise go untreated, increases consumer confidence in products already prescribed, and generally results in a more informed public.20 Others argue that advertising prescription drugs interferes with the physician-patient relationship, confuses patients, increases the cost of drugs, puts undue emphasis on drug treatment alterna- tives, pressures doctors to prescribe products, and results in unnecessary use.21 Several years ago, nearly 90% of AMA members responding to a poll stated that direct-to- consumer advertising had resulted in increased patient demand for specified brand-name drugs, and 73% said that it caused physicians to spend more time supplying accurate information. It has also been suggested that direct-to-consumer drug ads contribute to the medicalization of what was previously considered part of the normal range of human experience.22 Consumer Reports on Health23 has warned: Drug pitches are not public service messages—they’re com- mercial advertisements . . . designed with the drug manufac- turer’s health in mind. Even when the ad seems to be merely alerting you to symptoms that may require drug treatment, the message is usually overstated. . . . You should regard consumer figure 4-5. Informative ad which advised people that it is possible to have high blood pressure without knowing about it. The ad mentioned no product, but the manufacturer assumed that some people who were discovered to have “silent” hypertension would be appropriately treated with one of its products. Figure 4-6. A useful message from the manufacturer of a prescription drug that can help control the symptoms and reduce the transmission of genital herpes. Whether you have a mild, intermediate or severe case of genital herpes, you should see your doctor to help gain new control over your outbreaks— especially if you haven’t seen your doctor within the past year. The medical profession now has more infor- mation than ever before about the treatment of herpes, as well as effective counseling and treatment programs that can help you reduce the frequency, duration and severity of your outbreaks. If in the past, you were told that nothing could be done for herpes, it’s no longer true. Herpes is controllable. Ask your doctor about these treatment pro- grams, and whether one of them would be suitable for you. Chapter Four Advertising and Other Promotional Activities 53 drug ads with the same type of skepticism as you would any other type of salesmanship. The article noted, for example, that Rogaine’s manufac- turer had tried to hook worried men by asking whether “an emerging bald spot” can “damage your ability to get along with others” or “influence your chances of obtaining a job or a date.” A 2004 survey24 of major network prime time televi- sion ads made the following observations:

• More than 80% made some factual claims and rational arguments for product use, but only about 25% described the causes, risk factors, and prevalence of the targeted problems. Nearly all made emotional appeals.
• No ads mentioned lifestyle change as an alternative to prod- ucts, though some portrayed it as an adjunct to medication.
• About half portrayed the product as a medical breakthrough. • The ads had limited educational value and tended to over-

sell the benefits of drugs in ways that might conflict with promoting population health. Frosch and others25 believe that direct ads should (a) be written at an eighth-grade level, (b) clearly indicate whether the product might be useful to the viewer, and (c) provide realistic, quantitative information about the potential benefits and risks. nOnPrescriPtiOn drug Advertising In 1972 the FDA began a lengthy review process that has led to the removal of many ineffective ingredients from nonprescription drugs (see Chapter 17). In ad- dition, regulatory actions by the FTC have persuaded many major manufacturers to stop making blatantly misleading claims. As a result, except for homeopathic products (see Chapter 8), most nonprescription drugs sold today contain at least one effective ingredient, and ads for such products tend to be truthful. However, at least three problems remain: