Pills, liquor, and pot:

A prescription to promote

Note from the editor: This is the first instalment in a three-part series. Part two focuses on how alcohol is promoted in Canada. Cannabis promotion will be discussed in part three.

Since the moment the Liberal government committed to its strict public health approach to cannabis legalization, some have understandably wondered why a non-lethal substance used to quell the symptoms of dozens of medical conditions by hundreds of thousands of people is being presented to Canadians as more dangerous than either prescription drugs or alcohol.

Of course, cannabis use does come with its own set of potential risks—prior to legalization, cannabis accounted for 15 per cent of all substance use-related hospital stays in Canada—but it doesn’t take a statistician to recognize that the comparative harms alcohol and pharmaceutical drugs have on society far outweigh those caused by cannabis. Take, for example, the opioid-fueled overdose crisis, which killed one person every two hours in Canada in 2018, and as many as 1,500 in the province of British Columbia alone. And while opioids have been in the spotlight for good reason, 75 per cent of the 10 substance-related deaths that occur in Canadian hospitals each day are actually caused by Canada’s choice intoxicant, alcohol. Last year, there were more Canadians hospitalized per day for conditions and harms caused by drugs and alcohol than for heart attacks and strokes combined. And while experts wagered that emergency room visits for cannabis use would spike post-legalization, we’re still waiting for hard evidence to show that that has been the case. (Deaths caused by cannabis consumption continue to hover around zero.)

Our general understanding of cannabis is lacking. With so few exceptions to Health Canada’s blanket prohibition of cannabis promotion, experts wonder whether some exposure to cannabis brands and products, through carefully monitored advertising, would give consumers an opportunity to become more educated. The response to failing to provide consumers with information about this newly legal substance has been alarming. We saw it in the headlines prior to legalization, and as we prepare for legal edibles, extracts, and topicals, we are seeing it resurface: a fear among some Canadians of a substance that many could stand to benefit from, including those who abuse prescription drugs and/or alcohol. It’s worth remembering that our courts first ruled cannabis prohibition was unconstitutional precisely because of the barriers to accessing the plant’s benefits.

It could be argued that the strict marketing regulations in the Cannabis Act are a direct result of the federal government’s record of poor advertising policies around drugs, alcohol, and tobacco. Given the potentially lethal status of pharmaceutical drugs and alcohol and their negative impacts on Canadian society, one could conclude that it is in the best interest of public health and safety to regulate marketing around these substances more carefully. Several factors have kept various levels of government from reassessing existing legislation, including historic significance, cultural importance, industry pressure, and consumer behaviour.

While some have argued that comparing advertising regulations around these substances is moot, several researchers and health policy experts confirmed to Inside the Jar that they see value in stacking the real-life impacts of these substances up against our ad-generated perception of them, so that we may better assess the efficacy of existing marketing policies. This is not our way of suggesting that these three substances should by any means be viewed as “equal” or even remotely on the same plane. Instead, we believe that gaining a better understanding of the harms generated by these substances and the forces behind advertising laws around prescription drugs, alcohol, and cannabis could potentially allow us to reframe all three in a new way.

How Canadians use pharmaceutical drugs

Canadians are among the biggest consumers of pharmaceutical drugs in the world. In 2018, we filled a staggering 502 million prescriptions, spending a total of $28.8 billion on medication. Thirteen per cent of Canadians were prescribed opioids (in 2017, that added up to 21.3 million prescriptions dispensed), making us the second-largest per capita consumers of opioids in the world. Just behind Iceland and Ireland, nine per cent of the population uses antidepressants, also putting us among the top global consumers of that drug type. About 12 per cent consume sedatives, a number that has remained stable in Canada since 2013. While prescription stimulant use is relatively low (just one to two per cent of the population), drugs like Ritalin and Adderall are prescribed to nearly six per cent of youth aged 15 to 19. In 2016, nearly two thirds of Canadian seniors were prescribed five or more different drug classes.

Under the Canada Health Act, all medically necessary care delivered in hospitals and by physicians is covered by public funding. Historically, these two streams have dominated Canadian healthcare spending, as patients do not need to reach into their own pockets to pay for these services. Canada is the only country in the world to offer universal health care without universal prescription drug coverage.

Over the last several years, spending on prescription medication and over-the-counter drugs has risen faster than spending on hospital services or doctors, and is now the second largest healthcare expenditure after hospitals. In a 2018 report, the Canadian Institute for Health Information (CIHI) predicted that spending on drugs would outpace federal spending on physicians by 0.6 per cent, at $33.7 billion nationally, with Canadians spending an average of $1,074 per person on medication—among the highest in the world, behind only the United States and Switzerland. While Canadians can access drug coverage through private insurance plans or government-run programs, as many as 7.5 million Canadians, or one in five, either do not have prescription drug insurance, or have inadequate coverage.

Dr. Cheryl Camillo is an assistant professor at the Johnson Shoyama Graduate School of Public Policy at the University of Regina, where she also serves as the director for the school’s Masters of Health Administration program. Camillo has spent more than 25 years researching health system reforms and developing policy and governance solutions in both Canada and the United States. She uses a comparative lens to determine which policies best improve the health of the population. Her view is that among a combination of factors, Canada’s long-standing biomedical approach to health is partly to blame for how eager Canadians have become to consume pharmaceutical drugs.

Dr. Cheryl Camillo (handout)

“We think of health being addressed by the application of hospital and physician services, and increasingly, regulated drugs, as opposed to stepping back and thinking of health as being influenced by many other forces, including alcohol and cannabis,” the former senior federal policy advisor and lobbyist told ITJ by phone from Regina.

“We spend a tremendous amount of money on prescription and over-the-counter drugs here in Canada, and while each individual filling a prescription could argue—and each person writing the prescription could argue—that it was necessary, all of those prescriptions and all of that spending doesn’t add up to improved health.” Without a more holistic approach to healthcare, Camillo says she isn’t confident that Canada’s healthcare system will ever produce the health outcomes that are equivalent to the investments made in prescription drugs.

With so much money pouring into Canada’s pharmaceutical industry, one could assume that corporations like Johnson & Johnson and Novartis are dedicating a significant portion of their revenue to research to create new medicines. That assumption would prove to be naïve: in 2017, a year Canadian drug manufacturers made $27 billion in sales, just $870 million, or three per cent of total sales, was spent on research and development. Since 2001, industry R&D spending has fallen by a whopping 27 per cent, while spending on advertising has increased dramatically. One study found that in 2015, the pharmaceutical industry spent $563 million on journal advertising and sales representative visits alone, accounting for 3,720,000 visits to Canadian doctors. That amount does not account for the enormous costs associated with 14 million samples left with physicians, engaging experts and politicians in meetings, conference booths and appearances, direct-to-consumer advertising, or other forms of marketing.

In modern medicine, the motivation to make money has outweighed the motivation to innovate. Rather than funneling resources into research and development, drug makers use different strategies to ensure that their revenue remains stable when their patent on a “blockbuster” drug expires. Often legal measures are used to extend market exclusivity. Other times drug makers anticipate the expiring of valuable patents and remarket slightly modified versions of the same drug, ensuring that they can still sell it at designer prices. A 2018 study published in Journal of Law and the Biosciences examined ten years worth of patent entries and exclusivities added by drug companies in the United States. It found that 78 per cent of drugs associated with so-called “new” patents were not actually new drugs, but existing ones.

“Rather than creating new medicines, pharmaceutical companies are recycling and repurposing old ones,” writes the study’s author, Robin Feldmen of Hastings College of the Law.

That assumption would prove to be naïve: in 2017, a year Canadian drug manufacturers made $27 billion in sales, just $870 million, or three per cent of total sales, was spent on research and development. Since 2001, industry R&D spending has fallen by a whopping 27 per cent, while spending on advertising has increased.

The goal, ultimately, is to make a consumer of the patient, and to manage, rather than cure health issues. In her 2008 book, Our Daily Meds, former New York Times columnist Melody Petersen sums up this phenomenon as such: “Whether a medicine helps or harms a patient has become secondary to how much it will bring shareholders in profits.” This notion has served executive-level staff and investors, but not the general public. The same trend could be observed in the cannabis industry, where product quality and consumer satisfaction has taken a backseat to investor satisfaction.

Camillo says that for most people, trust in physicians and media outweighs a desire to “Google” a drug and truly understand what sort of effect it might have on the body—“that is if you can remember how to spell it”. When we’re feeling like our health is lacking, we’re more inclined to believe what we see in drug ads.

“We’ve been trained to think that taking care of ourselves involves consuming a health service, whether it’s getting surgery or taking a pill. The inclination is, ‘I’m not feeling 100 per cent so I need to consume something,’… And that’s when seeing an advertisement for something [can work],” Camillo says.

“Our predisposition is to go for it, as opposed to think very carefully about how [taking] that [prescription] could fit into lapsed health in an overall balance.”

Camillo says while there are strict regulations and restrictions around pharmaceutical advertising in Canada, including a ban on direct-to-consumer advertising, companies spend hundreds of thousands of dollars on coming up with sophisticated advertisements that appeal to our predisposition to buy the product that’s being marketed to us. Ads from the U.S. also have an effect on how we view pharmaceuticals.

In the realm of health, but especially when it comes to medication, consumers are at a disadvantage because they lack a genuine understanding of what is being presented to them in drug ads. Camillo credits the economic principle of information asymmetry (the idea that one party in a transaction has a competitive advantage over the other because they hold more information about the goods or services in question) for our willingness to accept what we see and hear in advertisements.

“Even someone like me with a PhD who has worked in health feels pretty inadequate to evaluate what’s being marketed towards me,” she says. “Consumers will think, ‘well, gee, it must have been approved by the government, and they know more than I do’… There’s definitely human nature and an inclination to believe what you want to believe, and not present yourself with contrary evidence. The average consumer is going to justify to themselves why they need it today.”

Impacts of pharmaceutical drug use and misuse in Canada

While prescription medications do improve the lives of hundreds of thousands of Canadians who are suffering from chronic pain, diabetes, high blood pressure, high cholesterol, mental health issues, and much, much more, all drugs come with the risk of side effects, even when used as directed. Risks are increased with long-term use, polypharmacy (taking more than five medications at one time), and misuse, and can lead to chronic side effects, dependence, injuries caused by intoxication, and increased risk of premature death, including fatal overdose. In a 2017-2018 report by CIHI, health issues arising from the use of opioids, stimulants, and depressants accounted for nearly 50,000 hospital stays in Canada, with another 26,459 caused by the use of multiple or unidentifiable substances. A report published by the Canadian Institute for Substance Use Research (CISUR) in 2018 determined that the abuse of opioids, depressants, stimulants, and other substances costs Canadian taxpayers an average of $12.7 billion annually in healthcare, criminal justice, and lost productivity costs.

Since 2016, opioids have dominated the Canadian health news cycle, and for good reason: between January 2016 and March 2019, more than 12,800 Canadians suffered from opioid-related deaths. While shining the media spotlight on this issue has improved our general understanding of how and when these particular drugs should be used, it has taken some of our attention away from harms caused by other drug types (which, ironically, are often indicated in so-called “opioid” overdose deaths). Because recent statistics associated with drug-related deaths in Canada include deaths caused by a toxic illegal drug supply, it is next to impossible to locate up-to-date statistics on the misuse of and number of deaths caused solely by prescriptions drugs. Even the Canadian Centre on Substance Use and Addiction has stated that there is little Canadian data available on the harms associated with prescription sedative and stimulant use.

That’s not to say that the overdose crisis is at all separate from Canada’s medical framework. Some experts, and even Health Canada, have placed part of the blame for the overdose crisis on physicians, even though illicit fentanyl is the leading cause of opioid-related overdose deaths in Canada outside of hospitals. According to Scott Bernstein, director of policy at the Canadian Drug Policy Coalition, when used as prescribed, opioids are safe for “about 90 per cent” of people who are prescribed them. But when misused, they can lead to dependence, adverse drug reactions, poisoning, and death. When the overdose crisis began, some policy experts told the media that the over-prescription of drugs like oxycodone, morphine, and codeine (those most commonly responsible for opioid-related hospital visits in Canada) lead to dependence in some patients. When prescriptions ran out, many were forced to resort to illicit, often tainted sources for relief, resulting in overdose.

Scott Bernstein (handout)

On the other hand, Bernstein says that the reaction to the overdose crisis of reducing the number of opioids prescribed to a patient, or cutting back their dose under pressure from health authorities, has also caused patients to seek out additional sources when their needs are not met by their prescription.

“We’ve responded to the overprescribing, or the perception of an opioid crisis, by restricting prescribing, which ultimately turns people to the poisoned illegal market,” Bernstein tells ITJ by phone. “People do have legitimate pain concerns, and so we shouldn’t overreact by cutting those people off.” The senior policy advisor says Canadian physicians have “run amok” when it comes to the overprescribing of other medicines in Canada, as well, like mood-altering drugs and stimulants.

In addition to overprescribing, a 2018 report issued by CIHI credits aggressive marketing tactics for making Canadians among the highest consumers of prescription opioids worldwide.

While we don’t have solid numbers on the exact number of deaths caused by prescription drugs, we do have the 2017 Canadian Tobacco, Alcohol, and Drugs Survey, which paints a picture of just how much of prescription drug use in Canada is considered problematic. (The 2019 survey is currently underway.)

What’s interesting is that the report, authored by Statistics Canada, highlights opioids as the “most used” psychoactive pharmaceutical drugs among the three classes (opioid pain relievers, stimulants, tranquilizers and sedatives), with 12 per cent of Canadians, or 3.5 million people, reporting past-year use, and three per cent reporting problematic use. However, several paragraphs down, the report states that the same number of Canadians—12 per cent, or 3.5 million people—reported past-year use of sedatives, with one per cent reporting problematic use. It’s not clear why the emphasis in this report is put on opioids when it’s obvious that both drug types were reportedly used equally among Canadians, especially because sedatives can have devastating health effects when used improperly or for long periods of time. For example, one U.S. study found that people who were prescribed as few as 18 sleeping pills per year increased their likelihood of premature death by as much as three times.

It’s not clear why the emphasis in this report is put on opioids when it’s obvious that both drug types were reportedly used equally among Canadians, especially because sedatives can have devastating health effects when used improperly or for long periods of time.

While cannabis has received much attention for use and misuse among young people and is the substance responsible for the most substance-related hospital visits for Canadians aged 10 to 24, problematic prescription drug use among youth also occurs in Canada as well. A 2014-2015 study found that about four per cent of Canadian students in grades seven to 12 had used psychoactive pharmaceuticals. In the same study, 37 per cent of students said they thought it would be “fairly easy” or “very easy” to find prescription pain medication. A Drug Free Kids Canada report found that 48 per cent of Canadian homes contain prescription drugs, with just 11 per cent storing them safely and out of children’s reach. A CIHI report published in 2019 found that from 2014-2015 to 2016-2017, the prevalence of non-medical use of sedatives among students in grade 10 to 12 doubled, while a 2017 report on drug use among Ontario students found that 11 per cent of youth in grades seven to 12 had consumed an opioid for a nonmedical purpose.

Side effects associated with misuse
Opioids Anti-anxiety medications and sedatives Stimulants
Source: Mayo Clinic
Constipation Drowsiness Increased alertness
Nausea Confusion Feeling high
Feeling high (euphoria) Unsteady walking Irregular heartbeat
Slowed breathing rate Slurred speech High blood pressure
Drowsiness Poor concentration High body temperature
Confusion Dizziness Reduced appetite
Poor coordination Problems with memory Insomnia
Increased dose required for pain relief Slowed breathing
Worsening or increased sensitivity to pain Agitation
with higher doses (hyperalgesia) Anxiety
  • Opioids can cause low blood pressure, a slowed breathing rate and potential for breathing to stop, or a coma. Overdose has a significant risk of death.
  • Anti-anxiety medications and sedatives can cause memory problems, low blood pressure and slowed breathing. Overdose can cause coma or death. Abruptly stopping the medication may cause withdrawal symptoms that can include nervous system hyperactivity and seizures.
  • Stimulants can cause dangerously high body temperature, heart problems, high blood pressure, seizures or tremors, hallucinations, aggressiveness, and paranoia.

Direct-to-consumer ads in Canada: Legal, or permitted?

Dr. Barbara Mintzes is an associate professor at the School of Pharmacy at the University of Sydney, and an affiliate associate professor at the University of British Columbia’s School of Population and Public Health. As a research scientist, she specializes in the study of pharmaceutical policy, and in 2019 was the lead investigator of a study that found that between 2007 and 2016, Health Canada had only issued safety warnings for 50 per cent of drug-safety issues that had been identified in three other countries with similar demographics: the U.S., Australia, and the United Kingdom.

Dr. Barbara Mintzes (handout)

She says Canada’s direct-to-consumer advertising regulations may be similar to the rest of the world (only New Zealand and the United States allow direct-to-consumer advertising for prescription drugs), but that regulations are neither ample nor imposed.

“If you look at our Food and Drugs Act, we have (similarly to most countries in the world) laws against advertising prescription-only medicines to the public, but we don’t actually enforce [them],” Mintzes tells ITJ by phone while visiting Vancouver from Sydney.

Two Health Canada policy papers issued in in the late 1990s and early 2000s explain Canada’s lack of enforcement against pharmaceutical companies who break the law against direct-to-consumer advertising. The first came in 1996. Health Canada was under intense pressure from industry to permit direct-to-consumer advertising after Merck Frosst (now Merck), one of the world’s largest multinational pharmaceutical companies, submitted a policy paper stating that based on freedom of expression provisions, the industry had a “legal right” to advertise. This prompted Health Canada to issue a policy statement that redefined the distinction between advertising and “information dissemination”. Many companies saw it as implied approval to use disease-oriented advertisements that mentioned an ailment and encouraged a visit to the doctor, but didn’t mention the drug’s actual name.

The second policy statement from Health Canada had to do with the reinterpretation of a competitive price advertising clause that was introduced in 1978, according to Mintzes, who has authored several comprehensive papers on Canada’s direct-to-consumer advertising of prescription drugs. The clause, originally introduced with the intention of allowing increased competition among pharmacies by allowing them to advertise drug prices, was reinterpreted in 2000 in a way that, without explicitly stating it, permitted branded reminder ads. These are essentially the opposite of the aforementioned disease-oriented ads: they make mention of the drug’s name, but don’t speak to its indication. Consider the rainbow bus shelter ads for Viagra that appear during the gay pride parade, or TV advertisements for birth control pills that feature attractive young women name-dropping their favourite brand. Who can forget the viral campaign for one in particular that had everyone (at least in my middle school health class) asking, “What’s Alesse?”

It was complaints surrounding an Alesse campaign that sparked Health Canada’s second policy paper, which effectively stated that ads could either name a drug, or discuss a condition, but not do both in the same advertisement. Essentially, a campaign using both varieties of advertisement is illegal, but on their own, the ads are permitted.

“I would call it a commitment to non-enforcement of the law,” said Mintzes in a 2002 Globe and Mail interview on the subject. Canada is the only developed country to ban direct-to-consumer advertising while creating an exception for reminder ads. Even in the U.S., where direct-to-consumer advertising is legal, reminder ads are prohibited for any drug that carries serious health risks. Health Canada does not have such a restriction in place.

Mintzes says Canadians’ perception of pharmaceuticals has been greatly impacted by the way drug makers have been able to capitalize on loopholes that, in the minds of many experts, fly in the face of the law. A paper she authored that examined direct-to-consumer advertising in Canada and the U.S. found that allowing branded reminder and disease-oriented ads provided “no evidence of safer content or product choice… [as] many heavily-advertised drugs in Canada have been subject to safety advisories [in other countries]. Canada’s experience stands as a stark warning.”

How pharmaceutical ads are regulated in Canada

As per Health Canada’s website, advertisements for health products including prescription drugs are “reviewed and precleared” by independent agencies. But a closer look at the regulations shows that even though these provisions are in place, pharmaceutical companies are not legally required to use an approved preclearance agency—it is simply considered a best practice. While Health Canada handles complaints directly, there are no published guidelines for submission or handling of complaints about direct-to-consumer advertising.

“The way advertising and promotion is regulated in Canada is mainly delegation… to a multi-stakeholder group called the Pharmaceutical Advertising Advisory Board (PAAB), which is dominated by industry and industry-funded organizations,” says Mintzes. Imagine executives from licensed cannabis producers like Canopy Growth Corporation and Aurora Cannabis deciding whether or not cannabis ads were permitted for dissemination to the public.

Operating a voluntary pre-screening service, the PAAB deals with complaints internally, and allows ads to continue running while complaints are being adjudicated. If a company fails to comply with PAAB rulings, Health Canada steps in. The agency may also get involved if it deems an advertisement to pose a significant safety concern, or if an unapproved product is being marketed to the public.

In 2014, Mintzes and Dr. Joel Lexchin, a York University Professor and emergency room physician, published a study that found that between 2000 and 2011, Health Canada consistently evaded its advertising regulatory responsibilities, particularly when it came to direct-to-consumer-ads. This trend began after regulations were reinterpreted in its 2000 policy statement.

The study concluded that there was “an astonishing degree of discordance between public health priorities and regulation of direct-to-consumer advertising in Canada”, and accused the government’s current approach to enforcement as having a “lack of teeth and lack of accountability and transparency”. In a Vancouver Sun story detailing the study, Health Canada was accused of outright “failing” to properly regulate drug ads.

Five years since that study was published, Mintzes says very little has changed. Health Canada has taken some steps to try to regulate the advertising of opioids to a greater extent (Mintzes was part of an expert advisory committee on the subject for Health Canada in 2018), by creating a dedicated advertising compliance and enforcement team to “proactively monitor the Canadian health product and advertising environment”. In addition, Mintzes says the administrative policy issued in 1996 that redefined the distinction between advertising and information dissemination is currently under consultation.

She says the new version of the administrative policy that is being considered “still [has] a lot of problems”, but it does indicate some appetite on the part of Heath Canada to take the regulation of pharmaceutical advertising more seriously. For the most part, she says, regulation of pharmaceutical promotion in Canada has stagnated, and the only solution would be to bring the duty of regulation “back to the government”.

There are currently 42 active complaints relating to direct-to-consumer advertising of prescription drugs in Canada. Some were received as early as 2015 and have yet to be resolved.

“It’s really self-regulation. Health Canada has stated that for the most part, they wait for a complaint and then investigate and follow up from there,” says Camillo, weighing in on Health Canada’s current approach.

“It’s fairly simple math that the size of Health Canada hasn’t increased in proportion to the number of drugs coming on the market, not by any magnitude. As a consumer, and knowing colleagues of mine who’ve done this research, we feel that no, Health Canada is not fully on top of it.”

She says that in addition to making changes to existing policies, new ones should be introduced that call for individual assessment of each and every drug advertisement destined for the public eye. That, of course, would require a significant increase in staff at a federal department already mired in paperwork and red tape. Alternatively, Camillo says the potential implementation of pharmacare in Canada could present legislators with an opportunity to push for changes to regulations around the advertising and marketing of drugs.

The impact of American influence

Poor oversight in Canada is just one factor that influences our perception of a drug’s efficacy. Another major influencing factor in the way Canadians make decisions about medication has to do with our proximity to the U.S., says Camillo, who grew up in the border town of Buffalo, New York.

On paper, restrictions on pharmaceutical advertising in Canada are much stricter than they are in the U.S., but like so many other cultural phenomena, the influence of our neighbour to the south has rubbed off on us. Despite broadcasting regulations in Canada that prohibit direct-to-consumer drug advertisements on TV and radio, American drug ads are unavoidable on cable networks and in media geared to a North American audience.

“That gets into the consciousness… culturally, some of the consumer approach in the U.S. has bled over to Canada. In the U.S., things are readily available, if you can afford them, and I think that has infused Canadian culture as well,” says Camillo.

“You might see in a television ad from the United States that there is this mention of harm usually two thirds of the way through the ad, and often people are running through a field; they’re happy and smiling, and so the visuals are inconsistent with the audio.”

Mintzes echoes her sentiments about the gravity of American influence on Canadians through television networks and magazines, and takes it a step further. She says that the greatest threat to Canadians having a healthy understanding of pharmaceuticals is not necessarily branded reminder ads, but ads we see in American media.

“Most of the advertising that we get of prescription medicines in Canada is not these Made-in-Canada reminder ads; the major exposure has been to U.S. ads,” she says. “There hasn’t been an enforcement of the law in terms of requiring TV providers or even magazines that might have a North American edition rather than a separate Canadian edition… to remove the ads that are very clearly illegal in Canada.”

In the U.S., drug advertisements are required to provide consumers with information about frequent side effects and serious harmful effects that could come with use, but Mintzes says there is no requirement for them to “ensure that what they’re saying directly, or implying about the effectiveness, is consistent with the scientific evidence.”

“You might see in a television ad from the United States that there is this mention of harm usually two thirds of the way through the ad, and often people are running through a field; they’re happy and smiling, and so the visuals are inconsistent with the audio.”

The result? Mintzes says this causes consumers—whether Canadian or American—to perceive drugs to be 100 per cent effective.

Spending on direct-to-consumer advertising in Canada

A peer-reviewed study Mintzes, Dr. Steve Morgan, and Dr. James Wright of UBC authored in 2009 paints a clear picture of just how Health Canada’s policy reinterpretations impacted the spending habits of pharmaceutical companies on promotional materials.

By examining spending on direct-to-consumer ads in Canada between 1995 and 2006, researchers were able to observe the impact of the policy reinterpretations that occurred in 1996 and 2000. They found that, when adjusted for inflation, spending on branded direct-to-consumer ads in Canada grew from less than $2 million per year before 1999, to more than $22 million in 2006, with the vast majority spent on broadcast advertisements. It also found that brands that spent the most on consumer advertising were often the same ones that had received warnings for their drugs: of eight brands that had spent more than $500,000 annually on advertising, six had been subjected to Canadian safety warnings, and four had received U.S. “black box warnings”, the strictest warning issued by the U.S. Food and Drug Administration.

Another study authored by Mintzes’ colleague, Joel Lexchin, in 2017 examined the therapeutic value of Canada’s most heavily promoted and top-selling drugs and the way they are promoted not to consumers, but to physicians. Visits are made to Canadian physicians by pharmaceutical company representatives to provide “awareness about new treatments and provide science-based and Health Canada approved advice on how to administer these medications.” Lexchin’s idea was that by assessing whether or not the most-promoted medicines also provided the most therapeutic gain, it could aid in determining whether doctors should be in engaging with promotional materials and representatives at all. Looking at lists of the top 50 drugs in each category, he found that both the drugs most-promoted to physicians and the top-selling drugs offered “little to no therapeutic gain.” What’s more, he references previous research that found that during visits, representatives were providing physicians with “minimally adequate” safety information in fewer than two per cent of visits to physicians in two major Canadian cities.

“Promotional material does not appear to be a way for doctors to learn about therapeutically important products,” writes Lexchin. “The focus on promoting primarily drugs with little to no therapeutic gain calls into question the value of doctors' reading journal advertisements or seeing sales representatives if their purpose in doing so is to acquire information about important medical therapies.”

When a drug that offers little to no therapeutic gain is marketed to Canadians as being a necessary part of their overall health, or 100 per cent effective, the health and safety of our population ultimately suffers. As advertising has increased dramatically over the last two decades, so too has the number of prescriptions for the same medicines that Lexchin says offer us next to nothing; so too has the number of opioid-related deaths; so too has our trust in an industry that has no interest in truly increasing the overall health and wellbeing of Canadians.

A physician’s perspective

Dr. Jeremy Rezmovitz is a physician specializing in family medicine, operating an independent practice in Toronto, Ontario. He says direct-to-consumer advertising does result in requests for specific medicines from patients, but only from a very small percentage (“less than 10 per cent”). More often than not, patients hear about a new drug from friends or family.

Dr. Jeremy Rezmovitz (handout)

“Advertising is problematic depending on the lens or hat you’re wearing,” Rezmovitz told ITJ in a written email. “As a treating physician, I welcome the input from my patients—the result is either education for my patients, or education for me.” Rezmovitz also recognizes the issues that can arise when physicians are oversold on prescription drugs at events and through journal advertisements:

“If I am at a conference or talk, I would hope that the organizing bodies would bring someone to speak that would help with decision-making without bringing in their bias, however, I think it’s impossible,” he says.

As the chair of a scientific planning committee for a large conference, he’s well aware of the difficulties that the medical industry faces in creating educational content without endorsing any one drug. While studies have shown that promotional content geared to physicians does impact their prescribing habits, he admits his attitude is a little different.

“I feel that if we can enter into a business relationship with pharmaceutical companies (prescribing a drug for someone), then we are smart enough to enter into an educational relationship as well. It behooves us (physicians) to gather enough information from multiple sources in order to best serve our patients. Unfortunately, time is an issue and not everyone does that, and so the relationship with industry is considered biased and unholy.”