“With the advent of Facebook, Twitter and YouTube, there are a lot more opportunities for American firms to use that type of advertising. The feedback we’ve gotten is that social media advertising has circumvented the old regulations.” Dr. William Cunningham president of the British Columbia Medical Association

Last fall, Pfizer Canada, the domestic arm of the world’s largest drug company, decided to dip its corporate toe into a new form of Internet-based promotion, launching a website called PfizerStrive.

The site — pre-approved by Canada’s Pharmaceutical Advertising Advisory Board (PAAB), an industry group — came loaded with various types of health information, as well as consumer surveys.

But its main raison d’être was to promote Pfizer’s new “payment assistance program.” Essentially a discount card for the firm’s top prescription drugs, the site asks visitors to navigate an online registration process, during which they provide Pfizer with personal information.

PfizerStrive is the firm’s latest foray into a multi-platform digital marketing strategy that extends beyond corporate and drug-specific websites into social media channels such as Facebook, Twitter, RSS and YouTube, as well as smartphone apps.

Vincent Lamoureux, Pfizer Canada’s director of corporate communications, says the company launched its corporate Facebook site last year and has been running another Facebook-based promotion associated with the contraceptive Alesse. A third is set to launch this summer.

It all traces back to a savvy brand-awareness ad campaign launched in 2008 called “More than Medication,” which allows Pfizer — the maker of blockbuster drugs such as Viagra and Lipitor — to promote healthy living strategies by focusing on topics (stress, fitness) linked to some of its leading product groups (anxiety and cholesterol medications).

The More than Medication website includes links to more than 10,000 non-commercial patient forums, while the accompanying campaign has directed millions of dollars in contributions to federal and provincial health research organizations.

“There’s no question we are putting a focused effort on trying to develop new platforms and social media is a part of that,” says Lamoureux.

Enormous potential

Pfizer, of course, isn’t alone. While the pharmaceutical industry’s spending on “direct-to-consumer advertising” (DTCA) has fallen sharply in the past few years as some of the world’s top-selling prescription medications become available in generic form, drug companies are beginning to direct promotional dollars into social media, spending at least $1 billion (U.S.) in 2011, according to a study published by the American Medical Association (AMA) on the drug industry’s interactive marketing.

“The potential effect of online DTCA is enormous, allowing for interactive marketing to millions of potential consumers globally,” wrote the authors of the AMA study.

They note that the drug industry’s new-found interest in promoting prescription medications through social media will cut across borders and reach people who live in countries — like Canada — that restrict this kind of advertising in traditional media.

“The Internet is globalized direct-to-consumer advertising,” warns one of the co-authors, Tim Mackey, a University of California San Diego health law policy researcher.

Moreover, drug industry executives are also seizing on the opportunity to use social media to better “engage” physicians, while collecting demographic and personal information on potential customers. “People don’t understand how much information they’re giving to the industry,” says Mackey.

Besides the U.S. and New Zealand, most developed countries have strict limits on prescription drug ads. The reason? Heavily promoted pharmaceuticals tend to be newer, with side effects that may be less understood.

In Canada, a long-standing rule allows drug firms to run ads that only include the name, price and quantity of a prescription drug, as well as “reminder ads,” which depict suggestive situations — middle-aged people doing physical activity — along with an entreaty to ask their doctors about remedies to problems like stiffness. Ads have to be pre-cleared by the PAAB.

But Canadians see a lot of U.S.-based drug advertising on cable TV, and some of it has an impact on prescribing rates. For example, a 2008 British Medical Journal study showed a 42 per cent increase in prescriptions in English Canada for tegaserod, for irritable bowel syndrome, after the manufacturer Novartis started plugging the medication on U.S. cable channels. U.S. and Canadian regulators pulled the drug on the same day in 2007 after reports of cardiovascular complications.

The move to social media marketing of drugs threatens to make a mockery of Canada’s already weakened policies, say a growing number of academics and critics, who point to research showing a link between spending on consumer drug advertising and prescribing rates by physicians. Some want the federal government to pay much closer attention to this looming promotional shift.

New guidelines

The U.S. Food and Drug Administration (FDA) is paying attention. Since 2011, the agency has released two sets of controversial guidelines for social media-based drug promotion, with more due by 2014.

Federal officials say Canada’s long-standing DTCA restrictions will still apply in the social media universe.

Drug companies “have to be very careful” with unrestricted online information, such as tweets and Facebook pages, says PAAB commissioner Ray Chepesiuk. He points out that disease forums sponsored by drug companies have become increasingly common, yet the firms have to invest adequate resources to referee the discussions and “scrub” user comments that suggest, for example, alternative uses for a medication.

But Pfizer’s Lamoureux says those rules have made it difficult for drug companies to communicate with consumers using rapidly evolving social networking technologies. “It’s not easy to maintain an ongoing conversation (with consumers) when everything you write has to be pre-approved.”

Health Canada has delegated responsibility for monitoring this activity to PAAB, which will release its own social media guidelines this month.

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“We had a committee of real-life digital marketers and regulatory folks who covered the waterfront,” says Chepesiuk, who notes that he’s seen a marked shift in the way drug companies are approaching these new media in the past two or three years. “The new standards are reflecting the new opportunities.”

Some groups, however, feel Ottawa’s response is inadequate. “With the advent of Facebook, Twitter and YouTube, there are a lot more opportunities for American firms to use that type of advertising,” says Dr. William Cunningham, president of the British Columbia Medical Association, which wants Ottawa to set up a special agency to vet drug ads. “The feedback we’ve gotten is that social media advertising has circumvented the old regulations.”

Tough questions

Every day, millions of people go online looking for health information. According to surveys conducted by the Pew Research Center’s Internet and American Life Project, almost three-quarters of U.S. Internet users sought health information online in 2012, and there’s little reason to think the Canadian statistics are much different.

There is plenty of online information on drugs, from Wikipedia entries to technical monographs. The drug companies, moreover, have had a corporate web presence for years. But the use of social media marketing is relatively new, and it has raised tough questions for both regulators and consumers searching for reliable information.

For example, a drug company may have a Facebook page for a prescription medication. But what happens if two users begin discussing so-called “off-label” uses of the drug, such as treating conditions for which the medication wasn’t approved? Or what becomes of negative comments about a drug that are posted?

Most drug companies have elaborate Facebook usage policies that sharply limit such discussions and inform visitors that negative comments will be removed. The American sites also warn that the comment strings are for U.S. residents only.

Less clear is what happens if non-U.S. residents post comments, or if the firm’s marketing team pays freelancers to plug its treatments anonymously in online discussion groups. Says Mackey, “You really don’t know who’s posting information” to these forums or other social media sites.

Other forms of promotion can be even more subtle. Many drug companies and their ad agencies are creating new ways to raise brand awareness in the digital universe. Some firms, for example, have developed smartphone apps that remind patients to take their medications or monitor their calorie consumption. Others have Twitter accounts that disseminate information about certain conditions but stop short of providing advice about the medication.

Are these ads? The answers aren’t clear, although U.S. regulators are taking a much closer look these days. In one recent case, the FDA launched an action against a health supplement manufacturer that “liked” a Facebook comment from a consumer who wrote positively about the product.

In a far more high-profile prosecution, the U.S. Department of Justice in 2011 hit Google with a $500-million fine, the highest ever of this sort, for allowing illicit ads by Canadian online pharmacies selling popular medications into the U.S.

Mackey adds that U.S. prosecutors are becoming increasingly vigilant about false claims in drug ads, as well as undisclosed financial relationships between the pharmaceutical companies and physicians.

There are no such prosecutions in Canada, which may be why the British Columbia Medical Association wants Health Canada to take a harder line, especially when it comes to the exploding realm of digital marketing. As Cunningham points out, the growth in social media promotion could translate into more physician visits and increased health costs.

However, not everyone agrees that tougher enforcement is the correct response. Health industry lawyer Rajeev Sharma, a partner at Torkin Manes who used to work for Bayer Canada, says Canada’s DTCA restrictions mean there’s a dearth of authoritative consumer-oriented drug information. “I think Health Canada needs to loosen the rules enough to allow the pharmaceutical companies to give better layman’s information about the drug and the disease.”

But York University health policy expert Joel Lexchin, a frequent critic of big pharma, feels drug companies would balk at using the Internet to disseminate the full range of information about their prescription medications, including other similar drugs, target patient groups and non-medicinal alternatives.

Lexchin and others also point out that individual governments will never be able to adequately police online marketing of drugs through far-flung social media channels because of the borderless nature of the Internet.

“This kind of an issue is really something that is incredibly difficult to regulate,” he says. “I don’t think a national approach (to regulation) has any chance of being successful.”

Yet Mackey, at UCSD, points out that it is technically possible to restrict non-American users from accessing the drug companies’ U.S. websites and social media platforms by blocking visits from non-U.S. IP addresses. But, he adds, such moves would depend on the co-operation of major Internet service providers.

The risks of inaction, Mackey feels, grow with each new “like.” If health regulators don’t get a grip on what’s happening in the burgeoning social media universe, he warned in a 2011 paper, “patient safety may be compromised.”

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