With little evidence of health benefits, television advertisements for testosterone were very successful at persuading men to seek treatments for a questionable disorder, a new study in JAMA suggests. The potent commercials may have been a significant driver in the boom in testosterone use, which launched sales ten-fold in the US between 2000 and 2011.

The study, led by researchers at the University of North Carolina, Chapel Hill, examined insurance claims of around 17.2 million American men in 75 television markets between 2009 to 2013. During that time, more than a million of the men got their testosterone levels tested and more than 283,000 started treatment.

Looking at advertising patterns, the researchers calculated that a single ad aired to a million men was linked to 14 new tests, five new prescriptions following testing, and two new prescriptions given without testing. Ad exposure varied by market, with some seeing as many as 200 ads during the study period.

The findings further the debate on the use of direct-to-consumer advertising, which has long been frowned upon by the medical community. In 2015, the American Medical Association called for a ban of such marketing, which is well linked to driving up the use of certain medications, often pricy brand name drugs. But in the case of testosterone, the study links the ads to more than just pricy options; there are links to “potentially inappropriate use and increasing initiation during a time when most testosterone use was of questionable value for age-related testosterone decreases without strong evidence of benefit,” the authors conclude.

An estimated seven percent or so of men do need testosterone treatment for a disease called hypogonadism, which involves problems in the hypothalamus, pituitary gland, or testes resulting in low testosterone levels. But as men age, their testosterone levels naturally decline. Drug makers went directly to consumers to raise awareness of this normal scenario, dubbed “low T,” and persuaded them to get tested and possibly treated for it. But doctors debate whether it requires treatment at all, as well as whether the risks of taking testosterone are outweighed by benefits—which have also been shaky.

Low “E” for evidence

As Ars reported last month, researchers conducted a series of studies showing that testosterone treatments offer little benefits to men with “low T.” The treatments could improve mild anemia and bone health, researchers found. But the treatments appeared useless at improving memory. Perhaps most concerning, researchers found yet again that treatments can raise risks of cardiovascular disease.

Earlier studies from 2013 and 2014 showing similar risks led the Food and Drug Administration to change the warning labels on testosterone therapies. Television ads dropped off after that, as did sales.

But at their height, those ads were “startlingly effective,” Richard Kravitz, a medical researcher at the University of California, Davis, wrote in an editorial accompanying the study in JAMA. They “implicitly promised better quality of life and improved performance ‘in the boardroom and the bedroom,’” he wrote.

The new JAMA study suggests that these ads directly influenced whether men asked their doctor about testing and/or treatment. Previous randomized clinical trials have found that patient requests strongly influence doctors' prescription decisions.

Though the study had several limitations—such as only providing a correlation, not causation, and not tracking other forms of marketing—the authors say the study raises important questions about the use of direct-to-consumer ads.

Kravitz goes further, concluding, “Findings like these suggest that [direct-to-consumer advertising] of prescription drugs as currently regulated in the United States is unlikely to yield consistent public health gains.”

Currently, the US and New Zealand are the only two developed countries that allow such drug advertisements.

JAMA, 2017. DOI: 10.1001/jama.2016.21041 (About DOIs).