The study raises the question of medicines’ promotion the pharmaceutical industry follows and its leverages in terms of ethics. The research considered the realities of the last two decades. The paper presents evidence of unethical marketing the pharmaceutical corporations implemented. Also, the report provides evidence of the negative influence of pharmaceutical marketing on physicians’ prescribing and postulated that medicines’ advertising is a tool to promote, but not to inform. Summarizing point reveals the advertising of medicines as unhelpful tool, which threatens the health of the population and requires comprehensive regulation. ​

The Unethical Pharm-Marketing: Findings

Pharmaceutical marketing is a activity aimed at studying consumer demand to improve the quality of life of each individual and the welfare of society as a whole. It can be said that marketing is revenue making by satisfying the needs of the consumer wherein the principles of marketing should be versatile enough. In other words, it does not matter what to sell - cars, oil or medication. However, it appears that the sale of medicines has a number of features. This is due to the fact that drugs are a special commodity because they affect the most valuable thing any human has – his/her health. Moreover, the health of the nation influences the prosperity of any country. Thus, one of the main objectives of the pharmaceutical industry is the production and distribution of safe, effective and quality medicines. In addition, this objective should play a key role in the economy.

Currently, most pharmaceutical companies are trying to adhere to the concept of socially responsible marketing, which involves defining interests and needs of the target groups of consumers to satisfy their queries with more efficient than the competitors have, ways while preserving and strengthening the well-being of the consumer and society as a whole. Being an integral part of marketing, pharmaceutical marketing can be characterized as a process by which a pharmaceutical care is provided.

The emphasis of pharmaceutical marketing is on pharmaceutical care, but not just on drugs since pharm corporations’ ultimate goal is to meet the needs of the patient, not the manufacturer or pharmacist. Any product, service or idea related to pharmaceutics (including marketing of drugs) may be the subject of pharmaceutical marketing. The latter is not quite a synonymous to marketing of drugs. Drugs’ market is a complex of various organizations which interact in order to get profit selling a particular product to the consumer the drug. This is characterized by such parameters as capacity, structure, affordability, availability, and presence of the legislative framework to govern the market participants’ interaction.

The factors to determine the product’s demand are morbidity, medical- demographic, socio-economic and climatic factors. Pharmaceutical marketing considers products as medicines in various dosage forms, medical instruments, dressings, etc., the use of which depends on the disease of the patient and qualifications of physicians who form demand. The main goal of pharmaceutical products’ advertising does not differ from any other product’s advertising. Thus, it is needful to make the potential client acquire the advertised product. However, pharmaceutical products’ advertising has unique features. It is explained by the specific objects, which are closely related to medicine and health and forces one consider the impact of advertising on people not only in terms of commerce, but also through the prism of public and personal security.

The main difference, however, lays in the set pharmaceutical advertising’s restrictions to use various relevant to advertising media, such as print media, television, radio, the Internet (the Internet audience grows faster than the audiences the other advertising media), etc. Moreover, the main difference is in the presence of regulatory documents on international and national levels. To short, goods’ advertising of pharmaceutical market is limited. Ethical standards of the pharmaceutical market prohibit the direct connection of the manufacturer and patients. Most advertising media, such as television, radio, local newspapers are not used to promote drugs to be prescribed by the doctor. Moreover, there are legal restrictions on advertising of all kinds of drugs in some countries.

Any pharmaceutical company seeks to focus its efforts on selling the right product in the right quantities in a convenient place at a convenient time and at a price that the consumer is able and willing to pay. This is the very nature of marketing, so here are the four components of classical marketing.

Research department in conjunction with the marketing department develop the right product taking into account the characteristics of the drug, which by far would satisfy the needs of patients. Quantitative characteristics of the drug are closely related to packaging and release form. The efficacy and relative safety of the drug highly depends on this. Quantity is an important characteristic of product marketing and is essential for health talking about medicines.

At first glance, the distribution places of prescribed-to-be medicines are predetermined. These are hospital (doctor) or pharmacy. In fact, creating complex structure of distribution channels consisting of wholesalers, retailers, hospitals, clinics, and various organizations (government, health care management, and pharmacy management services) is important for the effective dissemination of prescribed-to-be drugs. The demands and needs of patients have valuable influence on the operations of these institutions.

The task of the marketing department is to ensure the availability of the drug at the right time. To determine the appropriate time for the drug’s introduction on the market is also highly important. Undoubtedly, any period of time suits the introduction of an effective and relatively safe drug for the treatment those patients who fight diseases, which previously have been or are severe by nature having no respond to treatment.

Price is one of the components of the marketing. Some medications due to their uniqueness and urgency (for example, the elimination of the epidemic) will be in demand regardless of the price (the demand for these drugs is inelastic), albeit with some reservations. Therefore, it is necessary to pay attention to some particular item, which pharmaceutical industry produces in order to understand what the impact of prices on consumer demand is. One of the unique features of medications as commodity is the undesirability of these goods since ideally, every person wants to be healthy and avoid resorting to medicines. More willingly and gladly any consumer buys other goods, such as clothing, concert tickets, and pays for dinner at the restaurant as an example. Medications are unpopular products, so their prices are unpopular as well thus regularly subjected to criticism.

Complaints about the high cost of drugs will never stop. In this regard, there are no acceptable prices for the drug for the consumer because it is always high. Non-state companies that produce drugs must reimburse insure risks, which are associated with scientific research and development. Regardless of who pays for the drug, the patient, a government organization, organization of medical aid management, organization for managing pharmacy services, the task of the marketing department of trade or industrial enterprise is to determine the correct price for the drug.

By overall, advertising of medicines is a particular area of activity where the commercial interests of pharmaceutical manufacturers, distributors of drugs, the informational needs of professionals and the public do closely overlap. At the same time, there is a public concern about the impact of promotional activities for the safety of taking pharmaceuticals. Therefore, the vital importance (and at the same time the danger) of drugs caused the strict rules that are designed with extreme rigor and detail for their advertising. Generally, other industries forcing unfair advertising make suffer only competitor and consumer purses while in the pharmaceutical area may suffer health or even life. Furthermore, a scenario when the market’s introduction of a new drug is one of the priorities of the manufacturer is known by ensuring its availability in the greatest possible number of drugstores.

A significant role belongs to pharmacists’ first table in promotion of prescription-free drugs because only they have the ability to influence the patients’ selection. Patients who do not have time to visit the pharmacy having generated decision to purchase a particular drug, as well as switching drugs, which are recommended by the doctor. Pharmacies administrations, in turn, have the ability to influence the actions of subordinates to ensure the preference to a specific producer. All these factors lead to the fact that manufacturing companies promoting their drugs are actively using various methods to motivate their workers to purchase and sale those. This, sometimes, contradicts the general principles of ethical marketing.

Resuming the introduction part, the researcher put an emphasis on the ethical norms the pharm-marketing must function within. The topic is undoubtedly worth attention since the aspects of unethical pharm-functioning concerns everyone in each country, no matter more or less. As has been mentioned above, countries prove rather productive laws frameworks and the others are still processing those. However, industry practices breaking the frameworks almost in every country, using the advertisement tools mainly and others available. Therefore, there is fierce competition between manufacturers of drugs on the market of medical products and services in developed countries. After all, the one who breaks through to patients will have a steady income. Of course, the regulatory authorities of many countries critically evaluate the negative impact of competition race on the market quality and care of the legal and ethical regulation of market relations activities of the participants in this industry.

Literature Review

Independent information search, focused on problem analysis, has provided the research following goals: searching for relevant information, searching of analogue information in related areas (extension of the baseline), summarizing and clarifying the information received; analyzing and evaluating the information based on own set tasks. The challenge of self-information search is explained by the objective character of the law of scattering information, on the inability to collect all the sources of documentary information necessary for the researcher in one place and other features of the flow of information. To some extent, these problems are solved by using modern information and communication technologies, and the Internet information resources. However, the web sources cannot completely solve the problem of shortage of information (apparent completeness of the information found in the Internet is deceptive, also raises the question of the validity and authenticity of the studies). In general, all the real diversity of information retrieval problems can be reduced to basic information deficit. Stages of information retrieval are formulation of the search question, the development of the working program of research, implementation of search, execution of the search results.

The formulation of the search problem is caused by deficiency of relevant information. In essence, this is a brief definition of the subject (content) search. The formulation of the problem is done in the form of elemental thematic headings. However, it can be in the form of a plan (the list of subject headings, structured key words) in the form of annotations. The formulation of the search problem is to determine the area and especially literature used, to facilitate the preparation of the program search. The search was tied to the topic and purpose, especially when there was a need for a wide coverage of information sources, literature, i.e. bibliographic and documentary kinds of search during the implementation of information retrieval. Only then the information search was specified, the content was limited to the immediate problem to be solved.

The online libraries were widely searched to access the relevant studies or experiences according to the research issue. This data was suitably different to expand the whole idea of conducted research since each article claimed own outcomes and salvations presenting clearly the time, population and medical aspects that are considered as the stable study’s circumstances. The volume and content of taken information itself divided the sources to primary and secondary. However, the researcher does not mean the extra necessity of one article over another one.

One of the most common and difficult tasks faced by the performer of this work was to search for information on the Internet. The cause of the complexities involved in information retrieval in the Internet is determined by two main factors. First, the number of sources in the network is extremely large. Second, the amount of information in the network is not only enormous in size, but also is extremely dynamic.

As was mentioned before in strategy search section, electronic sources were also widely used. This allowed capturing the different results of world studies, European, Asian or American.  To get the needed material the researcher used search engines and internet directories, which guided to the works with specific and unique contents. Abstracts of published or unpublished material were read carefully to understand the possible value of a material next after the abstract. Moreover, such articles as a rule contain bibliography, which also helps to find the right material in turn. The most important elements, which were to be taken first while evaluating the content, are the treatment features, medicaments, periods and outcomes.

Exclusions were made to the sources which did not present the idea well, that had no outcomes, improvements or clearly seen study’s circumstances. The articles, which contain any proportional evidential results in figures, were limited by the year publish aspect. Thus, the articles that were published or revised before the 1990 year were excluded since the author dares to suggest them being rather old having no requirements’ connection to the up-to-date research. The material presented in any foreign languages was also not accepted. In case the article had no author, the year of study implementation or bibliography, for a reader to know the sources that were pointed out to build the logical chain while conducting the study, such articles were excluded as well. All other materials were accepted as the credible ones. Their pre-final sorting was based on the year of publishing, the content similarity and the place of implementation. The final sorting appeared to present the relevant outcomes and results with the same resuming statements.

The literature database concluded the studies which were accepted as primary ones and the other works of authors from different world areas to cease the general point of view or results upon the research topic. That was done to generate the whole concept from analyzing numerous studies, print or electronic. Some sources were highly evaluated by the researcher giving a wide scope to the questions that were set before the implementation of literature identification and analyzing. Below is the analysis of literature sources the researcher accepted as credible.

Publications

The pharm products’ advertising is allowed only to doctors in many countries. Most of the magazines, including such prestigious publications as the BMJ, New England Journal of Medicine and JAMA, contain such advertising. Advertising revenues constitute a weighty part of the journals’ budget. For example, the income the six major journals in the United States receive on drug advertising is ranging from 2 to 31% of all income. These revenues are comparable and even significantly higher than (up to 8 times at the New England Journal of Medicine) subscription revenue (Smith, 2005). In addition, companies pay for additional volumes of the magazine with reprints of their research, and dissemination of magazines around the world through the marketing departments of pharmaceutical company increases the number of subscribers of the magazine.

Wilkes et al. provided the analysis of advertising materials in medical journals, which showed that 32% of headers contain incorrect information about the effectiveness of drugs, and 44% of information can lead to improper prescribing, as these do not contain the necessary additional information (Hersh, 2008, p. 79). Moreover, 44% of advertising slogans are not supported by references to the relevant studies, such as the drug is recommended for patients who have not been studied specifically (Villanueva et al., 2003).

Magazine advertising is used along with visits to sales representatives and detailed materials that they leave in order to bring advertising idea to the doctors. The Editor of “The Lancet” Richard Horton once said “Magazines select the information in favor to the pharm business” (Horton, 2004). This attitude to the events was supported by Marcia Angell, former editor of the medical journal “New England Journal of Medicine”, who described the incoming information from pharmaceutical companies as “a mixture of exaggeration, bias and misinformation, which is very difficult to recognize” (Angell, 2004, p. 336).

For example, in Australia, thiazide diuretics are the most advertised class of antihypertensive drugs (48.7% of all advertising materials), but most of them are promoted being put in combined medications. Only one thiazide, promoted as a single agent, was the most expensive indapamide. None of the advertisements mentioned the fact that thiazides are the first line of therapy. Statistical indicators were often expressed in relative rather than absolute terms, thus the prices were mentioned without comparative analysis. Side effects were usually presented only as a small inset. There were no other recommendations for lifestyle changing given besides mentioning the drug interactions with alcohol and table salt. Only 2.7% of advertising material referred to the need for risk assessment on the part of the cardiovascular system (Montgomery et al., 2008). Australian Regulatory Agency has not properly warned doctors about the potential cardiovascular risk associated with cyclooxygenase-2 inhibitors, which led to catastrophic consequences (Vitry, Lexchin & Mansfield, 2007).

Advertising of medicines in medical journals is unhelpful and potentially threatens the health of people. It has a greater effect on the drugs’ market share than the quality of appointments has. For instance, reducing the promotion of the angiotensin-converting enzyme inhibitors and blockers of slow calcium channels with the help of magazine advertising decreases the proportion of their sales in the market (Spurling, Mansfield, Montgomery et al., 2010). Physicians who well remembered ads were significantly more likely prescribing an advertised drug. For example, frequency of administration of hormone replacement therapy and angiotensin receptor antagonists increased under the influence of magazine advertising (Hemminki, Karttunen, Hovi et al., 2004).

Doctors who unperceived magazine advertising and other marketing techniques as reliable information of the medicinal product, had higher quality of assignments and examination of their knowledge compared to their counterparts, who extracted information on the medicinal product from the journals’ marketing technology. It was found that doctors, who prescribed more expensive drugs, often read medical journals containing advertisements (Watkins, Harvey, Carthy et al., 2003). Advertising, which does not reach its goal (increasing the number of appointments), is also potentially detrimental, as doctors spend some time to read it out, thus it increases the cost of the drug because promotion is also included in the price. Magazine advertising along with direct mail and visits to medical representatives is one of the most unreliable sources of information. While health workers themselves believe that magazine advertising is an important source of information (Hume & Shaughnessy, 1991). Doctors prescribe new drugs more often using ads published in journals as sources of information. Moreover, the appointments increase dramatically if the publication of a single promotion turns into an advertising campaign (Engle, 1994). The more the magazine advertising, the higher the frequency of assignments is.

It is noteworthy that later studies have shown that students and pharmacists consider more than half of advertising in medical journals as false information (Mackowiak, O’Connor, Geller et al., 1997). Residents who did not undergo training to recognize medicinal drug promotion, were 2 times more likely than their colleagues considered advertising magazine as a useful source of information (Jewesson & Herar, 1996).

It should be noted that physicians better distinguish medicaments by their international nonproprietary name if they rely less on magazine advertisements. Thus, doctors, who oriented on the information, which is obtained as a result of drug promotion (including advertising in medical journals), get lower quality of prescribing and the higher frequency of the polypharmacy.

Very often, pharmaceutical companies indicate incomplete information about drug safety. Thus, Tomson and Weerasuriya (1990) proved that information about the side effects was found only in 25% of analyzed magazine advertising cases. Often, advertising in specialized periodic medical journals did not meet the regulatory requirements or it distorted the presented information (Rothermich & Pathak, 1996).

Regulatory Authorities

Independent public bodies are designed to regulate the pharmaceutical market. However, informal relationships between drug manufacturers, government officials and involved consultants were identified recent years. In late 2003, financial ties of some employees and pharmaceutical companies, contrary to the ethics programs of the organization and demanded administrative measures to prohibit employees to collaborate and receive compensation from pharmaceutical companies were revealed in the system of the National Institutes of Health, USA (Steinbrook, 2004).

The situation described above was unreasonably prolonged widespread usage of coxibs, which might increase the risk of cardiovascular events, was created including the FDA committee resolution. It turned out that 10 of the 32 voting members of the FDA committee, which gave permission for the use of drugs, had financial ties to manufacturers (Steinbrook, 2005). Investigation revealed that 28% of the members of various FDA committees had a conflict of interest due to the co-operation with pharmaceutical companies in the form of advice, contracts and investment from pharmaceutical companies. Yet, they participated in decisions on drugs. Often, there is no so strong influence on expert, but many well-known psychological phenomena are used, for example, it is difficult to express criticisms of the drug, which is manufactured by friendly and helpful pharm team.

Physicians and scientists

Doctors prescribe the major part of drugs both prescribed-to-be and prescribed-free; therefore, marketing departments of pharmaceutical companies have focused on working with practitioners. A lot of forms of enhanced communication with physicians are used to enlarge the promotion of drugs. These are providing the drugs samples, gifts, compensation costs for education and attending conferences, fees for consultations and speeches, participation in advisory committees, the selection of patients for studies (Campbell et al., 2007).

Thus, the literature sources that were discussed proved the crime facts the researcher wanted to reveal. The problem remains unsolved and requires developing and modernizing the existed law frameworks the governments apply to.

Implications of the Literature

The state seeks to regulate all markets, but pharmaceutical market is preferable one. Availability, efficiency and patient satisfaction are the main aims of society. Politics greatly influences the management of pharmaceutical sector, and this sector, anyway, involved many players, including industry producing both new and generics medicaments, companies, which are engaged in wholesale trade and pharmaceutical products’ import, doctors, pharmacists and, finally, patients. Interests of market participants often compete, and state hardly satisfies all of them while managing the pharmaceutical industry. World practice has already developed legal rules that protect the patient from the promotional activities of pharmaceutical companies. Legislation of most countries in Europe, America and Asia regulates advertising activities of medical products under the separate laws. Government regulation is the major component of the system of external monitoring of promotional activities in these countries. It is implemented through the creation of a broad legislative framework, the formation of the executive bodies of different degrees of exercising control.

In recent years, much of the researches were done by private contract research organizations (contract research organizations). This approach is attractive for medicaments manufacturers since in comparison with the organization of academic research institutions it reduces costs and facilitates research. In this case, severely limited access may be provided to scientists to research data, analysis, and interpretation of results and to form conclusions. Research results are not always published if they do not meet the objectives of the drug manufacturer. It is necessary to conduct a placebo-controlled study for the successful introduction of a new medicament, and this, however, is contrary to the Declaration of Helsinki, as part of the patients will not receive treatment. Therefore, the comparison of new drug with known drugs is performed more frequently. There are many tricks to increase the probability of a positive test result. For example, less worthy competitor is collected as a competitor or unreasonably low or high dose is selected to proceed with medications comparison (with an increase in the incidence of side effects). Selecting multiple combined studies’ endpoints and their adjustment in the course of the study also contributes to a positive outcome.

The use of false information in medicaments advertising is the main method of unfair competition for professionals, mainly for doctors. Typically, such information is not distributed through special editions - scientific and practical journals, professional press, but in the form of prints (copies) of scientific papers or reports. These materials under the guise of scientific literature are distributed during scientific conferences, or are given out to doctors during the exhibitions.

The problem of unethical advertising in specialized medical journals is particularly topical and requires careful control counting that for the medicaments prescriptions, as part of the drug benefit programs, doctors play a key role in ensuring the rational use of drugs, including those who are guided by specialized publishing periodicals. This happens while advertising in specialized periodicals is largely unregulated by the law. There are no clear rules to limit the insatiable desire of pharmaceutical companies to promote their products in any way. Distorted information, which is based on unpublished or substandard clinical studies, can lead to irrational use of drugs. At the same time self-regulated model of industry in the field of promotion of drugs, which is used in many developed countries, does not work. Editors of medical journals rarely require fixing the data that are contained in the advertising incision. Thus, neither the industry’s self-regulation nor reviewing of editors of medical journals is capable to protect the public against poor, distorted advertising. Drug regulatory violations in this area are less common in countries with a strong tradition of promoting.

Regulatory bodies sometimes meet negative attitude of experts since public interests come into conflict with the personal due to the discovery of facts regarding pharmaceutical companies. Public disclosure of interests’ conflict and removal of specialist from voting on important issues of the usage of certain drugs, if the conflict caused, can increase the objectivity of decisions.

Despite numerous publications on ethical issues between physicians and the pharmaceutical industry, permissive principle in respect of the marketing activities of pharmaceutical companies remain in most hospitals. The U.S. Government, being aware of the possible negative consequences of financing the medical workers by pharm industry, constantly develops and implements the laws, which require open public information about financial aid to physicians. Pharmaceutical companies accept giving work to scientists and opinion leaders (highly qualified specialists, whose opinion materially affect the health practitioners and can enormously increase drug sales) as the most important business trick.

Conclusion

The pharmaceutical industry plays an important positive role in modern medical science and practice. Creating new drugs to save lives is the result of intensive work of a large army of chemists, pharmacologists, clinicians and managers. Development of low-cost generic medicines can effectively treat a greater number of patients. Doctors receive up to date information, access to new medicines and technologies of patients’ treatment and the opportunity to communicate with leading experts at the conference, etc. through the activities of major pharmaceutical companies.

However, the large financial costs of drug development, the orientation of the pharmaceutical companies to maximize profits create tough conditions of inadequate competition for the use of medicines. In this regard, it is necessary to continuously improve mechanisms of objective assessment of a drug’s role in the prevention and treatment of disease. Large randomized study with impartial scientific analysis of the results should be conducted in medical practice for successful medicaments’ introduction to pharmaceutical market. Objective experts’ position and open publication of interest’s conflict are needed to adequately assess the results of any researches or studies.

Ideally, establishing a direct link between the health professional and receiving any financial incentives for giving patients a certain pharmaceutical product should be considered categorically unacceptable to maintain objectivity of general therapeutic approach. The researcher hopes that future economic development will eliminate the problems, solutions of which cannot be presented today. However, this position, in no way, does not mean that everything can be left as it is. Being critical to the actions of medical representatives is not difficult; one can always use back their own tactics. Any manufacturer willing to invest money in medicine should not put the dignity of a doctor under a question. By principle, a pharmaceutical product is just a means in the hands of the clinician, and not vice versa, thus one should always keep in mind who should lead the situation.

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