Drug advertising directed to pharmacists in Brazil : information or sales promotion ?

Analyses of drug advertising reveal important social and cultural values and attitudes at a certain point in history. The purpose of this paper was to investigate how pharmaceutical industry communicates with pharmacists in Brazil, using drug promotion as a valuable tool. The point of departure was the analysis of a series of drug advertisements published in three Brazilian technical journals targeted at pharmacists and other health professionals. For the present study, the focus was on the content of the messages directed to pharmacists, in order to critically analyze the role attributed to these professionals as portrayed by the ads, and to discuss it in the context of pharmaceutical care. The collection and analysis of the data followed Anvisa’s methodology. Pharmacists’ social responsibility includes the reduction of preventable drug-related morbidity and mortality, but the information provided by the ads only refers to sales growth and profitability. Pharmacists are portrayed as salesmen, rather than health professionals, and encouraged to sell pharmaceutical drugs which are being heavily advertised to medical doctors. Consequences for pharmaceutical care are discussed.


INTRODUCTION
Analyses of drug advertisements reveal important social and cultural values and attitudes produced by and influencing societies at a certain point in history.Gomes (2006), for instance, investigated images of old drug ads as a valuable source for the history of medications in Brazil.Huertas and Campomar (2008) analyzed an advertisement of a prescription weight loss drug in order to understand the consumers' perspectives toward medications, as well as their attitude and behavior in response to direct-to-consumer advertising.Other researchers have discussed the strategies used by the pharmaceutical industry to maximize profits through marketing efforts, including the redefinition of diseases to increase the number of patients and the reduction in thresholds for therapy, in order to expand their markets (e.g., Sillup;Porth, 2008).Disease mongering in drug promotion is being discussed by several researchers, such as Moynihan, Heath and Henry (2002), Moynihan and Henry (2006) and Mintzes (2006).
Advertising messages vary according to the target audience and to the kind of product to be sold.Inohara (2005) discussed the four basic kinds of strategies: the informative, the persuasive, the comparative and the reminder advertisements, which can be used isolatedly or in various combinations, depending on the desired goal.And drug advertising and marketing is acknowledged as one of the factors which do influence consumption of pharmaceutical products.
Studies on drug advertising directed to prescribing physicians -the main target of drug promotion -have been extensively published.They confirm that this is not a reliable source of information for lay people, nor for health professionals.Brazilian studies on the quality of information given to medical doctors show that all advertisements are made in order to increase sales, omitting or neglecting important data on contraindications, side effects, risks, and other warnings (Pizzol, Silva, Schenkel, 1998;Barros, Joany, 2002;Mastroianni, Galduróz, Carlini, 2003;Nascimento, 2003;Luchessi et al., 2005;Soares, Lasmar, Figueiredo, 2005;Wzorek et al., 2007;Mastroianni et al., 2008;Soares, 2008).These data agree with international studies which have been developed for decades as well.
But, so far, analyses of drug ads targeted specifically at pharmacists have not received the same attention in the literature.One study was found, in Portugal, by Galhardo (2006).The author analyzed the way the linguistic components of drug ads communicate with pharmacists, the mediators between the producer and the final consumer.Her research on ads published in Farmácia Distribuição, a Portuguese journal, showed that the messages intend not only to make pharmacists informed about the drugs, but to encourage them to recommend the products to their clients.
In Brazil, our regulatory authority, the National Agency for Health Surveillance (Anvisa), started a national project for monitoring advertising and publicity of products under health surveillance in 2002, working in partnership with almost 20 universities all over the country (Brasil, 2002).The MonitorAÇÃO Project at Fluminense Federal University (UFF) was coordinated by this author.For one year, almost 200 drug advertisements were analyzed from pharmacotherapeutic, legal and linguistic points of view, by students from different graduation courses (Soares, 2005;Soares, 2008).
In 2005, during the MonitorAÇÃO Project, 10 drug ads published in Guia da Farmácia were analyzed.The messages directed to pharmacists were explicit on their purely commercially-driven content, seriously infringing Brazilian legislation.The analyses were then sent to Anvisa, so that the legal and necessary interventions could be made (Soares, 2005).We considered important to continue collecting data on this specific kind of advertising.Thus, the main purpose of this paper was to investigate how pharmaceutical industry communicates with pharmacists in Brazil, using drug promotion as a valuable tool.The point of departure was the analysis of a series of drug advertisements published in three Brazilian technical journals targeted at pharmacists and other health professionals.For the present study.we focused on the content of the messages directed to pharmacists, in order to critically analyze the role attributed to these professionals as portrayed by the ads, and to discuss it in the context of pharmaceutical care.A similar version of this article was the basis for an oral communication presented at The Third International Conference The Pharmaceutical Lifecycle (Soares, 2009).

MATERIAL AND METHODS
The journals reviewed were Revista ABCFARMA, K@iros, and Guia da Farmácia, all published monthly and directed to health professionals, particularly to pharmacies' staff.They are mainly distributed to private pharmacies in Brazil.The issues were obtained through the contact with pharmacists working at private community pharmacies in Niterói and in Rio de Janeiro.The time range was from June 2005 to June 2008.
The methodology of data collection and analysis was defined by Anvisa (Brasil, 2005).Five among the 10 drug advertisements published in Guia da Farmácia first analyzed in 2005 were reviewed for the present study.Moreover, the research was expanded in order to check if this pattern of advertising strategy could also be found in other journals distributed to pharmacies, as well as to investigate if there were any changes since 2005.The main results are presented and discussed below.
Considering that words and images play an essential role in the information, manipulation or publicity of products or ideas, the analyses focused on the linguistic content of the messages and on the images displayed in drug advertisements which were specifically targeted at pharmacists.The ads were chosen so that they could illustrate the main purposes of marketing campaigns portrayed in the different journals.
As the study was limited to drug advertisements analysis, no ethical approval was required.The aims of the message were to inform about the new package, with reduced number of tablets, and to encourage pharmacists to order the product.
Headline: "The package of Femina was reduced so that your sales continue to grow." Other information: "Big promotional campaign with the force of Aché's representatives.Order now." The image shows a beautiful woman, hair and clothes in the wind, creating a very light and relaxed atmosphere.The aim of the advertising message was to expand the target population of consumers, to include men, as this is a very popular product among women.The ad also encourages pharmacists to sell it.
Headline: "Double your profits: men also have colic." Other information: "Increase sales with Buscopan.

Ideal for men, women and your income." "Always have Buscopan in your pharmacy."; "It's fast. It's effective. It's Buscopan."
The image highlights the different pharmaceutical presentations of the product.The green and yellow colors of the product are displayed in the background.SORINE ® -collected on Aug. 10, 2005, published in Guia da Farmácia, 151: 49, June 2005.Sodium chloride + benzalkonium chlorhydrate, topical nasal decongestant, OTC.
The aim of the advertising message was very clear: to explain the marketing strategies used to seduce the population, so that pharmacists can play their role: be ready for the increased sales of the product.
As it is a topical nasal decongestant, there is a game of words with congestion as a medical event and congestion of people.The analysis showed that the information about adverse reactions, warnings and contraindications were omitted.
Headline: "Congestion?Only at your point of sale."

Other information: "Prepare your stock of Sorine infantil [for children]. There will be congestion at your point of sale."; "Sorine infantil was launched on TV with the winning advertising 'Congestion', besides the POS materials, merchandising and ads on the main magazines".
The image displays the product with a relaxing light blue background.The aim of the advertising message was to make pharmacists buy the product in order to have it for sale in the pharmacy.No need for therapeutic information: adverse reactions, warnings and precautions were omitted, as well as dosage.Contraindications were partially informed, and on a separate place in the journal.
Headline: "The consumer who does not find Anador

will always look for it at another pharmacy. Do you see the damage a headache can cause?"
The image displays a drawing of a human figure, with a big smile and Anador pills as its eyes.The aim of the message was to announce the launching of a new advertising campaign.
Headline: "A great campaign in order not to leave doubts in consumers' minds, nor Flogoral on the gondola." Other information: "Flogoral will be everywhere this winter.The big 2005 campaign will bring insertions and TV shows sponsorship, besides the greatest investment on POS in the history of the product.Prepare your stock.Flogoral is effective at treating throat problems, and a specialist at raising your sales".
The images shows different ways to display the product, as well as logos of the TV channels where the campaign will be inserted.
The aim of the advertising message was to encourage the dispensing of this generic product.
Sales argument: the promise of a benefit (increased sales).There is a game of words with prescription and recipe.In Portuguese, both words can be used to refer to a prescription.
Headline: "Sibutramina Medley.When you dispense this prescription, it becomes a recipe for good business".
Other sentences: "Sibutramine: leader of prescriptions and sales".
Aim of the image: to encourage pharmacists to have the product in the pharmacy, because medical prescriptions are being filled out.
The aim was to advertise that the product had changed from Rx to OTC.
Headline: "With such a package, do you think we would be hiding behind the counter?" Other sentences: "New package, no red stripe and now available for self service.""Good for the clients, better for your sales"."Claritin.More freedom, to make you breathe easily." No information on therapeutic data.The aim of the image was to show that the product had changed from Rx to OTC, implying more freedom to sell it.A new package, with new colors; the goal was to distinguish it from the previous package, which was red and had the red stripe obligatory in Rx products.The blue background matches the blue package... with a green field, reminding of freedom, as the sale is not linked to a prescription anymore!This open space also relates to the fact that the product can be more exposed now that it is OTC.Aim of the advertising message: to launch this new product and to reinforce the sales slogan "simple and fast".These words are repeated in several places.Sales argument: the promise of a benefit (simple and fast to sell).
Headlines: "Levcin, levofloxacin.Simple as that.Fast as that." "Launching with support from medical visitation staff." Other sentences: "The prescription is made by the doctor.Simple as that." "The patient comes to your pharmacy.Fast as that.""Get ready to supply Levcin!" "The treatment is simple and fast." There is the image of a physician, a reminder note that doctors will be visited, and several boxes of the product.Technical information in very small font.This is an example of a seasonal product advertising campaign.The aim was to remind the product.The ad has no technical information, but goes into details about the producer's marketing strategies to reach prescribing physicians.
Headline: "FLUTICAN -fluticasone propionate" "Glenmark Line of Respiratory Products" "Take advantage of the pre-high and guarantee your winter!" Other sentences: "aggressive sampling to physicians" "Intense advertising for medical specialists" "More than 3,500 otolaryngologists" "More than 3,000 pneumologists and allergists." The image highlights the sentences and displays the product, in a light blue background.
The aim was to announce a new package of the product.
Headline: "V from vending more in your pharmacy".
Other sentences: "Viagra, the greatest potency at the market.Now, package with 2 pills.Prepare your stock for increased sales".
The image displays a hand with the "V" -from Viagra, Victory, Vending -and the new package of the product.Aim of the image: to encourage sales and to present the new package with two pills.The background is a black and white photograph, and the blue of Viagra is highlighted in the sentences, name of the laboratory and in the pills themselves.
Aim: to inform about a new product for erectile dysfunction.
Headline: "Our specialty is to put up… your business".
Other sentences: "Holographic seal and perforated package; more protection against fraud: more comfort and discreetness"; "Helleva has arrived.The most recent product for erectile dysfunction." The name of the product (Helleva is very similar to Eleva, which means elevate, raise), the game of words and the use of a high tree highlighted among other ordinary trees are explicitly related to the problem of erectile dysfunction.This advertisement was banned by Anvisa on June 29, 2009.

Double page. Acetylsalicylic acid + dexchlorpheniramine + phenylephrine + caffeine, OTC.
Aim: The use of TV stars is a very common strategy to publicize drugs.Here, there is a picture of Regina Casé, a very popular TV and film star in Brazil.The ad goes into details about the marketing strategies: the TV channels where the ad will be shown, the TV shows where the merchandising will appear, the promotional material that will be distributed to the pharmacies.The only technical information is on the contraindications, in very small font.
Headline The image of a beautiful and happy child lying on a woolen pillow intends to show the benefits of this antiallergic product.But this drug should not be used in children under 2 years of age.
There are also images of the different packages of Polaramine, and a reminding message: "no stripe", to remind that it is an OTC drug.Furthermore, there are pictures of covers of popular magazines and logos of the TV shows where the ads will be displayed.Farmácia, 157:21, Dec.2005.Sulfacetamide sodium + triethanolamine.OTC.Analgesic, antibiotic, emollient, healing.
It says: "Adults and pediatrics uses", though the product should not be used in children under 12.
Queimalive is registered at Anvisa as a combination product: triethanolamine/sulfacetamide sodium, indication: topical antiinfective agent.But in the ad, there are other therapeutic indications: analgesic, antibiotic, emollient, healing.And the whole propaganda, including the name of the product -Queimalive refers to "burnrelief" -recommends the product for the treatment of sunburns and domestic burns.
The only technical information relates to contraindication: "do not use it if you are allergic to sulfa or any ingredient of the formula and in breastfeeding women." Image: the background is the sun shining on the beach, and a sunshade protects the product, in an analogy to the product's alleged therapeutic action.

DISCUSSION
The three journals contain a great amount of advertisements (51%, on average).Even considering only full-page advertisements, 31% of the journals' content are, in fact, drug ads, thus suggesting their promotional goal.In her analysis of a monthly journal from Portugal -Revista Farmácia Distribuição -targeted at health professionals, Galhardo (2006) found that 35% of the pages were full-page advertisements, the majority of which were drug ads.As it can be seen, her results are quite similar to our findings.Such pattern has also been found in medical journals published in Brazil.Barros and Joany (2002) studied all ads present in the issues of Jornal de Pediatria, Jornal Brasileiro de Medicina, and Revista Brasileira de Medicina from August 2000 to February 2001.A total of 30.4% of the 1,774 pages reviewed were advertisements.In only about 20%, adverse reactions, contraindications, and interactions were mentioned.The authors concluded that the ads were tendentious, responding to commercial objectives, and should not be considered a source of information for a good quality prescription, nor for the correct use of pharmaceuticals.
The critical part of a marketing campaign is determining the theme to be exploited in the individual advertisements and other forms of communications.The theme is responsible for the whole tone of the campaign, as several strategies and media are used in order to reach out to the target audience and to communicate with the customers.There are different types of advertising appeals but, in general, emotions are manipulated in order to achieve the advertising goals, and as little information as possible is given, especially in relation to unwanted aspects of the product.Riera, Fuente and Rodriguez (2007) analyzed several characteristics of 195 drug advertisements in four Spanish medical journals of four different medical specialties.In relation to the advertising message, the researchers evaluated five factors: communication aim, sales argument, communication treatment, and use of text and image.A total of 72.6% of the ads presented communication treatment, and the information was portrayed in quite a standardized way: a large headline, in order to attract the reader's attention and to synthesize the sales arguments; a photo, which symbolically represented the product and promised a benefit; sales arguments and reinforcing arguments as well.A slogan was also present in half of the ads.From the results obtained, the authors designed a fictitious drug advertisement (p.376).
This pattern is quite similar to the one in our ads indeed.However, their sales arguments were 87% rational, based on efficacy (61%) and comfort/convenience (22%).
In the ads portrayed in the present article, most sales arguments were also rational, but based on marketing strategies, pure advertising language, in order to explicit how pharmacists will make money with the products: "Heats up sales, without cooling off on the shelf"; "The package was reduced so that your sales continue to grow".The ads also go into detail about the marketing strategies to be used with the physicians, in the case of Rx drugs, as seen in the ad for Flutican ® , for instance.In the case of OTC products, the target group is the lay population.So: "A campaign to inform your clients about allergy and Polaramine.Ads in magazines, merchandising in TV shows, radio communication in the main Brazilian capitals." The vocabulary used is very limited, and the sentences are short, simple and objective.This point also coincides with Galhardo's findings.But, while in the Portuguese journal the messages also intended to make pharmacists informed about the products, in our case, the main information given was related to sales arguments and strategies.As seen above, in drug ads targeted at Brazilian pharmacists, very little information on therapeutic and technical data about the products was provided, infringing Brazilian legislation, which was basically the Anvisa's Ruling 102/2000 at that time.
The messages to pharmacists also differ from the ones directed to physicians, as seen in the studies mentioned above.Even if the information is neither complete nor of good quality, some technical information about the products is presented.This was observed in the Brazilian studies developed by Pizzol, Silva and Schenkel (1998), Barros and Joany (2002), Mastroianni, Galduróz and Carlini (2003), Nascimento (2003), Luchessi et al. (2005), Soares, Lasmar and Figueiredo (2005), Wzorek et al. (2007), Mastroianni et al. (2008), Mastroianni, Noto and Galduróz (2008), Soares (2008).International studies, such as the ones by Mejía and Avalos (2001), Loke, Koh and Ward (2002), Cooper et al. (2003), Riera, Fuente and Rodríguez (2007), presented similar results.As stated by Monnerat (2003), the study of advertising messages reveals not only linguistic contents, but cultural and historical aspects, attitudes and values of a certain society.So, when drug makers communicate with pharmacists, informing only contents which are important to salesmen, omitting all information which should be provided to health professionals, this message has an important and implicit meaning: pharmacists are not acknowledged for their relationship with patients seeking healthcare.Their role in pharmaceutical care does not seem to be considered.
As for the limitations of the present research, it must be stated that the samples discussed are not representative of all drug advertisements portrayed in the journals, and the results cannot be generalized.It must be also noted that more research must be developed in order to compare the present results with drug advertisements launched after the new Resolution by Anvisa, approved in 2008(Brasil, 2008), as a result of many debates which included the results presented by the advertising monitoring project.
But, as evidenced by previous experience and research, real and efficient changes do not come only as a consequence of new legislation.Other factors influencing the context of drug use must be dealt with as well, in an integrated approach.Even if the data presented here refer to the period 2005-2008, all the analyses developed on the quality of drug advertising have shown that, after RDC Anvisa 102/2000, the legal infractions continued to be present in over 90% of the ads, according to the results of Anvisa's drug advertising monitoring project.This was discussed by Soares (2008), in her defense of the banning of drug advertising.Though limited because of the time passed, the empirical data presented here continue to be a valuable source for present and future analyses, from our point of view.

CONCLUSIONS
As it has been observed in several studies, Brazilian pharmaceuticals' market presents many problems.Although it is the biggest market in Latin America and the ninth greatest per capita consumer in the world, the access to the products is extremely unequal: around 20% of the population has no access at all, while 50% do not get what they need at the healthcare public system (Rozenfeld, 2008).The economic and commercial dimension of drug use largely prevails: pharmaceuticals are consumer goods to be used by those who can afford them.Besides, the market is not well regulated, frauds are quite common, data on pharmaceuticals' consumption in the country are not well known, just to mention some of the facts reported.
According to the Brazilian College of Pharmacists, there were 122,915 pharmacists, and 72,480 pharmacies and drugstores in the country, in December 2008.Far from the recommendations by the World Health Organization − 1 pharmacy or drugstore to every 8,000 inhabitants −, this proportion is around 1:2,550 in Brazil.As there is no regulation concerning the establishment of new pharmacies, they are spread throughout the country without any planning.This excessive number is also motivated by the economic and commercial aspects of the activity.Although all pharmacies must have a responsible pharmacist, these professionals are not present in many cases; the distribution of bonuses to the employees as rewards according to the sales is quite frequent; most prescription drugs are sold without any prescription, with a daily exposure of the population to several risks.
In the Brazilian Consensus of Pharmaceutical Care, published in 2002, it is stated that pharmacists should direct their activities towards health education, pharmaceutical care, patient orientation, dispensation, etc (OPAS, 2002).According to Vieira (2007), they should also play an important role in rational drug use promotion, and their participation in multidisciplinary teams adds value to health services and contributes to health promotion.But, at present, Brazilian pharmacists have a very small insertion in health professionals' staff.Pharmaceutical training is still inadequate to the population's needs.Studies on the role of pharmacists in the private pharmacies or in the public healthcare system confirm that these professionals are not acting in the interest of patients, of health promotion, nor of rational drug use, in our country.Private community pharmacies and drugstores are purely and simply commercial facilities, pharmaceuticals are consumption goods and pharmacists' work there are focused on commercial activities rather than on health promotion.In Brazilian public healthcare system, pharmaceutical care does not respond to society's demands either (e.g., OPAS, 2001;Vieira, 2007;Rozenfeld, 2008;Araujo et al., 2008).In the PAHO proposal for Pharmaceutical Care, a similar diagnosis of the Brazilian context was made: lack of social acknowledgement and a weak insertion in the multiprofessional healthcare staff; failures in pharmaceutical education, which is still excessively technically-driven and with weak training in the clinical area; gap between pharmaceutical education and the demands of private and public healthcare units; dissociation between economic and collective health interests, the first ones prevailing (OPAS, 2002).Oliveira et al. (2005) investigated the obstacles to pharmaceutical care in Curitiba and concluded that it is necessary to stimulate professional practice, mainly among students and recently graduated professionals, in order to overcome the existing problems.Vieira (2010) identified various failures in pharmaceutical care in the National Health System (SUS) as well.
In the present context, pharmacists are not socially acknowledged in Brazil.The drug advertisements targeted at pharmacists confirm this scenario.They do not provide the necessary information a pharmacist would need in order to practice good quality pharmaceutical care.On the contrary, they reinforce and encourage the role of pharmacists as mere salesmen.They are not portrayed as health professionals by the pharmaceutical industry.The advertising messages mostly "teach" pharmacists how to achieve sales growth and a better profitability.As evidenced by the material discussed above, they communicate with these professionals by means of the standard language used by advertising directed to suppliers, distributors and sellers, in which the main words are sale and money.They also emphasize and explicit the strategies used to attract prescribing doctors (Rx drugs) or the lay population (OTC drugs), so that pharmacists improve sales.
The advertisements portrayed here disclose important social, political and cultural aspects related to pharmacists' attitudes and to pharmaceutical care in Brazil; they also reinforce the image and role of pharmacists as commercially-driven professionals in our society.Therefore, they are important indicators for the urgent changes that are needed in this field.Furthermore, failures and breaches at Anvisa become evident too.This kind of research may contribute to the debate on pharmaceutical policy, as it discloses several obstacles to good quality pharmaceutical care and claims changes in pharmacists' attitudes and practices.It is clear that, in spite of all the improvements achieved in the field of drug use in our country, there is still a long and complex way to go, which requires educational, investigative, managerial and regulatory interventions within an integrated approach.

TABLE I -
Information about the journals analyzed
Headline: "SLENFIG/ sibutramine".Other sentences: "The slim figure recipe: • accessible price, which encourages clients' loyalty; • aggressive brand exposure in medical practices and scientific journals all over Brazil; • intense promotional investment on 30,000 physicians.""Slenfig is the recipe for the slim figure and the em-