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Universiteit van Tilburg. 2010
Anorexia and Bulimia; What
Role Can DTCA Play?
Effects of Direct-to-Consumer Advertising on Anorexia and Bulimia Patients
and their Family
Bram Voets
S476122
Supervisor: Ernst Osinga
Bachelor Thesis Marketing
Table of Contents
Abstract ...................................................................................................................................... 3
Chapter 1: ................................................................................................................................... 4
Introduction ................................................................................................................................ 4
§1.1 The Problem Background............................................................................................... 4
§1.2 The Problem Statement .................................................................................................. 5
§1.3 Research Questions ........................................................................................................ 5
§1.4 Relevance ....................................................................................................................... 5
Chapter 2: ................................................................................................................................... 7
Conceptual Model ...................................................................................................................... 7
§2.1 Structure of the Thesis.................................................................................................... 7
§2.2 Conceptual Framework .................................................................................................. 7
§2.3 Definition of the Constructs ........................................................................................... 8
Chapter 3: ................................................................................................................................. 10
DTC Advertising and its Effects .............................................................................................. 10
§3.1 DTC Advertising .......................................................................................................... 10
§3.2 Effects ........................................................................................................................... 10
Chapter 4: ................................................................................................................................. 12
Characteristics of Anorexics and Bulimics .............................................................................. 12
§4.1 Anorexia ....................................................................................................................... 12
§4.2 Bulimia ......................................................................................................................... 13
§4.3 Summary; Differences and Similarities ....................................................................... 14
Chapter 5: ................................................................................................................................. 15
DTCA‘s Direct Influence to Anorexics and Bulimics ............................................................. 15
§5.1 Recognition .................................................................................................................. 15
§5.2 Treatment ..................................................................................................................... 15
Chapter 6: ................................................................................................................................. 17
Social Pressure ......................................................................................................................... 17
§6.1Parental Role Model ...................................................................................................... 17
§6.2 Recognition; Family and Friends ................................................................................. 17
§6.3 Treatment; Family and Friends .................................................................................... 18
§6.4 DTC Advertising‘s Effect on Social Pressure .............................................................. 18
Chapter 7: ................................................................................................................................. 20
Type of Advertisement ............................................................................................................. 20
§ 7.1 Education ..................................................................................................................... 20
§ 7.2 Eating disorder category.............................................................................................. 20
§ 7.3 Summary; type of advertisement ................................................................................. 21
Chapter 8: ................................................................................................................................. 22
Conclusions .............................................................................................................................. 22
§8.1 Discussion .................................................................................................................... 22
§8.2 Limitations & Future Research .................................................................................... 22
§8.3 Conclusions .................................................................................................................. 23
References: ............................................................................................................................... 24
2
Abstract
This literature review investigates whether pharmaceutical DTC advertising can
contribute to a more early recognition and better treatment of Anorexia and Bulimia. It takes a
closer look at the role of social pressure in this process and investigates the most effective
way of advertising. Results of the thesis show that directly aiming DTC advertising towards
anorexia and bulimia patients will most likely prove to be ineffective. Instead informational
advertisements targeted at family and friends of these patients will likely improve recognition
and treatment of both diseases. The pharmaceutical industry should therefore target family
and friends with honest, open and accurate advertisements to educate social peers about
anorexia and bulimia. This could lead to a win-win situation for both the pharmaceutical
industry, by increased sales, and the anorexia and bulimia patients with a more early
recognition of their illness and a more effective treatment.
3
Chapter 1:
Introduction
§1.1 The Problem Background
Extreme weight loss, denial and hiding the illness, psychological problems and an
unwillingness to comply with treatment are all among the characteristics of the prevalent
eating disorders like anorexia and bulimia nervosa1 (Haller, 1992). These illnesses are
estimated to affect between 1% and 10% of adolescent and college age women (Haller, 1992).
Although causes of this disease can spring from different sources patients are often very
similar in behaviour and treatment. Responsible use of medication can often help patients
with their recovery, several different categories of drugs have shown to be beneficial among
which fluoxetine (Prozac), an antidepressant, is most known2.
Nowadays advertising for any medications are (in the USA) more often directly
targeted at consumers. These Direct-To-Consumer (DTC) advertising expenditures have
grown since the Food and Drug Administration loosened the legislation around DTC
advertising in 1997. These marketing expenditures increased from $800 million in 1996 to
$2.5 billion in 2000, in 2006 this amount was said to have grown to $4.5 billion3. Controversy
about this legislation is highly present, and opinions are therefore divided. Proponents of DTC
argue that marketing expenditures help recovering high R&D costs allowing pharmaceutical
companies to survive. Moreover DTC advertising is said to educate consumers about certain
drugs, medications or treatments and thereby help consumers improve their health outcomes
(e.g. Rubin 2003). Opponents argue, however, that DTCA has a business-stealing effect that
misleads patients into demanding heavily-advertised drugs, leading to inappropriate drug use
and the unnecessary purchase of expensive drugs when cheaper generics are available (Iizuka
& Jin, 2005; De Laat, Windmeijer, & Douven, 2002; Rizzo, 1999).
This paper questions if DTC advertising can help recognizing and treating eating
disorders in a more successful way, by communicating information directly to the patients and
their family and/or close friends. This would create a win-win situation for both the patient
and the pharmaceutical company. This paper contributes to the knowledge concerning the
effectiveness of DTC advertising for neurotic and psychological illnesses. Especially because
1
www.bulimia.com
http://www.bulimia.com/client/client_pages/newsletteredt11.cfm
3
http://pharmexec.findpharma.com
2
4
the disease category of neurotic and psychological drugs (medications for eating disorders fall
in this category) were not sufficiently included in a recent meta-analysis (Kremer et al. 2008)
who investigate effectiveness of several promotional instruments. This paper‘s aim is to
provide a clear understanding of the effect of DTC advertising on recognition and treatment
of eating disorders.
§1.2 The Problem Statement
 What is the effect of direct-to-consumer advertising on the recognition and treatment
of eating disorders?
§1.3 Research Questions
 What is DTC advertising and what are the known effects?
 What are the characteristics of anorexia and bulimia patients?
 How does DTC advertising directly influence the recognition and treatment of
anorexics and bulimics?
 What is the effect of social pressure on anorexics and bulimics concerning
recognition and treatment?
 How does DTC advertising influence social pressure?
 Does the type of advertisement (and possibly drug) in the eating disorder category
moderate the effectiveness of DTC advertising?
§1.4 Relevance
 Academic relevance: Various studies have been conducted investigating the effect of
DTC advertising. Some report positive effects such as Rosenthal et al. (2003) who
find that DTC advertising is effective especially in increasing drug class sales,
whereas others account for negative effects for example Ling et al. (2002). This paper
will dig deeper into the effects of DTC advertising in the eating disorder category.
This is particularly relevant because the neurotic and psychological category were not
sufficiently included in a recent meta-analysis concerning DTC advertising and other
pharmaceutical marketing tools conducted by Kremer (2008). Besides looking solely
at the aspect of profitability for pharmaceutical companies this paper will primarily
5
investigate if there are any effects concerning individuals suffering from anorexia or
bulimia (the information function of DTCA). Who often face years of illness and
rehabilitation because of this severe disease. Moreover this paper will investigate if
social pressure (family and friends) on anorexics and bulimics are a possible mediator
for sooner and better treatment of eating disorders. The importance of social pressure
(family and friends) has already been identified as being an important factor for
anorexia and bulimia patients (Vandereycken 2006, Haller 1992). However the
effects of pharmaceutical advertisements aimed at peers of anorexia and bulimia
advertisements have not yet been investigated.

Managerial relevance: As pharmaceutical companies tend to spend ever more money
on DTC advertising it becomes questionable whether these expenses are worthwhile
both for the companies themselves and for the public and patients. Pharmaceutical
companies often face an image problem, the public often wonders whether
pharmaceutical firms are more concerned with profit than with developing new
beneficial drugs. The fact that the pharmaceutical industry is spending more on
marketing than on R&D only adds to suspicion and a degrading image of companies
(e.g., the top nine firms spend 2.5 times the amount on marketing than on R&D
(www.familyusa.org)). This paper could provide a justification for pharmaceutical
companies for their growing use of marketing in antidepressant eating disorder
category and moreover it might help increasing the image of the pharmaceutical
industry.
6
Chapter 2:
Conceptual Model
§2.1 Structure of the thesis
In Chapter 3 this paper will discuss the basics of DTC advertising, what are its effects?
Chapter 4 provides an overview of the characteristics of anorexia and bulimia patients.
Chapter 5 will discuss the possible direct effect of DTC advertising on anorexics and
bulimics. After that in Chapter 6 we will discuss the mediating effect of family and close
friends. Then in Chapter 7 we will discuss the possible differences among different types of
advertisements. Finally the paper will end with conclusions and suggestions for future
research.
§2.2 Conceptual Framework
Recognition of
Eating Disorders
Social
Pressure
DTC Advertising in
the Neurotic and
Psychological
Category
Treatment of
Eating Disorders
Type of
Advertisement
7
§2.3 Definition of the Constructs
In this section the constructs from the conceptual model will be defined in more detail.
Eating disorders: As Haller (1992) already noted patients of anorexia and bulimia can
‗switch‘ of illness in the course of time. General characteristics of both bulimia and anorexia
can be found in tables 1 & 2. In our model we will only focus on patients suffering from these
diseases, obesity (although an eating-disorder) is not included. Some results, however, might
be generalized for these illnesses, as some diagnostic criteria overlap with anorexia and
bulimia. This should however be investigated in further research. Therefore when this paper
speaks of eating disorders it only includes anorexia and bulimia.
Recognition: This paper will distinguish between recognition and treatment
throughout the thesis for the coming chapters. The difference is explained briefly here.
Recognition in this context means an anorexic‘s or bulimic‘s first visit and diagnosis by a
physician.
Treatment: Treatment in this context means a period of doctor/psychologist visits in
combination with medications (such as prozac and olanzapine). Due to extraordinary
characteristics of anorexics and bulimics (which will be discussed in chapter 4), this paper
will also consider treatment compliance. This is the extent to which a patient complies with
drug treatment.
DTC advertising in the neurotic and psychology category: DTC advertising here refers
to directly aiming promotional advertisements at consumers in the pharmaceutical industry. In
this paper we will focus on DTC advertising in this specific category. This category for
example includes: Depression, eating disorders, anxiety and phobias, PMS (Premenstrual
syndrome), panic disorders and drug and alcohol addiction.
advertising will be further defined.
8
In the next chapter DTC
Type of Advertisement: This construct refers to the difference between informational
and product claim advertisements. The distinction here concerns on the one hand
advertisements that inform patients and their peers about general characteristics of an illness
and on the other hand advertisements that focus on the appraisal of a certain drug also aimed
at patients and their peers.
Social Pressure: Social pressure refers to the influence of family and friends on
anorexics and bulimics. A construct that most probably fulfils a mediating function for
recognizing and treating eating disorders. Haller (1992) already claimed that recognition of
anorexia only occurs when others grow concerned and insist on medical treatment for the
individuals. This paper explores whether this is the case. Moreover the treatment of anorexics
and bulimics often makes great demands on family and friends. Outpatient treatment with
family has been studies frequently and has shown beneficial outcomes (e.g. Robin et al, 1994,
Le Grange et al, 1992). In chapter 6 this thesis will further explore the mediating effect of
family during treatment as well as during the recognition phase of eating disorders.
9
Chapter 3:
DTC advertising and its effects
§3.1 DTC Advertising
DTC advertising is gaining popularity with pharmaceutical firms. This marketing tool
has conquered its place amongst the other promotional methods used by the pharmaceutical
industry (Direct-to-Physician advertising). According to Lavidge & Steiner (1961) advertising
is a force which must move people through a certain number of steps. First of all advertising
raises awareness, educates consumers through knowledge and builds up preferences and it
ultimately can lead to actual buying decisions. However due to the uniqueness of
pharmaceutical DTC advertising consumers will never arrive at this final step, making an
actual purchase, because physicians make the ‗buying‘ decisions by prescribing medications.
Though restricted by this condition, it is still accountable for many positive and negative
effects.
§3.2 Effects
DTC advertising has been generally found to have a small and positive effect on
pharmaceutical drug demand (Wittink, 2002, Xie, 2003) although some exceptions exist (Ling
et al., 2002). An overview with the most important effects of DTC advertising relevant to this
thesis is shown in table 1.
Iizuka (2005) finds that, since 1997, every $28 increase in DTCA has led to 1 doctor
visit within 12 months. Furthermore Frank et al. (2002) report that public awareness is very
high, over 90% of survey respondents recall to have seen prescription drug advertisements.
Moreover drug specific ads were recalled on a rate varying between 11% and 71%. This
extended awareness and knowledge could lead to earlier recognition and treatment of
illnesses. The market expanding effect is of similar magnitude across patient demographics
(Iizuka, 2005).
DTC advertising generally leads to a market expanding effect, the advertised brand
attracts a lower number of new patients. This is most probably due to the fact that physicians
make the final decision of what drug to prescribe.
Proponents of DTC advertising also argue that this advertising tool could lead to
patients proposing drugs that their physicians have not yet considered (Monaghan et al.,
10
2003). In addition to the market-expanding effect this all adds up to increased patient welfare
due to the fact that most diseases are under-diagnosed (Iizuka & Jin, 2005) However this
increased awareness, knowledge and preference do not necessarily lead to better treatment of
all patients. For example Pirisi (1999) argues that patients drug requests can pressurize
physicians which, on its turn, can lead to unnecessary drug prescription. Overuse, misuse and
misprescription of medications are some of the negative effects which have to be taken into
account when one considers DTC advertising (e.g. Chetley, 1995).
Wosinska (2005) describes how DTC advertising affects patient compliance, in her
study she shows small positive effects, but these are insignificant. Moreover she reports that
DTCA leads to a small positive effect on therapy compliance for patients taking competitor
drug brands. This improved compliance then leads to more satisfaction with the current
competing brand and makes it harder for the advertised brand to acquire these new patients.
DTCA Effects. Table 1
Effect
Description
Author
Market expanding effect
DTCA can convince consumers with certain
symptoms to visit a doctor where
they would not have done so without
marketing. Category expansion rather than
brand expansion, this means patient‘s entry
in the market rather than physicians direct
choice for the advertised brand.
DTCA can raise awareness for a new
product
Rosenthal et al.,
2002; Xie, 2003;
Izuka Jin; 2005 and
Trouw, 16/6/2001
Awareness effect
Price effect
Elasticity effect
Compliance effect
Request effect
Business-stealing effect
De Laat, 2002;
Lavidge & Steiner,
1961
Expenses in marketing drive up the price for De Laat, 2002
consumers (general marketing effect)
Pharmaceutical marketing leads to lower De Laat, 2002
price elasticity for physicians
DTCA leads to a positive effect for patients Wosinska, 2005
taking competitor brand, and negative effect
for patients taking advertised brand
regarding therapy compliance. (small effect)
DTCA effect on patient‘s requesting and Kaiser family
getting the advertised drug prescribed by a foundation, 2001
physician.
Overuse, misuse and misprescription of Chetley, 1995;
drugs
Fenter, 2006
11
Chapter 4:
Characteristics of Anorexics and Bulimics
§4.1 Anorexia
The general characteristics of Anorexia are included in table 2, however more
sophisticated effects of the illness need to be taken into account when looking at anorexics.
For example the anorexic‘s distorted self-image: Vandereycken (2006) hypothesises that
anorexics restricted self-image could for a great part be attributed to a
neurological
impairment of self-awareness, a direct consequence of anorexia. ―The lack of concern to the
potentially dangerous consequences of undernourishment indeed suggests that alarming
information might not be processed or might not reach awareness‖ (Casper, 1998, p. 387).
This is much more complex than just
Diagnostic Criteria for Anorexia Nervosa
Table 24




denying the illness, however denial can
Refusal to maintain body weight over a minimal
normal weight for age and height-for example,
weight loss leading to maintenance of body
weight 15% below that expected-or failure to
make expected weight gain during period of
growth, leading to body weight 15% below that
expected.
Intense fear of gaining weight or becoming fat,
even though underweight.
Disturbance in the way in which body weight,
size or shape is perceived- for example, the
person claims to ― feel fat‖ even when emaciated,
believes that one area of the body is ―too fat‖
even when obviously underweight.
In women, the absence of at least 3 consecutive
menstrual cycles when otherwise expected to
occur (primary or secondary amenorrhea) (A
woman is considered to have amenorrhea if her
periods occur only following hormone-estrogenadministration
come on top of this impaired perception
depending on the individual. This denial
can spring from a great number of
motives, Vandereycken (2006) finds that
a high degree of perfectionism and
control are characteristics prevalent in
anorexic
patients,
striving
for
self-
imposed goals, or goals they feel are
imposed by others (e.g. weight loss).
Anorexics feel they have to fulfil these
goals with great perfection to be more
distinguishable from peers, hence they see
their extreme loss of weight as natural
and not dangerous. Moreover a person who is a high achiever and comes from a neglectful
background, is not likely to ask for help, since that could be seen as failure (Manley &
Leichner, 2003).
Thus whatever reasons are rooted in the mind of an anorexic, they all show signs of low
awareness of their illness, possible denial and often refusal of help. Treating anorexics
4
Source: the American Psychiatric Association
12
involves restoring the lost weight, helping them with psychological and or depression
problems and a long-term sustainable recovery5.
§4.2 Bulimia
Bulimia is a disease that is more often seen in women a few years older than the
average anorexia patient6. Some general characteristics of Bulimia can be found in table 3. A
significant aspect prevalent mostly among bulimics is the secrecy, shame and guilt (Fairburn,
1982 and Herzorg, 1982). When bulimics have admitted their disease they are more eager
(than anorexics) and open to receive medical help (Fairburn, 1982), but also here denial
can still play a role. This often occurs in the form of partial denial, Vitousek et al. (1998)
reports a partial denial rate of 15 – 80%, this is after that the patient has admitted his/her
disease. Moderate to severe cases of bulimics and anorexics often consider their disease not
worrisome enough to counsel a physician (Meyer, 2001). This combination of partial or full
denial and the secrecy, shame and guilt
only underlines the fact that a bulimic or
Diagnostic Criteria for Bulimia nervosa
Table 37

anorexic will most likely not seek help by
him/herself. Treatment of Bulimia

involves setting up a healthy diet and

stopping the binge and purge behaviour.
Encouraging healthy non-excessive
exercise and treating psychological

disorders are also part of a bulimia

recovery therapy8.
5
www.avalonhills.org
www.avalonhills.org
7
Source: the American Psychiatric Association
8
www.avalonhills.org
6
13
Recurrent episodes of binge eating- rapid
consumption of a large amount of food in a
discrete period of time.
A feeling of lack of control over eating behavior
during the eating binges.
Regularly engages in either self-induced vomiting,
use of laxatives or diuretics, strict dieting or
fasting, or vigorous exercise to prevent weight
gain.
A minimum average of 2 binge-eating episodes a
week for at least 3 months.
Persistent overconcern with body shape and
weight.
§4.3 Summary; Differences and Similarities
Patients of both diseases show an obsessive preoccupation with weight and thinness.
However due to the extreme weight loss seen in anorexia patients, one can more easily detect
this disease, compared to detecting bulimia. Moreover anorexia is most prevalent among
children/teenagers and therefore parents (peers) most probably have a closer and more direct
view on the situation of their child (for example due to a shared home). Whereas bulimia
patients are generally older and therefore more likely to be more self-reliant. Treatment of
both bulimia and anorexia involves a great number of specialists such as doctors,
psychologists and dieticians.
14
Chapter 5:
DTCA’s Direct Influence to Anorexics & Bulimics
DTC advertising can be ascribed to influence many different groups in society. At first
sight the most obvious are the anorexics and bulimics themselves. Will these patients sooner
recognize their own illness and visit a physician in a sooner stage than they would have done
without DTC advertising, and will they cooperate and comply with treatment?
§5.1 Recognition
According to Haller (1992) anorexics and bulimics come under medical care only
because of the concerns of others. This can essentially be traced back to the neurological
impairment of self-awareness, high denial rates and refusal of help. These characteristics of
the illness make it hard for DTC advertising to reach its full potential as a direct effect. For
example a patient suffering from anorexia is likely to think that his/her situation or shape is
‗not as bad‘ as is advertised for in the media or the outspoken concerns of relatives and
friends simply do not find a grip in his/her mind. He/she is then likely to remain unaffected
and continue his/her diet. This will prove to be a huge threshold for advertisements aimed at
anorexics, especially when patients also develop a denial of their illness. One can therefore
assume that impacts of DTC advertising directly to anorexics concerning recognition are
likely to be small, if they exist at all. The model of advertising proposed by Lavidge & Steiner
(1961) will thus most probably only reach the step of awareness (and possibly not even this
simple step), and it will in most cases not lead to further information for the patient.
One can imagine the effort and the convincing message which has to be placed into an
advertisement which has to trigger an anorexic or bulimic to consider medical help. It is
therefore doubtful that DTC advertisements in this specific category will have the same
magnitude with respect to recognizing an illness compared to other ‗straightforward‘ drugs
(for example for heart diseases). Instead the effect of DTC advertising is likely to be smaller.
§5.2 Treatment
When anorexia is recognized by the patients and his/her relatives, this does not
automatically mean that the patient is willing to receive and comply with treatment. For
example because he/she is scared of ‗what others might think of him/her‘ or being labelled as
someone with a disorder (Vandereycken, 2006). Nonetheless eventually anorexics and
bulimics will be in need of treatment, a treatment which is likely to involve medications.
Examples include fluoxetine (Prozac) and olanzapine (Zyprexa), both drugs require the
15
patient to cooperate with the treatment by taking the medications on a timely basis for a long
period. Convincing an anorexic to comply with treatment however is not without any
implications. First of all it is questionable whether anorexics are willing to take or even
request their drugs when, according to them, they do not feel sick and on top of that these
medications often only have little effect (Haller, 1992) (‗The only right medicine for
anorexics is food‘). Another notable factor for anorexics is that their disease is chronicle,
sudden drops of weight and non-compliance to therapy occur after a period of gaining weight
(Mehler, 2001). This means that patients again have to start a new cycle of treatment, often
leading to frustration and desperation with the patient. Also anorexics sometimes do not want
to receive help, a reason might be that they feel that their illness is a part of them, and
therefore obstruct treatment: 17% of adolescents and another 7% of the adult anorexia patients
clearly do not want medical treatment (Vandereycken 2006).
Bulimics on the other hand, once they acknowledge their illness, are much more
willing to comply with treatment and they are more motivated to bring their illness to an end
(Haller, 1992 & Fairburn, 1982).
It remains questionable whether DTC advertising will lead to a better compliance to
therapy both by anorexics and bulimics. Wosinska (2005) investigates whether DTC
advertising has positive effects on patient‘s compliance. In her study she finds that DTC
advertising does not contribute much to increasing patient compliance in relation to other
drivers. However effects are positive although they are small Moreover the advertising
campaigns studied in this research only include campaigns targeted at the acquisition of
patients instead of the retention of patients. This might be a possible explanation for the low
positive effects observed. It remains unclear whether advertisements specifically aimed at the
retention and compliance of patients will have a more positive effect. A negative effect might
as well exist due to high commitment requested from patients. This might discourage the
acquisition of new patients who as a result might not want to start with treatment. Another
interesting effect drawn from Wosinska‘s (2005) research suggests that advertising one brand
might increase compliance with competing brands, this will be further discussed in chapter 7.
In relation with anorexia and bulimia strong indications exist that also for purposes of
drug compliance DTC advertising will only have small effects.
16
Chapter 6:
Social Pressure
Recognition and treatment of an eating disorder often require social pressure from
family and friends. Parents often serve as a role model for anorexics, with notable influence.
Bulimia however is a disease prevalent among the more older and more self-reliant
individuals and they, therefore, are likely to feel less social pressure.
§6.1Parental Role Model
The primary focus of this chapter is on parents of anorexia and bulimia patients
(although bulimia patients most likely are less influenced by their parents). Because especially
parents play a detrimental role when it comes to developing and treating eating disorders.
Golan and Crow (2004) found that ―parenting style and feeding style are crucial factors in
fostering healthy lifestyle and awareness of internal hunger and satiety cues and
deemphasizing thinness.‖ When families are unable to follow this line, or even worse do the
direct opposite, this can lead to anorexia and/or bulimia. For example Keel et al. (1997)
suggests that there is a causal relationship between parent‘s comments to their child
suggesting weight loss and the occurrence of eating disorders with the same child.
§6.2 Recognition; Family and Friends
Recognition of eating disorders proves to be hard, when are you dealing with anorexia
or bulimia or when is it a simple and ‗innocent‘ diet? In an Australian study aimed at
students 94% of the women confessed to have tried to diet at least once, and 79% said they
wanted to lose some or a large amount of their weight (Abraham & Llewellyn-Jones, 2001).
In some cases this can result in an eating disorder and it is often up to the family and friends
to discover which case is evolving into an eating disorder. Keitner et al. (1995) indeed
suggests an association between family functioning and recovery of depression (including
eating disorders). As this paper has already noted, the recognition of an eating disorder relies
on individuals other than the patient him/herself (Haller, 1992).
17
§6.3 Treatment; Family and Friends
Mobilizing family and friends for treating anorexia and bulimia is a key in
successfully fighting the disease (Lock et al., 2001). Concerning treatment, and treatment
compliance, which includes therapy and also medications, family plays a crucial role. One can
for example think of an anorexic who is faking that he/she is feeling fine and in that way
trying to avoid treatment. Although it is hard for family to discover and break through to such
behaviour, it is the family that is most affected and most knowledgeable about the patient.
Parents and peers should keep supporting the patient in the best way possible. This is shown
by Kenny & Hart (1992) who find that a supportive role of parents is inversely associated
with bulimic behaviour. Such a supportive role can be established by family therapy for
example (which can help both patient and family), Dare et al. (1990) find that family therapy
was more effective in treating patients with anorexia and bulimia compared to individual
treatment. Another example to support anorexics and bulimics can be reminding them to take
their medications, helping them with eating schemes and stimulating them to get therapy.
These factors can all improve treatment compliance. It is essential that family keeps involved
although treatment is often time-consuming. It requires patience and persistence from all
involved parties (Hsu, 2006).
§6.4 DTC Advertising’s Effect on Social Pressure
As the direct effect between DTC advertising and anorexia and bulimic patients seems
to be almost absent, this thesis now investigates whether family and friends could be a more
appropriate target. Therefore the following questions arise: Does a mediating effect of social
pressure between DTC advertising on the one hand and recognition and treatment of eating
disorders on the other exist, and if so how large is this effect?
A threshold for the success of DTC advertising towards family and friends could be
the fact that a family has to make a decision for the patient, and making decisions for others
can prove to be hard (e.g. Davis et al. 1986). ‗Preferences‘ of the actual consumer, or in this
case patient, are difficult to assess, therefore peers will experience great difficulty in decision
making.
Reconnecting to Lavidge & Steiner (1961) we note that DTC advertising could raise
awareness of the disease, which sends a warning message towards parents. Moreover the
18
educational (informational) function of DTC advertising could help families in recognizing
illnesses in their household. Therefore it is more likely to be more successful when
advertisements are aimed at family instead of patients, because families and friends have an
unaffected mental state (at least in most cases), whereas anorexia and bulimia patients often
suffer from a neurological impairment to properly assesing their situation.
The supportive role of family discussed earlier is not always a natural ―given‖ in all
families. Teaching family and friends about their role in order to prevent, recognize and help
treating patients could prove to be an excellent target for DTC advertisements. In this case
DTC advertisements have an educational purpose, teaching parents how to deal with
treatment of their children. Different advertisements could provide parents with some general
feedback about dealing with the anorexia or bulimia of their child.
DTC advertising can prove to be a useful tool to help family and friends to recognize
eating disorders. Moreover DTC advertising may help parents to deal better with the illness of
their child and assist in treatment. Also therapy and medication compliance could be
strengthened by advertisements aimed at family and friends, making it easier for them to
handle the anorexic or bulimic.
.
19
Chapter 7:
Type of Advertisement
§ 7.1 Education
Bell, Wilkes and Kravitz (1999) find that the educational impact of pharmaceutical
DTC advertisements is highly variable. One of the causes for this high variance can be
ascribed to the type of the advertisement used to inform consumers.
The construct ―type of advertisement‖ refers to the difference between informational
and product claim ads, and it is likely to moderate the effect between the direct link between
DTC advertising and recognition and treatment of eating disorders, as well as the link
between DTC advertising and family and friends. Both groups are exposed to pharmaceutical
ads and the difference between both promotional tools will therefore most likely be
influential.
According to Xie (2003) informational advertisements or non-brand specific ads, have
a larger impact on patient visits than brand-specific or product claim ads. As we have already
seen the direct effect of DTC advertising and recognition and treatment by patients
themselves is likely to be closely to zero regardless of the type of advertisement. Therefore
we assume that also the moderating effect of different types of advertisements is greatest for
the link between DTC advertising and social pressure. And more specifically the
advertisements that are aimed at providing information to parents.
Wilkes, Bell & Kravitz (2000) suggest that there exist several implications for
successful and responsible use of DTC advertisements, among which they mention the use of
less drug-centric (brand-specific) and more disease-specific (informational) advertisements.
As this is both in the interest of the pharmaceutical industry and the consumer or patient.
Providing openness, honesty and accuracy to the consumer will lead to the best results.
§ 7.2 Eating Disorder Category
It is worth noting that most drugs prescribed to anorexics and bulimics often have use
for other psychological illnesses. For example a drug like Prozac which is, according to
Fenter (2006) prescribed for its core diseases: depression, obsessive-compulsive disorder and
several off-label conditions among which eating disorders. Advertisements for these drugs are
therefore likely to be of a different nature than medications which are of use for only a small
amount of diseases, this would probably also accompany different responses by patients and
relatives. The difference in informational and product claim advertisements for these drugs
20
might make it less attractive for the pharmaceutical industry to focus on just one illness
(anorexia/bulimia), as the drug itself is used for many other psychological illnesses.
§ 7.3 Summary; Type of Advertisement
Informational, responsible, accurate advertisements are likely to be most useful for
both the pharmaceutical industry as well as the customer and/or patient. An advertisement
aimed at family and friends of anorexics or bulimics, focused on the specific characteristics of
a disease, will probably lead to a sooner recognition of the disease and a better treatment.
21
Chapter 8:
Conclusions
§8.1 Discussion
The usefulness, accurateness and
appropriateness of DTC advertising in the
pharmaceutical market is a highly debated topic. This paper shows some of the contradictions
which are apparent in the available literature. The specific type of advertising proposed in this
paper tends to reflect the more social use of marketing tools in society, instead of the more
questioned sales-related marketing. The informational disease-specific advertisements
proposed in this paper are more likely to appeal and to help the people that they are meant to,
namely the anorexia and bulimia patients. The idea that pharmaceutical advertisements lead to
misuse, misprescription, overuse or are solely aimed at increasing the wealth of the
pharmaceutical industry is therefore likely to be of less meaning in the eating disorder
category.
Literature shows that anorexia and bulimia patients often have to deal with
psychological disruptions and/or show signs of denial of their illness. This finding is
supported by many scientific articles of which Vandereycken (2006), Mehler (2001) and
Haller (1992) are examples. Due to this it is highly likely that pharmaceutical DTC
advertising is ineffective when aimed directly at these patients.
Social pressure can have a major influence on the recognition and treatment of eating
disorders. However not all anorexics and bulimics are under the direct supervision of parents,
other family or friends. Restrictions of the successful recognition and treatment of anorexia
and bulimia include the low involvement of family (for example due to low contact), or the
secrecy, shame and guilt of the patient him/herself which makes it hard for peers to discover
the disease or help the anorexic or bulimic. The success of DTC advertising in this category
therefore will be conditioned by the relation a patient has with his/her social group.
§8.2 Limitations & Future Research
This paper has several limitations: It does not take into account the exact prescribing
behaviour for specific drugs by physicians, so the total benefit for pharmaceutical companies
remains somewhat unclear. Moreover the prevention of anorexia has not been taken into
account sufficiently: The distorted body-image of anorexics and bulimics might sometimes
find its roots in the family life. Therefore it can be one of the causes of the disease, for
example Keel et al. (1997) suggest that there is a causal relationship between parental
22
comments (especially by the mother) on weight loss and eating disorders of their daughters.
Can DTC advertising help preventing anorexia and bulimia in the first place?
This paper is limited by the fact that it only considers advertisements for eating
disorders whereas it may well be that such advertisements could be aimed at a broader public.
For example an advertisement for a drug like Prozac is likely to influence not just anorexics
and bulimics but also patients with different psychological illnesses such as Fenter (2006)
mentions: depression, obsessive-compulsive disorder, panic disorders etcetera. Especially for
the pharmaceutical industry it might be interesting to aim advertisements for one drug at a
broader target group, however this paper‘s scope is too limited to look further into this aspect.
DTC advertising in this specific category is also likely to influence more groups than
just the anorexics, bulimics and their family. The role that physicians, therapists,
psychologists and self-help groups play has not yet been taken into account in this research.
Moreover this paper lacks empirical support, future research should investigate the
exact magnitude of the effect of DTC advertising on the recognition and treatment of anorexia
and bulimia.
§8.3 Conclusions
The central question which is dealt with in this thesis is: ―What is the effect of direct-to
consumer advertising on the recognition and treatment of eating disorders?‖
This paper distinguished several major factors which could lead to a better recognition
and treatment of eating disorders. Not all effects of DTC advertising are equal in size on
affecting the different stakeholders described in this thesis. The influence of DTC advertising
directly towards anorexics and bulimics on recognition and treatment is likely to be less
effective than promotional advertisements aimed at an anorexic or bulimic‘s social peer
group. Especially advertisements towards parents of anorexics could lead to a more early
recognition, better treatment and better compliance of the patient. It remains somewhat
unclear how much pressure family and friends of bulimics can place on these patients, as
these patients are often older, more self-reliant and harder to discover due to less distinctive
symptoms than anorexia. It can however be concluded that social pressure has a significant
mediating influence on recognition, treatment and therapy compliance of anorexia and
bulimia patients. Moreover the type of advertisement fulfils a moderating function, which is
most prominently shown in relation with DTC advertisements and social pressure. Diseasespecific informational pharmaceutical DTC advertisements are likely to be more effective
than product-claim ads.
23
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