Small Promotional Items From Drug Companies May Influence Medical Students' Attitudes

"Discussions about the influence of pharmaceutical promotion on physicians often focus on gifts and payments of relatively large economic value," the authors write as background information in the article. "The underlying assumption is that smaller gifts are unlikely to exert influence on prescribing decisions." However, marketing and psychological research suggests that even trivial items can sway attitudes and behaviors.

David Grande, M.D., M.P.A., of the University of Pennsylvania, Philadelphia, and colleagues conducted a randomized controlled experiment involving 352 third- and fourth-year medical students. Of these, 154 were enrolled at the University of Pennsylvania School of Medicine (Penn), which has a policy prohibiting most gifts, meals and samples from drug companies. The other 198 attended the University of Miami Miller School of Medicine (Miami), which permits these marketing practices. One hundred and eighty-one of the participants were randomly assigned to be unknowingly exposed to small branded promotional items for the cholesterol-lowering medication Lipitor, including a clipboard and notepad used when they signed in to study appointments. The other 171 students received no such priming.

All of the participants completed a test of implicit attitudes toward Lipitor (one of the most heavily promoted brand-name statins in the United States) and Zocor (which is available generically and considered to be equally effective). The test involved matching the brands to attributes of the brands (such as pleasant and unpleasant) in a computerized image- and word-association test. Differences in reaction times help reveal unconscious attitudes. The students also reported their explicit (conscious) attitudes toward both drugs by completing a questionnaire about safety, superiority, efficacy and convenience.

"Overall, students in both class years and both schools demonstrated implicit attitudes favoring Lipitor over Zocor as reflected by the positive values even among control students," the authors write. "However, there were significant differences between the exposed and control groups among fourth-year medical students at Penn and Miami." Fourth-year students at Miami demonstrated stronger preferences toward Lipitor after exposure to promotional items, whereas fourth-year students at Penn exhibited the opposite response, with those in the exposure group showing weaker preferences toward Lipitor than the control group.

There were no differences between the control and exposure groups among third-year students. This could be because fourth-year students have more clinical experience and have formed attitudes toward treatment options that can be primed with branded promotional items, the authors note.

"Our results provide evidence that subtle branding exposures are important and influential, as the psychology and marketing literature would suggest," they conclude. "Our findings are particularly notable because they are attributable to simple exposure to promotional items independent of other effects attributable to the social relationships associated with gifts. Our study also suggests that institutional policies, by way of their influence on student attitudes toward marketing, could lead to different responses to branded promotional items."

 Dr. Grande was supported by the Robert Wood Johnson Foundation Health & Society Scholars program at the time of this research. Co-author Dr. Frosch is supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

Editorial: The Time Has Come to Adopt Policies Restricting Drug Marketing

"The powerful influence by drug companies on physicians and medicine has drawn increasing public attention," writes Philip Greenland, M.D., of the Feinberg School of Medicine, Northwestern University, Chicago, in an accompanying editorial.

"Grande et al in this issue of the Archives present interesting data on the effects of more restrictive institutional policies, such as those enforced at the University of Pennsylvania," Dr. Greenland writes. "The authors concluded that institutional policies can reverse the effects of drug marketing tactics, and the data suggest that adopting these more restrictive policies will reverse longstanding adverse trends on physicians' prescribing habits."

"As others have outlined, it is time to act and adopt restrictive policies," he concludes. "It is imperative that the profession police itself, or it is inevitable that government will step in and create a policing structure that will be punitive and require expensive oversight. Why are most of us still waiting? The evidence is clear, and the path is defined. It is time to act."