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Self-reported responsiveness to direct-to-consumer drug advertising and medication use: results of a national survey
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Title: Self-reported responsiveness to direct-to-consumer drug advertising and medication use: results of a national survey
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Language: English
Creator: Nicholas J. Dieringer
Lisa Kukkamma
Grant W. Somes
Ronald I. Shorr
Publisher: BMC Health Services Research
Publication Date: 2011
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Abstract: Background: Direct-to-consumer (DTC) marketing of pharmaceuticals is controversial, yet effective. Little is known relating patterns of medication use to patient responsiveness to DTC. Methods: We conducted a secondary analysis of data collected in national telephone survey on knowledge of and attitudes toward DTC advertisements. The survey of 1081 U.S. adults (response rate = 65%) was conducted by the Food and Drug Administration (FDA). Responsiveness to DTC was defined as an affirmative response to the item: "Has an advertisement for a prescription drug ever caused you to ask a doctor about a medical condition or illness of your own that you had not talked to a doctor about before?" Patients reported number of prescription and over-the-counter (OTC) medicines taken as well as demographic and personal health information. Results: Of 771 respondents who met study criteria, 195 (25%) were responsive to DTC. Only 7% respondents taking no prescription were responsive, whereas 45% of respondents taking 5 or more prescription medications were responsive. This trend remained significant (p trend .0009) even when controlling for age, gender, race, educational attainment, income, self-reported health status, and whether respondents "liked" DTC advertising. There was no relationship between the number of OTC medications taken and the propensity to discuss health-related problems in response to DTC advertisements (p = .4). Conclusion: There is a strong cross-sectional relationship between the number of prescription, but not OTC, drugs used and responsiveness to DTC advertising. Although this relationship could be explained by physician compliance with patient requests for medications, it is also plausible that DTC advertisements have a particular appeal to patients prone to taking multiple medications. Outpatients motivated to discuss medical conditions based on their exposure to DTC advertising may require a careful medication history to evaluate for therapeutic duplication or overmedication.
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RESEARCHARTICLE OpenAccessSelf-reportedresponsivenessto direct-to-consumerdrugadvertisingand medicationuse:resultsofanationalsurveyNicholasJDieringer1,LisaKukkamma2,GrantWSomes3andRonaldIShorr1,2,4*AbstractBackground: Direct-to-consumer(DTC)marketingofpharmaceuticalsiscontroversial,yeteffective.Littleisknown relatingpatternsofmedicationusetopatientresponsivenesstoDTC. Methods: Weconductedasecondaryanalysisofdatacollectedinnationaltelephonesurveyonknowledgeofand attitudestowardDTCadvertisements.Thesurveyof1081U.S.adults(responserate=65%)wasconductedbythe FoodandDrugAdministration(FDA).ResponsivenesstoDTCwasdefinedasanaffirmativeresponsetotheitem: Hasanadvertisementforaprescriptiondrugevercausedyoutoaskadoctoraboutamedicalconditionorillness ofyourownthatyouhadnottalkedtoadoctoraboutbefore? Patientsreportednumberofprescriptionand over-the-counter(OTC)medicinestakenaswellasdemographicandpersonalhealthinformation. Results: Of771respondentswhometstudycriteria,195(25%)wereresponsivetoDTC.Only7%respondents takingnoprescriptionwereresponsive,whereas45%ofrespondentstaking5ormoreprescriptionmedications wereresponsive.Thistrendremainedsignificant(ptrend.0009)evenwhencontrollingforage,gender,race, educationalattainment,income,self-reportedhealthstatus,andwhetherrespondents liked DTCadvertising.There wasnorelationshipbetweenthenumberofOTCmedicationstakenandthepropensitytodiscusshealth-related problemsinresponsetoDTCadvertisements(p=.4). Conclusion: Thereisastrongcross-sectionalrelationshipbetweenthenumberofprescription,butnotOTC,drugs usedandresponsivenesstoDTCadvertising.Althoughthisrelationshipcouldbeexplainedbyphysician compliancewithpatientrequestsformedications,itisalsoplausiblethatDTCadvertisementshaveaparticular appealtopatientspronetotakingmultiplemedications.Outpatientsmotivatedtodiscussmedicalconditions basedontheirexposuretoDTCadvertisingmayrequireacarefulmedicationhistorytoevaluatefortherapeutic duplicationorovermedication. Keywords: Advertising,medicationuse,consumerism,prescriptionmedication,non-prescriptionmedicationBackgroundConsiderablecontroversysurroundsthepracticeofdirectto-consumer(DTC)marketingofpharmaceuticals.While somearguethatDTCadvertisingservesasaneducational resourceforpatients,[1]otherssaythatDTCadvertising contributestothemedicalizationoftrivialailments,and leadstooveruseandmisuseofpharmaceuticals[2].Since initiallyallowedbytheFoodandDrugAdministrationin 1985,[3]spendingonDTCadvertisinggrewsteadilyover thefollowingdecade.DTCadvertisingspendingacceleratedrapidlyafter1997,whentheFoodandDrugAdministrationprovideddraftguidancewhichdescribedhow sponsorscoulddisseminateinformationondrugsandbiologicalproductsusingradioandtelevision[4,5].PharmaceuticalindustryexpendituresforDTCadvertising increased330%between1996and2005.In2005,$4.2billionwasspentonDTCadvertising,whichaccountedfor 14%ofallpromotionalspendingforprescriptiondrugs[6]. Expenditureshavedecreased(inabsoluteterms)since 2007followingapeakof$5.4billionin2006[7]. *Correspondence:rshorr@ufl.edu1DepartmentofMedicalEducation,MethodistHealthcare,1265Union Avenue,Memphis,TN38104,USA FulllistofauthorinformationisavailableattheendofthearticleDieringer etal BMCHealthServicesResearch 2011, 11 :232 http://www.biomedcentral.com/1472-6963/11/232 2011Dieringeretal;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited.

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Althoughitisdifficulttofinddataontheeffectiveness ofDTCadvertisingforindividualdrugs,10-35%ofsurveyrespondentssaytheyhavediscussedmedicalconditionsormedicationswithth eirphysiciansasaresultof DTCadvertising[8-10].Furthermore,patientswhospecificallyrequestmedicationsduringanofficevisitare muchmorelikelytoreceivethemthanthosewhodo not[9,11-13]. Whilemuchhasbeenwrittenregardingconsumerand physicianattitudestowardDTCadvertising,lessis knownrelatingpatientcharacteristics,notablymedicationuse,andresponsivenesstoDTCadvertising.One surveyfoundthatresponderstoDTCadvertisingwere morelikelytobenonwhite, havelowereducational attainmentandlowerincome,[10]whereasBellfound thatwomen,aswellaspersonswithapositiveattitude towardsDTCadvertising,inpoorerself-reportedhealth, andwithbetterself-reportedinsurancecoverageof medicationsweremorelikelytorespondtoDTCadvertising[9].Thissurveyalsofoundthatpersonsusingprescriptiondrugsatthetimeoftheinterviewweremore likelytobeinfluencedbyDTCadvertising.Tofurther investigatetherelationshipbetweenself-reportedmedicationuseandresponsivenesstoDTCadvertising,we conductedasecondaryanalysisofdataobtainedinan FDAsurveyofexposureto,perceptionsof,andattitudes towardDTCadvertising.MethodsDataSourceThedatacomefromanationaltelephonesurveyof adultsintheU.S.,investigatingthedemographiccharacteristicsandattitudinaleffectsofDTCprescriptiondrug advertisingofsurveyrespondents[5].Thesurveywas conductedbyaprofession alresearchfirmfortheFood andDrugAdministrationbetweenAprilandJuly1999 toexamineattitudesandinfluenceofDTCadvertising ofprescriptiondrugsuponthehealthcareexperience. ThetargetpopulationforthesurveywasEnglishspeakingconsumersaged18orolder. Respondentswerecontactedusingrandomdigitdialingmethodologyandseveralstepsweretakentooptimizetheresponserate.Interviewswerescheduledfor varyingtimesofthedayinanefforttolocatepotential respondentsataconvenienttime.Respondentswere allowedtoschedule callback appointmentstocompletethesurveyatamoreconvenienttime.Unlimited callbacks(morethan40)wereutilizedforphonenumbersthatdidnotinitiallyyieldarespondentcontact. Respondentswhoinitiallyrefusedtoparticipate,orterminatedtheinterviewbeforecompletionwerecontacted byamailedfollow-upletteraswellastwofollow-uptelephonesolicitations.StudyPopulation1081personsrespondedtothesurveyrepresentinga responserateof65%(eligiblerespondentswhocompletedsurveyplusineligiblerespondentsdividedbythe totalcontactedminusbadtelephonenumbers).From these,310personswhohadnotbeenexposedtoDTC prescriptiondrugmarketinginthethreemonthsprior tothesurvey,andthereforedidnotanswerthequestion ofinterest,wereexcluded. Table1describesthosepersonsexcludedfromtheanalysis.Thusourstudypopulationincluded771persons.MainMeasures ResponsivenesstoDTCdrugmarketing wasdefinedas anaffirmativeresponsetothesurveyitem: Hasan advertisementforaprescriptiondrugevercausedyou toaskyourdoctoraboutamedicalconditionorillness ofyourownthatyouhadnottalkedtoadoctorabout Table1CharacteristicsofRespondentsNotExposedto DTCA,ExcludedFromStudyCharacteristic Prevalence Age Lessthan65years 72.0 65yearsorolder 28.0 Gender Male 35.2 Female 64.8 Race White 66.5 Non-white 33.5 MaritalStatus Married 49.7 Single,widowed,divorced,other 50.3 EducationalAttainment Collegegraduateorhigher 23.2 Somecollegeorless 76.8 AnnualIncome Lessthan$35,000 57.9 $35,000ormore 42.1 Timesincelastvisittophysician Withinonemonth 40.7 Morethanonemonth 59.3 Self-reportedhealth Excellent 17.8 VeryGood 29.1 Good 27.2 Fair 18.1 Poor 7.8 Mean#ofRxdrugsinpast6months 2(S.D.1.6) Mean#ofOTCdrugsinpast6months 1.2(S.D.1.2)n=310Dieringer etal BMCHealthServicesResearch 2011, 11 :232 http://www.biomedcentral.com/1472-6963/11/232 Page2of7

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before? PrescriptionandOTCdrugusewasdetermined usingtheself-reportednum berofprescriptiondrugs, andOTCdrugsusedwithinthesixmonthperiodprior tothesurvey.CovariatesCovariateswerealsodeterminedfromthesurvey.These includedgender,race,income,maritalstatus,dateof lastphysicianvisit,self-re portedhealth,self-reported knowledgeabouthealthandmedications,andattitude towardDTCdrugadvertiseme nts.Self-reportedhealth wasassessedwithasingleitemusingafivepointscale rangingfrom1("excellent health)to5("poor health). Self-reportedknowledgeabouthealthandmedications wasassessedwithasingleitemusingafourpointscale rangingfrom1("extremely knowledgeable)to5("not atall knowledgeable).AttitudetowardDTCdrug advertisementswasassessedwithasingleitemasking howmuchtherespondent liked DTCadvertisingwith responsesonafivepointscalerangingfrom1("strongly agree )to5("stronglydisagree ).StatisticalAnalysisWeusedT-testandchi-squaretestsforunivariateanalyses.Formultivariateanalysis,weusedlogisticregressioncontrollingforcovariates.Thesecovariates includedage,gender,race,educationalattainment,maritalstatus,income,self-re portedhealthstatus,selfreportedknowledgeofmedicinesandhealth,andattitudetowardDTCadvertising.WeperformedallanalysesusingSASversion9.1(SASInstituteInc,Cary, NC).Allp-valueswere2-sidedand a wassetat.05.ResultsCharacteristicsoftheStudySampleTheaveragerespondent sagewas(means.d.)46.1 15.7years,64%werefemale,and81%werewhite.Fortytwopercenthadcompletedatleastacollegedegreeand 57%weremarriedattimeofinterview.Onaverage, respondentshadencountered2.41.3modesofdeliveryofDTCprescriptiondrug advertising(e.g.magazines,television,newspaper,etc.)inthethreemonths priortotheinterview.Respondents meanscoreforhow muchthey likedseeing theseadvertisementswas2.7 1.4.Themeanresponseforrespondents self-reported knowledgeofmedicationsandhealthmattersingeneral was2.60.7.Similarly,meanresponseforrespondents self-reportedhealthstatuswas2.41.1seeTable2.RelationshipbetweenRespondentCharacteristicsand ResponsivenesstoDTCMarketingOverall,195(25.3%)respondentsansweredaffirmatively toourvariableofinterest,indicatingthattheyhad initiateddiscussionofame dicalproblemwiththeir physicianbasedonDTCadvertising.Comparedto respondentswhodenieddiscussingmedicalproblems withtheirphysiciansbasedonDTCadvertising,respondentswhousedDTCadvertisingasafoundationfor discussinganewhealthproblemwiththeirphysician wereolder,possessedlesse ducationalattainment,and liked seeingDTCprescriptiondrugadvertisements. Gender,race,maritalstatus,self-reportedhealthstatus, self-reportedknowledgeab outhealthandmedications, andincomewerenotsignificantlyassociatedwiththe primaryendpoint(seeTable2).RelationshipbetweenSelf-ReportedPrescription MedicationUseandResponsivenesstoDTCMarketingThemeannumberofprescriptiondrugsusedinthesix monthspriortothesurveywas2.41.6.Of108personsusingnoprescriptionmedications,9(8.3%)were responsivetoDTCadvertisements.Of131persons usingfiveormoreprescriptionmedicines,50(38.1%) wereresponsivetoDTCadvertisements.Therewasa strongtrend(p<.0001)intherelationshipbetween numberofprescriptionmedicationsusedandresponsivenesstoDTCadvertise ments.Thisassociation remainedhighlysignificant(p=.0009)evenwhencontrollingfordemographics,sel f-reportedhealthstatus, educationalattainment,race,maritalstatus,self-reported knowledgeofmedicationsandhealth,numberofOTC medicationsused,income,andattitudetowardDTC advertisementsseeFigure1.RelationshipbetweenSelf-ReportedOTCMedicationUse andResponsivenesstoDTCMarketingTheaveragenumberOTCdrugsusedinthesixmonths priortothesurveywas1.81.4.Of136personsusing noOTCmedications,44(32.3%)wereresponsiveto DTC.Of61personsusingfiveormoreOTCmedicines, 20(32.7%)wereresponsivetoDTC.Therewasnolinear trendineitherunivariate(p=.54.)ormultivariate(p= .76)relationshipbetweennumberofOTCmedications usedandresponsivenesstoDTCseeFigure2.DiscussionOurdataindicatethatacro ss-sectionalrelationship existsbetweennumberofprescriptiondrugsusedand responsiveness toDTCadvertising.Thisstronglinear relationshipremainsevenwhencontrollingfordemographicandsocioeconomicvariablesandself-reported health.Overall,25.3%ofrespondentsweremotivatedby DTCadvertisingtoinitiatediscussionregardingnew healthproblems.Amongrespondentstakingnoprescriptionmedications,fewerthan10%weremotivated byDTCadvertising.Conversely,amongrespondents takingfiveormoreprescriptionmedicines,nearly40% weremotivated.Dieringer etal BMCHealthServicesResearch 2011, 11 :232 http://www.biomedcentral.com/1472-6963/11/232 Page3of7

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In2002,theGovernmentAccountabilityOfficehas identified13surveys,primarilyforlaypublications, whichattemptedtoassessconsumerbehaviorrelated DTCadvertising[8].Sincethattimeseveraladditional surveyshavebeenpublishedinthemedicalandscientificliterature[10,14-16].Inthesestudies,theproportion ofrespondentswhoreportedbeinginfluencedbyDTC advertisingtoseekmedicalcarerangedfrom10.5to 35%.Althoughthereissomevariationinhoweach surveydefinesresponsivenesstoDTCadvertising,our findingthat25%ofrespondentshaddiscussedanew medicalconditionwithaphysicianbasedonDTC advertisingisgenerallyconsistentwithothers. Ourresultsconfirmthoseof previousstudies,[10,17] whichidentifyolderage,lo wereducationalattainment andapositiveattitudetowardsDTCadvertisingasfactorsassociatedwithresponsivenesstoDTCadvertising [9,10].Incontrasttootherstudies,[14,18]wedidnot Table2SampleCharacteristicsbyResponsivenesstoDTCAdvertisingCovariate PrevalenceProportionresponsiveto DTCadvertising MultivariateassociationwithresponsivenesstoDTC advertising(OR,95%CI) Age Lessthan65years85.923.22.5(1.5-4.1) 65yearsorolder14.137.6 Gender Male36.122.21.0(.7-1.5) Female63.827.3 Race White82.624.5.7(.4-1.0) Non-white17.431.1 MaritalStatus Married57.525.51.1(.7-1.6) Single,widowed,divorced,other42.125.0 EducationalAttainment Collegegraduateorhigher57.828.9.7(.4-1.0) Somecollegeorless42.120.3 AnnualIncome Lessthan$35,00048.625.81.2(.8-1.9) $35,000ormore51.324.8 Self-reportedhealth Excellent23.213.41.1(1.0-1.4) VeryGood41.425.1 Good22.132.9 Fair11.928.5 Poor4.444.1 Timesincelastvisittophysician Withinonemonth59.627.4.9(.6-1.4) Morethanonemonth40.422.2 Self-reportedknowledgeabouthealth andmedications Extremelyknowledgeable 8.8 22.1 1.0(.8-1.3) Veryknowledgeable 30.0 25.5 Somewhatknowledgeable 58.2 25.4 Notatall 3.0 26.1 Likeseeingadvertisementsfor prescriptiondrugs Stronglyagree 20.4 41.6 1.4(1.2-1.6) Agreesomewhat 31.0 24.4 Neitheragreeordisagree 20.8 20.7 Disagree 10.9 18.1 Stronglydisagree 16.9 15.5n=771Dieringer etal BMCHealthServicesResearch 2011, 11 :232 http://www.biomedcentral.com/1472-6963/11/232 Page4of7

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findanassociationbetweenethnicity,incomeorselfreportedhealthstatusandDTCA. Wefoundthatacross-sectionalrelationshipexists betweenresponsivenesstoDTCandself-reporteduseof prescription,butnotOTC,drugs.Becausetherewasa trendtowardspoorerself-reportedhealthandresponsivenesstoDTC,isplausiblethatusersofprescription medicationsrepresentasickerpopulation,andonethat maybemoreattunedtothemessagesconveyedinDTC advertising.Alternatively,becauseDTCadvertisinglargelyfocusesonprescriptionmedications,personswho areresponsivetoDTCmayhaveapproachedtheirprescribersbasedoninformationinDTC,resultinginmore prescription,ratherthanOTC,use.Bellandcolleagues foundthatcurrentuserso fprescriptiondrugswere morelikelytobeinfluencedbyDTCadvertising,[9]but didnotquantifythenumberofprescriptions,andlimitedtheirsampletoonecountyinCalifornia. Ourinvestigationconfirmsresultsofasmallerstudy ofMinnesotansbySchommeretal.[15]thatfoundprescriptionmedicationusetobestatisticallygreaterin respondentswhowereresponsivetoDTCadvertising thanthosewhowerenot.Similartoourresults,no significantdifferencewas foundinthenumberofOTC medicationsusedbyresponsiveversusunresponsive patients. Themainstrengthofourstudyisthatthesourceof datacomesfromalargenationallyrepresentativesample withahighresponserate. Furthermore,unlikesome otherstudies,OTCaswellasprescriptiondrugusewas ascertained.Ourstudyhasse verallimitations.First, thesedatawerecollectedin1999.Penetrationand awarenessofDTCadvertising,aswellastypesofmedia outlets(e.g.internet),haveincreasedconsiderablyin subsequentyears.Despitethis,however,weareencouragedbysimilaritiesinregard toattitudinal,socioeconomicanddemographicpredictorsofsusceptibilityto DTCadvertisingdemonstratedinmorerecentsurveys, [14,15]andlikewisefeelthattherelationshipbetween numberofprescriptiondrugsusedandsusceptibilityto DTCadvertisingshouldbenolesstruetoday.Second, thisisasecondaryanalysis ofFDAdataoriginallycollectedtoinvestigateattitudinalanddemographiceffects towardDTCadvertising;thus,rigorousascertainmentof medicationusewasnotincluded.Althoughtheselfreportedmedicationusemeasureisalimitation,ithas 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 012345 or More Number of Prescri p tion MedicationsPercent Respond to DTC 159 108 130 164 131 74 Figure1 Proportionofrespondentswhowereresponsivetodirect-to -consumer(DTC)advertising,bynumberofself-reported prescriptionmedicationsusedinsixmonthspriortostudy .Thenumberofrespondentsineachcategoryisembeddedinthebars. Dieringer etal BMCHealthServicesResearch 2011, 11 :232 http://www.biomedcentral.com/1472-6963/11/232 Page5of7

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beenusedinaprevioussurveyofDTCadvertising,[15] andhasbeenfoundtobecongruentwithpharmacyprescriptiondata[19,20]. Thecross-sectionalnatureofthisstudydoesnotallow forunequivocalstatementsregardingthedirectionof causality.Althoughthisrelationshipcouldbeexplained byphysiciancompliancewithpatientrequestsformedications,itisalsoplausiblethatDTCadvertisements haveaparticularappealtopatientspronetotakingmultiplemedications.Finally,themainmeasureinthis studyspecificallyasksabouti nitiatingdiscussionwitha physicianaboutanewmedicalproblemandthusmay nothavecapturedthosepatientswhouseDTCadvertisementstopromptdiscussionofpreviouslydiscussed problems,orthosepatientswhomayhavediscontinued amedicationduetoinformationcontainedinDTC advertisements.ConclusionThereisastrongcross-sectionalrelationshipbetween thenumberofprescription,butnotOTC,drugsused andresponsivenesstoDTCadvertising.Althoughthis relationshipcouldbeexplainedbyphysiciancompliance withpatientrequestsformedications,itisalsoplausible thatDTCadvertisementshaveaparticularappealto patientspronetotakingmultiplemedications.Outpatientsmotivatedtodiscussmedicalconditionsbasedon theirexposuretoDTCadvertisingmayrequireacareful medicationhistorytoevaluatefortherapeuticduplicationorovermedication. Furtherresearchneedstobeperformedtounderstand thispopulation seagernesstoutilizeprescriptiondrugs andtodetermineifthiseagernesstranscendstoutilizationofotherhealthcareresources.Clearly,theseDTC advertisementsarepowerfulmotivators.Perhapsthey couldbeusedtoenhanceevidence-basedprescribing andadvancepublichealth.Acknowledgements Thisresearchwassupportedinpartbythe21stCenturyScholarsProgram, TheUrbanChildInstitute,Memphis,TN.Theauthorswouldliketothank KathrynJ.Aikin,Ph.D.DivisionofDrugMarketing,Advertisingand Communications,CenterforDrugEvaluationandResearch,FoodandDrug Administrationforherhelpfulcomments;andKathrynM.Jemmott,M.A., MSWforhereditorialassistance.Materialinthispaperpresentedas: DieringerNJ,ShorrRI.Effectivenessofdirecttoconsumeradvertisingamong thealreadymedicated.(PosterPresentationatthe27thAnnualMeetingof theSocietyforGeneralInternalMedicine,Chicago,IL5/04) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45 % 012345 o r M o r e Number of Non-prescription dru g sPercent Respond to DT C 216 136 118 209 61 31 Figure2 Proportionofrespondentswhowereresponsivetodirect-to-consumer(DTC)advertising,bynumberofself-reportednonprescriptionmedicationsusedinsixmonthspriortostudy .Thenumberofrespondentsineachcategoryisembeddedinthebars. Dieringer etal BMCHealthServicesResearch 2011, 11 :232 http://www.biomedcentral.com/1472-6963/11/232 Page6of7

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Authordetails1DepartmentofMedicalEducation,MethodistHealthcare,1265Union Avenue,Memphis,TN38104,USA.2GRECC(182)NF/SGVeteransHealth System1601SWArcherRoad,Gainesville,FL32608,USA.3Departmentof PreventiveMedicine,UniversityofTennesseeHealthScienceCenter, Memphis,TN3810,USA.4DepartmentofAgingandGeriatricResearch, UniversityofFlorida,Gainesville,FL,USA. Authors contributions NDandRSconceivedofthestudy,participatedinitsdesign,performed statisticalanalyses,interpretedthedata,andhelpeddraftandrevisethe manuscript.LCandGSparticipatedintheanalysisandinterpretationofthe dataandhelpeddraftandrevisethemanuscript.Allauthorsreadand approvedthefinalmanuscript. Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. Received:1January2011Accepted:23September2011 Published:23September2011 References1.HolmerAF: Direct-to-consumerprescriptiondrugadvertisingbuilds bridgesbetweenpatientsandphysicians. JAMA 1999, 281 :380-382. 2.RadosC: TruthinAdvertising:RxDrugAdsComeofAge. 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HenryJKaiserFamilyFoundation [http://www.kff.org/rxdrugs/ 3197-index.cfm.],PublishedNovember29,2001.AccessedAugust7,2011. 12.KravitzRL,EpsteinRM,FeldmanMD,FranzCE,AzariR,WilkesMS,HintonL, FranksP: Influenceofpatients requestsfordirect-to-consumer advertisedantidepressants:arandomizedcontrolledtrial. JAMA 2005, 293 :1995-2002. 13.MintzesB,BarerML,KravitzRL,KazanjianA,BassettK,LexchinJ,EvansRG, PanR,MarionSA: Influenceofdirecttoconsumerpharmaceutical advertisingandpatients requestsonprescribingdecisions:twosite crosssectionalsurvey. BMJ 2002, 324 :278-279. 14.MurrayE,LoB,PollackL,DonelanK,LeeK: Direct-to-consumer advertising:publicperceptionsofitseffectsonhealthbehaviors,health care,andthedoctor-patientrelationship. JAmBoardFamPract 2004, 17 :6-18. 15.SchommerJC,SinghRL,HansenRA: Distinguishingcharacteristicsof patientswhoseekmoreinformationorrequestaprescriptionin responsetodirect-to-consumeradvertisements. ResSocialAdmPharm 2005, 1 :231-250. 16.KhanfarN,LoudonD,Sircar-RamsewakF: FDAdirect-to-consumer advertisingforprescriptiondrugs:whatareconsumerpreferencesand responsetendencies? HealthMarkQ 2007, 24 :77-91. 17.WeissmanJS,BlumenthalD,SilkAJ,NewmanM,ZapertK,LeitmanR, FeibelmannS: Physiciansreportonpatientencountersinvolvingdirectto-consumeradvertising. HealthAff(Millwood) 2004,, SupplWeb Exclusives: W4-33. 18.LeeD,BegleyCE: Racialandethnicdisparitiesinresponsetodirect-toconsumeradvertising. AmJHealthSystPharm 2010, 67 :1185-1190. 19.CurtisJR,WestfallAO,AllisonJ,FreemanA,KovacSH,SaagKG: Agreement andvalidityofpharmacydataversusself-reportforuseofosteoporosis medicationsamongchronicglucocorticoidusers. Pharmacoepidemiol DrugSaf 2006, 15 :710-718. 20.CaskieGI,WillisSL: Congruenceofself-reportedmedicationswith pharmacyprescriptionrecordsinlow-incomeolderadults. Gerontologist 2004, 44 :176-185.Pre-publicationhistory Thepre-publicationhistoryforthispapercanbeaccessedhere: http://www.biomedcentral.com/1472-6963/11/232/prepubdoi:10.1186/1472-6963-11-232 Citethisarticleas: Dieringer etal .: Self-reportedresponsivenessto direct-to-consumerdrugadvertisingandmedicationuse:resultsofa nationalsurvey. BMCHealthServicesResearch 2011 11 :232. Submit your next manuscript to BioMed Central and take full advantage of: Convenient online submission Thorough peer review No space constraints or color gure charges Immediate publication on acceptance Inclusion in PubMed, CAS, Scopus and Google Scholar Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Dieringer etal BMCHealthServicesResearch 2011, 11 :232 http://www.biomedcentral.com/1472-6963/11/232 Page7of7