1 A CONTENT ANALYSIS OF THE INFORMATION CONTENT OF OVER THE COUNTER DRUG ADVERTISING IN MAGAZINES By SHINE LYUI A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREME NTS FOR THE DEGREE OF MASTER OF ADVERTISING UNIVERSITY OF FLORIDA 2011
2 2011 Shine Lyui
3 To my family
4 ACKNOWLEDGMENTS I am hear tily thankful to the co chairs of my committee Dr. Zheng and Dr. Sutherland, for their support and help to ma ke this thesis possible. Especially, I would like to show my gratitude to Dr. Zheng for giving me the opportunity to work with her and to Dr. Sutherland for guiding me patiently through the thesis work. I would like to thank Dr. Weigold for being willing t o serve on my committee. I am also greatly indebted to my parents. I would like to thank them for financing my education all along and for their love, support and guidance throughout my studies. Lastly, I am grateful to all those who contributed to this th esis. This thesis would not have been possible without their combined efforts.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 ABSTRACT ................................ ................................ ................................ ..................... 8 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 10 Problem Statement ................................ ................................ ................................ 10 Significance of the Study ................................ ................................ ........................ 13 2 LITERATURE REVIEW ................................ ................................ .......................... 14 History of the Conversion of Prescrip tion Drugs to Non prescription Status ........... 14 Regulation of Over the Counter ( OTC ) Drug Advertising ................................ ........ 16 Health Literacy and OTC Drug K nowledge among Consumers .............................. 18 Consumer Perception of OTC Drug Advertising ................................ ..................... 19 OTC Drug Advertising Information and Purchase Decisio ns ................................ .. 20 Information Content of OTC Drug Advertising ................................ ........................ 22 Research Questions ................................ ................................ ............................... 28 3 METHODOLOGY ................................ ................................ ................................ .... 30 Content Analysis ................................ ................................ ................................ ..... 30 Sampling Frame Development ................................ ................................ ............... 30 Unit of Analysis ................................ ................................ ................................ ....... 31 Identification of OTC Advertisements ................................ ................................ ...... 32 Drug Classification ................................ ................................ ................................ .. 33 Information Cues ................................ ................................ ................................ .... 34 Recoding ................................ ................................ ................................ ................. 36 Reliability ................................ ................................ ................................ ................ 36 4 RESULTS ................................ ................................ ................................ ............... 37 Description of Sample ................................ ................................ ............................. 37 Answers to Research Questions ................................ ................................ ............. 40 5 DISCUSSION ................................ ................................ ................................ ......... 46 Educational and Promotional Cues ................................ ................................ ......... 47 Discussion of Educational C ues ................................ ................................ ............. 48 Discussion of Promotional Cues ................................ ................................ ............. 49
6 Strengths and Limitations ................................ ................................ ....................... 50 Future Research ................................ ................................ ................................ ..... 51 Conclusions ................................ ................................ ................................ ............ 52 APPENDIX A CODING SCHEME ................................ ................................ ................................ 53 B DESCRIPTIONS OF INFORMATION CUES ................................ .......................... 55 LIST OF REFERENCES ................................ ................................ ............................... 57 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 63
7 LIS T OF TABLES Table page 4 1 Advertised over the counter ( OTC ) drugs ................................ .......................... 42 4 2 Magazine categories ................................ ................................ .......................... 43 4 3 Ad sizes ................................ ................................ ................................ .............. 43 4 4 Educational cues ................................ ................................ ................................ 44 4 5 Promotional cues ................................ ................................ ................................ 44 4 6 Educational and promotional content levels ................................ ....................... 45 4 7 Average number of educational cues ................................ ................................ 45 4 8 Average n umber of promotional cues ................................ ................................ 45
8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Advertising A CONTENT AN ALYSIS OF THE INFORMATION CONTENT OF OVER THE COUNTER DRUG ADVERTISING IN MAGAZINES By Shine Lyui August 2011 Chair: Lu Zheng Cochair: John C. Sutherland Major: Advertising Consumers in the United States are becoming self reliant in the ir selection of m edication s as many former prescription drugs are now available to the public as over the counter medications Meanwhile misuse of over the counter drugs has also become a major problem affecting people of all ages. Advertising plays a significant role in providing drug information to consumers and influencing consumers purchase decisions. This study examined the information content of over the counter advertisements in magazines and explored educational and promotional content levels. The study employed c ontent analysis to analyze the advertising content. A total of 744 over the counter drug advertisements were found in 216 magazine issues over a 3 year period and analyzed using a coding scheme comprising 34 information cues. The findings revealed that on average an over the counter drug ad vertisement contained 6.63 information cues. Among the 6.63 cues, 2.82 were educational in nature and 2.70 were promotional in nature. Although no significant differences in the average numbers of educational and promot ional cues were found during the 3 year period (i.e., 2008, 2009 and 2010 ) the interaction between year and type of cue was significant.
9 Significant differences were found in both the usage of different types of educational cues and promotional cues by y ear, with symptoms/indications being the most frequently used educational cue and tangibles being the most frequently used promotional cue.
10 CHAPTER 1 INTRODUCTION Problem Statement The regulatory history of over the counter (OTC) drugs (drugs that can be p urchased without a prescription) began with the passage of the Food, Drug and Cosmetic Act in 1938, which has been amended twice with the most recent being the Kefauver Harris Amendment in 1962 (Harrington & Shepherd, 2002). The original legislation provi ded the basis for subsequent amendments to differentiate between prescription and OTC drugs as well as establish regulatory requirements for drug approval (Harrington & Shepherd, 2002). The conversion of prescription drugs (Rx) to non prescription status e xploded following the introduction of an OTC drug review program in 1972 (Hoy, 1994). The OTC drug market with a total of $27.5 billion in revenues had a steady growth rate for the period 2005 to 2009 and is forecast to remain moderate for the upcoming 5 years reaching a value of $31.9 billion by 2014 (Datamonitor, 2010). The surge in the OTC drug market is predominantly attributed to the switching of prescription drugs to OTC status, which has made numerous prescription drugs available on retail shelves over the past decades (Hoy, 1994; Kittinger & Herrick, 2005). E xperts predict that the growth of self medication will continue to expand with the influences of OTC drug advertising and the transfer of prescription drugs to OTC status (Rx to OTC) (DeLorme, Huh, Reid, & An, 2010) Research by Roper Starch Worldwide (2001) found that 77% of Americans ha ve used OTC drugs in the last 6 months to treat themselves when they are sick, 69% ha ve chosen to wait and see if the condition would go away, 43% ha ve consulte d a physician, 38% ha ve taken prescription medications,
11 26% ha ve taken dietary supplements and 25% ha ve opted to change their diet. A study conducted by Harris Interactive on behalf of the National Council on Patient Information and Education (NCPIE) (200 8) indicate d that more than 80% of adults in the United States rel y on self medication for those conditions that can be treated or relieved by OTC medications such as cold s and coughs The number one reason for self medicating among adults is familiar ity w ith the treatment based on past experience s followed by the need to save time, the belief that seeing the doctor is unnecessary, the ability to care for oneself, and the perception that OTC drugs are just as safe and effective as prescription drugs (NCPIE 2008) Although the market for OTC drugs seems quite promising, the problem of OTC drug misuse remains widespread (Tsao, 1997). A national survey conducted by Harris Interactive for NCPIE found that one third of adult Americans ha ve experienced OTC drug overdose and most Americans overlook the dosage level and active ingredients in the products (Levy, 2002). T he 2006 National Survey on Drug Use and Health estimated that more than 3 million individuals 12 to 25 years old, ha ve misused an OTC cough and co ld medication (Substance Abuse and Mental Health Services Administration [SAMHSA], 2008). Non prescription drug abuse is also prevalent among children and teens, and obtaining these medications has become a pathway to more serious drug use ( Patient Care U pdate: Over the Counter Drug Abuse, 2007). The emergence of the transfer of prescription drugs to over the counter status ( Rx to OTC ) and self medication ha ve played significant roles in driving OTC drug advertising (DeLorme et al., 2010). A national sur vey demonstrated that mass media have become the primary source of information about OTC medicines for Americans
12 (NCPIE, 2002). In 2008, approximately $684 million was spent to advertise OTC drugs in national magazines (OTC Perspectives, 2009a). Advertisem ents for OTC drugs pl ay a vital role in informing consumers about the product they intend to purchase and conversely, consumers rely on advertisements to give them the information they need (Patil, 1995). Many people purchase OTC drugs under the influence of advertising (McGrath, Crome, & Crome, 2005). Marketers of OTC drugs frequently use p rint and television advertising to reach retail consumers Many consumers rely on the information cues presented in advertisements to make their purchase decisions (Kav anoor, Grewal, & Blodgett, 1997). However, fewer than 30% of patients said that they refer red to magazines for sources of drug information and half of patients did not think advertising increased their knowledge of medications. Interestingly, a lthough the respondents did not seem to place a lot of trust in drug advertising, they were still likely to use the information given in advertisements to make purchase decisions (Koch, Ernst, & Kelly, 2002). Although OTC drug advertisements provide consumers with pu rchasing information advertisers tend to make claims that have no rational basis (Wigder, 1979) One study found that s ome OTC advertisements promoted unapproved purposes of the products and did not specify their active ingredients (Vener & Krupka, 1986). In the study of S. Sansgiry, Sharp and S. S. Sansgiry ( 1999 ), five clinical pharmacists examined the OTC drug advertisements in periodicals and reported that 50% of the advertisements reviewed contained inaccurate information. Sansgiry et al. (1999) argu ed that clarifying drug information in advertisements could help consumers make appropriate purchase decisions as well as decrease adverse events.
13 Although no direct correlation has been found between misleading information in OTC advertisements and the mi suse of OTC drugs, the possibility still exists that false and misleading advertisements which are in fact illegal may lead to serious issues regarding the safety and knowledge of OTC drugs given that consumers to a certain extent can be influenced by the information contained in the advertisements. Based upon these facts, it is clear that mass media are an important source of information about non prescription medicines for consumers and the information content of OTC drug advertisements can influence cons umers purchase decisions. Significance of the Study Th e purpose of this study is to examine the information content of OTC drug advertising in magazines to better understand the overall picture of the informative levels of OTC drug advertising. This stud y is significant for several reasons. First, to date no study has exclusively examine d the information content of OTC drug advertisements in magazines since 2000. Thus, t his study helps fill a n identified research gap. Second, the OTC drug market is expect ed to continue to expand with advertising remain ing a dominant driver of the purchase of OTC drugs (Delorme et al., 2010). F i nally, given the fact that OTC drug advertising tends to contain inaccurate and promotional content (Sansgiry et al., 1999; Zheng & Phelps, 2008), this study seeks to offer some useful data and guidance for officials as well as consumers to better understand and evaluate current OTC drug advertising from an educational point of view in an effort to promote proper drug use and avoid u nintended co nsequences.
14 CHAPTER 2 LITERATURE REVIEW According to DePinto ( 1997 ), approximately 60% o f medications purchased by American consumers are not prescribed by physicians. These medications are the ailments (Roper Starch Worl d wide, 2001) with 8 5% of American consumers believing it to be important to have access to OTCs to relieve m inor medical problems (American Pharmacists Association, 2000) and a majority of A mericans believing that OTCs are safe when used as directed (Roper Starch Worldwide, 2001). Most individuals take precautions such as reading directions before taking a non prescription product for the first time, reading labels to choose appropriate OTC medicines, and reading about possible side effects and interactions before using non prescription drugs (Roper Starch Worldwide, 2001). In 2009 OTC drug sales resulted in an estimated $27.5 billion in revenues and sales are expected to reach the $30 billion mark by 2014 (Datamonitor, 2010) Hoy ( 1994 ) and Kittinger and Herrick ( 2005 ) attributed the growth of the OTC market to the sale of prescription drugs that have been converted to non prescription status. Mahecha (2006) suggested that Rx to OTC conversions account for 50% of OTC sales. His tory of the Conversion of Prescription Drugs to Non prescription Status The histor ies of the differentiation between prescription and non prescription drugs (OTC) and the Rx to OTC conversion in the United States can be traced t o the 1938 Food, Drug and Co smetic Act (Temin, 1979). The regulation created a distinction between prescription drugs, which had limited labels and could only be sold by a prescription or OTC drugs, which had detailed labels and were sold without a doct This differentiation was
15 reinforced in 1951 with the Durham Humphrey Amendment to the Food, Drug, and Cosmetic Act of 1938 which defined prescription drugs as those that are safe for use only under professional supervision ( Food and Drug Administration [ FDA ] 2001, as cited in Harrington & Shepherd, 2002). In 1962, the Kefauver Harris Amendment added a consumer safety perspective by requiring that both prescription and non prescription drugs be proven to be safe and effecti ve for their stated claims prior to introduction in to the market (Edwards, 1972, as cited in Hoy, 1994 ; FDA, 2001, as cited in Harrington & Shepherd, 2002; Stringer, 1999, as cited in Harrington & Shepherd, 2002). I n 1972 with the introduction of a n OTC d rug safety and effectiveness review program ( CHPA, n. d., OTC Monographs and Federal Legislation, para. 1; FDA, n.d., OTC Drug Review section, para. 1 ), the FDA addressed the switching (conversion) of prescription drugs to OTC status (Rx to OTC) (Hoy, 19 94) by defining an Rx to OTC switch as over the counter (OTC) marketing of a drug product that was once a prescription (Rx) drug for the same indication, with the same strength, dose, duration of use, dosage form, population and route of administration ( Mahecha, 2006, p. 1). Generally, a prescription drug can be transferred to non prescription status when the FDA decides that the benefits outweigh the risks and the drug is safe and appropriate for self medication (Kittinger & Herrick, 2005). The switching process can take from 12 months to several years to come to fruition (Mahecha, 2006). The motivation for a n Rx to OTC switch is largely to extend the lifecycle of a drug facing declines in sales and profits as a result of a generic entry into the market, typically at the time of a
16 In 2001, the CHPA (2001) estimated that more than 700 OTC products used ingredients and dosages that had been available only by prescription 30 years earlier. Accordingly, CHPA ( 2009) estimated that since 1976, 84 ingredients, dosages or indications have made the Rx to OTC switch including Advil, Afrin, Aleve, Lamisil, Nicorette, Pepcid AC, Rogaine and Zantac 75 (Kittiner & Herrick, 2005). The number of prescription drugs bein g switched to OTC status is likely to continue to increase as well as the classes of available OTC drugs (Cohen, Paquette, & Cairns, 2005). After an Rx to OTC conversion, consumers primary sources of information shift from the prescribing physician and di stributing pharmacist to mediated communication ( e.g., advertising, packaging ) Pharmaceutical companies consequently turned to direct to consumer (DTC) advertising campaigns to promote their new OTC products leading to the question of the need for regula tion s of OTC advertising. Regulation of OTC Drug Advertising The Federal Trade Commission (FTC) is responsible for OTC drug advertising and applies existing advertising standards to OTC advertisements under the FTC Act which authorized the FTC to prevent unfair or deceptive acts or practices (Delorme et al., 2010; Pohl, 2010 ; Watts & Wilkenfeld, 1992 ) The principle of FTC advertising law is that all advertising need s to be truthful, non deceptive, no n misleading and reliable (Delorme et al., 2010; Watts & Wilkenfeld, 1992) ; puffery remains acceptable (Pohl, 2010). Specifically, the amended Section 5 of the FTC Act provides the FTC with specific authority to prevent and monitor deceptive OTC drug advertising (Delorme et al., 2010). OTC drug adve rtising claims must be truthful and non deceptive ( just like any other product ). epending on the claim, advertisers may be required to back up their
17 representations with competent and reliable scientific evidence, including tests, studies, or other obj ective data (Drug Advertising section, para. 1). The FTC defines deceptive advertising as an advertisement that makes false claims or misleading statements in a material respect (Delorme et al., 2010; Watts & Wilkenfeld, 1992). Two key considerations in a nalyzing an ad vertisement are that the c ommission (1) interprets the advertisement in its totality from the point of view of the consumer and (2) considers whether the particular claims are likely to affect the audience to whom the ad vertisement is directe d (Delorme et al., 2010; Watts & Wilkenfeld, 1992). The FTC also looks at whether the advertiser is able to support both express ed and implied claims with sufficient and reliable evidence. T he FTC is concerned about what an ad vertisement does not say and w hether the claim made is important and useful to a consumers buying decision. (FTC, 2001, Advertising FAQ s: A Guide for Small Business, para. 1 4). Zheng and Phelps (200 8 ) suggested that a major problem with the regulation of OTC drug advertising is th at the FTC does not require advertisements to contain fair balance. That is to say, advertisers are not required to present information about the benefits as well as the contraindications and risks of the drug being advertised. Likewise, these standards do not dictate that OTC drug advertisers must educate consumers about OTC drug use and safety (Zheng & Phelps, 2008). In addition to these issues, debates have centered on whether the FTC or the FDA should be regulating OTC drug advertising (CHPA, n. d.; Te inowitz, 2008) P rescription drug advertising has been regulated by the FDA (FDA, 2009; Pohl, 2010). Legislation that would empower the FDA to supervise ad vertisement s for OTC drugs
18 was introduc ed in 2007 by Representative Henry Waxman (D Calif.) and Senat or Edward Kennedy (D Mass.) (Teinowitz, 2008) who believed that the FDA could prevent not only untruthful ad vertisement s but also ad vertisement s that did not prominently present any potential side effects. Objectors on the other side claimed that OTC dru gs should n o t be treated the same way as prescription drugs because OTC drugs were supposed to be much safer (Teinowitz, 2008). The CHPA has also adopted an opposing stance towards the shifting of OTC advertising oversight from the FTC to the FDA, indicati ng that such a change would add unwanted responsibility to the agency ( CHPA, n.d. OTC Drug Advertising, para. 3) The CHPA (n.d.) argued that more than 229 enforcement actions over the past decade have been initiated by the FTC against false and mislead ing health and safe claims, and a total of 19 enforcement actions were directed at 31 products with deceptive claims from April 2006 to August 2007 ( OTC Drug Advertising, para. 4) Regardless of those responsible for the regulation of OTC advertising, e xisting standards provide consumers the right to truthful, non deceptive claims that can be substantiated. In the future, OTC drug advertising will continue to face the FTC s close scrutiny over its claims and more efforts will be made to focus on inappro priate drug use that may result from the advertisements (Watts & Wilkenfeld, 1992). However, t he extent to which consumers rely on information to make informed decisions remains another question to address. Health Literacy and OTC Drug Knowledge among Cons umers Although most individuals take precautions to read directions and labels and e xplor e possible side effects and interactions before using OTC drugs (Roper Starch Worldwide, 2001), a concern exists According to
19 Bone, F rance and Aikin (2009), only 12% of American Basic health related skills such as understanding an OTC drug product label and following prescri ption instructions are considered difficult for more than one third of the American population (Sondik, 2007, as cited in Adkins & Corus, 2009). Hustad, Courtney and Heeler (1979) found that respondents tended to trust the safety of OTC drugs that were av ailable on the market due to government controls, but they concluded that this level of confidence could lead consumers to pay less attention to the information on package labels. Likewise, Hus tad et al. found that advertising information was also believed to be effective only when the product was being newly introduced or was deemed an alternative by those who had had unsatisfactory experiences in the past. Consumer Perception of OTC Drug Advertising Existing evidence suggests that general perceptions of O TC drug advertising are unfavorable (e.g., DeLorme et al., 2010 ; Diehl et al., 2008; Geller, Nguyen & Wilkes, 1997 ; Toohey, 1985). Toohey (1985) found less favorable attitudes toward advertised OTC drug products among respondents who believ ed that the information about drug performance was overstated and that complex scientific issues contained in advertisements using scientific tests tended t o be oversimplified and distorted. Mackowiak et al. (1997) examined the characteristics of 87 OTC advertisements in journals for pharmacists and the attitudes of pharmacists and pharmacy students toward OTC advertising. The majority in both groups believed that OTC drug advertising presents valuable information about the products, but about half
20 of each group perceived the advertisements to be misleading and untruthful (Mackowiak et al., 1997). Diehl et al. (2008) found that American consumers attitudes toward advertising for OTC products w ere less favorable than attitudes toward advertising in gen eral. American consumers perceive OTC drug advertising to be uninformative, untruthful, and unreliable as well as lack ing essential information. Interestingly, Toohey (1985) found that 54% of university students and 37% of high school students purchased O TC drugs based on mass media advertisements on radio, television, and magazines despite their overall negative perceptions of OTC drug advertising. Diehl et al. (2008) also found that consumers tend to be less skeptical of OTC drug advertising than adverti sing in general ; they also tend to believe its information content more than advertising in general. Diehl et al. argued that consumers may overestimate the credibility of drug advertising content because the governmental regulations of drug advertising ar e in fact less stringent than consumers believe them to be. In terms of OTC knowledge, Krupka and Vener (1987) found that young adults in general do not possess adequate knowledge with regard to the appropriate use of drugs. The scholars argued that the m ass media may be responsible for the low levels of drug that providing more educational info rmation in the advertisements is necessary to lower potential health risks. OTC Drug Advertising Information and Purchase Decisions Although existing research suggest s that consumers have negative attitudes toward OTC drug advertising and may not have ade quate knowledge for OTC use,
21 scholars have also explored the effect of OTC drug advertising on consumer decision making. Portner and Smith (1994) in their study of the relationship between college students perceptions of information source characteristic s and the likelihood to use that source for information found that (1) physicians and pharmacists were rated as the most accurate, but most expensive, most time consuming and least convenient source of OTC drug information and (2) informal sour ces (friends, family and t elevision advertisements) were rated as more accessible more convenient, less expensive and less time consuming. Family received the highest mean likelihood to use rating while t elevision advertisements received the lowest. The scholars explained that the low ratings for advertisements as an information source could be attributed to less substantive advertising content. Mackowiak et al. (1997) reported that students named TC drugs. Stephens and Johnson (2000) examin ed the significant factors affecting older purchase decisions finding that older adults rely heavily on the advice of healthcare professionals and product labels when purchasing OTC drugs In addition, younger adults reported that informal care providers (e.g., friends ) were the primary sources of information regarding the purchase of OTC drugs. Older adults were found to recall less information from t elevision commercials than younger adults. However, recall of advertisement s was not found to influence the purchase decisions of either older or younger adults. Kim and King (2009) study reviewed the information search process of 205 adults for prescription and non prescription drugs They foun d that physicians and pharmacists were the most important sources of information for both prescription and
22 non prescription drugs and that mass media and interpersonal sources were considered to be significantly more important for non prescription drugs. Although some of the se findings seem to run counter to the belief that OTC advertising has a strong influence on consumer decision making, the Nonprescription Drug Manufacturers Association (NDMA) claims that advertising is one of the four major sources of information regarding the purchase of OTC drugs for most Americans (Stephens & Johnson, 2000). Likewise, f rom a broader perspective, Garner (1982) suggested the need to consider the mind to receive and interpret incoming message, to store som e impressions made by the messages and to act on those impressions at some later time (Gardner, 1982, p. 7) when considering the effects of mediated message. He added that here is much registered on the brain that is not accessible to memory but that leaves an imprint that affects future interpretation and even behavior (Gardner, 1982, p. 9). In addition, at times we think we are ignoring the input even though our minds are actually receiving the message (Gardner, 1982). These messages may not arous e immediate response but can be recalled at a later time (Gardner, 1982). Information Content of OTC Drug Advertising Many scholars and critics have focus ed their inquiries on the amount of information contained in advertising. Most studies have measured the information content of advertising using a procedure introduced by Resnik and Stern (1977) (Abernethy & Franke, 1996). Resnik and Stern (1977) developed 14 evaluative criteria identified as information cues to determine the informativeness of commercia ls. The 14 evaluative criteria were price or value, quality, performance, components or contents, availability, special offers, taste, packaging or shape, guarantees or warrantees, safety,
23 nutrition, independent research, company sponsored research and ne w ideas. Although advertising may explicitly or implicitly affect consumer decision making, the amount and quality of information provided to consumers in OTC advertising is an important question because consumers cannot rely on physicians or pharmacists f or OTC drug information as they would for prescription medications. Most scholarly OTC advertising studies were conducted in the 1980s and 1990s including Rallapalli and Smith ( 1994 ) Sansgiry et al. ( 1999 ) Tsao ( 1997 ) and Vener and Krupka ( 1986 ) M ore recent studies have included Abernathy and Adams Price ( 2006 ) Cline and Young ( 2005 ) Mastin, Andsager, Choi, and Lee ( 2007 ) Pinto ( 2000 ) and Sokol, Wackowski and Lewis ( 2010) literature specifically concluded tha t a need existed for more research. In an early content analysis of magazine OTC advertisements, Vender and Krupka (1986) found that t opical medications, central nervous system medications, nutritionals, simulated sun tanning, diuretics, gastrointestinal, and respiratory were the most commonly advertised OTC products. Interestingly, they also discovered that women were the primary target of OTC drug products with 86% of the total number of OTC drugs advertised found in women s magazines (Vemder & Krupka, 1986) The majority of women oriented advertisements centered around appearance concerns whereas most men oriented advertisements focused on boosting energy levels with stimulants. T he FDA subsequently clarified many drug classifications ( FDA, 201 0, Is it a cosmetic, a drug, or both ? ) in written form on July 8, 2002 ; more recently, the FDA (2009) moved nutritionals to a special category of dietary supplements which are generally placed under the umbrella of foods instead of drugs
24 Rallapalli and Smith ( 1994) explored the information content of 167 OTC advertisements from four magazines targeted at female audiences using Resnik and Stern s (1977) information cue criteria Based on a set of 13 information cues, 92.8% of the ad vertisement s were found to con tain at least 1 cue with the average number of cues for OTC advertisements being 3.1 ( Rallapalli & Smith 1994). Performance was the most frequently mentioned information cue An interesting discovery of the study was that smaller advertisements had more i nformation cues on average than larger advertisements Significant differences in the number of information cues were found between different products. An average of 4.5 information cues were found in the advertisements for personal care, contraceptive s, a nd laxative s, while only 1 information cue on average was found in advertisements for oral health and diaper rash. Although not a study based in the United States, Hoog (1994) added to the knowledge base of OTC drug advertising with a content analysis of O TC drug newspaper ad vertisement s in Sweden. of 267 ad vertisement s found that OTC advertising was less argumentative (informative) and persuasive (aesthetically pleasing, news, and humor) than advertising in genera l, and that the most f requently presented information cues were indications, place of purchase and dosage form. Hoog persuasive content with ethical codes for OTC drug advertising. Sansgiry et al ( 1999 ) studied the accu racy of product claims and information on side effects in OTC drug advertising. Fourteen unique OTC advertisements from three health related consumer periodicals over a nine month period were examined independently by five clinical pharmacists. The scholar s found that more than half of the
25 advertisements analyzed lacked accurate information ; only one contained information on side effects. The researchers concluded that OTC drug advertisements appeared to be more promotional lacking the information necessar y for consumers to make informed purchase decisions. Main Argo and Huhmann (2004) analyzed the rational appeals, positive emotional appeals and negative emotional appeals used in the advertisements for DTC drugs (prescription products advertised to con sumers) OTC remedies and dietary supplements. Although the data analysis focused primarily on DTC drugs, Main et al. found no difference s in the use of rational appeal s among the advertisements for these three product categories but they did find more p ositive and negative emotional appeals in advertisements for DTC drugs than for OTC remedies or dietary supplements. Tsao (1997) pioneered the empirical study on the informational and symbolic content of OTC drug advertising on television finding that to pical, respiratory, central nervous system, gastrointestinal, nutritional and antiperspirant s were the most frequently advertised OTC drugs Using 16 major information cues as the basis of measurement, Tsao found an average of three information cues per O TC drug advertis ement, consistent with Rallapalli and Smith (1994) finding of an average of 3.1 consistent with Vener and Krupka (1986) finding that only 18% of the advertisem ents provided complete information on the names and functions of the advertised drug In this regard, although d rug disclosure (of potentially harmful effects) and drug performance frequently appeared in commercials, Tsao noted concerns about the
26 readabili ty and preciseness of such drug disclosures. Tsao also noted the lack of time lapse of usage in before and after ad vertisement s Tsao concluded that most OTC drug advertising tended to be brand oriented and did not provide valuable information to consumers arguing that OTC drug advertisers must shoulder the responsibility of informing consumers about the educational and factual aspects of product use. Byrd Bredbenner and Grasso (1999) studied the health related content of 700 television commercials aired during children oriented primetime network programs Byrd Bredbenner and Grasso found 29 medicine advertisements including 25 for OTC medications. A ll OTC commercials advised consumers to take the drug as directed but only a few mentioned drug interactio ns and potential side effects. Consistent with Tsao (1997) findings these OTC drug commercials tended to emphasize drug performance rather than medical rationale with most portrayed as simple and risk free solutions for relieving symptoms. Byrd Bredben ner and Grasso (1999) concluded that the magic of medicine belief cultivated in many OTC advertisements along with a lack of information about drug safety may lead to casual drug use. More recently, Zheng and Phelps (2008) examined OTC drug television co mmercials using a coding scheme of 34 information cues use of 1 6 information cues, it is not surprising that Zheng and Phelps (2008) found a greater overall informati on in OTC drug commercials with an average of 11.08 informatio n cues per commercial. Further more Zheng and Phelps classified information cues into educational cues, promotional cues and other cues according to their nature. The notion of educational and promotional cues was similar to that of argumentative and pers uasive contents used by Hoog (1994) who defined argumentative statements
27 as messages that aid the consumer in finding and using OTC products (p. 72) Zheng and Phelps defined educational cues as information that helps consumers to understand and use OT C product appropriately ( 2008, p. 12). The p ersuasive method was defined by Hoog as methods that create a positive attitude toward a product without the support of argumentative statements ( 1994, p. 72) while Zheng and Phelps concluded that promotional cues focus on touting tangible and intangible benefits of the advertised drug and demonstrate a strong sales orientation ( 2008, p. 12). According to Zheng and Phelps, only 36% of the information cues were educational in nature (argumentative for Hoog, 1 994) compared to 5 9 % that were promotional cues (persuasive for Hoog, 1994). Zheng and Phelps (2008) were critical of the lack of information cues in OTC advertising and of the ability of the educational cues that were present to provide information that w ould help consumers in the selection and use of OTC drugs. Zheng and Phelps also noted problems regarding the readability of information c ues Similar to Tsao (1997) Zheng and Phelps suggested th e need for clarification of educational cues that could more effectively assist consumers in OTC drug information seeking and purchase decisions Abernethy and Franke (1996) conducted a meta analysis of the information content of advertising using 18 measures of advertising information including the 14 information cues developed by Resnik and Stern (1977) to analyze the differences in the numbers of cues found in print and broadcast media. On average, t he most information was found in newspaper s (2.60 cues) and magazine s (2.38 cues), followed by radio (2.24 cues). Differences in the type of information were also identified among
28 advertising media, with magazines leading in quality, performance, nutrition, packaging and research information ; television did not lead in any category. Abernethy and Franke concluded the ir study by pointing out the needs to report advertising information in countries other than the United States and consider product differences when studying advertising information content. In summary, the authors of the reviewed studies suggest that the information content of OTC drug advertising is less than ideal in order to facilitate informed decisions among consumers ; as such, they argue for additional research. An important improvement in this area of research has been the identification of more com prehensive lists of information cues and the recognition of the need to analyze both print and broadcast advertising within current classifications of OTC drugs. Although OTC drug television commercials have been recently examined (Zheng & Phelps 2008), t he most recent study on print advertising was published in 199 9 ( Sansgiry et al 1999 ) Research Questions The purpose of this study is to add to the body of knowledge of OTC drug advertising by analyzing magazines using more current lists of information cues from a broader sample of magazines from 2008 through 2010. The study will provide a more current assessment of the information in OTC advertisements as well as provide an assessment of changes in the use of information in OTC advertisements. The prim ary research questions for this study are: RQ 1 : What is the overall information content level of OTC drug advertisements published in magazines in 2008, 2009 and 2010 ? RQ 2 : Has the information content of OTC drug advertisements in magazines become more ed ucational or promotional since 2008?
29 RQ 3 : Does a difference exist in t he average number of cues per ad vertisement between educational cues and promotional cues? RQ 4a : Do differences exist in the usage of different types of educational cues? RQ 4 b : Do differ ences exist in the usage of different types of promotional cu es?
30 CHAPTER 3 METHODOLOGY Content Analysis The purpose of this study is to examine the information content of OTC drug advertisements in magazines and explore the educational and promotional con tent levels Given these objectives, the research approach of content analysis was employed. Several research efforts previously mentioned have also employed content analysis in attempts to examine the information content of OTC drug advertising (Rallapall i & Smith, 1994; Tsao, 1997; Zheng & Phelps, 2008). Krippendorff (2004) defined content analysis as a research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use (p. 18). Content ana lysis can be applied to the study of any book, magazine, newspaper, individual story or article, motion picture, news broadcast, or television program (Tan, 1985, p. 49) and is used to code and describe objectively the content of communication (p. 51). According to Berelson (1952), two of the main uses of content analysis are to audit communication content against objectives and identify the intentions and other characteristics of the communicators (as cited in Krippendorff, 2004, p. 45). These char acteristics and advantages of content analysis make it appropriate for the current study. Sampling Frame Development In order to fulfill the recommendations of Rallapalli and Smith (1994), who urged th e inclusion of more diverse magazines ( targeting genera l and male audiences) in content analyses of OTC advertising, six popular magazines from three magazine categories (i.e., women, men and general interest ) were selected Based on the
31 magazine circulation statistics provided by the Audit Bureau of Circulat ion (ABC) (2010), the top two magazines from the category of women, men and general interest over a three year span (i.e., from 2008 to 2010 ) were chosen. The magazines chosen were Good Housekeeping Woman s Day Maxim, Men s Health Reader s Digest and National Geographic Every magazine was published monthly except Woman s Day which has a frequency of 17 issues each year. To address this disparity in annual publishing frequency, one issue from each month was included in the current study As a result, 12 issues of Woman s Day for each year were chosen so that a sample with equal numbers of issues of each magazine could be ensured. After examining 3 randomly selected issues from the top 6 general interest magazines from 2008 to 2010 all but one magazine were judged to contain sufficient OTC advertising to be worth including in the sample. In addition, because National Geographic h ad less than 10 OTC ad vertisement s during the 2008 2010 period, it was replaced with the 6 th ranked general interest magazine, Vanity Fair which had a much greater number of OTC ad vertisement s Unit of Analysis The first decision in content analysis is to select the unit of analysis or portions of the message that are to be analyzed (Tan, 1985, p. 49). The unit of analysis in this study was the magazine advertisement. These advertisements were limited to those at least one quarter page in size and that included both black and white and color advertisements. D uplicate and unique advertisements were included resulting in 744 OTC advertisements in total, among which 4 01 were unique advertisements Duplicate advertisements were included in the analysis for three reasons. First, most previous scholars retained duplicate advertisements in their studies, including Rallapalli and
32 Smith (1994), Tsao (1997), and Main et al. (2004). Second, consumers exposure to OTC drug advertising is important because exposure is the first and necessary event leading to cognitive, attitudinal, and behavioral reactions (Delorme et al., 2010, p. 222). T hird, it was assumed that many unique advertisements use highly similar contents to advertise different products made by the same company, thus making it unnecessary to analyze unique advertisements in isolation Identification of OTC Advertisements OTC product advertisements were identified using FDA (2010) guidelines that define drugs as articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease and articles (other than food) intended to affect the structure or any function of the body of man of other animals ( Is it a Cosmetic, a Drug, or Both, para. 3). C osmetics, defined by their intended use as articles intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the hu man body for cleansing, beautifying, promoting attractiveness, or altering the ( Is it a Cosmetic, a Drug, or Both, para. 2) are not generally considered OTC products. Products that can be considered as both a cosmetic and a drug were includ ed must comply with the requirements for both cosmetics and drugs (FDA, 2010, Is it a Cosmetic, a Drug, or Both, para. 4). Such cosmetic/drug combinations included in this study were anti wrinkle/aging products, cosm etic products with sun protection claims, anticaries products, anti gingivitis/plaque products, and shampoos with hair growth claims However, d ietary supplements were eliminated from the current study T he Dietary Supplements Health and Education Act (DS HEA) places dietary supplements in a special category under the general umbrella of foods, not drugs, and requires that
33 every supplement be labeled a dietary supplement (FDA, 2009, What is a dietary supplement? section, para. 1). Thus, d istinguishing d ietary supplements from OTC drugs is an easy task as the majority of the advertisements for dietary supplements had either the label of dietary supplement on the product packages or a statement that reads t hese statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. However, when collecting OTC drug advertisements from magazines for the current study one advertisement was identified for a product that was clai med to reduce cellulite. This intended use should make the product a drug according to the definitions given by the FDA ( 2010). Interestingly and perhaps surprisingly, the advertisement portrayed the product as a dietary supplement by including the aforeme ntioned statement and labeling itself as a dietary supplement. To avoid confusion, this particular advertisement was excluded from the current study. Drug Classification M ost previous studies have classified OTC drugs into major categories such as topical, respiratory, central nervous system, gastrointestinal nutritional and others N early all pertinent studies have included nutritional supplement products (e.g., Rallapalli & Smith 1994 ; Tsao 1997) which are not supposed to be a category of drugs as m entioned earlier. To clarify this problem, t he Division of Drug Information in the FDA s Center for Drug Evaluation and Research was contacted through email. The FDA explained that no complete list of OTC drug categories could be provided at the time as no t enough resources were available (FDA, personal communication, February 1, 2011). Therefore the current study adopted the OTC drug categories as specified by the OTC monographs which dictate the regulatory standards for acceptable ingredients,
34 doses, fo rmulations, indications and labeling (CHPA, 2009) OTC drugs must either be the subject of an approved New Drug Application ( NDA ) or comply with the appropriate monograph, or rule, for an OTC drug ( FDA, 2010, Is it a Cosmetic, a Drug, or Both, para. 9 ). OTC monographs provided possibly the most complete list of OTC categories while simultaneously allow ingredients to its corresponding category which was extremely helpful when the product category could not be determi ned at first glance. However, close observations revealed that the OTC monographs do not cover all classes of OTC drugs. Thus, f or product categories not addressed by the monographs, such as smoking deterrents, a new category was created and named based on their intended use. As a result, 24 drug categories were identified in a total of 744 OTC drug advertisements: skin protectant, sunscreen, acne, external analgesic, cough/cold, smoking deterrents, laxative, antacid, antidiarrheal, digestive aid, overindul gence in alcohol/food, anticaries, gingivitis/plaque, oral health care, relief of oral discomfort, internal analgesic, nighttime sleep aid, antiperspirant, vaginal drug product, head lice, hair growth, leg muscle cramps, weight control and otic. Informati on Cues Although m any studies have ad o pted the method introduced by Resnik and Stern (1977) to examine the information content of OTC drug advertisement s this method is limited as it identifie s only 14 information cues and ignore s certain types of informa tion cues that advertising may contain (Abernethy & Franke, 1996) Similarly, because Resnik and Stern (1977) examined commercials ranging from food to hobbies toys and transportation, the ir information cues are considered too general and less comprehens ive for this study. As a result, the exact same list of information cues used in the study of Zheng and Phelps (2008) was adopted The final list of information cues
35 included 34 items (see Appendi ces A and B). In addition to the 34 information cues, drug n ame, drug category, magazine category, magazine title, year, month, page, frequency and size were also coded for each advertisement. Since the values for each of the 34 information cues were dichotomized as 1 = yes or 0 = no, the frequency of a certai n information cue represents only the minimum number of appearance s in the advertisements In other words, similar to Resnik and Stern s (1977) procedure, the coding scheme explicitly measures types of cues rather than instances of information (Abernet hy & Franke, 1996, p. 16). Although most studies used the general term information cues to analyze the information content of OTC drug advertisements, Zheng and Phelps (2008) study provided the foundation for dividing information cues into educational cue s and promotional cues E ducational cues focus on appropriate drug use and consumers understanding of OTC drugs, whereas promotional cues stress the benefits of the products and are sales oriented (Zheng & Phelps, 2008) Zheng and Phelps (2008) coded t he following 18 types of information as educational cues: i ndication, frequency of the indication, medical symptoms, ingredient/substance, dosage form, dosage frequency, dosage size, dura bility of the treatment, dura bility of the effect, use as directed, side effects, who should not take, drug interaction, other warnings, medical rationale, safety, only for occasional use, and doctor consultatio n The following 11 information cues were coded as promotional cues: th erapeutic results, quality, drug popularity, s uperiority claim, improved or new features, quick acting, convenience in use, taste, sensory information, packag e appearance user s satisfaction/loyalty Finally,
36 five information cues were coded as other cues: independent research, research from unidenti fied sources company research company information and website. Recoding In order to test the differences in advertisements in terms of magazine category, ad vertisement size, drug category, educational cues and promotional cues across advertisements in 2008, 2009 and 2010, ad vertisement size, drug category, educational cues and promotional cues were collapsed into major categories to eliminate unrepresentative ad vertisement s and facilitate the analysis process. Ad vertisement sizes were collapsed into f our major groups: quarter to one third page, half page, one to one and one quarter pages and two or more pages. Using and Tsao s (1997) drug classification, the original 24 drug categories were collapsed into 7 major categories: skin ca re, respiratory problems, teeth and mouth, body odor control, gastrointestinal discomfort, central nervous system and others. The 18 educational cues were collapsed into 6 major categories: symptoms/indications, p roduct f orm/ingredient medical rationale, dosage, durability of effect and cautions for users. The 11 promotional cues were collapsed into 3 major categories: tangibles, intangibles and superiority claim. Since each major category of educational and promotional cues was considered a new cue, any value greater than 1 was recoded as yes. Reliability To test for reliability of coding, this study adopted the method used by Zheng and Phelps (2008).Two graduate students served as coders after being trained. Then 40 OTC drug advertisements were divided equally and assigned to the two coders for coding The inter coder reliability was 0.93 using the measure of Scott s pi.
37 CHAPTER 4 RESULTS Description of Sample Table s 4 1 through 4 5 present the general description of the 744 OTC drug advertisemen ts found in terms of their drug categories, magazine categories, ad vertisement sizes, educational cues and promotional cues. Among the 24 drug categories identified, skin protectant topped the list accounting for 34% of the sample, followed by cough/cold medicine comprising 19% and antiperspirant accounting for 7%. Regarding magazine category, 441 advertisements were found in women s magazines, 238 were found in general interest magazines and 65 were found in men s magazines. In terms of ad vertisement s ize, 84% of the ad vertisement s were one page ; t wo page ad vertisement s accounted for 8% and one third page ad vertisement s accounted for 5% of ad vertisements Indication (38%) and dosage form (25%) represented the most frequent educational cues, while packag e appearance (47%) and therapeutic results (44%) represented the most frequent promotional cues. To determine whether differences exist ed among the three years studied regarding occurrences of drug category, magazine category, ad vertisement size, education al cues and promotional cues crosstabs with chi square, drug category, ad vertisement size, educational cues and promotional cues were collapsed into major categories. As shown in Table 4 1, the 24 drug categories were collapsed into 7 major categories a ccording to the drug classification used in the studies of Zimmerman (1992) and Tsao (1997). Under this classification, skin protectant, sunscreen, external analgesic and acne were collapsed into skin care; cough/cold and smoking deterrents were collapsed into respiratory problems; laxative, antacid, ant i diarrheal digestive aid
38 and overindulgence in alcohol/food were collapsed into gastrointestinal discomfort; anticaries, gingivitis/plaque, oral healthcare and relief of oral discomfort were collapsed in to teeth and mouth; internal analgesic and nighttime sleep aid were collapsed into central nervous system; antiperspirant was classified as body odor control; and the remaining 6 types of drugs ( including vaginal drug product, head lice, hair growth, leg m uscle cramps, weight control and otic ) were collapsed into others as none of them had a significant occurrence using the 95% confidence interval. The 95% confidence interval for the 744 advertisements was +/ 3.6% ( N = 27). A total of 22 cases were includ ed in the other category. Although that number was below the minimum 27 for specific categories, the other category was retained for analysis. A chi square test of independence of the relationship among advertised drug categories across the three years pro vided evidence that the incidence of drug categories was related to year : X 2 (12, N = 744) = 26.79, p = .008. A residual analysis revealed more skin care products (56%) than expected were advertised in 2010 while fewer than expected were advertised in 2008 (43%) and 2009 (40%). Drugs for respiratory problems appeared more than expected in 2009 and less than expected in 2008 and 2010. Drugs for gastrointestinal discomfort appeared more than expected in 2008 and 2009 and less than expected in 2010. Overall, t he incidence of advertisements for the drug categories was not consistent across the three years studied Table 4 2 shows the magazine categories covering women, men and general interest. A chi square test revealed no significant difference in magazine ca tegories across the three years : X 2 (4, N = 744 ) = 8.97, p = .062.
39 Table 4 3 shows the reclassification of ad vertisement sizes. One q uarter page and one third page advertisements were collapsed into 1/4 1/3 page; one half page fell under 1/2 page; one pag e and one and one quarter page were collapsed into 1 1 1/4 page; 2 pages and 3 pages were collapsed into 2 or more pages. A chi square test of independence of the relationship among ad vertisement sizes across the three years provided evidence that ad vert isement size was not related to year : X 2 (6, N = 744) = 7.76, p = .256. This suggested that the incidence of ad vertisement sizes was similar across the three years studied The 18 educational cues were collapsed into 6 major categories ( see Table 4 4). Med ical symptoms, indication and frequency of the indication were collapsed into symptoms/indication; dosage form and ingredients/substance were collapsed into p roduct f orm/ i ngredient ; medical rationale was collapsed into medical rationale; dosage frequency, dosage size and duration of the treatment were collapsed into dosage; duration of the effect fell under duration of effects; and use as directed, other warnings, side effects, drug interactions, safety, occasional use, doctor consultation, and who should not take were collapsed into cautions for users. A chi square test of independence of the relationship among educational cues across the three years studied provided evidence that the incidence of educational cues did not vary by year : X 2 (10, N = 744) = 1 7.43, p = .065. The proportional use of various educational cues did not vary across the years. The 11 promotional cues were collapsed into 3 major categories ( see Table 4 5). Package appearance, improved or new features, sensory information, convenience i n use and taste were collapsed into tangibles; therapeutic results, quality, quick acting,
40 user s satisfaction/loyalty and drug popularity were collapsed into intangibles; and superiority claims were collapsed into superiority claim. A chi square test of independence of the relationship among promotional cues across the three years provided evidence that the incidence of promotional cues did not vary by year : X 2 (4, N = 744) = .46, p = .977. The proportional use of various promotional cues did not vary acr oss the years. Answers to Research Questions This section uses the data to address the identified research questions The following research questions can be answered jointly: RQ 1 : What is the overall information content level of OTC drug advertisements pu blished in magazines in 2008, 2009 and 2010 ? RQ 2 : Has the information content of OTC drug advertisements in magazines become more educational or promotional since 2008? RQ 3 : Does a difference exist in t he average number of cues per advertisement between e ducational cues and promotional cues? The average number of information cues (possible range was 1 to 34) was 6.63 ( SD = 2.18, Mdn = 7, Min = 1, Max = 12) Among the 6.63 information cues, the average number of educational cues (possible range was 1 to 18) was 2.82 ( SD = 1.65, Mdn = 3, Min = 0, Max = 8) while the average number of promotional cues (possible range was 1 to 11) was 2.70 ( SD = 1.13, Mdn = 3, Min = 0, Max = 6) ( see Table 4 6). Of all the presented information cues within an OTC drug ad vertiseme nt on average 41% were educational in nature and 42% were promotional in nature. Repeated measures analysis of variance comparing the average number of educational cues per ad vertisement to the average number of promotional cues per
41 ad vertisement across t he three years studied indicated no significant differences in cues across the years, F (1 741 ) = 3.44, p = .064, with a significant interaction between year and type of cue, F (2 741 ) = 4.82, p = .008. This interaction was the result of more promotional c ues occurring in 2010 than educational cues compared to 2008 and 2009, when there were more educational cues than promotional cues. RQ 4a : Do differences exist in the usage of different types of educational cues? A repeated measures analysis comparing the a verage incidence of educational cues by year ( see Table 4 7) was significant, F (5 737 ) = 574.87, p = .000, with a significant interaction effect between cues and years, F (10 1476) = 3.91 p = .000. A post hoc analysis revealed more symptoms/indications c ues occurred than all other types of educational cues. Product f orm/ingredient cues ranked second in use, accounting for less than symptoms/indications but more than all other educational cues. Cautions for users ranked third with medical rationale, durab ility of effects and dosage tied for fourth. In summary, differences emerged in the use of educational cues. Although not directly related to the question of the existence of differences in the average use of educational cues, the significant interaction effect was attributed to the change in the average number of cues for dosage and cautions for users along with the stability of the average number of durability of effects cues. RQ 4 b : Do differences exist in the usage of different types of promotional cu es ? A repeated measures analysis comparing the average incidence of promotional cues by year ( see Table 4 8) was significant, F (2 740 ) = 1 357.78 p = .000. N o interaction effect occurred between cues and years, F (4 1482 ) = 81 p = .520 A post hoc analysi s revealed that tangible cues were the most used promotional cue and were
42 significantly greater than intangibles or superiority claims. Intangibles ranked second, accounting for significantly less than tangibles and significantly greater than superiority c laims, which ranked last. Overall, the data provided evidence of differences in the use of different promotional cues. Table 4 1 Advertised over the counter ( OTC ) drugs Drug category Total # % Skin Care 339 45.6 Skin protect ant 254 34.1 Sunscreen 47 6.3 Acne 18 2.4 E xternal analgesic 20 2.7 Respiratory Problems 145 19.5 Cough/cold 138 18.5 Smoking deterrents 7 0.9 Gastrointestinal Discomfort 48 6.5 Laxative 26 3.5 Antacid 18 2.4 Antidiarrheal 2 0.3 Digestive aid 1 0.1 Overindulgence in alcohol/food 1 0.1 Tee th and Mouth 96 12.9 Anticaries 41 5.5 Gingivitis/plaque 37 5.0 Oral health care 15 2.0 Relief of oral discomfort 3 0.4 Central Nervous System 44 5.9 Internal analgesic 42 5.6 Nighttime sleep aid 2 0.3 Body Odor Control 51 6.9 Antiperspirant 51 6. 9 Others 21 2.8 Vaginal drug product 7 0.9 Head lice 6 0.8 Hair growth 3 0.4 Leg muscle cramps 2 0.3 Weight control 2 0.3 Otic 1 0.1 Total 744 1 00.0
43 Table 4 2. Magazine categories Magazine category T otal # % Women 441 59.3 Good Housekeeping 244 32.8 Woman s Day 197 26.5 Men 65 8.7 Men s Health 36 4.8 Maxim 29 3.9 General Interest 238 32.0 Reader s Digest 131 17.6 Vanity Fair 107 14.4 Total 744 100 Table 4 3 Ad sizes Ad size category T otal # % 1/4 1/3 page 37 5.0 1/4 page 3 0. 4 1/3 page 34 4.6 1/2 page 17 2.3 1/2 page 17 2.3 1 1 1/4 page 627 84.3 1 page 626 84.1 1 1/4 page 1 0.1 2 or more pages 63 8.5 2 page s 62 8.3 3 pages 1 0.1 Total 744 100.0
44 Table 4 4. Educational cues Total Educational category # % Symptoms/Indications 658 88.4 Indication 657 88.3 Medical symptoms 123 16.5 Frequency of the indication 5 0 .7 Product f orm/Ingredient 497 66.8 Dosage form 443 59.5 Ingredient/Substance 140 18.8 Cautions for Users 292 39.2 Use as directed 233 31.3 Other warnings 69 9.3 Doctor consultation 31 4.2 Side effects 20 2.7 Safety 20 2.7 Only for o ccasional use 13 1.7 Drug interactions 10 1.3 Who should not take 0 0 Dura bility of Effects 121 16.3 Dura bility of the effect 121 16.3 Medical Rationale 92 12.4 Medical Rationale 92 12.4 Dosage 88 11.8 Dosage frequency 58 7.8 Dosage size 40 5.4 Dura bility of the treatment 24 3.2 Table 4 5 Promotional cues Total Promotional category # % Tangible s 690 92.7 Packag e appearance 674 90.6 Improved o r new features 238 32.0 S ensory information 36 4.8 Convenience in use 30 4.0 Taste 20 2.7 Intangible s 622 83.6 Therapeutic results 580 78.0 Quality 214 28.8 Quick acting 69 9.3 User s satisfaction/loyalty 19 2.6 Drug popularity 18 2.4 Superiority Claim 110 14.8 Superiority claims 110 14.8
45 Table 4 6 Educational and promotional content levels Type of Cue Average # of Educational and Promotional Cues 2008 (n = 239) 2009 (n = 238) 2010 (n = 267) Total (N = 744) Educational 2.86 2.98 2.6 4 2.8 2 Promotional 2.54 2.72 2.82 2. 70 Total 2.70 2.85 2.73 2.76 Note. Total does not include other cues Table 4 7 Average number of educational cues Type of Cue Average # of Educational Cues 2008 2009 2010 Total Rank Symptoms/Indication .90 .92 .84 .89 1 Product form/Ingredient .68 .70 .63 .67 2 Cautions for users .40 .50 .30 .40 3 Dura bility of Effects .16 .17 .16 .16 4 tie Medical Rationale .13 .08 .16 .12 4 tie Dosage .12 .11 .13 .12 4 tie Total .39 .41 .37 .39 Table 4 8 Average number of promotional cues Type of Cue Average # of Promotional C ues 2008 2009 2010 Total Rank Tangibles .90 .9 3 95 .93 1 Intangibles 81 86 84 .84 2 Superiority Claims 15 16 14 .15 3 Total 62 65 64 .64
46 CHAPTER 5 DISCUSSION The purpose of this stud y was to examine the information content of OTC drug advertising in magazines. T he current study ha d a sample size of 744 OTC drug advertisements Duplicate advertisements were included in the analysis in order to more accurately reflect the information co ntent that consumers encounter An overall analysis of the information content found an average of 6.63 information cues per OTC drug advertisement on a 34 cue scale This finding is inconsistent with Rallapalli and Smith s (1994) study, in which only 3.13 cues were found per advertisement using a 13 cue scale However, the increase in the average number of information cues can be attributed to the different coding schemes adopted in Rallapalli and Smith s study and the current study. Rallapalli and Smith a dopted the method introduced by Resnik and Stern (1977) whereas the current study used the coding instrument developed by Zheng and Phelps (2008). Compared with Zheng and Phelps study in which 11.08 information cues on average were found per OTC drug tel evision commercial, the smaller number of information cues per advertisement found in the current study may indicate that OTC drug advertisements in magazines are less informative than those on television in general. This finding is inconsistent with Abern ethy and Franke s (1996) meta analysis of the information content of advertising, which found that magazine advertising averaged the most information while television advertising contained the least amount of information among five major media ( i.e., outdo or, television, newspaper, magazine and radio). Likewise, Rallapalli and Smith (1994) also argued that magazine ad vertisement s tend to provide more information than television commercials.
47 Educational and Promotional Cues The current study found that an O TC drug advertisement s in magazines contained an average of 2.82 educational cues and 2.70 promotional cues, whereas Zheng and Phelps (2008) found an average of 4.09 educational cues and 6.46 promotional cues per OTC television commercial. Moreover, the fi ndings of this study indicate that of all the presented cues within a magazine OTC ad vertisement 41% were educational in nature and 42% were promotional in nature, whereas the findings of Zheng and Phelps study revealed that of all the provided cues withi n an OTC commercial 36% were educational and 59% were promotional. Such findings suggest that although OTC drug advertisements in magazines are less informative than those on television overall, the information content tends to balance its focus on both e ducational and promotional aspects of the drugs. This finding contradict s the findings from Tsao (1997) and Zheng and Phelps (2008) studies which suggested that OTC drug ad vertiesment s tended to contain more promotional content and less educational inf ormation. Although drug categories differed significantly across years, no significant differences were found in the educational and promotional content levels of OTC drug ad vertisement s among the three years studied in the current study However, the inte raction between year and type of cue was significant. The results showed that more educational cues were included than promotional cues in 2008 and 2009, whereas more promotional cues were included than educational cues in 2010. This finding suggests that a tendency exists for educational content level to decrease and for promotional content level to increase. T he results revealed significant differences in the average incidence of both educational cues and promotional cues, indicating that some
48 particular aspects of educational and promotional contents were relatively emphasized while some were relatively ignored. Discussion of Educational C ues Consistent with the findings of Zheng and Phelps (2008) study, symptoms/indications cues (88%) were the most freq uently used cue among the six major types of educational cues. Within product form/ingredient cues which ranked second in usage, ingredient/substance appeared in only 1 9 % of all advertisements examined. This information is important to consumers who are a llergic to certain ingredients (Cowley & Hager, 1990, as cited in Tsao, 1997) Not knowing the active ingredients would make it impossible for pharmacists to make recommendations to their patients (Mackowiak et al., 1997). In Zheng and Phelps (2008) study several important educational cues related to cautions and dosage including side effects, drug interaction, who should not take, safety, doctor consultation, only for occasional use, other warnings, dosage frequency, dosage size and durability of the t reatment were relatively ignored. Consistent with their findings, the current study also found that despite ranking third in usage all educational cues within the cautions category except use as directed were rarely presented, with each appearing in less t han 10% of all the advertisements. Similarly, all three cues within the dosage category appeared in less than 8% of the advertisement samples. As such, OTC drugs are often portrayed as safe medicines that do not have to be used with caution De spite the fa ct that OTC drugs are available to consumers without a doctor s prescription, only 4% of the 744 OTC advertisements examined contained the doctor consultation cue. However, older adults tend to rely heavily on the recommendations of healthcare professional s when making OTC purchase decisions
49 (Stephens & Johnson, 2000). Tsao (1997) stressed the importance of disclosing potentially harmful effects in OTC drug advertising. Zheng and Phelps suggested that these rarely presented educational cues related to cauti ons and dosage should be included in an effort to help consumers use OTC drugs appropriately. Strictly speaking, the actual number of educational cues found in the advertisements examined would have been smaller if the definition of each cue were to be na rrowed down. Many advertisements were coded as having a specific cue regardless of whether the cue contains complete information and whether it can be clearly read. For instance, the frequency of the ingredient/substance cue could have been different if co mpleteness of information were taken into account when examining the information content. Tsao (1997) and Zheng and Phelps (2008) both questioned the readability of several information cues on television OTC commercials. Although these problems may also ex ist in magazine OTC drug advertisements, the current study did not include readability in the coding instrument. In other words, the frequency of several information cues could also have been less if readability were factored into the analysis. In summary the findings suggest that the educational content of magazine OTC drug ad vertisement s is primarily centered on the indications and symptoms of the drug rather than on the dosage and medical rationale. To a certain extent, this conclusion supports Tsao s (1997) finding that OTC drug ad vertisement s tend to focus on the concern of what the drug will do for the consumer, rather than on the reasons why the drug should be ingested (p. 186). Discussion of Promotional Cues Tangibles (93%) were the most frequent ly used promotional cue, occurring significantly more often than intangibles (84%) and superiority claim (15%). Consistent
50 with Zheng and Phelps (2008) findings, within tangible cues and intangible cues, package appearance (91%) and therapeutic results (7 8%) were the most frequently presented cues. This supports Tsao s (1997) claim that most OTC drug advertise ments tend to focus on the performance and benefits of the drug. Time lapse was a major concern in Tsao s (1997) study. He used many examples to illu strate that OTC drug television commercials tended to ignore the time needed for the medicines to take effect Although therapeutic results and quick acting may provide some evidence and support for this issue, time lapse was not included as an information cue in the current study. Therefore, whether magazine OTC drug ad vertisement s tend to ignore time lapse remains to be seen. Within tangible and intangible cues, sensory information, convenience in use, taste, quick acting, user s satisfaction/loyalty and drug popularity were relatively ignored, each appearing in less than 10% of the OTC drug ad vertisement s. In contrast, the findings of Zheng and Phelps (2008) indicated that user s satisfaction/loyalty, sensory information, convenience in use and quick ac ting were the most frequently presented cues in television OTC commercials. In conclusion, the findings suggest that the promotional content of magazine OTC drug advertisements is centered primarily on the packaging and therapeutic results of the drug. T o a certain extent, this supports Tsao s (1997) finding that the advertising strategy for OTC drugs is centered on consumer awareness of the product as the primary goal (p. 186). Strengths and Limitations As one of the few studies conducted on the infor mation content of OTC drug advertising over the past decade the present study offers several significant
51 contributions. First, the current study used a sample size of 744 ad vertisement s while 5 of the 6 magazines selected were the top 2 in circulation in their corresponding category. Second, the coding scheme employed is also more comprehensive than most previous studies, which used the instrument developed by Resnik and Stern (1977) to measure information content of advertising However, u sing the instrum ent developed by Resnik and Stern (1977) to analyze OTC drug advertising may not be appropriate because the scheme was originally designed for general television advertising and has several limitations as highlighted by Abernethy and Franke (1996) Finall y unlike most studies examining OTC drug advertising, dietary supplements were removed from the current research to comply with the FDA definitions and provide more accurate results. The current study also suffers from several limitations. Firs t, althoug h the magazines selected target multiple audiences, it would still be hasty to make generalizations about other magazine categories not included in the research. Further more the coding scheme used in this study ignores certain types of information cues th at OTC drug advertising may contain such as time lapse. Future Research Additional information cues that may be helpful in understanding the information content of OTC drug advertising such as time lapse should be included in future research. Other use ful items such as readability and completeness of information should also be added to the coding scheme to provide more insightful findings. Although a number of scholars have analyzed magazine and television advertisements much less is known about OTC dr ug advertising in other media such as the Internet. According to OTC Perspectives (2009b), advertising spending for the
52 top 25 OTC brands declined in 2009 ; Internet spending was the only exception to the downswing in media spending. Finally dietary suppl ement ad vertisement s may also be of interest to future research. In addition to the 744 OTC drug ad vertisement s examined in the current study, the coders identified another 342 dietary supplement advertisements. Although the se ad vertisement s were excluded from the current study because dietary supplements are not recognized as drugs, a comparative study directed at this special category in the future may produce insightful findings. Conclusions This study sought to examine the information content level of OTC drug advertisements in magazines. According to the findings, an average of 6.63 information cues per ad vertisement was found The average number of educational cues per ad vertisement was 2.82 while the average number of promotional cues per ad vertiseme nt was 2.70. Educational and promotional content levels did not differ across 2008, 2009 and 2010. However, promotional cues are increasingly being used in magazine OTC drug advertisements. Although the educational content tends to focus on the indication aspect of the drug, d rug performance and product awareness seem to continue to be the cent er of the advertising strategy.
53 APPENDIX A CODING SCHEME The coding instrument was developed according to the stu dy of Zheng and Phelps (2008) (p. 24) (1) Drug name : ____________ (2) Drug Category: 1=Skin protectant, 2=Sunscreen, 3=Cough/cold, 4=External analgesic, 5=Internal analgesic, 6=Anticaries, 7=Gingivits/plaque, 8=Laxative, 9=Antacid, 10=Acne, 11=Nighttime sleep a id, 12=Antidiarrheal, 13=Smoking deterr ents, 14=Head lice, 15=Hair growth,1 6 =Weight control, 1 7 =Overindulgence in alcohol /food, 1 8 =Leg muscle cramps, 19 =Vaginal drug product, 20 =Digestive aid, 2 1 =Otic, 2 2 =Relief of oral discomfort, 2 3 =Oral health care, 2 4 = Antiperspirant. (3) Magazine Category: 1=Women, 2=Men, 3=General Interest. (4) Magazine Title: 1=Good housekeeping, 2=Woman s day, 3=Maxim, 4=Men s health, 5=Reader s digest, 6=Vanity fair. (5) Year: 1=2008, 2=2009, 3=2010. (6) Month: ____________ (7) Page: ____________ (8) Frequ ency: _____________ (9) Size: 1=1/4, 2=1/3, 3=1/2, 4=1, 5=2, 6=3, 7=4, 8=5, 9=6, 10=1 1/4. (10) Indication: 1=Yes, 2=No. (11) Frequency of the indication: 1=Yes, 2=No. (12) Medical symptoms: 1=Yes, 2=No. (13) Ingredients/substance: 1=Yes, 2=No. (14) Dosage form: 1=Yes, 2=No. (15) Dos age Frequency: 1=Yes, 2=No. (16) Dosage size: 1=Yes, 2=No. (17) Dura bility of the treatment: 1=Yes, 2=No. (18) Dura bility of the effect: 1=Yes, 2=No. (19) Side effects: 1=Yes, 2=No. (20) Who should not take: 1=Yes, 2=No. (21) Drug interactions: 1=Yes, 2=No. (22) Other warnings: 1=Yes 2=No. (23) Medical rationale: 1=Yes, 2=No. (24) Safety: 1=Yes, 2=No. (25) O nly f or o ccasional use: 1=Yes, 2=No. (26) Doctor consultation: 1=Yes, 2=No. (27) Use as directed: 1=Yes, 2=No. (28) Company research: 1=Yes, 2=No. (29) Independent research: 1=Yes, 2=No. (30) Research from ident ified sources: 1=Yes, 2=No. (31) Therapeutic results: 1=Yes, 2=No. (32) Quality: 1=Yes, 2=No. (33) Drug popularity: 1=Yes, 2=No. (34) Superiority claim: 1=Yes, 2=No. (35) Improved or new features: 1=Yes, 2=No.
54 (36) Quick acting: 1=Yes, 2=No. (37) Convenience in use: 1=Yes, 2=No. (38) Tas te: 1=Yes, 2=No. (39) S ensory information: 1=Yes, 2=No. (40) Packag e appearance : 1=Yes, 2=No. (41) Company information: 1=Yes, 2=No. (42) Website: 1=Yes, 2=No. (43) User s satisfaction/loyalty: 1=Yes, 2=No.
55 APPENDIX B DESCRIPTIONS OF INFORMATION CUES The descriptions of inf ormation cues were developed according to the study of Zheng and Phelps (2008) (p. 25) (1) Drug name: the brand name and product name (if any) of the advertised drug. For example, Vicks DayQuil, Prilosec OTC, etc. (2) Drug Category: Based on the Over the Counter ( OTC ) monographs. (3) Magazine Category: 1=Women, 2=Men, 3=General Interest. (4) Magazine Title: the name of the specific magazine. (5) Year: the year of the specific magazine issue. (6) Month: the month of the specific magazine issue. (7) Page: page number of the advertisem ent. (8) Frequency: the number of times the exact advertisement appears in all the magazines examined. (9) Size: the page size of the advertisement. (10) Indication: medical condition that the advertised drug can treat or target such as cold, allergy, etc. (11) Frequency of the indication: how often the medica l conditions occur among people ? For example, about 20% of kids experience such allergy in spring. (12) Medical symptoms: detailed and specific signs of getting an illness. For example people who catch cold could have a series of symptoms including running a fever, having a headache, having a runny nose, etc (13) Ingredients/substance: include s both active ingredients and inactive ingredients (14) Dosage form: whether the advertised drug is in tablets, liquid etc. (15) Dosage Freq uency: how often should the patient consume the drug? For example t his drug should be taken 3 times a day (16) Dosage size: what is the appropriate dosage of the drug per time? For example 2 tablets per time (17) Dura bility of the treatment: when the treatment should be interrupted, specified as a number of days or as a physiological reaction. (18) Dura bility of the effect: how long can the therapeutic results last? For example after taking one pill, you will feel pain free for an entire day (19) Side effects: code i f the advertised drug is said to have or not have a certain side effect. There should be no coding if the absence of side effects for the advertised product is expressed in general terms, such as safe or lenient. (20) Who should not take: coded if the adve rtised drug mentions who should not take the drug. For example, this drug is not for children under six years old. Or this drug can not be taken for women during their pregnancy. (21) Drug interactions: people can not take drug A with drug B. The two drugs wil l interact with each other. (22) Other warnings: refer to other types of warnings than (19) (2 1 ). (23) Medical rationale: coded if the ad explain the reasons why the symptoms occur or why the medicine has to be used. (24) Safety: what safety features are available on the OTC drug product compared to alternative choices? For example, drug A will not cause drowsiness which may be
56 experience d after taking drug B. (25) Only for o ccasional use: does the ad warn you that the drug should be used on an occasional basis? (26) Doctor con sultation: does the ad provide any information about situations when a doctor should be consulted ? (27) Use as directed: does the ad present the sign of use as directed or use as directed only ? (28) Company research: information about tests of the product or u sers of the product that were carried out by the company manufacturing or distributing the product (29) Independent research: Information offered about tests of the product or of product users that were carried out by an identified individual or organization other than the company manufacturing or distributing the product, such as Underwriter's Laboratory, a leading university, or the U.S. government. Such testing may contain objective product characteristics ("lasts twice as long") or may be related to user p references ("preferred by two thirds of the people surveyed") (30) Research from identified sources: information about tests of the product or users of the product when the source of the test results is not identified (31) Therapeutic results: effects of the adv ertised product in gener al terms, such as (32) Quality: information about the quality of the advertised drug (33) Drug popularity: is the drug widely accepted? (34) User s satisfaction/loyalty: refers to any information concerning users' satisfaction, dedication, preference for the brand, or length of time consumer has used the advertised product. E. g ., "I've always used...." (35) Superiority claim: information that claims the advertised product is better than competitive products or better than an older v ersion of the advertised product in some particular ways (36) Improved /new features: refers to any information concerning a new product introduction, new components, ingredients, features, or characteristics of an existing product or improvement (qualitative or quantitative) in any feature, component, ingredient, or characteristic of an existing product (37) Quick acting: information concerning the product can act fast (38) Convenience in use: information concerning the ease which the product may be used. For exampl e, Tylenol GoTabs commercial claims that this drug designed for fast, chewable, portable pain relief for people on the go. (39) Taste: refers to any statements on the taste of the drug. For example, the drug is available in strawberry, kiwi, and peppermint tea flavors. (40) S ensory information: refers to any statements on the sensory (other than taste) information of the drug. E. g ., the wipes feel very soft (41) Packag e appearance : photography or drawing of the package. (42) Company information: may refer to any informati on about the image or reputation of the company that manufactures or distributes the product. (43) Website:
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63 BIOGRAPHICAL SKETCH Shine Lyui was born in Anderson, South Carolina in 1987. Four years later h is family moved back to their home country, Taiwan and spent the next five ye ars or so living in Taipei. In 1995, t he entire family moved to Shanghai, China where they lived for five years before moving to Foster city, California, for a brief one and a half year period. His family spent the next 7 years in Shanghai, where he gradu ated from Shanghai High School International Division and e arned a Bachelor of Science in i nternational e conomics and t rade at Fudan University. Soon after his graduation, Shine enrolled in the master s program at the University of Florida, majoring in ad vertising. He plans to work in the marketing fiel d after receiving