Transcript of Direct-to-Consumer Promotion Public Hearing - Panel 2
PANEL 2 PROCEEDINGS
I would now ask that Panel 2, Jon Schommer and Julie Magno Zito, please come up.
DR. SCHOMMER: Thank you very much.
Panel 2 consists of two academics, and we are just commenting. We are not used to sitting down when we give presentations, so this will be a new experience for us. And we don't have chalk in our hand either, and there is no blackboard.
My name is Jon Schommer. I am a professor at the Ohio State University. I have no financial interest. I am going to be presenting some research results from a stream of research that we have been doing at the Ohio State University regarding consumer responses to prescription drug information.
MS. PEDERSEN: Thank you. Are you appearing on your own behalf?
DR. SCHOMMER: On my own behalf.
MS. PEDERSEN: Thank you.
DR. SCHOMMER: The funding was provided by the American Association of the Colleges of Pharmacy, but it was an unrestricted educational grant.
MS. PEDERSEN: Thank you.
DR. SCHOMMER: There are two handouts for those interested. Both contain what I will be presenting. One is a forthcoming research article, and the second is a press released provided by the Ohio State University. If you are interested and don't get one, you could also get one from me later.
Our study that I will be reporting today was focused only written prescription drug information, and we used the paradigm of information processing to study this, and specifically something called information overload. The idea behind information overload--and this was introduced in the 1970s and has been debated since--is that our finite limits to process information can be surpassed. If it is surpassed, we can become overloaded with information, and that can lead to dysfunctional consequences. What are dysfunctional consequences?
Those can be exhibited through either behaviors, through cognitions, or through what I call affective components, and I will spend just a second to explain what I mean by that.
An example of a behavioral consequence of being overloaded with information would be an individual who might be taking a particular drug. The fact that they are already on the drug and they are paging through their Newsweek or Time Magazine, the ad might be targeted at increasing or inducing demand for the product; but since the person is already taking the drug, they already have a high involvement with that prescription. That ad might trigger information search, and they might actually read that blasted brief summary of information because it is my health, I am on the drug, I am going to try to tackle this information because I want to learn more about my drug.
If that person would start reading the brief summary of information, they might become overloaded, which could lead to a behavioral response such as: Well, there's something called agranular cytopenia. I don't know what that is. I am not sure if I am pronouncing that term correctly, but it is in this information. I am completely overloaded. I give up. It looks like I can't understand what this drug is supposed to do. I am going to stop taking my prescription. So a behavioral consequence could be non-compliance with the prescription medication if a person is overloaded.
What about a cognitive response? That relates to understanding or comprehensive of information. Again, let's use that same individual who is already taking the prescription. My doctor and my pharmacist have counseled me how to use this drug appropriately. I am a woman, I am pregnant. I asked both my physician and my pharmacist if it is okay to take this medication, and they said in my case, yes, we are going to use the drug even though you are pregnant. I am reading the brief summary information. I look under complications in pregnancy or risk in pregnancy, and there is a little thing talking about there have been no well-controlled studies yet, so it is a certain category that it is inconclusive. Again, my understanding, even my trust or faith in my health-care providers, could become confused or decreased.
Lastly, affective responses, emotional responses. I think we all experience this in our daily lives. We are probably experiencing it today. You are probably going to experience it with my talk. You say this guy is talking too fast, giving too much information, I'm going to check out for a while. I'm going to take a coffee break. I'm going to spend a buck and buy a cup of coffee. We check out if we become overloaded with information.
Our purpose of this study was to start looking just at affective or the emotional component of information. We started here because a professor by the name of Young suggested that people will evaluate services--and I would consider information a service--first through emotional means, then through experiencing it, and then actually trying to learn from it. So we started with the affective component to see if people can become overloaded emotionally with written prescription drug information.
We differed the scope and the depth of information leaflets. By scope, I mean how many different topics were covered. We varied information leaflets consisting of two topics, seven topics, or 12 topics. For the depth, that is the complexity of information. Complexity was varied as what we called the simple version. We designed this one ourselves. We designed it to be at a sixth-grade reading level: small words, short sentences. It was very difficult to do, but it tested out at a sixth-grade reading level.
The next level of complexity was what we called patient norm. Patient norm level was taken right out of the USP-DI dispensing information targeted at patients. It is claimed to be targeted at an eighth-grade reading level. It tested on a flush reading scale at a level of 13, grade 13.
And the last version of complexity was the professional level, as we called it, and that was taken from brief summary information for the drug that we used in this study, which happened to be Seldane. That was taken from the brief summary information with a few modifications.
We varied the different levels, and if you have a 3 by 3 matrix, you have nine total leaflets that we could have. In the validation process, however, we ended up using the four corners and the middle scenario to have a total of five leaflets. We measured affect, or this emotional response, using 15 items in a survey. We distributed randomly to 150 patrons of a medical clinic one of the five versions. So each person received only one of the five versions in a random fashion.
Then they were asked, after they looked at the materials, to fill out a survey and hand it back to us. We used 15 items to measure their affective response.
I would just like to mention that we had three components of affect called judgmental, emotional, and evaluative components. We based these on some work by Dr. Westbrook back in the 1980s in which he identified some of these items that we used.
I have already talked about the individuals that we used. We can go to the next slide. I won't bore you with the statistical analysis that we used. I will just show it to you instead.
First, we wanted to validate whether our conceptualization of this affective component was a good rationale or if we should change our view. Dr. Morris, I have read your work. Maybe you are the only person who cares about this, but I will mention this anyway. We used factor analysis to look at the factor structure of these 15 items in bold. I will just let it suffice to say that we did find the anticipated factor structure of the underlying components of this emotional response. The loadings in bold are higher, and that showed that the five items--confused, unsure, doubtful, overwhelmed, and foolish--were measuring what we call the judgmental component. The next five--frustrated, angry, anxious, vulnerable, and irritated--were what we called the emotional components. And in the last five, which were positively worded now--how useful, valuable, satisfying, beneficial, or helpful--that was more of the evaluative component.
As researchers, we were jumping for joy because what we thought were these components were actually being validated.
These are the mean scores for the five items used to measure the judgmental component. Leaflet Type 1, 2, 3, 4, and 5 are explained in the footnote. I would like to focus on Leaflet Type 2.
Leaflet Type 2 was significantly different than Leaflet Type 4 and in some cases Leaflet Type 5. Well, what was the second leaflet, the leaflet that resulted in the least confusion, the least doubt, the least reaction of being overwhelmed? That leaflet was the simplest information, which we expected, but what surprised us was it was the most, the highest number of different types of information.
As we think about it, it makes sense. People want a lot of information, but just the facts, please. I would like a short, single sentence of what I need to know about all sorts of different information. The 12 types of information that we included were based on over 90 counseling regulations, and that includes things like the name of the drug, purpose, directions for use, side effects, interactions, et cetera.
To validate the leaflets and to find out which two types of information we should put into the two information version, we asked pharmacists to tell us which types of information were most important to give first, and so we based our leaflets on that.
The worst, if I can say "worst," leaflets mimicked those that would be the brief summary information. What is very interesting, though, to us, even though we have small sample sizes in this study, we are seeing some differences in the complex information, but between the one that had two pieces of information versus the one that had 12. Counterintuitively, the shortest leaflet, which had only two bits of information but at a professional level, actually resulted in the most confusion, if you will. Even though it is not statistically significant, I base that on the fact that Leaflet No. 5 is not statistically significant than No. 2, but 4 is. So I am saying that there is--I could argue that with larger sample sizes and better measures, we might be getting some effect.
When it comes to the emotional component, as some researchers argue, people can stop themselves short of being overloaded in some respects. Here there are no significant differences between the different versions of leaflets, although the same pattern exists. Leaflet No. 2 resulted in the lowest means; however, these are not statistically significant with the number of sample size.
Lastly, the evaluative component--these were worded positively--the mean scores show that no matter what leaflet people received, on average they were more on the side of the information being useful, valuable, satisfying, et cetera. So some information is better than none, is how we are interpreting it.
Here is our spin on our results. First of all, individuals desire written information that covers many topics but is provided in very simple language.
And the application of that would be that direct-to-consumer advertising that contains brief summary information presently might be too complex and lead to negative affective responses. A lot of us argue that people are not reading the brief summary information. Granted, that is true. I would argue that if I am on a drug and have high involvement and want to learn about it, I am likely to at least look at that information. What we are finding--and we have anecdotal evidence--is that our study subjects, as we handed out these leaflets, did not take the time to read the whole thing. We as consumers can view information, and if we become overloaded, we can pick out certain pieces of information. And I would argue, again, using that patient as an example, looking at the side effect information, because I like to know what this drug could cause in me.
If I see a word like agranular cytopenia, thrombocytopenia, or whatever--fill in the blank--even though I don't understand what it is, I might gloss over it, it might lead me to some information overload that could have some inappropriate consequences.
I will stop right there except to say that this study is ongoing. We are expanding it, and we are also expanding it to videotape versions.
MS. PEDERSEN: Thank you, Dr. Schommer.
DR. ZITO: I'm Julie Magno Zito from Baltimore, Maryland. I'm associate professor at the University of Maryland School of Pharmacy and research associate professor in the Department of Psychiatry of the School of Medicine.
What else do I have to tell you? My expenses are paid by the university, and I am not representing any other organization than myself, although I will talk about my work with the medical-care section of the American Public Health Association, and that is really the reason that I got to thinking about the issue of direct-to-consumer prescription drug advertising. My research area is not evaluating advertising or anything related to this issue. My work is in pharmacoepidemiology, and I have 28 years as a health-care professional to give me some background to think about the issues that relate to this.
MS. PEDERSEN: Dr. Zito, could you apeak to Paragraph 5 since you are appearing as an individual?
DR. ZITO: I have no financial interest in any pharmaceutical industry, related activities, or in any advertising activities.
Does that do it?
MS. PEDERSEN: Yes. Thank you.
DR. ZITO: Okay. It will be very obvious by the end of this.
About a year ago, as part of coming home from the American Public Health Association meeting, it seemed that in the month or two or three after that meeting, I was bombarded by New York Times advertisements that were appearing on a regular basis, full-page ads, some of which I will show you in a minute, that took my attention because they seemed to be different. And since I don't monitor this area very closely, I really didn't know. I just knew that something was afoot from just being a consumer. And so a graduate student who is here in the back, Lynette Bradley, has helped me to monitor some of these activities, and I appreciate Lynette's efforts in bringing me up to speed on the science and professional literature that relates to this area.
As a result of our monitoring for a few months, it became clear that something is clearly afoot, and so gradually we put together our knowledge and our heads, and we came up with a resolution which we will be putting forward. So this is a draft resolution which will go to the American Public Health Association meeting in San Diego in two weeks. And so I don't represent APHA today because of that reason. At that time the Governing Council will consider this resolution.
Now I want to share with you why we are doing that. Some of the things that we thought made a resolution at this particular time appropriate is because we began to recognize the following things:
First, we know that FDA needs to have adequate resources to fulfill its responsibilities for prescription drug advertising, and that might mean financial resources or it just might mean prioritizing or reprioritizing based on recent events that are clearly a change in the way prescription drugs are being advertised. And so, to wit, you know that there has been an increase in direct-to-consumer advertising, up 42 percent in measuring from 1993 to 1994, about a $187 million increase, which seems substantial, until you think about the overall media budget, which is something like $4 billion. I had no idea it was up that--that it represented such a great amount of resources of the industry.
Health information is a potential byproduct of promotion of drugs, but information is really not the primary or first goal of promotional materials. Promotion has been defined "to encourage the existence of progress of an object, including a product, a service, an idea, or an organization." So it is really pushing something forward into our minds, into our memories, into our speech, into our daily interactions, into our working knowledge base. It is to remind us about something. And the objectives are not just to inform in the sense of that concrete information that is now available to you, but it is also to persuade, which is to persuade us to ask for this prescription drug, to see to it that we get this prescription drug, to purchase.
Wayne Pines, former FDA Associate Commissioner of Public Affairs, has reminded us in published information that non-drug or comparable drug alternative treatments are often omitted from advertising or the emphasis is not there, and so it really makes it difficult to make unbiased judgments or fair judgments when we look at advertisements.
Consumers definitely, clearly, absolutely have an important role in the selection, use, and monitoring of drug therapy, and nowhere is that more important than in the area of chronic drug use or treatment for chronic conditions. So this presentation should in no way be interpreted as preventing consumers from playing a strong, active role in negotiating drug therapy with their health-care providers.
But having information is in no way, in my mind or in many people's minds, the equivalent of having an appreciation and an understanding--appreciation and understanding, two words that the legal community should be comfortable with when it comes to informed--consent documentation--appreciation and understanding of the benefits and risks of a given drug therapy. And here I use the word "context" because the context of making a decision ultimately always comes down to an individual patient and an individual health-care provider. And that context, if you can get that in--what was it?--20 words you would like to reduce it to, I mean, I think these are just fantasy ideas that we can ever advertise in a way that is going to meet the demands of any one individual case of patient and provider, although you can make some general statements that will apply to large groups of individuals. And if we can recognize that we fit the profile of the large group, then that is fine.
Two examples of ads that really got me going about this topic: the first one was the Neurontin ad. Gabapentin is the generic name. It was a large advertisement. I have samples with me and can pass them around if you would like to see them, but I can give you the gist of it.
The Neurontin ad starts out: "If you have epilepsy and your current medication isn't controlling your seizures." Well, if that's not an invitation to a vulnerable population of individuals--somewhere between a quarter and a third of our seizure patients fail to respond adequately to standard treatment. This is, I think, really just not the way in which to provide objective information or to suggest that this does not result in bias. And it is not the appropriate way to inform individuals who are in need of improvement in regard to the management of their current therapy for epilepsy.
The second ad, Hytrin, terazosin, an ad again appearing in the January 20, 1995, New York Times, in which treatment for benign prostatic hypertrophy, the statement is made which is technically correct, but I think I would need, you know, my English professor with me to assure a lot of clients that this is a reasonable statement to make. Surgery compared with watchful waiting, the treatment alternative, surgery, watchful waiting, or oral medication. When you read the sentence through and don't pay attention to the semicolon, oral medication sounds like part of the watchful waiting approach.
Next point: Advertising might heighten our expectations for magic bullets. We have a long tradition in the United States already of expecting great things from medical treatments that often are completely unrealistic. So that I think there is a real opportunity to bias the benefit-to-risk assessment that any individual will make, Harvard-educated or eighth-grade education. We are not talking about our formal abilities here. We are talking about the ability of information to persuade on an emotional level rather than a pure objective level.
And the benefits are often more easily recalled than the risks, and this was very poignantly made in the experimental study of drug advertising information, and Dr. Morris, the senior author, is here today so he could enlighten us even further. I think that is a human tendency that we all have to accent the positive, but it is extremely difficult to bring this issue of risk into balance with when we want to take it, when we want to use it, and when we are being reminded about something out of context and without a fundamental need to negotiate that benefit-to-risk ratio really being there.
Another point we learned was the FDA, of course, does not have the authority to require the approval of advertising materials before they are actually used out there if we are talking about a medication that has already been marketed. I would dare say if we did a survey on the street corner out there, there would be very few individuals who knew that the ad that they were looking at did not receive FDA approval. I have spent 25 years explaining to patients many points that because a medication is marketed does not mean that--you know, the nuances of the word "safety," the nuances of what drug information we really have in place, and how much is fair to expect to have in place before the product is marketed.
So it is an ongoing, empirical game that we play, and that is the point that always needs to be there, that risk-to-benefit ratios are going to change both for large groups as more and more information accrues on the use of a product and--let's go on now, I think, to the last points here.
Our major points are clinical concerns that advertising will, indeed, lead to increased sales and increased marketing, and I can't make the assumption that all of that increased marketing that results is because of under-utilization of the product. So I am assuming that at least some of that will result from inappropriate use of medications, and there are serious monetary and human costs associated with that.
But the most important issue and reason, I think, to worry about this is that advertising actively works against or disrupts the patient's professional relationship, and we are talking here about the need for a therapeutic alliance between patients and providers, with patients really being on a par, on a one-on-one relationship in which their subjective information and their knowledge base does enter into the monitoring of that drug therapy.
We think this will work toward bypassing efforts that are needed to increase the consumer's role in this collaboration for optimal drug therapy.
Finally, we think it ignores the use of more unbiased patient or consumer prescription drug information sources, for example, the USP-DI, and I have no financial interest in the USP-DI. I just bring it to you today because I think you might like some concrete examples of fine sources of information which do help to meet the needs of consumer prescription information.
So what we and our resolution are hoping to put forward to urge Congress first to remember that it needs to direct the FDA to renew its efforts in regard to direct-to-consumer advertising and that it needs to remember that it might cost some money to do that more adequately or more effectively than it has been able to do in the past.
Second, we urge the FDA to do what you are doing today and to continue to conduct hearings and after the hearings to develop policies and to assert your oversight role in a way that will address some of the concerns that it hasn't been as effective as it might be or that it might be too time-consuming or that it might be too bureaucratic. We can fix those things, I'm sure.
Kessler and Pines remind us that FDA's regulatory framework really must be able to meet the challenges of a changing environment, and that changing environment has been alluded to by many of the previous speakers. The TV and other creative ways in which we are getting information out to people now, the Internet and all that stuff, means that lots of facts will be floating around. Some of them may improve people's understanding; some of them may muddy the waters and confuse them a great deal and maybe create more non-compliance than the reverse, as has been suggested earlier.
Next we ask health-care professionals to take more seriously the consumer's role and to use and make available to consumers these more unbiased drug information resources such as we have mentioned. And, finally, we ask that consumers would recognize the distinction between consumer education and pharmaceutical promotion and to consult health-care professionals and to use their drug information resources, and, finally, to make the health-care system more responsive to their needs. That is what I think the real issue is if we are going to talk about patient education.
The last point I would like to make is based on my own research experience. I work in the area called pharmacoepidemiology, and in regard to psychiatric disorders, primarily, for the past 12 years. And during that time--the reason I am in this area is because I am so acutely aware of the limitations of the knowledge base that we have about prescribed medications if we are simply to be focused on the information that comes from clinical trials, which are mandated for the marketing of the medication.
So the consumer really needs to know that the research base is growing and will continue to grow, I hope with new and more sophisticated methods to collect information on post-marketing surveillance. HMOs would be a great place, for example, for us to learn how well the effectiveness and side effect profile that you see now in the package insert, whether that is going to hold up over the long haul and show you that that profile is appropriate five years post-initiation of treatment, ten years post-initiation of treatment. We have chronic--
MS. PEDERSEN: Dr. Zito, could you wrap it in maybe 30 seconds?
DR. ZITO: Yes. So that the least amount of advertising new products guarantees that people are taking medications which have the smallest knowledge base associated with them, and so it is large on expectation, small on knowledge of effectiveness and safety.
Questions for the Panel
MS. PEDERSEN: Thank you, Dr. Zito.
Questions from the panel for either Dr. Schommer or Dr. Zito? Ms. Baylor-Henry.
MS. BAYLOR-HENRY: I have a question for Dr. Schommer. Your research dealt primarily with written information. Do you have any comments about the application of your research to, say, a television advertisement?
DR. SCHOMMER: Right now we are beginning to look at that. We have translated the written information to different levels in videotapes. I would also couch it in my experience with patient counseling by health-care professionals. Some of the research suggests that people can be overloaded with the verbal information. But when it comes to ads on television, I can't comment on that because that is another realm where the person might be used to watching advertisements and actually be able to cope with information. So I can't comment on that specifically yet, but we are going in that direction to look at that.
MS. BAYLOR-HENRY: Thank you.
MS. PEDERSEN: Dr. Temple?
DR. TEMPLE: Dr. Schommer, the study that you did, if I understand it, took several forms of information and asked people how they felt about it, and you found that when it was too complicated for them, they didn't like it and were frustrated and irritated.
You then go further--those were not people who were already on the drug or anything like that, necessarily.
DR. SCHOMMER: Not necessarily. We controlled for previous drug use, right.
DR. TEMPLE: Okay. That part of it seems understanding and makes intuitive sense. You then go on to suggest that having information that is at this level will actually get in the way of people's medication if they are already on it. That, I take it, is not something that you are ready to support with a study, but it is sort of your expert point of view.
DR. SCHOMMER: That's correct. And I base that on an argument between mostly Dr. Jacobi and Dr. Malhotra in the marketing area. And there is a series of articles that they wrote in the '70s, '80s, and even to today that argue this very point, the "so-what" question. What are the consequences of these experiences? And there is a mixed jury out on that. Some studies find that they are not making appropriate decisions. Others are finding that people can limit themselves from making inappropriate decisions.
What we find interesting as a next step is that we have narrowed down this affective component. We are focusing in on the judgmental responses, the confusion and the doubt, and not looking so much at the emotional or the evaluative components, and we are focusing more on that to go the next step.
A graduate student in the college of business at Ohio State also raises an issue about primacy and recency effects. What information is given first and what is given last? So there is a lot of work being done, but as academics say, we ask the questions. We don't necessarily have the answers. I wish I could give you a better answer.
DR. TEMPLE: I just wanted to be sure we knew what the study showed.
This is for Dr. Zito. I am probably not the most enthusiastic person for these ads around, but I thought the gabapentin ad looked pretty good. Could you elaborate? It basically tells people who are on a stable regimen of an antiepileptic that there is a new kid in town and it has some advantage and you should talk to your physician about it.
Ditto for the Hytrin. A lot of people whose urinary stream isn't what it used to be probably don't know they are sick. They may not even be seeing a physician. So it sort of comes in my category of things that someone needs to tell you or you won't know.
So what bothered you so much? Could you elaborate a little on what bothered you so much about those?
DR. ZITO: Well, I guess I work strongly in the bio-psychosocial model, for one thing, and I think that we all are out there with symptoms that we might not think are very important, and you are telling me that, gee, it is National Depression Day and let's think about this. Are we depressed?
There is a kind of intrusiveness, it seems to me, that is going on out there that ignores when people take themselves into treatment or ignores the idea--there is a trendiness, and it has happened a lot in mental health, where we have disorders of the month. We have obsessive-compulsive disorder. We didn't know we had that until we started really getting out there detailing it to very great measure. And it does change prescribing practice, and it does change the prevalence of disorders.
So I do think that promotion will lead to changes in prescribing, and I am very concerned that a physician becomes a sort of passive rider in this process because the marketer is skipping this now unimportant person because in managed care we have other rules operating over what can and cannot get prescribed, and going right to the user, the consumer. And it is okay to do that if the consumer wants to buy into this complex process of figuring out what works well and whether treatment of low-severity disorders, you know, treatments that you didn't know you had until you decided that now you need it, and it wasn't really functionally impairing you.
I don't know what the payoffs are going to be down the road, but there are social costs to that, and there is certainly personal health cost, because we all know there is no such thing as a side-effect-free drug. We all know that we don't know the rare adverse event to this new product that I am going to try based on your reminding me that maybe I ought to try it.
So I am very much in favor of models which educate in regard to serious issues. Come in for a mammogram, is a message that is clearly a public health message. Maybe you should grow more hair with Rogaine, I don't think is ever going to be in the same category of a worthy public health message, although it might make some consumers happy, and that is fine. And I don't worry about that.
But when I get to the seizure disorder, I feel that there is now going to be pressure coming from well-meaning families, friends, and so on around individuals and often their children with seizures--a lot of young kids involved here--where the notion that there is a better treatment--you see, you have to buy into the idea that gabapentin is going to pay off as a better treatment. I don't know that that is--we are going to have to wait and see how that plays out.
DR. TEMPLE: Actually, it is promoted as an additional treatment.
DR. ZITO: Yes.
DR. TEMPLE: That is an important distinction, too.
DR. ZITO: Right.
MS. PEDERSEN: I think Dr. Woodcock has a question.
DR. WOODCOCK: Let me see if I follow your point here. We know that misadventure, you know, adverse consequences of drug exposure in the United States, prescription drug exposure, is a huge economic toll for the country. And I think you are saying you don't know whether increased use of drugs, patient exposure to drugs that would be presumably based on advertising direct to consumers would be a public health benefit or actually cause more adverse consequences. Is that your basic point here? And you feel that stimulating use simply based on advertising, not really based on knowledge, would have your projecting potentially adverse consequences overall? Is that the point?
DR. ZITO: Yes.
MS. PEDERSEN: Dr. Morris?
DR. MORRIS: I just had a question for Dr. Schommer about the study itself. You measured people's response in terms of this evaluative, judgmental scale. Did you also obtain any measures of what information people took away from the ads? When I think of overload, I think of it as there is too much there for people to really learn anything from it. Any impressions about that?
DR. SCHOMMER: No.
DR. MORRIS: Also, the other point, if you could talk to it, you seem to have some ideas about it is not just the amount but how you structure the information, how it is chunked or ranged. What advice could you give us in that regard?
DR. SCHOMMER: I will try to be brief.
First, I am familiar with some work that Rand Corporation did and also some of your work, Dr. Morris, about understanding and comprehension. We did not do that. We focused on the emotional or the effective component. Anecdotally, as we distributed these to our respondents, our study subjects, we could watch them as they read the information and completed the survey.
It was very interesting to watch. Now, this is anecdotal, but people are very good at skimming, very good at targeting information that they want to look at. Even though they didn't spend--I don't think anybody read every word of our leaflets. But as they skim, they will get emotional responses to this information.
The second part of your question was the framing effects.
DR. MORRIS: Structuring.
DR. SCHOMMER: The structuring. One of my graduate students brought up the point that we have labs that we can watch eye-track movements. There is a lot of work to be done. I am not familiar with eye tracking or studies of that nature of how people actually look at the information.
Something exciting, though, is interactive kiosks or using electronic devices from a menu that we can select information, and I think there might be some people here that represent companies. I know there is one in Columbus, Ohio, that I am familiar with and talk with them quite often, about how people can select the information they want, and there are the interactive kiosks, and I think we could gain a lot of information about what type of information the consumers are accessing. That could help us to learn about how to frame the information.
The last comment on that, another graduate student is doing research on whether information about side effects is given first or last, and the consequences of that. She doesn't have the answer that, but she is doing her Ph.D. dissertation on it.
MS. PEDERSEN: Thank you, Dr. Schommer, and thanks to Dr. Zito.
We will now take a 10-minute break and reconvene at 5 minutes past 11:00.