Transcript of Direct-to-Consumer Promotion Public Hearing Panel 10
FDA Public Hearing
Thursday, October 19, 1995
3727 Colesville Road
Silver Spring, Maryland
- Juliet J. Goodfriend, Strategic Marketing, Corporation, Bala Cynwyd, Pennsylvania
- Leo Brandstatter, Rubin Ehrenthal & Associates, New York, New York
- Questions for the Panel
PANEL 10 PROCEEDINGS
MS. PEDERSEN: The next panel will be comprised of Juliet Goodfriend, Leo Brandstatter, and John Mack. I see Juliet Goodfriend. Are we missing Leo Brandstatter or John Mack?
MR. BRANDSTATTER: I don't think we're missing Leo Brandstatter.
MS. PEDERSEN: Okay, you're Leo Brandstatter, okay. Is John Mack here?
MS. PEDERSEN: We will proceed with Ms. Goodfriend making the first presentation.
MS. GOODFRIEND: Thank you. My name is Juliet Goodfriend and I am President of Strategic Marketing Corporation, which is one of the nation's largest marketing research firms dedicated to the pharmaceutical and health care industries and conducting only custom research. My company paid for my appearance today and my other fiduciary relationship to this is that I am a taxpayer and support the FDA in that way.
MS. PEDERSEN: Thank you.
MS. GOODFRIEND: I am going to present some data from an extremely large study, one of several that we have done on the effects of direct-to-consumer advertising, but first I would like to give you some history, going back farther, actually, than Sidney talked about earlier.
It was actually 20 years ago in the mid-1970s that I realized what an opportunity loss the pharmaceutical industry was experiencing by not tapping into the strongest potential influence on physician prescribing, the patient. But this idea did not come out of any sensitivity to the consumer. I actually, at that time, rarely interviewed consumers. The people I mostly interviewed were physicians. It was my job over and over again for all of the major drug companies in our country to discover and then to explain why physicians prescribed drug X and not drug Y and to learn what information would encourage them to prescribe more drug Y instead of drug X and to determine whether or not they needed a new drug Z.
After listening to literally thousands of physicians and focus groups and interviews back in the 1970s, I came to realize that a very significant determinant of prescription drug choice was the patient. If the patient complained about side effects, the doctor chose a more tolerable agent. If the patient complained of the drug's price, the doctor sought a cheaper alternative. If the patient commented that her symptoms were improved but not gone, the doctor augmented the course of continued it.
And if the patient mentioned that his golf partner's bursitis improved on a different brand, the doctor checked to see if that brand might be applicable and gave it, hoping for some placebo enhancement for the impressionable patient. That is what doctors told me in the early 1970s, and they actually are still telling us that now.
But perhaps the most compelling reason to promote directly to patients came to me personally in the course of studying an investigational anti-asthmatic and anti-allergic agent. I think it was a cromolyn-type drug actually in the early 1970s in Phase II trials. As an atopic/asthmatic, I had gone to the allergist 20 years prior to that and had learned about my condition and gotten some antihistamines and gotten some desensitization and had treated myself with the antihistamines and realized that the allergist was never going to cure me, so I never went back to the allergist. I just kept getting renewals from my OBG or PCP.
As I studied that breakthrough drug, I wondered, how could I have found out about this drug except through direct-to-consumer promotion, which, actually, they never did do, had I not been studying it for marketing research purposes. So I wrote the two articles that you have before you long before anyone else had said anything about this field and long before any manufacturer was doing anything about it in the late 1970s. So that's the origin of the movement.
Now, let me tell you what our research shows today. I will mask the therapy to protect our confidential client relationship, and it is only one example of many studies that we have done. In this recent example, we measured over two 12-week periods about 30,000 target consumers to determine their awareness of the ads and their subsequent behavior. We found that about ten percent of targeted consumers were aware of the ads. Remember, we were only going to the targeted audience.
Its major effect on these consumers was to cause them to bring up the topic of their symptoms on their next regular visit to the physician. Of those who were ad aware, only six percent said they would have not have gone to the physician had they not seen the ad. And less than ten percent of the ad-aware consumers actually received a prescription. The increase in prescribing that we determined was attributable to the ad was less than one percent.
However, a bigger effect, as I mentioned, was experienced in consumers' heightened awareness of the condition they otherwise had thought was something they had to bear. The outcomes from direct-to-consumer advertising seemed to hurt no one and possibly help many. The information that was of greatest value to consumers in motivating them to visit a physician was, one, information that there was a drug available through a doctor; two, information about the symptoms and their consequences or meaning; and three, information that there was a possibility of relief in a given period of time.
My recommendations to the FDA are fairly simple. I would keep control of direct-to-consumer advertising in the FDA, not in the FTC, because I would hate to see the increase of medically-trained staff necessary to review ads in the FTC. I am not against increasing the bureaucracy more than we have to, since I have this fiduciary responsibility to you all.
I would include also an excerpt modified, researched to determine how it can be communicable, but an excerpt from the patient package insert in any ad that mentions a drug by name.
And I would not restrict in any way the "see your doctor" disease-based ads that don't mention the drug. If they don't mention the drug, I see no reason for the FDA to have any jurisdiction whatsoever.
Now, in making these recommendations, I am also mindful that managed care company executives hate and detest direct-to-consumer advertising. I know this from other research, which I will talk about this afternoon. Why do they hate these ads so much? They hate them because the ads educate the consumer to make use of health care resources--perish the thought. They hate them because they educate the consumer to object to restrictions on drugs that managed care organizations place on those drugs primarily on an economic basis.
And because they strengthen the health of the consumer, the health awareness of the consumer, the managed care executives actually comment that they are not in the best interests of the managed care organization, but they certainly are in the best interests of people's health and they certainly are part of the FDA mandate. Thank you.
MS. PEDERSEN: Thank you very much.
MR. BRANDSTATTER: Good morning. My name is Leo Brandstatter. I represent Rubin Ehrenthal and Associates, a division of Gergentiuse, Butler, and McDowell [ph.], and all those names come together to form Advertising Agency. They have paid for my trip here. They service a number of pharmaceutical clients that do or at least are considering direct-to-consumer advertising.
MS. PEDERSEN: Thank you.
MR. BRANDSTATTER: In a sense, I feel at a significant disadvantage, since I have spent 20 of the 24 years since I left school working for various advertising agencies, and I should deviate a bit from my text and tell you that most of that time was spent working not on pharmaceutical advertising but on the type of advertising that was referred to earlier that really does create impressions that change minds, that cause people to do things that perhaps might not be ideal from the standpoint of medical care.
It is no secret that the advertising industry is an eloquent proponent of the First Amendment. When, then, should you be particularly interested in what I have to say? Well, here is one reason. I have spent most of my professional life not creating advertising or placing it or even selling it but in measuring its effect. In my role as an advertising researcher, I study consumer attitudes and behavior, and in the next few minutes, I would like to share with you some of what I have learned about how DTC advertising affects consumers.
From primary studies as well as from secondary, from both quantitative research as well as qualitative, three key general principles emerge. One, consumers demand precisely the type of information that DTC provides. Two, consumers frequently respond behaviorally based upon what they learned from DTC ads, yet, three, consumers' responses tend to be far more sophisticated than most of us ever imagined they would be.
To better understand why these are true, it would be helpful to appreciate the underlying need that they represent. Consumers are uncomfortable with the rather substantial changes taking place in today's health care environment. Gradually disappearing is that special trusted relationship with that one doctor, with "my doctor", and in its place grow a host of acquaintanceships with all kinds of health care professionals, from primary care to specialty care to associates, nurses, physicians assistants, administrators, pharmacists, labs, third-party payers, et cetera and et cetera.
In a nutshell, the patient alone with the possible assistance of close family and friends is frequently assuming the position of health care advocate which used to be the domain of the family doctor. In addition, today's consumers, far more than their parents or even their older siblings, are educated and curious and they want to understand what ails them and what they can do about it.
This combination introduces a demand for understandable and believable consumer information far more pronounced than any I have seen in any other marketing category. Consumers have always shown a thirst for information in such areas as travel, high-ticket electronics, automobiles, homes, and generally in all products and service areas where the issues are complex and the decisions are important.
For this very reason, the demand for health care information is greatest of all, because today, no other product category offers the consumer as complex a set of considerations and as important a set of decisions as does health care.
Consumers are satisfying their increased demand for information from a variety of sources. They avidly read newspaper stories, magazine articles, and books. They tune into television and radio programs of interest. They do read DTC ads. They also talk to each other. But they know that, at best, these sources are incomplete and that the most important source of health care information is the health care professional. In fact, consumers use all of these various other information sources to be better able to speak intelligently and confidently with their doctors.
In my experience, DTC advertising of prescription pharmaceuticals often serves as the beginning of the process during which consumers learn about a disease or about treatment options. From there, they frequently look for more detailed information, usually culminating in a discussion with a doctor or a pharmacist. The benefit of the advertising is that it is short enough and simple enough to spark the process.
Consumers read relevant ads carefully and they frequently act on what they have learned. However, regardless of how motivating the ad, regardless of what kind of an impression this ad creates, the action is usually quite measured and sophisticated, not quick or impulsive.
In the 37 DTC copy tests we conducted over the past several years, an average of 52 percent of the consumers claimed they would take action after reading an ad. However, 83 percent of them expected this action to take the form of a discussion with the doctor at the next scheduled appointment, and only 17 percent expected to call the doctor to discuss it or to set up a specific meeting about it.
There are a number of reasons that DTC does not prompt a more aggressive consumer response. First of all, medicine to most laymen is quite complicated, and the more consumers learn, the more they realize how little they know. In addition, the required fair balance information, the side effects, warnings, and contraindications included in the body copy of the ads demonstrates clearly that there are pros and cons to be carefully considered before using any prescription medicine.
As a matter of fact, the specific negatives of the fair balance are less important to the reader than the mere fact that there are negatives to consider and that the advice and consent of the doctor are therefore mandatory.
Parenthetically, as carefully read as the fair balance is, I have never seen evidence that consumers read the required brief summary, even in part. In fact, I have frequently seen that they do not. By now, I have watched hundreds of focus group discussions and individual depth interviews in which consumers were shown a prospective DTC ad. They frequently comment on the warnings and side effect information, usually favorably. It lends credibility to the entire ad.
However, I cannot recall more than four or five occasions where a consumer read even part of the brief summary page. They apparently have learned that the information it contains is usually too technical and often irrelevant, and therefore not worth the effort. I am not convinced that it, unlike the fair balance, is helpful to anyone.
Third, as hard as it may be for many of us in my industry to admit, consumers are skeptical about advertising. Research shows that over half feel it insults their intelligence. Now, granted, we have studies that show DTC to be far more credible than the average consumer advertising. Over seven in ten call it valuable and worthwhile. Nevertheless, only one in four considers DTC to be objective and less than half consider it reliable. They have come to expect advertising to try and sell them something. So, frankly, their resistance is up.
At the same time, they have learned that DTC ads can educate and inform them and they welcome this information even as they remain suspicious about the objectivity of its provider.
I would add that, unlike my distinguished colleague who spoke before me, I do not believe that you have to separate the information from the sell. I think the consumer is savvy enough in most cases to recognize that the ad is doing both. In fact, it is doing both. It would not be possible to do advertising if all that was permitted was educational advertising because no company would do it. But in the process of selling, it's perfectly conceivable that education can happen, as well.
The bottom line, DTC advertising is one of several important sources of consumer health care information in an area where information is crucial. It, together with additional learning that it often sparks, provides the background and confidence a patient may need before asking the physician about a particular condition or treatment option. DTC is balanced and truthful, primarily because of your efforts. It is targeted directly at those who should read it, primarily because of ours, and in some categories, it represents the first and most understandable exposition a consumer is likely to encounter on the condition in question. Thank you.
MS. PEDERSEN: Thank you very much, Mr. Brandstatter.
This is a final call for John Mack. If he is here, please come forward.
MS. PEDERSEN: Since he does not appear to be here, we will move to questions for the panel. Ms. Bernstein?
QUESTIONS FOR THE PANEL
DR. BERNSTEIN: This question is for Ms. Goodfriend. In your recommendations, you suggested a modified version of the package insert be included. Did your research lead you to that conclusion, and if it did, can you comment on that, please?
MS. GOODFRIEND: It really should say, a modified version of the brief summary. I don't mean the entire package insert. And no, that is not coming directly from research. The research of our company would confirm some of what my distinguished colleague who was the speaker after me. I was not the one before him.
MR. BRANDSTATTER: I apologize. I was talking about Sidney Wolfe.
MS. GOODFRIEND: At any rate, our research would confirm that there is--or would suggest, not confirm--suggest that the material that is now in the brief summary is not well understood, but I don't have actual readership figures or comprehension. I have, however, done enough research in the past 30 years with communications vehicles to know that there is a better way and one could determine, I think to everyone's satisfaction, that there is a better way to communicate the benefits and risks of the medication. I was only stating that I think something like that should be there, if the ad or the vehicle mentions the drug.
MS. PEDERSEN: Dr. Ostrove?
DR. OSTROVE: I have two questions, one very briefly for Ms. Goodfriend. In the research that you reported, was that for a product-specific advertisement or for a help-seeking advertisement?
MS. GOODFRIEND: No, that was a product-specific advertisement.
DR. OSTROVE: Thank you. And the other question is for the two of you. I know that there are concerns about the proprietary nature of much of the research that you do and the fact that it's for pharmaceutical companies. Is there any way that you can think of that we can somehow communicate with them, with you, get together, to try and, if necessary, mask information that would be a problem for them so that we can actually have access to this mass of information which we currently do not have and would be very useful to us in terms of where we go from here?
MS. GOODFRIEND: Absolutely. I see no reason that this information should not be released to you once we get authorization from our clients in a masked way. I served on the coalition--I have forgotten now what the name of that was, but the task force or coalition for communicating directly to consumers in some way or another.
MS. GOODFRIEND: It met for years and the moral of the story was, no one could agree on how to do the research, so I really urge you not to do research on direct-to-consumer advertisement because it's already been done on a proprietary basis and you can critique that and see how objective it is rather than trying to reinvent another survey. It was a lesson in camel building by committee.
But we have a great deal of worthwhile and clear research that is sufficiently objective. I mean, our results may not have come anywhere near to meeting what the clients were hoping that they would show, but we can definitely go through that with you and I think our clients--I hope our clients would be willing for us to mask it.
If I could just hearken back to the first question, you said if it was a direct product research, it was direct product advertisement, I should say, it was a direct product, and therein lies the point that what patients got out of it, yes, was brand recognition--I didn't report on that, but they did recognize the brand--but they got worthwhile information about symptoms of a disease that were not at all buried but very prominently displayed in the ad and the benefits that an earlier speaker today spoke of. The benefits were communicated in a fairly realistic way. So I'll be happy to work with you to get that information.
DR. OSTROVE: Thank you.
MR. BRANDSTATTER: If I may address your second question, I did include in what I hope will be printed in the summary of today's proceedings masked information for the data to which I alluded. I also have it here on acetates if we want to put it up on the wall, but I didn't think that it was particularly helpful in the context of today's proceedings to discuss it.
DR. OSTROVE: Thank you.
MS. PEDERSEN: Dr. Temple?
DR. TEMPLE: Ms. Goodfriend, you drew a fairly bright line between ads that don't mention the drug at all, which you said basically could go on without any consideration by the agency, and those that actually mentioned the drug. I just wondered whether you could see gradations in the latter group, depending on how much was said about the drug. One can imagine, for example, an ad that mentioned an anti-hypotensive agent that didn't say too much more than it's good to lower blood pressure. All drugs have side effects. We think ours are generally pretty good. See your doctor. You know, not much content.
Could that have a lesser degree of information, for example, than something that made a direct comparison with some rival drug and said, I'm way better because I don't cause impotence or this or that. Do you see possible gradations along this line?
MS. GOODFRIEND: I think we have to be careful. I think there may be gradations which I'm not aware of. I haven't seen gradations that I could say--nor have I tested any, but I do obviously go back to the pre-Oraflex and the Oraflex experience and I think that's given me some degree of concern that we need to be educating the physician and whatever we say to the consumer--we need to be educating the physician that we are going to say something to the consumer and what we say to the consumer, I think, should be consonant in some way with what we say to the physician, because without that, there's a disconnect. It irritates physicians, as well it should, and it has the potential to mislead consumers. So I can't picture what you're saying, but I would say maybe yes.
DR. TEMPLE: Okay, and I have a short question for Mr. Brandstatter. I thought I heard you say that most of the direct-to-consumer ads you've seen have been pretty good so far because of our efforts and well targeted because of your efforts. I wondered if you thought that the fact that they were pre-cleared had something to do with that and how you, therefore, feel about pre-clearance.
MR. BRANDSTATTER: I think that the fact that they're pre-cleared has a lot to do with that, and I think that pre-clearance is a positive activity. I would love to see the process streamlined. I would love to see a way of getting the information more quickly. I would love to see a greater spirit of cooperation on the part of FDA in terms of helping to get the information in front of consumers, but I do not object to pre-clearance and I think the net effect of it is to make for a stronger advocate.
MS. PEDERSEN: Dr. Morris?
DR. MORRIS: Also for Mr. Brandstatter. Thank you very much for bringing your testimony today and offering your expertise, and I would like to draw upon that. This is kind of a how-to issue. In the ads that you have seen where there is balancing information, do you have any impressions on what types--does it matter how it's in there, what's in there? Are there suggestions of ways that it might be more efficient, things that we can avoid, based on what consumers have told you across these different types of ads?
One of the questions we always have is how much is enough, how prominent need it be, things like that. I wonder if you could offer some advice.
MR. BRANDSTATTER: The best I can do is this. Most consumers are really so far behind the physician, the pharmacist, the nurse, any of the health care professionals in terms of the kind of information that they possess that simply to indicate, as I suggested earlier, that it isn't all rosy, that this particular drug, if, in fact, I'm advertising a drug, is not for everyone because there are contraindications, because there are warnings, because there may be problems.
To give specific indications as to what kind of problems these may be helps in that it adds the details that allow the consumer to believe that, in fact, this is serious and that therefore they should speak to the physician rather than instruct the physician about what they want.
DR. MORRIS: As a follow-up question, one of the suggestions we heard yesterday was the use of a more global statement that says there are problems. You need to talk to your doctor. What would be your analysis of that as a means of balance?
MR. BRANDSTATTER: In the fair balance specifically, I'm in favor of keeping the details there. I would not increase those details but I would have them there so that consumers see some of the nature of the specifics that need to be considered and so that they do truly speak to their doctor and listen carefully to what he has to say.
MS. GOODFRIEND: I would just like to reiterate my agreement with him on that. The more global statements would be about as effective as don't drink when you're pregnant and don't smoke, something might happen to you, and don't take this medication when you're driving. That's even a little bit more specific. I think that the global warnings are relatively ineffective.
MS. PEDERSEN: Ms. Stifano?
MS. STIFANO: This is directed at Ms. Goodfriend. I hope I didn't misunderstand you, but is there evidence in your research that would suggest or further support as to why you feel the drug-specific ad is more beneficial than, say, an institutional ad that speaks only of the disease?
MS. GOODFRIEND: No. We have done no comparisons of direct-to-consumer advertising that is disease specific versus drug specific.
MS. STIFANO: Thank you.
MS. PEDERSEN: Ms. Baylor-Henry?
MS. BAYLOR-HENRY: I think you said that FDA does not regulate direct-to-consumer ads that don't discuss specific drugs, or should not, maybe you said, and I don't known that we totally disagree with you on that point, but I wanted to raise the possibility, if there was only one treatment modality for a particular condition and even though the particular piece did not discuss a particular--by brand name--a particular treatment modality, would you be of the same opinion in that particular instance?
MS. GOODFRIEND: Absolutely. I would definitely be of the same opinion. If I were not of the same opinion, I would be making the judgment based on what the economic impact of the ad is. But I don't think that the economic impact of the ad should be any of your concerns. Your concerns should be the informational impact, and if there's only one drug or many, the patient won't discover that until they get to the doctor anyhow and the doctor could say, all the other drugs are not appropriate for you and this is the only drug for you even if there had been many to start with.
So my feeling would be that the FDA should permit disease-type "see your doctor" ads for any disease, even if there is only one drug for it because it's almost an irrelevant issue, how many drugs there are for it, what information is being communicated.
MS. PEDERSEN: Ms. Bernstein?
DR. BERNSTEIN: This question is for Mr. Brandstatter. I thought I heard you say earlier that a negligible amount of people that responded in your studies said that they didn't read the brief summary information, and then what you just said a moment ago is that people want the details and that you suggested the details remain in.
How do you reconcile that? Is that because they want information that they understand or is there something else that--can you give me a little bit of insight?
MR. BRANDSTATTER: Consumers do not want a page full or certainly more than a page full of information that pertains to less than one-tenth of a percent of the population that may be taking a drug. Much of what is included in the brief summary in the package insert that must accompany a branded ad is totally irrelevant to most consumers. More than the irrelevancy, it is complicated.
I have worked hard, along with a number of dedicated professionals, to try to make it clearer, to try to remove the complications, to make it patient friendly.; Let me tell you something. Science is simply not patient-friendly. Science is patient-complicated, and you can't streamline it to the point where the average consumer, even the average educated consumer, will quickly grasp it.
What you're ending up doing is guaranteeing that they will not read it, and the only benefit is to make it difficult for the less-affluent advertiser to place a DTC ad.
DR. BERNSTEIN: So in those instances where you have worked with people and made that part more easy for the consumer to understand, do you still find, do they read it or not?
MR. BRANDSTATTER: As soon as they recognize that it is the third page, the package insert, they skip it. What they do read is the body copy of the advertisement, and when that body copy contains enough detail to indicate that the news should be tempered, that there is at least some bad news involved, that there are some contraindications and warnings and reasons not to take this, that therefore they should discuss anything with the doctor because it isn't open and shut, even though they may recognize themselves in the ad and they may indeed desire the benefit that is offered there. That does the job of alerting the patient to the fact that they can't make this decision, that they need help to do so.
MS. PEDERSEN: Dr. Ostrove?
DR. OSTROVE: Mr. Brandstatter and Ms. Goodfriend, risks are relatively straightforward. Many products carry efficacy that is not necessarily there for everybody. That is, it only works for some people under some circumstances. We have struggled with how you communicate that to consumers. In terms of your experience, have you looked at how consumers perceive the benefits of the product based on the advertising that you've seen? Have you looked at whether they understand that certain products don't work for everyone and may not work for them? Is there any advice you can give about how to communicate that kind of information?
MR. BRANDSTATTER: My advice would be simply to have it in there. If it doesn't work for everyone--first of all, it's my impression that the FDA is doing exactly that by asking body copy and headlines in many cases to say "may" instead of "will". In some cases, instead of just a blanket statement, those things do convey the fact that this is not going to work in all cases. That, combined with what I feel is the physician's responsibility to give the patient a sense of, look, this works in X percent, or in my experience, it is not going to make a difference in your case, and therefore I'm not going to put you on it. That combination, I think, serves the public interest.
MS. GOODFRIEND: You open up a Pandora's box when you even start to think about how to define how many people it works for and, more importantly, what "works" really is. What is efficacy? Is it efficacious if it reduces your death, the likelihood of death, as happens in many oncologic drugs, if it reduces the likelihood of death from eight weeks hence to five weeks hence? That's enough to perhaps have shown efficacy, but that's--
MR. BRANDSTATTER: The other way around, five to eight.
MS. GOODFRIEND: No, it's reducing the likelihood of death--well, you know what I'm to say.
But the point I'm trying to make, albeit awkwardly, is that what works in the doctor's mind is not necessarily what the patient hears about when he hears the word "works". So a cancer patient may think when the doctor says this drug works, and the doctor means it delays death, that, oh, I'm going to get up and walk, whereas that's not the case.
So I'm very hesitant about suggesting we put in anything about what the efficacy is in the sense of what that "works" is unless we can agree that it means something to the consumer. I think that the consumers will pick up whether they're in the right category to be considered a possible candidate for the drug if you include symptomatic cues in the advertisements.
I'm not sure that I've answered your question directly, but I think that it may work in the right direction, but maybe not quite there.
MS. PEDERSEN: One last question from Dr. Morris.
DR. MORRIS: One quick question about the generalizability of the research that you're talking about. My understanding is that you're talking primarily about the results of copy testing types of research, Mr. Brandstatter?
MR. BRANDSTATTER: That's correct.
DR. MORRIS: I think that tells us that if presented with an ad, people. will read the ad in that environment. Do you have any other information or insights about how an ad might work in a less forced-exposure-type environment where "the real world"--in terms of people's willingness to ready the body copy. Clearly, I would expect that the brief summary information would be generalized, but you're suggesting that people actually, in copy testing they read it, but do they read the full body copy, or what segment of the population would read it?
MR. BRANDSTATTER: Research that we have conducted suggests that far more so in medical advertising than in general advertising. People that have an interest in the subject matter read an ad very carefully. Now, the first step is to get the attention of the reader. That's the job of the ad's overall appearance, of the visual, perhaps of the headline, of the impact that the ad creates, and we test for that separately.
Once you have the attention of the reader that you're seeking, then it's the job of the ad and the way it's constructed by virtue of what it's talking about and the way it presents its information of getting read. Medical advertising gets read by the people who need to read it. It obviously won't get read as soon as someone who is not in the right target audience recognizes that this ad is not for them. They'll just turn the page. But people who need a particular drug or may recognize a particular condition will read an ad very carefully.
MS. GOODFRIEND: The research I was reporting on was not copy testing. I just want to clarify that. That was absolutely real world testing.
MS. PEDERSEN: Thank you very much to both Ms. Goodfriend and Mr. Brandstatter.