ISSA Proceedings 2006 – Reading Direct-To-Consumer Advertising Of Prescription Medicine. A Qualitative Study From Argumentation Theory On Its Dialectical And Rhetorical Features

• by: Sara Rubinelli - Peter J. Schulz, Health Care Communication Laboratory, University of Lugano, CH & Kent Nakamoto - Department of Marketing, Virginia Tech, USA

1. Introduction
The expression Direct-to-Consumer Advertising (thereafter DTCA) refers to “any promotional effort by a pharmaceutical company to present prescription drug information to the general public in the lay media” (Huh et al. 2004, p. 569). Currently, DTCA is allowed only in the United States and New Zealand. Yet, its introduction in the early 1980’s has inflamed a debate that today seems to have assumed a seemingly chronic non-conclusive orientation both at an academic and institutional level (Areni 2002; Tanne 1999; Raven 2004).
The core of the debate on DTCA essentially concerns the identification of DTCA either as a beneficial procedure to be promoted or as a damaging procedure to be abolished and consequently not introduced in other countries. Promoters of DTCA present several arguments supporting its positive educational influence on people’s health literacy. DTCA is here seen as a way to provide people with adequate information for them to have a safe use of medication, as well as a way to create effective knowledge for evaluating the benefits and risks of drug products, and generally managing health autonomously and appropriately. For promoters of DTCA, pharmaceutical companies can provide more accurate, balanced and scientifically based information than any other sources. Opponents of DTCA emphasise the financial gains of the pharmaceutical industries and the fact that DTCA enhances medicalization of normal human experience. In this last perspective, DTCA is depicted as being devoid of any effective educational value insofar as it does not give adequate information on side effects and non-pharmacological options for treatment and prevention. To cut a long story short, prescription drug advertising generally contains some information about diseases or treatment options, but according to a conspicuous part of the literature, its primary aim is to create name and brand recognition with a view to enhancing the use of the products advertised (Murray et al. 2004; Bonaccorso & Sturchio 2003; Lexchin & Mintzes 2002; Calfee 2002).

The literature on DTCA suggests that the debate over DTCA is getting bogged down in chains of arguments pro and con, yet the issue per se is surely of crucial social importance, especially because there is strenuous lobbying in many countries to relax national restrictions on DTCA (Raven 2004). In addition, de facto DTCA in the form of unbranded advertising about specific diseases and conditions increasingly occurs outside the United States and New Zealand (Raven 2004). As some scholars have pointed out, not a lot is known about the effect of DTCA of prescription drugs (Calfee 2003; Areni 2002; Jones & Garlick 2003). Consumer surveys, in particular those by the U.S. Food and Drug Administration (FDA), which has regulatory responsibility for DTCA in the United States, and Prevention magazine (Calfee 2002) show that consumers are generally aware of DTCA and that they find it useful. Nevertheless, such surveys are limited in that they do not permit a definitive determination of the impact of DTCA on people’s health (GAO-03-177 (2002).
Recently, a few studies have addressed the issue of how to improve the regulations of the Food and Drug Administration. These studies focus mainly on the comprehension level of the information delivered by the adverts, on the need for a ‘fair-balanced disclosure’ between information on risks and benefits and for less superficial information (Kaphingst et al. 2005; Spence et al. 2005; Maubach & Hoek 2005; Huh & Cude 2004; Chao 2005). Although these factors are important for promoting a positive impact on consumers’ health literacy, they do not seem to get to the core of the communication problem involved in DTCA, namely that these adverts are not simply informative as claimed by the pharmaceutical industry (Bonaccorso & Sturchio 2003), but they present information framed in potentially misleading argumentative structures (Rubinelli 2006).
Drawing on argumentation theory, we claim that DTCA can lead readers to make wrong inferences and misunderstand the drugs’ characteristics as a result of its interplay between dialectical and rhetorical features. In what follows, the nature of this interplay will be explored in detail, with the perspective of investigating the potential tension between practical persuasive success and normative directives about argumentative conduct.

2. Preliminaries
These preliminary observations introduce theoretical concepts that will be useful for the analysis of DTCA presented in this paper. In particular, we shall deal with the definition of dialectic and rhetoric, and with the main factors which they involve.
Following the evaluation made by Leff (2006), dialectic and rhetoric have been differently assessed by scholars. Weaver (1953) saw a fundamental distinction between the two disciplines; dialectic consists in winning rational assent for abstract matter, while rhetoric deals with ways of proceeding in individual situations. Contrary to the interpretation of Weaver, recent scholarship – including the authors of this paper – perceives a crucial overlapping between dialectic and rhetoric; the same overlapping that, we add, Aristotle saw in the Rhetoric while stressing in the opening lines of the treatise that dialectic is the counterpart (antistrophos) of rhetoric. As Wenzel (1990) claims, dialectic is a way of settling disputes through critical discussion. Rhetoric relates, however, to the persuasive factors of argumentative encounters. The main point stressed by Wenzel is that dialectical and rhetorical perspectives can both appear in concrete arguments.
According to the above perspective, dialectic results in the generation of norms for reasonable conduct. In particular, there are three broad principles – among those representing the asset of a critical discussion as codified by pragma-dialectics – which become relevant for our context: that arguers make clear what overall claim is being advanced, present support for the claim, and defend their views against objections (O’Keefe 2003; 2006). Let us discuss these principles in more detail.

a. Articulation of conclusion
For normatively sound dialectical argumentation arguers must show clearly what standpoint is advanced. An obligation to be clear in this respect is embodied in a section of rule 10 of pragma dialectics where we read ‘A party must not use formulations that are insufficiently clear or confusingly ambiguous’ (van Eemeren et al. 1993, p. 209; see also O’Keefe 2003, p. 310).

b. Articulation of support
Another requirement for a critical discussion is that arguers make explicit their premises in support of the standpoint being advanced. Again, this idea is partly represented by the “obligation to defend” highlighted by rule 2 of pragma-dialectics: ‘A party that advances a stand-point is obliged to defend it if asked by the other party to do so’ (van Eemeren et al. 1996, p. 283; see also O’Keefe 2003, p. 312-313).

c. Defence against counterarguments
Finally, arguers must be willing to defend their views against objections (rule 2 in van Eemeren et al. 1996 p. 283; see also O’Keefe 2003, p. 314; Hansen 2006). Counterarguments, in particular, must be faced and eventually refuted. Rhetoric, in its turn, is linked by Van Eemeren and Houtlosser (2002) to the strategic manoeuvring which is designed to support a standpoint – or, according to pragma-dialectics resolving a difference of opinions – in a way favourable to an arguer’s position. For these authors, rhetorical efficacy depends on three components: the selection of topic potential, the audience adaptation and the use of presentational devices. As Leff (2006, p. 201) points out, these rhetorical components are used with the intention of promoting one’s own standpoint rather than solving an opposition of points of views in a dialectical way.

Van Eemeren and Houtlosser (2002, p. 135) claim that, although dialectic and rhetoric should operate together, dialectic must have a priority which limits the application of rhetorical devices. Indeed, they support a resolution-oriented approach to argumentation where the main aim of argumentation is that of conducting a discussion in a way that is considered reasonable. Cases of audience-oriented argumentation are, however, spread. According to Tindale (1999), argumentation always involves rhetorical attention. Moreover, in argumentative practice correct dialectical manoeuvring is shadowed by contexts where the arguer’s main intention is that of winning the audience and leading it to adhere to her standpoint (see also Leff 2006).

In the following section, we will show how in DTCA, particularly, the traditional rhetorical goal of winning the adherence of the audience is the main function of these adverts. What is more interesting is that this goal is reached by putting forward a seemingly dialectical framework that rests, however, on persuasion-oriented elements of doubtful nature. In other words, DTCA presents arguments that at a superficial level appear as rational but, on deeper examinations, hide fallacious manoeuvring. We will show that this way of framing contents does generate persuasion, leading one to enquire into the relationship between the quality of the message’s argumentation and its outcome and impact.

3. Dialectical rules in DTCA
Following our interpretation, DTCA provides its audience with arguments whose rational structure can be easily perceived. We said earlier that the first principle for reasonable conduct is that an argument clearly articulates its standpoint. This is the case with DTCA. Elsewhere (Rubinelli 2006), we hypothesised that the standpoint for DTCA is the proposition “Ask your doctor about X (the medicine advertised)”, which explicitly occurs with almost the same wording in all the adverts. Linguistically speaking, this proposition is ambiguous: it could be intended with meanings ranging from simply “Ask your doctor if X is right for you” to the extreme “Ask your doctor to prescribe X” or “Get X, and thus ask your doctor for it”. Yet, whatever the meaning is, it is expected to generate some sort of positive response to the product advertised.
We can be sure that this is a proper standpoint because the validity of the proposition “Ask your doctor” is controversial. Since the medicines advertised always have competitors on the market, it is far from being evident why people should ask for that medicine and not for similar ones. In this light, this proposition instantiates an elementary single form of difference of opinions (Van Eemeren et al. 2002, chapter one), in the context of an arguing-as-presentation model of argumentation (Cohen 2003, p. 116).
In Rubinelli et al. (2006a), we showed that this standpoint is recognised as such by readers. We tested this factor in a pilot-study conducted with 36 students from a U.S. university. The students, randomly divided into two groups, were asked to read an advert. Group 1 was given an advert for Zoloft – an anti-depressive medication, while group 2 read an advert for Allegra180mg -an allergy medicine. Both were copies of actual print adverts appearing in U.S. magazines. Participants then completed a questionnaire on the advert. In the first part of the questionnaire we obtained data on the perceptions of the argumentative structure of the adverts. Since we could not expect readers to understand argumentation from a technical point of view, we enquired about perceived conclusions of the adverts by posing the general question “What is the advert suggesting that readers do?”, with an invitation to leave the space blank in case they did not see any suggestions. Results obtained confirmed our hypothesis. The Zoloft ad is perceived by all 36 respondents in group 1 as having an argumentative structure with the standpoint “Ask for/ Get Zolof”. Similarly, 35 people out of 36 in group 2 recognized an argumentative structure in the Allegra180mg advert with a similar standpoint.
The second principle explained above reads as ‘Articulation of support’; rational arguments put forward the premises in support of conclusion explicitly or, in any case, in a way that can be easily made explicit. Again, in DTCA this explicitness appears clearly. We reconstructed the premises of the standpoint “Ask your doctor for Allegra180mg” in Rubinelli (2006). There, the claim was that most of DTCA adverts support their claims by rather explicitly stating that the product advertised is better than similar ones on the market. Also, the adverts present what Toulmin (1958) calls the warrant of an argument, by giving certain medical information on the characteristics of the product for basing its supposed superiority. For example, in the case of Allegra180mg the advert says more or less explicitly that it lasts longer than most OTC allergy medicines. Similarly to before, data from our study (Rubinelli et al. 2006a) confirm that readers recall the premises that appear in the advert. 25/28 answers claim that the advert for Allegra180mg advices people on getting the medicine because it lasts longer than the other ones.

Let us now deal with the third principle mentioned earlier, concerning the necessity for a rational argumentation to take into account counter-arguments. In the context of DTCA, what works as one of the main potential counter-arguments is the fact that the medicine in question has side-effects. The perceived quality of a medicine would be diminished in case of significant side-effects. DTCA is legally bound to mention side-effects in detail; all adverts have a back-page explaining components and side-effects. All this information is, however, written in a very small font-size and employs a technical jargon that results unattractive. Indeed, from our tests it results that readers do not pay attention to this page (Rubinelli et al. 2006a). But DTCA also tackles the issue of side-effects in the front page of the adverts. Apart from legal reasons for doing so, there seems to be an attempt to face or even refute possible counter-arguments of the sort “This medicine is good, but it surely has side-effects”. To quote an example, in the front page of the advert for Cialis – a medicine for erectile dysfunction – there is a sentence stating that “Most men weren’t bothered by side effects enough to stop taking Cialis“. From our point of view, there seems to be no reason why this sentence appears in the advert other then the intention of refuting potential claims on possible limitations of the medicine.

We now enter in the domain of the relationship between the perceived rationality of an argument and its impact.

4. Argument Quality and Persuasive Effects
O’Keefe (2003; see also 2006) has conducted some meta-analytic reviews of experimental studies that compare the effectiveness of messages. Some of these messages include an explicit statement of the advocate’s overall point, provide support for their information sources, or are structured as refutational two-sided messages, discussing counter-arguments. Some other messages do not have these characteristics. Results from these studies show that there is a significant persuasive advantage for messages included within the former type as compared to the latter. More specifically, adhering to the normative principles of pragma-dialectics seems to enhance practical persuasive effectiveness. As O’Keefe explains (2003, 311-313):
“Across the 17 studies identified as relevant … a dependable overall effect (corresponding to a correlation of about .10) was observed, such that messages containing an explicit statement of the advocate’s overall conclusion were significantly more persuasive than parallel messages omitting such a statement. O’Keefe … reported a meta-analytic review of 13 … studies. Across these studies, a dependable difference (corresponding to a correlation of about .07) was observed such that messages providing citations to information sources were more persuasive than their less explicit counterparts. … a meta-analytic review of 18 … studies reported a significant persuasive advantage (corresponding to a correlation of about .14) for message with more complete supporting arguments. Refutational two-sided messages enjoyed a general persuasive advantage (corresponding to a correlation of .08) over their one-sided counterparts.”

As a matter of fact, economical data on DTCA appear to confirm this interpretation. DTCA has an evident dialectical structure and there is strong evidence that it is effective in increasing sales. In 1999, the 25 top-selling medicines promoted directly to consumers accounted for 40.7% of the overall $17.7 billion increase in retail drug spending. The same 25 top-selling drugs had an aggregate one-year sales growth in 1999 of 43.2%. The growth in sales for all other drugs was 13.3%. This coincides with a growth in the number of prescriptions for the 25 DTC-promoted drugs. In 1999 doctors wrote 34.2% more prescriptions than in 1998 for these drugs, while they wrote only 5.1% more prescriptions for all other prescription drugs. In addition, the US General Accounting Office estimates that 8.5 million consumers annually request and receive from their physician a prescription for a particular drug in response to seeing DTCA (Marks 2003).
O’Keefe (2006, p. 238), in discussing his points, raises the issue on whether the same persuasive advantage would obtain if poor-quality sources were to be used or if irrelevant evidence were to be offered. In what follows we will attempt to give an answer to this issue by showing how, indeed, the quality of information offered by DTCA appears to be rather poor despite the level of its effectiveness. Exploring this aspect will lead us investigate into some rhetorical features of DTCA that are in contrast with its superficial dialectical framework.

5. Dubious arguments in DTCA
The critical factor that, from a qualitative point of view, dismantles the roots of the dialectical setting of DTCA is the following. In DTCA adverts there is a clear intention to emphasise and support the superiority of a certain medicine comparing to others similar on the market. This need of support seems to push advertisers to select certain information to the detriment of other one which could be more useful for promoting the health literacy of consumers. To exemplify this claim, we report a section of the analysis conducted in Rubinelli (2006).
Allegra180mg is depicted as a medicine that lasts four times longer – 24 hours – than one dose of most OTC allergy medicines. In the advert, three other medicines available on the market are indicated, Benadryl, Tylenol and Chlor Trimeton which, it is written, only last up to 6 hours. Now, the main point to note here is that Allegra180mg is a strong medicine and its long-lasting property is connected to this strength. Nothing about this strength is said in the front page of the advert. The usual recommended starting dosage of Allegra – we read from the package insert – is 60mg twice daily. Moreover, nothing is said on the front page about the other fact that this dosage of Allegra180mg is not recommended for people with chronic idiophathic urticaria (CIU) or with decreased renal function. Unless those people who suffer from these two diseases read the package insert, the invitation to ask their doctor about Allegra180mg would lead them to ask for a medicament that is not appropriate for them. No doubts, he fact that not everybody can take Allegra180mg would surely affect the claim about its superiority, because it is a superiority that is limited in its application.

We are here dealing with a clear fallacy of omission, based on a failure to present information which, on one hand, would be relevant for consumers, but on the other hand would limit the number of consumers directly addressed by the advert. In Rubinelli et al. (2006a) we showed how this sort of fallacies goes unnoticed by readers.

The presence of fallacious arguments is not the only critical factor to underline in an attempt to reveal the rhetorical strategies behind DTCA. In Rubinelli et al. (2006b) we illustrated cases where the information presented in these advert is not fallacious per se, but is still dubious insofar as it invites readers to make wrong assumptions or invalid inferences. We tested this effect through a questionnaire, where we assessed people’s recall of the contents of the adverts. In the questionnaire, we presented sentences that really appear in the adverts (referred to as T = Truth), and statements that did not appear (referred to as F = False), and asked readers to indicate which sentences were/were not in the advert on a scale from -3 to 3 (where -3 = I am sure it is not in the advert; 0 = I do not know; 3 = I am sure it is in the advert). In the false sentences, we inserted contents which would facilitate the identification of readers’ processing mistakes. Such mistakes would suggest that implicit premises are picked by individuals in order to ground their conclusions about the drugs, that these premises are implicitly recovered, and that they can be known as such at various degrees of confidence and awareness. To give one glaring example, 60% of the sample (N= 21 out of 35 people) wrongly believed that the Zoloft advert contained the sentence “Taking Zoloft will make your life happy”. The advert only says – more or less explicitly – that if you suffer from depression, life becomes hard. It seems that from this information readers make the following inference:
If you suffer from depression, life becomes hard.
Zoloft will cure your depression.
… Zoloft makes your life happy.
Indeed, making life happy is definitely more complicated than simply not being depressed! The inference is logically invalid.

Similarly, the advert contains the sentence “You get one performance. Why do it with depression?”. Readers quote this sentence as a reason for wanting Zoloft. This means that they probably infer from it a necessary implication between “Taking Zoloft” and “Not having depression any more”. This implication is, however, only probable: there is no way of knowing exactly what effects the medicine will have on each individual person.

The elements discussed in this section point to the fact that in DTCA strategic manoeuvring has gone wrong.

6. Conclusion
As Aristotle emphasises in the Rhetoric, persuasion can be reached via qualitatively good or poor contents. DTCA seems to follow under the second group, where fallacious arguments are presented persuasively. In this case, our hypothesis is that what makes these adverts persuasive is the rational way of framing information and which is, indeed, perceived by the audience. Dialectical features prevail at the level of people’s perceptions of DTCA, while rhetorically dubious components seem to go unnoticed. The fact that a certain medicine advertised is superior to the similar ones on the market is a rationally compelling factor for generating a favourable attitude toward the medicine itself. Yet, this superiority is supported by poor information selected at the detriment of other information that, from a medical point of view, would be more appropriate.
It is difficult for us not to recognise in this way of presenting DTCA an intentionally designed strategy of argumentation which is applied to drive the audience in the expected direction. Current results in persuasion research are making more and more clear those factors that most affect people’s assessment of the contents they deal with. In particular, the elaboration likelihood model (Petty and Cacioppo 1986) show that when a topic is personally relevant people engage in extensive elaboration; in this context the rational framing of the message plays a crucial role. For the audience of DTCA, the products advertised are always relevant. We can surely generalise that people who are interested in DTCA are either those who are affected by a certain illness or have relative or friend for whom the medicine advertised would be of some importance. In this sense, the audience of DTCA expects a minimum level of dialectical scrutiny that these adverts do offer. Despite the fact that the topic is relevant, people who read DTCA do not seem to be critical enough to detach the poor strategic manoeuvring behind the superficial dialectical setting. Possibly, the critical skills required to conduct an adequate assessment depends on people’s level of health literacy and on their ability to generally process information. In any case, the main problem is that DTCA seems to contain elements that surely do not help people in making this assessment. We even dare to say that the way DTCA is currently designed seems to affect people’s ability to process certain contents, and invite its audience to make incorrect inference. In this light, a fundamental question arises is on whether DTCA would produce the same persuasion if its current rhetorical setting were taken away, and substituted by an exclusive informative framework based on the most medically relevant contents. We did some preliminary investigations of this point (Rubinelli 2006b) where we showed that when a medicine is presented for just its effective characteristics and in a less rhetorical fashion, it seems to be less clear to the audience why it should be chosen.
Enough to say, at this stage, that there is a lot at stake in the field of DTCA! Argumentation theory offers a powerful analytical tool that is rather unexplored by scholars interested in field of DTCA. We propose to explore all the factors underlined in this paper with further investigations where next to the theoretical interest of analysing the impact of real-life arguments, there is a fundamental need to enhance a qualitative improvement of a form of advertisement which is nowadays considered among the most critically powerful.

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