Killing me softly: myth in pharmaceutical advertising

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http://bmj.bmjjournals.com/cgi/content/full/329/7480/1484

 

Killing me softly: myth in pharmaceutical advertising

BMJ 2004;329:1484-1487 (18 December), doi:10.1136/bmj.329.7480.1484

 

Tim Scott, senior lecturer1, Neil Stanford, research assistant2, David R

Thompson, director3

 

1 School of Management, University of St Andrews, Fife KY16 9AJ, 2

Department of Health Sciences, University of York, York, 3 School of

Nursing, Chinese University of Hong Kong, Hong Kong, China

 

Correspondence to: T Scott jts1

 

In studies of how drug advertising influences doctors' behaviour, little

attention is given to visual and linguistic imagery. The authors argue

that myth is often deployed in drug adverts to depict exaggerated

therapeutic efficacy and that doctors should be aware of this

 

Although the influence of research on medical practice has become a key

concern, the influence of pharmaceutical advertising in medical journals

has received little attention. There is evidence that advertising

influences doctors' behaviour more than they might think.1-3 Important

pockets of research exist in this area but tend to focus on the scientific

validity of the text4-6 and rarely give much attention to visual and

linguistic imagery.7 8 If advertising influences beliefs and behaviour and

images are used in advertising, then images must contribute to influencing

beliefs and behaviour.9

 

One of a range of methods to promote pharmaceutical products,3 10 11

advertising in medical journals offers a privileged channel of

communication from drug companies to doctors.8 Concerns have been

expressed about the extent of its influence on prescribing. The industry

has been accused of medicalising normal phenomena and promoting drugs as

solutions to social problems.12 We examine how drug advertisers use images

to construct mythical and potentially misleading associations between

diseases and products.

 

Theoretical approach: semiology and mythology

 

Interpreting images is a domain of semiology (or semiotics), the general

science of signs. Some semiologists argue that we do not primarily consume

things but the meanings attached to them.13 For example, the Coca Cola

brand is less about a carbonated drink than a promise of social identity.

A sign is a relation between two terms: a signifier (word, sound, or

image) and a signified (a concept).14 Any object can become a sign. For

example, a black pebble may be used to signify a death sentence in an

anonymous vote.15 Roland Barthes initiated a branch of semiology termed

mythology to study modern myths, often derived from ancient forms or

archetypes.15 Myth involves two systems of signs: a language-object

providing myth with signs as its raw materials, and myth itself—a

meta-language, which appropriates the first to convey a specific message.

 

Methods

 

We selected a purposive sample of 60 advertisements from the BMJ for

1999-2001 inclusive. We hand searched all issues of the journal and

selected exemplars. The sample was not designed for generalising to the

population. Each advert was reviewed by two of us to assess its potential

contribution to the study. We selected a final sample of 26 adverts

promoting drugs for a range of medical conditions, including

cardiovascular, gastrointestinal, central nervous system, musculoskeletal,

and respiratory diseases. Each was interpreted jointly by discussion,

usually over several meetings. We present three of our analyses below. Our

interpretations are fallible, though they have been tested

opportunistically against those of a range of individuals not involved in

the study. Other interpretations are possible, and ours should be read as

plausible, not factual, accounts.

 

Results

 

Aprovel (hypertension) " Approval is what you get when you get it right "

This image transports the (UK) reader to an exotic location (fig 1). Clear

blue sky and calm sea denote a high pressure warm front, suggesting

hypertension. The pool's edge divides nature and culture; unbroken surface

tension signifying containment and control in contrast to the ocean's

unbridled force. The man seems to belong to nature, the woman to culture

(beauty and the beast?). Legs hooked over the board, he hangs apishly,

body massively contracted, even his extremities. This suggests an

association between hypertension and inversion: both increase blood

pressure in the brain, neither should be maintained for long. The athletic

stunt, like the medical condition, seeks attention, which comes as a kiss

of approval (or Aprovel).

 

 

 

Fig 1 Aprovel: " Approval is what you get when you get it right "

 

 

 

The woman is also quite taut. Her grip on the pool rim shows she is not

lifting herself up but apparently resisting an uplifting force. This is

another allusion to surface tension: if you imagine the board dipping into

the pool and slowly lifting out, the kissing couple represent a droplet

that clings and stretches between board and surface until it breaks. The

kiss is a tension, joining and separating two bodies. It marries natural

impulse to its acculturated expression, passion and institution, mediating

between nature wild and uncontrolled (untreated hypertension) and nature

tamed and pacified (medicated). The man personifies hypertension, the

woman Aprovel. An explicit association between Aprovel and hypertension is

linked to a series of parallel tensions: atmospheric, postural, muscular,

surface, sexual. Each is paired with an appropriate response: for hot

weather, bathing; for inversion, reversion; for contraction, relaxation;

for a perturbed ocean, the swimming pool; for man, woman; for nature,

culture; for hypertension, Aprovel. The advert naturalises an association

between Aprovel and hypertension by implying their membership of an order

of natural couplings. It is a sophisticated version of a generic

advertising myth: for indication Y, drug X is the natural choice.

 

Symbicort (asthma) " Adjustable maintenance therapy. You've got it in one "

Grotesquely distorted into a mnemonic S, Symbicort snake woman embodies an

alliterative, sibilant association between Symbicort, snake, sex, and

other provocative S-words (symbol, stretch, slither, sensual, slave, suck,

etc) (fig 2). The image signifies a graduated scale ( " Symbicort's

maintenance dose can be adjusted up and down " ). Aggressive colours repeat

the brand name and suggest eroticism. Red cocktail dress and lipstick,

long black gloves and shoes, hair swept back and roguishly un-brushed. She

is sensuous and monstrous; woman metamorphosing to reptile; a hybrid

symbol of disease and sex.

 

 

 

Fig 2 Symbicort: " Adjustable maintenance therapy. You've got it in one "

 

 

 

Evoking Plato's pharmakon, signifying both remedy and poison,16 snake

woman signifies therapy and disease; she soothes and constricts. The palm

trunk signifies a trachea, she its constricting inflammation—the

physiology of asthma. Her feet are rooted in the ground, legs splayed like

vine stems (poison ivy?). These further confuse the erotic and

pathological. Redness signifies inflammation of lust and immune response.

She entwines a phallus, stroking its shaft, head inclined, lips parted—and

simultaneously strangles her lover.

 

The image also invokes the caduceus—snake entwined staff, symbol of

Aesculapius, Greco-Roman god of medicine, and carried by Mercury. Linked

to the underworld, the snake is a mediator between one way of life and

another. The caduceus symbolises medicine as mediator between illness and

recovery. The explicit myth is about changing the way we conceive a

disease and its treatment. It is underpinned by a more remarkable

transformation of woman and snake that can hold the reader's gaze,

fascinated by the sight of a sensuous woman and boa constrictor becoming

one another.

 

Taxotere (cancer) " Leading the fight against advanced breast cancer "

An industry award winner in 2001, this example (fig 3) prompted debate in

the BMJ about what some saw as inappropriate eroticism.17 It is a tableau

of Delacroix's Liberty Leading the People (fig 4). Pink silk flags

substitute for sabres, muskets, pistols, and tricolour in the original

painting to evoke the pink ribbons of the (drug industry sponsored) breast

cancer awareness campaign. It implies that commitment and belief are more

important than blades and bullets in the fight against breast cancer, a

message simplified by removing the naked and dead littering the foreground

of original.

 

 

 

Fig 3 Taxotere: " Leading the fight against advanced breast cancer "

 

 

 

 

Fig 4 Liberty Leading the People by Eugène Delacroix, 1830, in the Musée

du Louvre, Paris

 

Credit: AKG IMAGES

 

 

 

A triumphant woman lofts her flag, her fine dress pulled down, revealing

her breasts. An armpit, site of lymph nodes involved in metastasis, is

exhibited. She is strong and beautiful, but her eroticism is restrained,

her nipples toned down, their paleness an attenuated sign of disease.

Baring her breasts suggest a political statement about divesting the shame

and secrecy associated with breast cancer.

 

The revolutionary stance echoes positions adopted during clinical

examinations. Her impassive face and sideways glance recall the blank

expression and posture of one undergoing mammography. An association is

made between gazing at art and medical images. Her muscular foot is

planted on rock (solid symbol of medical progress), and her expression is

dignified in adversity. The inspirational theme is reinforced by a

defeated woman kneeling at her feet, drawing strength from Liberty

" Leading the fight against advanced breast cancer. " The battle metaphor

for cancer has been discussed extensively.18

 

Treatment for advanced breast cancer can give mothers a few extra months

to spend with young children. Beside Liberty a boy, figure of pathos,

echoes her posture and waves his small flag. He signifies the hopes of

mothers and their children affected by breast cancer and its impact on

families. The top-hatted woman (a man in the original painting) is

ambiguous, perhaps signifying a male or female partner, but also an

institutional revolution, overthrowing outmoded attitudes that some may

associate with the ancien régime of a male dominated medical

establishment, and an ascendance of feminine values and patient advocacy

in cancer care. A hackneyed theme, victory against cancer, but beautifully

executed and interwoven with a modern mythology of patient advocacy, both

having at least a tenuous foothold in the recent history of the disease.

They in turn are associated with a mythology of liberation from

oppression, an age of reason and democracy, the French Revolution and the

start of the Enlightenment.

 

 

Summary points

 

Advertising in medical journals provides a privileged channel of

communication between the pharmaceutical industry and clinicians

 

A critical study of imagery employed in drug adverts reveals it to be one

the most powerful weapons of drug promotion

 

Drug advertising uses strong imagery to fabricate mythical associations

between medical conditions and branded drugs

 

Drug advertising manipulates readers' perceptions by subtle appeal to

ancient and modern mythological foundations of humanism and Western

psychology

 

Clinicians claiming immunity to drug advertising greatly underestimate

some advertising agencies, whose skill they should respect as comparable

to their own

 

 

Discussion

 

Our analysis suggests that myth is often deployed in drug advertising to

depict exaggerated therapeutic efficacy: armed with such drugs, the

clinician can liberate patients from the oppression of disease and restore

them to normality. With medicine as their alibi,15 advertisers exploit the

nude. Accused of eroticism, the company, agency, or reader has an alibi in

physiology. What could be more natural than to deploy a breast image to

promote Taxotere? Eroticism thrives on such ambiguity. For an

extraordinary moment, the seminaked patient is transformed into an

aesthetic nude, object of a thoroughly non-medical gaze, though the

clinical glance may quickly reassert itself. Mythology transports the

clinician into a wider sociocultural context than that of medicine alone.

Viewing exotic or erotic scenes derived from " old masters, " the reader is

relocated from office to gallery, obtaining visual relief from the

clinical grind.

 

In law and science, words are precise and accountable, justified by

evidence. In advertising, the image is ambiguous and unaccountable. It

makes its " killing " (an aggressive metaphor for selling) softly. Thus we

arrive at the very principle of myth: to transform history into nature.15

Associations between diseases and drugs are made to seem natural,

unmotivated by commercial interest. The manifold couplings conveyed in the

Aprovel advert show the principle well. Its administration for

hypertension seems as natural as kissing, bathing, and other variations on

a coupling theme. Condition and brand are presented as belonging to a

higher logical order of things that belong to each other. To naturalise is

also to neutralise or " dis-interest " the intention to promote.

 

Policy implications

The aim of our research is to raise awareness of mythology in drug

advertising, which may lead to doctors being better able to resist

misleading promotion. This implies a need for closer regulation of

journals as a privileged channel of communication from the drug industry

to clinicians. It also highlights a rhetorical mode of persuasion in

contrast with rational argument. By recognising that clinicians are also

consumers, researchers and regulators could learn from advertisers how to

change beliefs and behaviour more effectively than by reason alone.19

 

We thank Iain Chalmers and Barbara Mintzes for supporting the idea of this

study, staff and students at the University of California School of Public

Health and the University of St Andrews School of Management for comments

on seminar presentations of the study, Iain Munro for theoretical advice,

Alan Chandler and Peter Mansfield for suggested revisions to earlier

drafts, and colleagues at the University of York for support and

encouragement.

 

Contributors: TS was responsible for the conception, design,

establishment, analysis, and writing up of the study. NS contributed to

the conception, design, establishment, analysis, and writing. DRT

contributed to the design and establishment, analysis, and writing.

 

Funding: The study was funded by a grant from the University of York

Innovation Fund supplemented by the Department of Health Sciences. Some of

TS's work was done during a Harkness Fellowship in Health Policy 2002-3,

awarded by the Commonwealth Fund of New York.

 

Competing interests: None declared.

 

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