Behind the stealth ad campaigns for the EpiPen and other drugs

Mylan Pharmaceuticals has spent millions this year on television ads and celebrity testimonials that implicitly promote the EpiPen — without ever mentioning it by name.

“Talk to your doctor about a prescription treatment you should carry for severe reactions,” the narrator urges in a dramatic TV ad.

“There is still so much more we can do for the millions of people at risk of anaphylaxis, a life-threatening allergic reaction,” the actress Sarah Jessica Parker, at the time a paid Mylan spokeswoman, wrote on her verified Instagram account.

Welcome to the world of unbranded ads, a stealthy and lightly regulated form of drug marketing focused on educating the public about a health condition — which the pharma company just happens to sell a product to treat. The ads aren’t required to disclose side effects. Instead, they often direct patients to a website about the disease. Click on a few links and you’ll likely land on a page promoting the branded treatment.

The tack has fluctuated in popularity over the years, but it seems to be on the upswing, perhaps in part because public distrust of the pharma industry is so high that drug makers are scrambling for ways to promote their products more subtly, analysts said.

Two unbranded campaigns — Mylan’s allergy awareness ads and Merck ads about vaccines — both ranked among the top 10 most expensive TV drug ad campaigns last month, according to data from the ad tracking firm iSpot.tv, first reported by Fierce Pharma.

Other unbranded campaigns have also made headlines recently: The marketer of a drug for opioid-induced constipation aired one during the Super Bowl, stirring controversy. Another unbranded ad, from the maker of a heart failure drug, drew sharp condemnation from cardiologists who called it manipulative and shameful. And on the positive side, an inspiring unbranded ad from the maker of a portable oxygen device took the top prize at pharma advertisers’ equivalent of the Academy Awards in June.

All told, the drug industry has spent $171 million on unbranded ads so far this year, up 15 percent over the same period last year, according to the media research firm Nielsen.

That’s only a fraction of the industry’s total ad spending; last year drug makers spent a whopping $6 billion, mostly on branded ads that explicitly promote their products.

But the rise of unbranded ads worries some public health analysts. “The risks are magnified that misleading information will reach the consumer,” said Ameet Sarpatwari, an epidemiologist at Brigham and Women’s Hospital who has studied drug promotion.

Patients viewing unbranded ads “may not be able to attribute that this information is coming from a company with a clear profit motive,” Sarpatwari said. And they don’t get disclosure of the risks associated with treatment.  “That’s a twofold whammy for consumers,” he said.

‘More mileage for your dollar’

In Mylan’s 60-second branded ads for the EpiPen, the narrator rattles off a litany of possible side effects: “faster, irregular, or pounding heartbeat, sweating, nausea and vomiting, difficulty breathing, paleness, dizziness, weakness, or shakiness, headache, nervousness, or anxiety.” And if you have high blood pressure or diabetes? The side effects “may be more severe or last longer.”

Compare that to Mylan’s 30-second unbranded ads for anaphylaxis awareness, which don’t mention the EpiPen’s possible side effects at all.

Mylan has bought nearly $15 million worth of airtime for the unbranded campaign since it launched in April, according to iSpot.tv. That’s just a few million short of the sum the company has spent this year on branded EpiPen TV ads. Mylan also hired Parker as an unbranded spokesman, at additional cost. (The actress quit last week to show her anger at the EpiPen price increases.)

Mylan didn’t respond to a request for comment on its unbranded ads.

Being legally allowed to skip risk disclosures means “you can get more mileage for your dollar in getting the word out,” said John Kamp, executive director of the Coalition for Healthcare Communication, a trade group for pharmaceutical marketing companies and medical publishers. He sees that as a benefit for patients, because the ads can spend more time explaining the health condition and leave discussions of treatment risks and benefits to doctors.

To be sure, drug makers don’t get a total free pass with unbranded ads.  In 2010, the Food and Drug Administration issued a warning to GlaxoSmithKline over an ad in a medical journal that promoted a “NEW treatment option for refractory chronic lymphocytic leukemia” without mentioning the name of that option or its potential side effects. The problem? GSK’s new drug, Arzerra, was the only product the ad could possibly be alluding to, regulators said.

But such interventions are rare.

Unbranded drug ad or horror film?

If you watch enough unbranded drug ads, you’ll notice a theme: they’re often pretty ominous in tone.

In Mylan’s anaphylaxis awareness ad, a young woman is shown with alarming red splotches all over her skin after accidentally ingesting peanuts. She gasps and collapses as her panicked friends try to help.

In the heart failure awareness ad panned by cardiologists, from Novartis, an older man sits in an armchair obliviously reading the newspaper while his living room floods with more and more water. All the while, suspenseful music plays in the background while a narrator says that more than half of people die within five years of being diagnosed with the condition.

Those are tame compared to a recent interactive digital ad from Boehringer Ingelheim designed to raise awareness of chronic obstructive pulmonary disease for which the company sells a treatment. Users can press a key to toggle between two videos of an older woman’s day: In one, she embraces her grandchildren and enjoys a serene afternoon with them in a leafy park. In the other, colors are inverted and music fit for a horror movie blares as the woman gasps for breath and is rushed to the hospital.

Another recent unbranded ad, also from Boehringer Ingelheim, relies on eerie silence to raise awareness of a fatal lung disease for which the company sells a treatment.

It’s no coincidence that these ominous ads are unbranded, said John Mack, who has tracked many of them in his digital newsletter Pharma Marketing News.

If you’re a drug maker, “you don’t want to attach a dark image to the brand — so you’re attaching this dark imagery to a medical condition instead,” Mack said. That leaves room for a branded ad that shows “the bright side: that there’s this product that can save the day.”

Kamp defended the dark ads as appropriately clear-eyed about serious conditions. “I would expect them to reflect the alarming situation in which they’re used,” he said.

Diverting focus away from a distrusted industry

Drug makers are less popular than lawyers and oil companies, and just barely less hated than the federal government, according to a new Gallup poll of public opinion.

They’re also under fire for TV advertising on several fronts. The American Medical Association last fall called for a ban on all such ads. Pending bills in Congress would place new restrictions on the practice, and Hillary Clinton wants to crack down on the practice, too.

All of which means drug advertisers have a lot of incentive to distance themselves from the messages they’re trying to convey.

“I think that drug companies are aware that their credibility is fairly low among the public right now,” Sarpatwari said.

That’s where unbranded ad campaigns come in. With names like “Face Your Risk” and “Anaphylaxis For Reel,” Mylan’s disease awareness campaigns don’t sound much like a drug company’s marketing push. Indeed, Gizmodo reported last week that the TV show “The Doctors” incorrectly identified “Anaphylaxis for Reel” as a nonprofit initiative on a YouTube page featuring a clip of Parker. (That language has since been changed.)

Companies say that making celebrities the face of their unbranded campaigns simply amplifies the reach of important educational messages. But it’s also a way to downplay the drug company’s involvement.

Just last week the actress Jennifer Aniston signed up to promote dry eye awareness for Shire, which just launched a new drug for the condition. And Hall of Fame quarterback Joe Montana recently signed a deal to promote heart disease awareness for Amgen, which has a rich portfolio of cardiovascular drugs.

It’s hard to tell how effective unbranded ads are in actually driving sales; most of the research on that question is done secretly by drug makers, with CEOs only vaguely gesturing at the returns in quarterly calls with investors.

Such ads are best primed to succeed, experts said, in cases where the drug advertiser makes the only or the dominant treatment for the condition being advertised.

That’s the case with Vanda Pharmaceuticals, which has spent $29 million in the last two years on unbranded TV ads aimed at raising awareness of a rare sleep disorder that can afflict blind people. It makes the only treatment for the condition.

It’s also the case with Mylan, which dominates the anaphlyaxis treatment market, giving the company free rein to increase the price of the EpiPen more than fivefold in recent years — and ensuring that viewers who see the unbranded ads and rush to their doctors to request a treatment will emerge, more often than not, with a prescription for the EpiPen.