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1. Mandatory Disclaimers On Dietary Supplements Do Not Reliably Communicate The Intended Issues...... 1

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Mandatory Disclaimers On Dietary Supplements Do Not Reliably Communicate The Intended Issues
Author: Kesselheim, Aaron S; Connolly, John; Rogers, James; Avorn, Jerry

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Abstract:
Some efforts by the government to regulate the promotional statements of pharmaceutical manufacturers have
recently been found unconstitutional under the First Amendment, which has been interpreted to protect
commercial as well as personal speech. As an alternative means of protecting patients from unreliable
marketing claims, courts have proposed that the Food and Drug Administration could add disclaimers to
promotional messages that discuss off-label, or unapproved, uses. We conducted a systematic review of
studies of the disclaimers currently required for dietary supplements, to assess how well disclaimers inform
consumers' health choices. A few small studies reported a modest impact of disclaimers on consumers'
attitudes about dietary supplements, but larger and more rigorous studies generally revealed that many
consumers were unaware of a disclaimer or reported that it did not affect their perceptions of a product. The
available evidence indicates that replacing government restrictions on pharmaceutical marketing with potentially
ineffective disclaimers will be an inadequate way of informing patients about the efficacy and safety of drugs,
and it risks returning the United States to a previous era when inappropriate marketing claims about prescription
drugs proliferated and contributed to the inappropriate use of those products.

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Full text:
Headnote
ABSTRACT Some efforts by the government to regulate the promotional statements of pharmaceutical
manufacturers have recently been found unconstitutional under the First Amendment, which has been
interpreted to protect commercial as well as personal speech. As an alternative means of protecting patients
from unreliable marketing claims, courts have proposed that the Food and Drug Administration could add
disclaimers to promotional messages that discuss off-label, or unapproved, uses. We conducted a systematic
review of studies of the disclaimers currently required for dietary supplements, to assess how well disclaimers
inform consumers' health choices. A few small studies reported a modest impact of disclaimers on consumers'
attitudes about dietary supplements, but larger and more rigorous studies generally revealed that many
consumers were unaware of a disclaimer or reported that it did not affect their perceptions of a product. The
available evidence indicates that replacing government restrictions on pharmaceutical marketing with potentially
ineffective disclaimers will be an inadequate way of informing patients about the efficacy and safety of drugs,
and it risks returning the United States to a previous era when inappropriate marketing claims about prescription
drugs proliferated and contributed to the inappropriate use of those products.
Brand-name prescription drugs are heavily marketed to physicians and consumers in the United States. One
recent analysis estimated that manufacturers spend $30-$60 billion per year on such marketing,1 including over
$4 billion directed at consumers.2 For decades, the Food and Drug Administration (FDA) has restricted
manufacturers' promotion of prescription drugs in several important ways, including preventing manufacturers
from promoting their products to treat conditions for which the FDA has not determined adequate efficacy or
safety ("off-label uses"). Off-label prescribing activities by physicians are legal and may sometimes be evidence
based or clinically reasonable. However, most off-label uses are not supported by data.3
Off-label drug prescribing has led to poor efficacy or harm in many instances in recent years, such as the use of
nesiritide (Natrecor) for stable congestive heart failure,4 paroxetine (Paxil) for depression in children,5

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antipsychotic drugs in elderly patients with dementia,6 and anti-epileptic medications for certain mood
disorders.7 In each of these cases, patients were harmed by unsafe or ineffective off-label prescription drug
use, which led to litigation. Manufacturers' promotional practices were found to have encouraged these off-label
uses. To prevent patient harm and promote the evidence-based use of prescription drugs, the FDA requires
manufac- turersto submit data proving that a medication is effective and safe before they can promote the drug
for a particular indication.
Recently, the government's right to restrict off-label promotion has been the subject of criticism.8 In US v.
Caronia, a federal circuit court of appeals ruled in December 2012 that the First Amendment of the US
Constitution protects offlabel promotion by manufacturers and their sales representatives as a form of
commercial speech, as long as the marketing is not overtly false or misleading.9 The court's decision rested
largely on its finding that restricting off-label promotion by manufacturers was too broad a policy, because it
argued that other options could achieve the same goal without inhibiting companies' free speech rights. A
prominent alternative suggested by the Caronia court was the inclusion of a disclaimer to warn physicians or
patients when promotional materials described uses that were not approved by the FDA. The US Supreme
Court has also suggested the use of a disclaimer as an alternative to restrictions on promotions related to
prescription drugs.10
This contention is amenable to empirical assessment. The most common disclaimer in the health care
marketplace is the one that is displayed on the packaging and in the advertising of most vitamins and nutritional
supplements. Under the 1994 Dietary Supplement Health and Education Act (DSHEA) and subsequent
government regulations meant to implement the law,11 health-related statements made for dietary supplements
must be accompanied by a standard disclaimer: "This statement has not been evaluated by the Food and Drug
Administration. This product is not intended to diagnose, treat, cure, or prevent any disease."12
Because politicians, policy makers, and judges have mentioned disclaimers as a viable alternative to the
regulation of marketing statements by drug makers in numerous different contexts,13 we soughtto assessthe
evidencethatdisclaimers could fill this role. To determine how well such disclaimers can guide patients'
therapeutic decisions, we conducted a systematic review of all studies that empirically examined consumers'
response to health-related disclaimers.
Study Data And Methods
DATA SOURCES We first searched the PubMed, Embase, PsychInfo, Academic Search Premier, Cumulative
Index to Nursing and Allied Health Literature (CINAHL), and Health Business Elite databases via their
respective interfaces, such as theOvidSPgateway.Literature reviews inrelated subject areas and the abstracts of
known studies on disclaimers helped us refine the search strategy and identify a comprehensive list of search
terms, such as disclaimer, product safety, dietary supplement, and nonprescription drug.
Searches were limited to studies involving human subjects and studies published in English. There were no
date restrictions. Manual reference mining of studies and other reviews supplemented the search results.
We imported the search results into a single grouping using EndNote X5 and screened them for duplicate
entries. For a complete list of search terms and a study selection flow chart, see the online Appendix.14
STUDY SELECTION Studies were included if they collected empirical data on the effect of a disclaimer on
health-related behavior or perceptions. The sources of these data included randomized, nonrandomized,
controlled, prospective, retrospective, or natural experiment studies of volunteers or patients. Policy reviews and
economic simulations that were not driven by data were excluded.
We used a standard dictionary definition for disclaimer: a statement that denies something or "the renouncing,
repudiating, or denying of a claim."15 We thus excluded studies of warning labels on medications that described
the proper use of a product (for example, "Warning: Do not take on an empty stomach") or other healthrelated
warning labels,16,17 such as statements about dangerous health effects of cigarettes (from the Federal
Cigarette Labeling and Advertising Act of 1965), smokeless tobacco (from the Comprehensive Smokeless

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Tobacco Health Education Act of 1986), and alcoholic beverages (from the Alcoholic Beverage Labeling Act of
1988). These warnings tend to be in the form of direct statements, such as advice from the Surgeon General or
a statement that "smoking kills,"18 instead of disclaimers.
We focused primarily on health-related disclaimers. However, we defined health broadly, to include perceptions
of well-being and body image.
To reach consensus on applying these criteria, two of the authors reviewed 10 percent of the search results
independently and compared their results. The same two authors then divided the remaining abstracts and titles
to identify the remaining studies for further review. To qualify for further review, abstracts had to indicate that the
study evaluated health-related disclaimers. Studies that did not involve health-related outcomes, presented no
data, or did not empirically evaluate a disclaimer were excluded at the fulltext stage.
DATA EXTRACTION AND ANALYSIS Data were extracted and checked by three of the authors, with
disagreements resolved by consensus. Var- iables analyzed were study design, nature of the disclaimer, type of
health behavior involved, study population and size, and outcomes. Because of the heterogeneity of
interventions, it was not possible to conduct a formal metaanalysis.
LIMITATIONS One of the main limitations of this systematic review was that some of the randomized studies
were conducted using student volunteers and might not be generalizable to typical consumers of medications.
In addition, studies of disclaimers related to dietary supplements might not predict the effect of disclaimers
appliedto othertreatments, suchas prescription medications.
We found no studies that tested physicians' responses to disclaimers. However, we would expect the results of
such studies to be similar to those of studies that involved consumers, since physicians' observed behavior
mirrors consumers' responses to marketing experiments in other experimental contexts.19
Study Results
SEARCH RESULTS AND STUDY SAMPLE Our initial search identified 1,084 articles. After reviewing their
abstracts, we found that 102 appeared to examine disclaimers as part of the research question; 18 were
identified from manual reference mining (for a visual representation of the study selection process, see
Appendix Exhibit 1).14 After a review of the 102 articles, we found that 17- discussing 19 different studies-met
the inclusion criteria.
Ten of the seventeen articles (which collectively discussed eleven studies) studied the effect of disclaimers for
nutritional supplements on consumers' use or perception of these products. Nine of the studies used the
DSHEA-mandated disclaimer, while two tested a slight variation in the disclaimer's phrasing.We report these
data in detail below, because they were most relevant to our study question.
The remaining seven articles (which collectively discussed eight studies) addressed disclaimers related to other
health-related issues, including body image, perceptions of vaccine safety, and dental services. Results from
these studies, which supported the findings in our primary analysis, are discussed in the Appendix.14 We found
no studies that addressed disclaimers related to prescription drugs.
The eleven studies in our main analytic set were discussed in articles published between 2003 and 2011. The
studies used a number of different methodologies: written surveys (five studies, or 45 percent), phone surveys
(one study, or 9 percent), focus groups or interviews (three studies, or 27 percent), and a combination of these
(two studies, or 18 percent).
Five of the studies involved randomly assigning participants to view health-related information with or without a
disclaimer and then measuringtheir behaviors, beliefs, or both, as related to the product in question. These
controlled studies of consumers' responses to disclaimers present the most compelling data about the
disclaimers' effect. The remaining six studies were surveys and other qualitative studies of disclaimers that
provided descriptive insights into consumers' perceptions of dietary supplements.
RANDOMIZED STUDIES ON THE IMPACT OF THE DISCLAIMER The aforementioned five randomized
studies were of consumers' interpretation of the safety and efficacy of various dietary supplements when a

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DSHEA disclaimer was present (Exhibit 1). The two largest assigned participants to assess hypothetical dietary
supplements labeled with the DSHEA disclaimer or not.
In one, Karen France and Paula Bone presented 359 adult consumers in geographically diverse mall settings
with a dietary supplement (listed as either garlic or herb X) and bearing a claim that the supplement "maintains
a healthy circulatory system"20(p39) or "may reduce the risk of coronary heart disease."20(p29) The authors
then tested the effect of the standard DSHEA disclaimer on subjects' interpretation of these messages. The
authors found no effect of the presence or absence of the disclaimer on consumers' belief that the product
would have the effect it claimed to have, nor on their belief that the FDA had evaluated the manufacturer's
claims of effectiveness-despite the DSHEA disclaimer clearly stating that the FDA did not review the claims.
In the second study, Tonya Dodge and Annette Kaufman randomly assigned 266 undergraduates to assess a
hypothetical dietary supplement intended to improve muscle mass and burn fat, with or without the standard
DSHEA disclaimer.21 Participants answered seven questions about the product's effectiveness and safety.
Those assigned to the disclaimer group rated the product slightly less effective but rated the two
productsequallysafe. Interestingly,inaseparate arm of the study, listing the hypothetical dietary supplement as
"FDA approved" had a significantly positive effect on participants' view of its safety but had no effect on
perceptions of its efficacy.
In 2011 Tonya Dodge and coauthors published a follow-up study of 185 student volunteers.22 The authors
presented a hypothetical supplement intended to stimulate resistance to upper respiratory tract conditions. This
study also showed no evidence that the DSHEA disclaimer or information about FDA approval versus
nonapproval affected participants'evaluations ofthe product's effectiveness.
Two other randomized studies by Marlys Mason and coauthors focused on dietary supplement users to assess
whether the DSHEA disclaimer affected perceptions of two fictitious products. In the first study, the authors
presented a fictitious energy supplement without a disclaimer, with the standard DSHEA disclaimer,or with a
directwarning that the product"may result in side effects such as high blood pressure, heart attack, or
stroke."23(p83) They found no effect of the DSHEA disclaimer on safety ratings, overall product evaluations, or
efficacy ratings by the respondents. By contrast, the direct warning of the risk of side effects was associated
with perceptions of lower product safety, compared to both the disclaimer (p 0:001) and the absence of a
disclaimer (p 0:03), and with perceptions of higher product efficacy, compared to the absence of a disclaimer
(p 0:04).
In the second study,23 the same researchers presented a fictitious weight loss supplement to 199
undergraduates, of whom 61 were current or previous weight loss supplement users. The researchers found
similar results. Respondents tended to be more aware of potential health risks when presented with a direct
warning, as compared to a disclaimer (p<0:001). Compared to participants who viewed the disclaimer, those
who saw the direct warning of side effects had lower perceptions of the product's safety (p<0:001) and lower
overall evaluations of the product (p 0:001) on a seven-point Likert scale. Neither the disclaimer nor the safety
warning affected perceptions of effectiveness, with undergraduates who had experience with weight loss
supplements more likely to rate the product's effectiveness higher.
SURVEYS AND QUALITATIVE STUDIES ON NUTRITIONAL SUPPLEMENT DISCLAIMERS The remaining
six studies used various qualitative metrics to address how consumers interpret and react to disclaimers (Exhibit
2). The largest study, by Janine Pillitteri and coauthors, was a phone survey of 3,500 adultsthat assessed their
perceptions of dietary supplements.24 The investigators found that 48.8 percent of self-identified supplement
users and 45.0 percent of nonusers agreed with the statement that over-the-counter "appetite suppressants,
herbal products, and weight loss supplements must be approved for efficacy, or effectiveness, by a government
agency like the FDA before they can be sold to the public."24(p791) The DSHEA disclaimer notes clearly that
the effectiveness claims made for the product have not been reviewed by the FDA.
The authors similarly found that supplement users and nonusers were equally likely to believe that supplements

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must be approved for safety by the FDA (OR: 1.00; 95% CI: 0.81, 1.25). The researchers concluded that the
disclaimers commonly found on these items did little to reduce consumers' misperceptions of the role of the
FDA in the supplements' approval.
Marlys Mason and Debra Scammon confirmed these results in a qualitative face-to-face interview study of
dietary supplement users.25 The authors found that users knew about the disclaimer, but many still believed
that the FDA had tested the claims made by the manufacturer. Mason and Scammon also found that
consumers generally distrusted the government's ability to effectively regulate dietary supplements.
Mary Meer and coauthors conducted focus groups of thirty-four people to investigate their views of nutritional
claims.26 The authors found that there was widespread use of dietary supplements and that 27 percent of the
study population was unaware of the disclaimer. Similarly, Carla Miller and Teri Russell conducted a qualitative
study of fifty-one supplement users and found that only a third of them believed that the FDA did not approve or
regulate supplements, despite the presence of the disclaimer.27
The two remaining studies included small numbers of participants. Melanie Cupp mailed a survey to 500
patrons of five West Virginia pharmacies but obtained only twenty-five responses.28 Participants read a
supplement label and DSHEA disclaimer taken directly from a product label and described in their own words
whatthe disclaimer meant. Only about half of the respondents correctly described the meaning of the disclaimer,
and only 28 percent of the subjects who understood the intended use of the product correctly interpreted the
disclaimer's meaning. Sara Eggers and Baruch Fischhoff interviewed sixteen men about a supplement used for
prostate health, both with and without a disclaimer, and found that the disclaimer increased confusion and led to
worse decision making than the health claim alone.29 Both studies, however, lacked sufficient power to enable
any firm claims about the effect of the disclaimer.
As noted above, in addition to the eleven studies in our main analytic set, we found eight studies that looked at
disclaimers relating to products other than dietary supplements (for results of these studies and additional
discussion of them, see Appendix Exhibit 2).14 In general, these studies also found that disclaimers tended to
be misinterpreted or had little effect on people's views of product safety and effectiveness.
Discussion
We identified only a handful of studies that attempted a rigorous assessment of the impact of mandatory
disclaimers attached to dietary supplements on consumers' perceptions of the safe- ty and effectiveness of the
products or of their regulatory status. Nearly all of these studies found that consumers were generally unaware
of the disclaimer or attached no weight to it in their perceptions of the product. Overall, the existing evidence
base presents a disappointing picture of the effectiveness of disclaimers as a means of communicating the
limitations of health claims that do not meet scientifically rigorous standards for validity.
There are at least three reasons why disclaimers may have had such unimpressive effects. First, recipients of
advertising messages may be overwhelmed by the totality and complexity of the marketing messages to which
they are subjected. Instead of focusing on the disclaimer, recipients may be distracted by the more prominent
images30 or accompanying statements provided by manufacturers' representatives or paid endorsers.31 Social
psychology studies demonstrate that people reading complex advertising messages tend to devote minimal
attention to any one stimulus element32 and generally do not process the full meaning of most advertising
messages to which they are exposed.33
The concern that the disclaimer may be overwhelmed by other marketing content is particularly relevant to
complex health products, including dietary supplements and prescription drugs promoted for off-label uses.
Promotional materials for such products are notoriously complex. They generally feature numerous
healthrelated claims; statistical or anecdotal information to back up those claims; and, in the case of prescription
drug advertising, extensive text about safety information.
Second, readers or viewers may be aware of the disclaimer but discount its importance. One survey found that
a majority of Americans believed that advertising associated with health-related products was "generally

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true."34
In the pharmaceutical marketplace, some studies have shown that physicians tend to trust marketing messages
that they receive, even when contradictory scientific evidence is available.35 This psychological predisposition
may explain the success of manufacturers' previous off-label marketing promotional campaigns that
encouraged physicians to use products for unapproved indications-such as antipsychotic medications for
behavior control in elderly patients with dementia, paroxetine for childhood mood disorders, or nesiritide for
stable heart failure-despite the lack of adequate evidence supporting the effectiveness or safety of such use.
These attitudes may be changing, at least among physicians. More recent research indicates that physicians
are more skeptical of studPromotional ies supported by pharmaceutical companies than they are of similar
studies supported by the National Institutes of Health.36
Third, disclaimers also may not have had much impact because consumers who do not understand the role of
the FDA in the marketplace may discount the relevance of a given disclaimer.37 The studies in our systematic
review that investigated this question found that consumers generally did not understand the limited role that the
FDA plays in dietary supplement regulation, even when it is described verbatim in a disclaimer. This concern is
also applicable to off-label promotion, since consumers-and even some physicians-may not understand the role
of the FDA in approving indications for prescription drugs or the lack of regulatory oversight for off-label
indications or claims.
Our study has important implications for nutritional supplement regulation. First, it is revealing that only a small
number of controlled studies have tested the impact of the DSHEA disclaimer on consumers. Second, the
studies that do exist were nearly all conducted in experimental settings instead of among real patients making
health-related choices. The DSHEA did not include funding for studies to determine whether the disclaimer was
having its intended effect.
Despite the growth of the dietary supplement industry into a multibillion-dollar enterprise, currently consuming
over $30 billion in the United States, the regulators and health services researchers still know very little about
the impact of the dietary supplement disclaimer or how it influences consumers' health behavior. Similarly, little
is known about ways of maximizing comprehension of such disclaimers, related to their positioning on the
product, wording, or other practical characteristics. For example, previous research has found that small
alterations in the wording of warning statements can have a substantial influence on consumers' perceptions.38
Additional research on this topic is sorely needed.
The limited effect of disclaimers is likely to be even more attenuated outside of the experimen- tal setting. For
instance, compliance with rules that require the use of disclaimers or mandate a certain positioning of them may
be poor. One review of real-life implementation of printed disclaimers for bodybuilding dietary supplements
showed that the disclaimers were typically not placed near the specific health-related claims and sometimes
were even placed on different pages.39 When present in advertisements or television commercials, the DSHEA
statement is often presented in a hard-to-find way, whether through tiny type or (on television) a fleeting
appearance, if it is there at all. In addition, the advertisements ignored FDA requirements that disclaimer
information be presented in a standalone paragraph in an appropriate contrasting typeface.39 One study of
Internet-based dietary supplement advertising found that 52 percent of 292 website ads that contained a health
claim omitted the required DSHEA disclaimer altogether.40
The impact of disclaimers on patients' perceptions of medical product marketing claims is important because
dubious claims about such products abound.41 In the dietary supplement market, for example, one retailer
supported its herbal supplement with reference to an allegedly scientific studythat turnedout to be a 1931 report
about a product that more rigorous subsequent studies showed to be dangerous.40
In the prescription drug context, government investigations of illegal off-label marketing have led to over $15
billion incivil and criminal fines.42 The marketing campaigns in many of these cases featured selective
promotion of positive results or relied on inadequatestudies to support an offlabel use of a prescription drug that

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would not have passed (or, insome instances, did not pass) FDA scrutiny for formal approval. They featured
selective promotion of positive results or relied on inadequate studies to support an off-label use of a
prescription drug that wouldnot have passed FDA scrutiny for formal approval. In response to these
investigations, some manufacturers have been required43 or have promised44 to change their marketing
practices to ensure that they promote only uses that have been validated by the FDA.
Our results also highlight the ongoing public healthconcernsposed by certain nutritional supplements. Numerous
reports have detailed the hazardous substances-such as amphetamine analogues and other stimulants-
included in some products labeled as nutritional supplements and sold to US consumers based on claims such
as reducing weight, enhancing athletic performance, or improving sexual function.45
The experimental evidence assembled in our review makes it clear that the mandatory DSHEA disclaimer does
not seem capable of exerting a substantial salutatory effect on consumers' behavior in relation to these
products. This can lead to adverse patient outcomes, as well as failure to use more effective, approved
treatments. The observed lack of impact of such disclaimers suggeststheneedto revisit whethercertainhighrisk
nutritional supplements should have better safety testing prior to widespread use, and it raises questions
concerning the adequacy of this approach for guiding the use of prescription drugs in a more permissive
environment.
Conclusion
Since 1962 the FDA has required that prescription drugs demonstrate safety and efficacy through standard
means of evaluation before they can be used by the public. Before courts or policy makers advocate
communication strategies such as disclaimers as an alternative to direct FDA regulation, it is reasonable to
evaluate the impact of these interventions.
Our review of the literature indicates that appending disclaimers to "free speech" claims for uses of medications
that have not passed scientific muster has not demonstrated sufficient effectiveness to warrant the use of
disclaimers on a large scale in the marketing of health care products. We found ample evidence that such
disclaimers are often misunderstood or ignored by consumers and had no effect on consumers' ability to
understand messages about health care products and critically evaluate potentially unsupported statements
about effectiveness or safety. Thus, the prospect of replacing FDA restrictions on permissible statements for
prescription drugs with largely ineffective disclaimers risks returning the pharmaceutical market to a previous
era when such inappropriate marketing claims proliferated, to the likely detriment of the public health.
Aaron Kesselheim's work is supported by a Greenwall Faculty Scholarship in Bioethics and an Ignition Award
from the Harvard Program in Therapeutic Science.
Sidebar
The government's ability to restrict off-label promotion has been the subject of criticism.
Promotional materials for dietary supplements are notoriously complex.
Footnote
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medications in the United States, 1995- 2008. Pharmacoepidemiol Drug Saf. 2011;20(2):177-84.
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44 Kindler J. Business must change to earn back the public's trust. The Great Debate [blog on the Internet].
2010 Mar 17 [cited 2015 Feb 4]. Available from: http://blogs.reuters .com/great-debate/2010/03/17/
businessmust-change-to-earn-backthe-publics-trust/
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AuthorAffiliation
Aaron S. Kesselheim (akesselheim@partners.org) is an associate professor of medicine at Harvard Medical
School, in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women 's Hospital,
in Boston, Massachusetts.
John Connolly is a research assistant in the Division of Pharmacoepidemiology and Pharmacoeconomics at
Brigham and Women 's Hospital.
James Rogers is a research assistant in the Division of Pharmacoepidemiology and Pharmacoeconomics at
Brigham and Women 's Hospital.
Jerry Avorn is a professor of medicine at Harvard Medical School and chief of the Division of Pharmaco-
epidemiology and Pharmaco-economics at Brigham and Women'sHospital.

Subject: Studies; Pharmaceutical industry; Dietary supplements; Marketing; Disclaimers; First Amendment-US;
Consumer protection;

Location: United States--US

Classification: 9190: United States; 9130: Experiment/theoretical treatment; 8641: Pharmaceuticals industry;
7000: Marketing; 4310: Regulation

Publication title: Health Affairs; Chevy Chase

16 March 2017 Page 9 of 10 ProQuest

Volume: 34

Issue: 3

Pages: 438-446

Number of pages: 9

Publication year: 2015

Publication date: Mar 2015

Section: PATIENT ENGAGEMENT

Publisher: The People to People Health Foundation, Inc., Project HOPE

Place of publication: Chevy Chase

Country of publication: United States

Publication subject: Insurance, Public Health And Safety

ISSN: 02782715

Source type: Scholarly Journals

Language of publication: English

Document type: Feature

Document feature: Tables References

DOI: http://dx.doi.org/10.1377/hlthaff.2014.0515

ProQuest document ID: 1660922229

Document URL: http://search.proquest.com.ezproxy.library.wisc.edu/docview/1660922229?accountid=465

Copyright: Copyright The People to People Health Foundation, Inc., Project HOPE Mar 2015

Last updated: 2015-03-10

Database: Agricultural & Environmental Science Database,Business Premium Collection

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16 March 2017 Page 10 of 10 ProQuest