reliance on promotion prescribe less appropriately, 13 and the patients who are exposed more to direct to consumer advertising request more advertised drugs. These requested drugs are usually prescribed, often despite doctors’ reservations about treatment choice. 14 Both critics and supporters of direct to consumer advertising agree that it is likely to expand drug treat-ment in healthier populations. This can occur through broader disease definitions, based on physiological measures rather than on clinical events; through promotion of drugs for disease prevention; and through prescription drug use for symptoms previ-ously treated with over the counter remedies or non-drug approaches. An additional effect, observed in the United States at a population level, is substitution of newer for older drugs among those already receiving treatment. Newer drugs are not necessarily better Evidence on clinical outcomes is often inadequate when drugs first come on to the market, at times lead-ing to false impressions. COX 2 inhibitors, for example, were widely believed to be safer than other non-steroidal anti-inflammatories when first launched. An assessment of the full experience of serious adverse events in comparative trials suggests the contrary. 15 This type of comparative information does not reach the public in direct to consumer advertisements. In a 10 year analysis of advertising in US magazines,
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