Articles

A Different Perspective: Placebo, SCAM, and Advertising

Summertime, time, time

Child, the living’s easy.

Fish are jumping out

And the handicap, Lord

Handicaps high, Lord so high

~ Janis Joplin

It is summer. Time for the kids and the outside, not the computer. What follows is a summertime blog entry, for which I admit to feeling guilty for the comparatively little time I have spent on it, but as I have said before, no dying patient has ever told me “Doc, I wish I had spent more time at work.”

Mt. Hood has been a constant feature to the east my entire life. The mountain, on a clear day at least, is Portland’s most impressive geologic feature. If you are in the right part of the city, you may see Mt. St. Helens or the tips of Jefferson, Adams and even Rainier, but Mt. Hood dominates. It is solitary mass of rock, (diminishing) ice and snow only 50 miles from where I live. I have spent uncountable hours hiking in the Mt. Hood wilderness. When I think of Mt. Hood, in my mind’s eye it is from the perspective of west Portland looking east.

Last week was our yearly summer vacation in Sunriver, just south of Bend Oregon on the eastern side of the cascades in the Oregon High Desert. Driving north/south on highway 97 puts Mt. Hood in a different perspective. From the high desert you can see the huge swaths of the Cascades: calderas, mountains, lava fields and cinder cones. You see Mt. Hood differently. Not a single mountain to the east, but part of a chain of recent and distant historical volcanic activity along the Rim of Fire. Photographs do not do the view of the Cascades justice from this vantage point.

The eastern view puts Mt. Hood in a broader geologic and time perspective. It is still the same Mt. Hood, but in a different context. Like running into a nurse outside of the hospital, you have to recalibrate the context in which you understand and know the person.

I have written on placebo, the placebo effect, and its relationship to SCAM. To my understanding the preponderance of literature indicates there is no placebo effect upon any objective medical problem, only a change in the patients perspective of the problem.

The placebo effect is, as I have mentioned before, the Beer Goggles of Medicine. I look a lot better and am infinitely more amusing if you have consumed a pint or two of Mirror Pond, but really, I remain the same. Of course, for treating pain a change in perspective can be of benefit. Depending on whether you are an ends-justifies-the-means kind of guy, placebo outside the context of a clinical trial is not ethical as it requires lying to the patient.

SCAMs are usually no better than placebo in well-performed trials and have no efficacy in the treatment of disease. There has been a tendency to suggest that when a SCAM has the same outcome as placebo, but is better than doing nothing, that the effect of the SCAM is due to powerful placebo effect. I have this long standing rant in my infectious disease lectures that the only thing in medicine that has 100% sensitivity and specificity is when a health care provider uses the terms “big-gun”, “strong” or “powerful” in relationship to antibiotics they know nothing, zip, zero, zilch about the treatment of infectious diseases. It is always the mark if profound ID ignorance. Similarly if someone refers to the placebo effect as “powerful” they are equally guilty of imitating Jon Snow, at least when it comes to altering physiology.

I would be the last to argue that interaction between patient and physician is not important. What is said and how it is said is very important in numerous ways, as long it says within the bounds of honesty. Part of my job is to ‘sell’ a particular course of action to a patient. I do not want to leave anyone nonplussed as to my use of the word sell. I am not talking monetary exchange. I am using it with the definition “To persuade (another) to recognize the worth or desirability of something.”

I need to convince people that I know what needs to be done diagnostically and therapeutically, interventions that can he painful, expensive and prolonged. Telling someone we need to take out their artificial hip, get a 6 week course of IV antibiotics at a nursing home, wait another few months and only then get another hip is no small undertaking. Part of the placebo effect, of changing the patient perspective, is, I suppose, part of the cheerleading and encouragement you need to do to coax people through very difficult times.

Although I have not considered placebo with this term before, my interventions with patients are a form of advertisement where I choose my words that help convince patients that their therapies are working and effective. I am trying to generate a positive placebo effect. Antibiotic goggles anyone?

What started me thinking about placebo and advertising was a curious reference “Advertisements impact the physiological efficacy of a branded drug” sent by a colleague.

The study is curious and I think the results are spurious, mostly noise of questionable significance rather than a manifestation of a real effect. The big cut and paste:

A subject was given a skin allergy test for common allergens. A research technician administered a histamine challenge on the subject’s forearm, and a baseline measurement of the wheal reaction was taken. The wheal reaction is the slightly reddened, elevated area at the site of the challenge and is a well-established measure of histamine response (2). All normal individuals, whether they have allergies or not, develop a wheal reaction to a histamine challenge. The subject reported her belief about the efficacy of Claritin. She was given 10 mg Claritin and was made aware that it was Claritin. She was shown a movie spliced with naturally timed advertisement breaks. In one condition (Claritin advertisements), one advertisement in each break was an advertisement for Claritin. In the other condition (Zyrtec advertisements), one advertisement in each break was an advertisement for Zyrtec. The Zyrtec advertisement stated that Zyrtec “starts working two hours faster than Claritin.” The histamine challenge and wheal measurement were repeated during the movie, 60 and 120 min after Claritin was administered. At the end of the experiment, the subject was again asked her belief about the efficacy of Claritin. We define the efficacy of Claritin (at 60 and 120 min) as the percentage decrease in the size of the wheal reaction relative to the baseline. We thus have a subject-specific measure of efficacy. By comparing the efficacy across the subjects in the two advertisement conditions, we identify the impact of advertisements on the efficacy of Claritin. In the subpopulation without allergies, we find that the efficacy of Claritin at 120 min is substantially higher for subjects who were exposed to Claritin advertisements. Claritin advertisements have no significant impact on efficacy 60 min after the drug is taken. This pattern is consistent with the observed changes in the subjects’ beliefs. Exposure to Claritin advertisements in this sub- population greatly increases the belief in the efficacy of Claritin. At the same time, the realized efficacy of Claritin at 120 min (but not at 60 min) is strongly correlated with the change in beliefs. In the subpopulation with allergies, we find no relationship between exposure to Claritin advertisements and the change in beliefs. Moreover, the advertisements have no impact on the efficacy of Claritin at 120 min. We do find a curious negative impact of Claritin advertisements on Claritin’s efficacy at 60 min in this subpopulation, but this effect cannot be mediated by the (nonexistent) impact of advertisements on beliefs.

After reading the study, the effect is barely statistically significant but clinically irrelevant results from the noise of clinical studies.

But it does bring up the issue of the importance of advertising in promoting efficacy of placebo effects. As they note in the paper,

A small existing literature examines the impact of commercial features of drugs on their efficacy. Previous experiments show that the color, the packaging, and the price of drugs affect their perceived efficacy.

What are most SCAMs but advertising an unneeded and useless product to people who do not need it?

My perspective of most SCAM has been focused on the truth and reality of their claims, but truth and reality have little to do with advertising. I have been shaving for 40 plus years and never, not once, has a female rubbed my cheek with the back of her hand after a shave. Never, even though that appears to be a common effect of shaving in most advertising see on TV.

The tools of rational thought and science may not be the best approach for an industry, SCAM, that is based on advertising. I need a different perspective to analyze SCAM, that of the psychology of desire. Not why people believe weird things, but why they buy weird things. I ran across an enormous number of books and journals, all behind paywalls, on the techniques used by advertisers to entice people to part with their money for sugared water.

That may be the paradigm, the perspective, to understand SCAM, but that will have to wait for a rainy winter’s day. I have a tee time with my kids and a mere two weeks before they disappear into school. Gotta run.

Posted in: Basic Science, Clinical Trials, Science and Medicine

Leave a Comment (32) ↓

32 thoughts on “A Different Perspective: Placebo, SCAM, and Advertising

  1. windriven says:

    “What are most SCAMs but advertising an unneeded and useless product to people who do not need it.”

    Brilliant!

    I view advertising as simply the art of monetizing credulity. And that is precisely what sCAMs do.

  2. windriven says:

    ” if you have consumed a pint or two of Mirror Pond, ”

    Am I alone in lamenting the passing of Bridgeport’s Blue Heron as a bottled beer? It is still available at the brew pub but no longer in stores. Well balanced craft beers seem to be giving way to an increasing fixation on brews that are hopped far in excess of, say, an India Pale Ale (another style that Bridgeport executes quite well).

    None of this to disparage Mirror Pond, an exceptionally well made pale ale. Deschutes, brewers of Mirror Pond, have also been pretty resistant to the hop madness sweeping Beervana and its environs. Hopping the bejesus out of (into?) ale started as a preservation technique to keep beer from spoiling in the heat and humidity of The Raj. The extra hoppiness has the serendipitous side effect of being especially refreshing on a warm summer’s day.

    Unfortunately, this is America where if something is good and a little more something is sometimes better, than a whole Texas crapload must be really great! Hence we are now assaulted with things like Bridgeport’s Kingpin, Laurelwood’s Hop Monkey, and Ninkasi’s Tricerahops.

    As Garrett Oliver, brewmaster of the Brooklyn Brewery was quoted in an NYT piece some years back:

    “The hoppiest beer? It’s a fairly idiotic pursuit, like a chef saying, ‘This is the saltiest dish.’ Anyone can toss hops in a pot, but can you make it beautiful?”

    1. angorarabbit says:

      Ah, Windriven, it is sadly here where we must part. It would be very difficult to add enough hops for my IPA. I recently spent time in Oregon and was in hop heaven, not the least of which sign was the OSU test hop fields directly behind where I was on sabbatical. Tricerahops…anything from Calpooia,..fresh hopped varieties from Rogue and Deschutes…I’d miss it more if I didn’t live in another Bheer Heaven. I know Santa is real because he puts Amarillos in my Xmas stocking. Hops Are Beautiful.

      Garrett Oliver? Hmph. Everyone knows that East Coasters can’t make beer. Well, apart from Dogfish and the most excellent Harpoon. ;)

      And while I’m waxing pedantic, I know the recording well, but shouldn’t it be George and Ira Gershwin? I’m just sayin’ as an operaholic. ;) the second time

      1. windriven says:

        Ah Angora, happily there is a beer for every palate here in the PNW. :-)

        But help me out: I’m not following the allusion to Gershwin. Porgy and Bess? Blue Monday? I’m feeling exceptionally stupid.

        1. mousethatroared says:

          The song Summertime at the beginning of the post, is originally from Porgy and Bess.
          Apparently there are, like 25,000 different versions…and dammit, now I have to spend the rest of the day listening to all the versions I can find to figure out my one.

      2. Mark Crislip says:

        I like hops. Less like salt, more like cinnamon or vanilla, which I add if not in the recipe and triple if present.

        As to the east, I am partial to Syracuse IPA which has an odd but delicious banana flavor. I drink it at Dinosaur Bar-B-Que when I visit my son at college. But then I love the Alaska ale with spruce tips they sell in the winter and think Sam Adams are all oddly bland.

        And is it my imagination, or are the comments different, more personal, on my blogs?

        1. windriven says:

          “And is it my imagination, or are the comments different, more personal, on my blogs?”

          The comments are more personal because your blogs are more personal. Also funnier. But no less cogent. Well done.

        2. It’s the beer–and the Portland connection for me. :-) Perhaps also the comparative lack of medical/legal-ese?

  3. Alia says:

    As an anecdote, I know several people who believe that brand-name paracetamol works much quicker on their headaches than a cheap, generic alternative (even though the formula and dosage are the same – we’re not talking about adding caffeine, for example).

    1. TwistBarbie says:

      I hear this from people occasionally, about various drugs. Excipients could potentially affect how a drug is absorbed, and different brands often have slightly different formulations. I remember as one example a prescription PPI (may have been Esomeprazole) the brand name dissolved in water very quickly while the generic didn’t at all. Though honestly, I think in most cases people are just imagining one works better, or there are other mysterious reasons for preference (methadone patients seem to be extremely particular about brands and formulations)

      1. Sean Duggan says:

        And this, of course, also depends on whether you’re actually buying what you think you’re buying. Getting a generic, or toothpaste, at a drug store is generally a safe and cheaper alternative, but some of the “dollar stores” carry foreign formulations that may or may not be equivalent, with toothpaste being a fairly prominent case.

        http://www.snopes.com/inboxer/household/toothpaste.asp

        But yeah, my wife turns her nose up at generic versions of many of the medications, claiming they just don’t work as well. Unfortunately, they tend to look different too, so my attempt to prove her wrong via substitution failed when she spotted the difference in the shape and color of the pills.

      2. angorarabbit says:

        TwistBarbie, may I just say, hopelessly off topic, how much I adore your name? I think mine is still around somewhere here (she says, looking toward the basement).

        I am starting to appreciate how many women actually post here, and it warms my furry heart.

  4. Next time I haul the little trailer to Portland, I propose to invite you to my campsite for a shave, following which I volunteer to run my hand lithely across your cheek (strictly platonically, assure your dear wife). It is the least I can do for the soothing images of Oregon you so artfully evoked for this native Northwesterner today!

    1. Mark Crislip says:

      Why does Sweeney Todd leap to mind?

  5. The really amusing this about advertising is that anyone you ask will assure you that he or she is absolutely unaffected by it! Having killed my television over twenty years ago and applied every ad-blocker I come across, I have minimized my exposure, but I still find myself responding to–eek!–packaging (equating it with quality, for example).

    The bright side is that I skip by vast amounts of products that I have never heard of in favor of my old standbys (which are starting to disappear of be found at fewer outlets). This is especially true of cleaning products, and especially in their simpler forms. But then, I don’t have a dishwasher, clothes dryer, garage opener, or power mower, so what do I know about detergent pods, dryer sheets, programmable gizmos in the car, or whatever goes with power mower maintenance?

    My favorite Beck’s Dark has also disappeared, in favor of some awful replacement called Sapphire, which is nothing at all like the former. One of the kids stumbles on a six pack here and there and brings it over like a sacred offering and we all celebrate as though it’s Christmas morning! Luckily, Milwaukee has lately returned to its craft brewing origins (way behind the Northwest’s early ventures) and some excellent local brews are on offer.

    1. windriven says:

      @irene

      “My favorite Beck’s Dark has also disappeared,”

      It has been a while since I last had a Beck’s dark. Have you tried Negro Modelo as an alternative? My recollection is that they have similar flavor profiles. The Becks might be a little maltier, sweeter?

      ” But then, I don’t have a dishwasher, clothes dryer, garage opener, or power mower, so what do I know about detergent pods, dryer sheets, ”

      “When I’m watchin’ my TV
      And that man comes on to tell me
      How white my shirts can be
      But he can’t be a man ’cause he doesn’t smoke
      The same cigarettes as me
      I can’t get no, oh no no no
      Hey hey hey, that’s what I say
      I can’t get no satisfaction”

      Mick Jagger and Keith Richards

      1. Thanks for the recommend on the beer! Hubby is beside himself so I will try the Negro Modelo. I’ve made inquiries to friends in Germany and am awaiting news.

        1. I am awaiting news…and “Sat-is-FAC-tion”!

    2. mousethatroared says:

      Every time you buy a product with attractive, well designed packaging… a graphic designer earns their wings…or is a least a bit less depressed and downtrodden. This is good for everyone, good graphic designers are the only thing that stands between you and a world over run with monster size logos.

      1. Thanks for that perspective Mouse; I feel a bit crass for not considering the art side of marketing.

  6. Carl says:

    Hey hey hey, that’s what I say

    One of the most incoherent lines ever written which is not scat.

    1. windriven says:

      I don’t know if you read Keith Richards’ memoir but as he tells the story Oldham (I think it was) locked he and Jagger in a kitchen or something and wouldn’t let them out till they’d written a couple of songs. Couldn’t so much as take a leak as I recall the story. I don’t recall whether or not Satisfaction was a product of that incarceration but it would explain that line ;-)

  7. Bobby Hannum says:

    I’m just going put this out there: SBM should have a conference, but instead of renting out some conference room in a hotel and having a lot of formality and tickets and A/V stuff, SBM should rent out a bar and have some sort of beer tasting conference interspersed with talks.

    That is what Dr. Crislip was trying to say, right?

      1. This is pretty much what the Chicago Skeptics group does–Dr. Gorski was a particularly popular guest speaker!

    1. angorarabbit says:

      I’m on. I’ll even bring a sampling including spouse’s special IPA. Mark, I think it’s because you have such a nice conversational tone. And because you mentioned beer.

  8. mho says:

    Oh Boy! a beer googles TAM

  9. Stephen H says:

    “…we find that the efficacy of Claritin at 120 min is substantially higher for subjects who were exposed to Claritin advertisements”. Surely the word “claimed”, or “subjective”, is missing in this sentence and several other parts of the quote?

    Or are they trying to say that the product is ACTUALLY more effective if you’ve been watching the ad? Because they seem to be mixing subjective observations and objective claims (which presumably is the point of the study – and the reason it fails as science).

  10. Sabio Lantz says:

    I commented here, but it did not show. I read your post today about commenting issues. So I will try again. But instead of trying to generate the comment, I will give you a link to a post I did quoting you.
    http://triangulations.wordpress.com/2013/08/09/beliefs-truth-vs-function/

  11. Adam Rufa says:

    I would love to meet Crislip at Dinosaur BBQ for an ImPaled Ale or Syracuse IPA and some SBM talk.

  12. David Tyler says:

    “… placebo outside the context of a clinical trial is not ethical as it requires lying to the patient.”

    What is the ethical status of a practitioner, who is deluded enough about what he/she is offering, to think it is not a placebo? With the influx of “integrated medicine” taught by true believers, is being misinformed still unethical? It seems that to be ethical all you have to do is believe.

Comments are closed.