Search the Internet to learn about your asthma, high cholesterol or other common disorder, and odds are you'll be directed to a pharmaceutical company-sponsored Web homepage. There you'll often find an offer for a free sample or a one-time discount on a top-selling prescription medication.

Is it a good deal? Not according to a study of such direct-to-consumer offers on the Internet by a research team led by Dr. William G. Weppner of the University of Washington (UW) Department of Medicine and the Veterans Affairs Medical Center in Boise, Idaho. The results were published in this week's issue of Archives of Internal Medicine.

The results showed that the value of such introductory offers is low compared with the retail cost the patient will pay to continue taking the brand-name medication, and in most cases a less-expensive generic equivalent is not available.

The researchers also found that information on efficacy, safety and side effects was de-emphasized, in contrast to the prominent positioning of the free offer. The benefits of the medication were described in a general way, and some included patient testimonials. Quantitative information on the medication's indications for use, effectiveness and risks was rarely presented. The researchers suggested that further studies would help determine if free offers distract or divert patients from reading risk information.

The United States has permitted advertising prescription drugs directly to consumers for only the past 12 years. Except for New Zealand, no other nation allows it.

The findings on the coupon and voucher pharmaceutical marketing strategy are published in the article "Direct-to-Consumer Offers for Free and Discounted Medications on the Internet: A Content Analysis of 'e-Samples.'" In addition to Weppner, other members of the study team were Dr. Matthew F. Hollon, UW clinical associate professor of medicine, Division of General Internal Medicine and a faculty member for the Internal Medicine Residency Spokane; Dr. Lisa D. Chew, UW assistant professor of Medicine; and Dr. Eric B. Larson, director of Group Health Research Institute in Seattle and UW clinical professor of medicine.

The article appears in the journal's Health-Care Reform section.

"Many of these discounts are aimed at co-pays, which could increase costs to consumers via health insurance premiums," Weppner said in explaining the relevance to the health-care reform debate on controlling costs.

The paper noted that among the 50 most prescribed medications of 2007 more than half have such Internet offers. The researchers pointed to a prior study of print advertisements: 13 percent of the print ads directed a discount offer to patients.

Patients typically must present the coupon or voucher to a prescribing health-care provider to obtain a prescription, and then give the coupon and prescription to a pharmacist. The researchers cited evidence that clinicians' decisions to prescribe specific medication may be influenced by patient requests based on direct-to-consumer advertisements and by the availability of samples.

E-samples and discounts for first-time prescriptions may get around efforts by medical schools, hospitals and clinics seeking to prevent the provision of drug-company samples, the researchers suggested. These organizations are trying to curtail the influence of samples on health-care providers' prescription-writing practices.

The study calculated that the mean yearly retail cost for the medications was $1,559, with a range of $84 to $5,668. The total yearly value of the free sample vouchers for these medications had a mean average of $86, and ranged from $5 to $176. The total yearly value of the discounts had a mean of $75, with a range of $5 to $300.

In other words, the coupon or voucher covered only about 5 percent of the yearly bill. The offers, according to the researchers, also seem to promote medications that are still under patent protection. These expensive brand-name medications have no lower-cost generic competition.

To obtain the offer, 71 percent of the Web sites required the patient to provide personal information such as e-mail or postal address, and medical information such as symptoms, diagnoses, current medical treatments and insurance status.

"Collection of such information may compromise patient privacy if made accessible to unauthorized users," the researchers noted. "An interesting feature of this marketing strategy is its potential role as a means in which Web users are coerced to provide consumer information that unwittingly drives the content of the Web sites they view. Such a new version of targeted direct-to-consumer advertising could automatically gather information from drug-offer forms, patient searches, previously visited Web sites or even text from e-mail. The strategy would then provide advertising links to Web pages offering discounted or free coupons for drugs."

The United States Food and Drug Administration (FDA) has distributed draft guidelines on direct-to-consumer prescription drug advertising, which, if adopted, would require a more balanced presentation of risks and benefits. These guidelines do not mention the offering of discounts or free samples to patients.

Ideally, guidelines and practices regarding e-samples would be based on research evaluating their effect on patients' understanding of risk and benefit information and on treatment decisions, according to Weppner.

"Web-based incentives," he said, "represent a new and common marketing technique that combines direct-to-consumer advertising with drug samples."

Through such highly prevalent marketing, they added, "patients and consumers may be poorly served by risk information that is not well-presented, and misled by a discount whose true value is only a small fraction of the true cost for a prescription with no generic alternative."

This study was supported in part by an institutional Ruth L. Kirchstein Research Service Award, sponsored by the U.S. Health Services and Resources Administration.

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