Pharmaceutical advertisements: How they deceive patients
Journal of Business Ethics
Copyright Kluwer Academic Publishers Group Feb 1999
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ABSTRACT. pharmaceutical advertising is one of the most important kinds of advertising that can have a direct impact on the health of a consumer. Hence, this necessitates the fact that it is essential for advertisers of such products to take special care and additional responsibility when devising the promotional strategies of these products. In reality, it has been observed that pharmaceutical product advertisers often promoted their products to achieve their own goals at the potential risk of having an adverse effect on the consumer’s health. This type of advertising is most often seen in over-the-counter drug product advertisements, and not as often in the case of prescription drug advertisements, which is relatively new. This article analyzes various purposes of advertising pharmaceutical products and also the potential problems that arise from the way pharmaceutical products have quite frequently been promoted. KEY WORDS: advertisements, behavioral, competition, consumerism, information source, nonprescription, prescription
The Essay on Advertisement: Advertising and Media Literacy Education
Children cannot escape them. They stare at them from every nook and corner. The highways, the roadways, streets all have hoardings, banners, posters screaming about the goodness of the product they are advertising. Newspapers have columns and columns, pages and pages devoted to advertisements. Greatest curse of modern times for children is advertisements. Advertisement reminds the children to buy ...
Humans are described as creatures of habit. We may resent this characterization because it seems to deny our individuality and free will. This is particularly significant in a “free” society. To be sure, much of what people do involves repetitive behaviors, usually the result of habits. Most people sleep on the same side of the bed each night, sit in the same chair at the table, have the same routine each morning, etc. These repetitive behaviors are rarely questioned and simply become a part of our being.
Consumerism is characterized as an organized movement of citizens and governement agencies to improve the rights and powers of buyers in relation to the rights and powers of sellers (Kolter and Armstrong, 1997, pp. 568-570).
Individuals, as well as populations, tend to exhibit certain patterns when shopping. Quite often it has been observed that many individuals have similar purchase habits and styles. Obviously, if manufacturers and marketing personnel can identify these habits and patterns, they can enhance sales. Motivational research can be a branch of marketing which involves psychologists and social scientists in the discovery of human purchasing trends and behaviors. In particular, it attempts to discover the factors that motivate consumers to make certain purchases or to select certain services.
In this article, the authors have made an attempt to discuss some of the potential problems that may arise with increased levels of pharmaceutical product advertising. Some unethical aspects of advertising this type of product directly to consumers are also discussed. During the process of writing this article, authors were unable to identify many literary works which have addressed this question of unethical pharmaceutical advertising despite an extensive literature search conducted by them.
Advertising frequently reflects the discoveries of motivational research as it applies to consumerism. This is particularly important in the case of nonprescription, or over-the-counter (OTC), medications because consumers spend hundreds of millions of dollars each year on their purchase (Mayo Clinic – Use versus Abuse, 1993).
The Essay on Direct To Consumer Pharmaceutical Advertising
The Misleading Truth About Pharmaceutical Advertisements Is a patient at liberty to diagnose his or her own affliction? If so, are they also qualified enough to know the right medication and take into consideration the drugs adverse effects? With the recent onset of direct to consumer advertising for prescription drugs, this is becoming the case. In 1994, expenditures on direct to consumer ...
All together, Americans spend over 30 billion dollars for medications and pharmaceutical products (Mayo Clinic – Medications and You, 1993).
Nonprescription drugs have been directly advertised to consumers over various kinds of media for several decades. After Boots Inc. first began advertising Rufen in 1983, the trend of direct-to-consumer-advertising has also included the advertising of prescription drug products (Shuler, 1984; Madhavan, 1993).
Advertisers of pharmaceutical products should not forget the fact that they are dealing with a product which can have a significant impact on a patient’s health. Thus, it is very important for pharmaceutical product advertisers to understand that the American public needs a higher quality of advertising from the pharmaceutical industry than from automobile or detergent makers (Waldholz, 1992).
They should consider the morality of their promotional efforts first before they consider the monetary advantages of these efforts. This might be a difficult task because for most organizations having monetary gains is their way of surviving in the highly competitive environment o! f business. However, at the same time, pharmaceutical product companies are not like most other companies because most other companies do not deal with a product which directly affect human health.
Manufacturers may attempt to familiarize consumers with brand names in hopes that the consumer will purchase a particular product. The consumer may think, “I’ve heard of this product!” and assume that it is somehow better than competitive products. Most people are aware of the high advertising costs involved with products and it is possible that if they see a product being advertised extensively, they might assume that the product is doing well in the market and that is why the company has money that they can spend on advertising. In turn, this may influence their purchase behavior towards this product, which is usually by the way of their purchasing this product. The consumer may even purchase the product as a result of impulse buying. Especially with this latter possibility in mind, advertising frequently attempts to achieve no other purpose than to cause the consumer to remember the name of the product. Thus, the advertisement may offer little useful information, but may! instead depend upon humor or other techniques which serve only to attract the viewer to the product name. Morris and Millstein found that the degree to which risk information is communicated to consumers via drug advertisements is related to the way the information is structured in the advertisement (Morris and Millstein, 1984).
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Promotion efforts frequently target certain segments of the population (e.g., women and teenagers with smoking advertisements), or they may target consumer weaknesses (e.g., pain medications designed for headaches) to which most people can readily identify (Mayo Clinic – How Hazardous is Smoking, 1993).
Purposes of drug advertising
Competition
Typically, there are many manufacturers providing similar health care products and services. In order to generate sales, manufacturers promote the advantages of their products or services as compared to their competitors. Thus, competition tends to encourage manufacturers to incorporate more “advantages” in their products or services (i.e., “building a better mousetrap at a lower cost”).
Theoretically, this means that the quality of products and services will tend to increase over time, and that costs may tend to decrease (at least in terms of cost/benefit consideration).
Unfortunately, the “extras” which are added may eventually become the “standard” by which the product or service is compared. In turn, this can lead to an increase in cost as consumers begin to demand these extra benefits as a basic component. As manufacturers continually attempt to “undo” their competitors, costs eventually tend to rise as marginal benefits are realized (e.g., as a result of product devel! opment research) for relatively exorbitant costs. Products and services may be “improved,” when in fact, no real improvements are necessary. Still, competition encourages new product and service development and availability.
Consumer interests
As a result of competition, prices may tend to remain stable for longer time periods, even when “improvements” have been added. For the consumer, this can provide for the availability of greater product selection at a more reasonable cost. At the very least, prices for similar products and services tend to be similar, even when they are high. However, the situation in the case of drug products is quite different. After a new drug marketing exclusivity, or monopoly, over the drug runs out, other companies can come out with similar “generic” products. The marketing exclusivity awarded to a company for an orphan drug, a drug developed to treat rare diseases, is usually for seven year (Mathieu, 1990).
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Since generic product manufacturers usually do not incur significant amount of Research and Development expense for this drug product, as did the primary company when they developed this new drug entity, they are able to bring their products in the market at a significantly lower ! price as compared to the original manufacturer of the brand name product. In this time and age when consumers are constantly trying to make ends meet with their limited income, most of them usually like to go for a generic drug product. However, at times, the significant differences in the prices of brand name product and a therapeutically similar generic drug product creates a doubt in the mind of the consumer regarding the effectiveness potential of the generic drug product. Consumers, in such situations, should get advice from pharmacists regarding their drug product selection.
Economic contributions
Advertising is thought to contribute to the economy as well. By effectively promoting increase in purchase and utilization of goods and services may occur, which in turn can result in increase in sales and the flow of money within society. A recent example of economic contributions which consumers in many societies could recall would be the case of having a casino in their city. In many cities and states in recent past it was extensively promoted how the inclusion of a casino in their society will have a positive impact on the society’s, city’s, or state’s economy. Casinos sure did have an impact on most society’s economy, but the discussion regarding this matter is beyond the scope of this article. We are more concerned with the impact of pharmaceutical product sales on the economy of a society. Recent times have also seen an increase in the number of mail order pharmacies. Many organizations want their employees to buy pharmaceutical products from these mail order pharmac! ies. Though it has been observed that most mail order pharmacies have lower prices as compared to the prices at local retail pharmacies for similar drug products, it is very difficult to justify the economic contribution of these mail order pharmacies in your society. Some justifications that come to mind are that they are convenient as the consumer gets it delivered where they want to and also that it is cheaper which in turn relieves some monetary pressure from the consumer’s mind. This monetary saving can then be spent by the consumer in the purchase of other items in his or her society.
The Term Paper on Examination Of The Phrma Guidelines On Direct to consumer Advertising part 1
... drug and health care costs. Thats why it is necessary to cooperate the efforts of all main components of direct-to-consumer advertising ... accurate and latest information about them. But avaliable information is just only the one side of the problem, pharmaceutical companies have ... In other hand, doctors has right to prescribe medications (product for sale) to patients. So, they are of great interest ...
Information source
Through advertising, consumers can learn about new products and services which are available to them. If the advertisement is appropriately written, then it can also help consumers learn about proper selection and use of products and services. Advertising tends to emphasize the advantages of one product or service as compared to another. Unfortunately, these “advantages” are frequently more the product of hype than fact.
A new source of product information becoming popular very rapidly is the Internet. Internet is also becoming a popular media for advertising drug products directly to consumers. Almost all major drug companies have their own world wide web site. Some people have visited these sites to get information regarding the products they have purchased. Consumers should be warned here that most of the information they get from a particular company may be biased or even incomplete and they may not get all the relevant information regarding their drug product. They should also be cautioned that there are many places over the network which may provide wrong and misguided information to consumers.
Manufacturing interests
The point of advertising is to generate sales of products and services in order for the manufacturer to remain economically viable and successful. This requires that the manufacturer must inform the consumer regarding the availability of products and services. Mass advertising can introduce products and services to large numbers of consumers in a very short period of time. For drug products, large scale advertising will be beneficial only to well established brand name product pushers. Large scale advertising directly to consumers is most likely not going to be economically feasible for generic drug manufacturers as they usually market their products directly to wholesalers, retailer, or chain stores. Once the retailer accepts the generic drug product for resale from its stores, then it is repackaged usually using the retail store’s brand name, like Kmart has its own brand name on the generic products in its stores.
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The current advertising for Target's CE department is not helping sales. In fact in some cases, it may be hurting sales. This section will address Target's current advertising strategy and the problems associated with it. Then alternative methods of promoting Target as a credible CE department with large variety of products will be proposed. Target's commercials are currently showing clips of ...
These are valid purposes, particularly regarding drug advertising, even though they frequently become distorted as a result of competition and promotional practices of questionable ethics (Cope, 1976; Day 1976; Rheinstein, 1976).
Problems with drug product advertising
There are several written regulations that can be used as a guidance tool when it comes to developing advertising strategies. However, these rules do not cover all aspects that should be considered, both from the marketers point of view as well as from the patient’s point of view. Fortunately, recent years have seen an increased emphasis on marketing ethics and socially responsible actions taken by several companies (Kotler and Armstrong, 1997, p. 92).
But there still needs work to be done in order to improve socially responsible marketing by many organizations.
Just as there are valid purposes for advertising, so too are the problems associated with advertising. A general problem associated with drug advertisements is that it is a powerful influence which may motivate consumers to select overly expensive, overrated, or less than optimum medications for their particular needs. More specifically, it is possible to identify numerous individual problems associated with the promotional practices. The most serious of these involve information problems (Griffenhagen, 1976; Rheinstein, 1976).
As far as they go, advertisements tend to be truthful. However, they frequently omit information which the consumer needs in order to make appropriate product selections. This is particularly interesting in the case of pharmaceutical products considering the fact that there are more than 500,000 OTC drug products available in the U.S. (Mayo Clinic Medications and You, 1993).
For example, consider advertisements that claim that their products contain ! “more pain reliever that doctors recommend most.” In fact, they do. Both “extra” strength aspirin and acetaminophen products contain more of these ingredients than “regular” strength products. What the consumer is not told is that this difference may not be clinically significant (i.e., consumers may not perceive a difference between 650 mg and 1000 mg of aspirin).
Our culture very much believes in the “More is Better” principle (i.e., if one tablet will do so much good . . . just think what 3 tablets will do!!!).
Another information problem involves unproven suggestions. In such cases, the advertisement makes claims beyond that which has been scientifically or clinically demonstrated by appropriate research techniques. For example, if vitamins could accomplish all that what is claimed in its promotions, we would no longer need health practitioners. Vitamins DO NOT “give you energy,” nor have they been definitely shown to prevent heart disease, cancer, aging or the myriad other problems that many vitamin supplement companies or salespersons would have us to believe. Indeed, careful clinical studies have repeatedly demonstrated that people can have a much more positive impact upon their health via the adoption of healthy life styles (e.g., adequate sleep, appropriate diets and exercise, no smoking, limited alcohol consumption), than they can with even excessive vitamin intake. This is not to suggest that vitamins are without value. Rather, it is to suggest that we are a culture that i! s continually attracted to “magic bullets” as an antidote for poor lifestyle choices. Hence, advertisers of vitamin supplements should take an active role in promoting the fact that vitamins should not be considered as a treatment of all health problems, some of which can be prevented by making proper lifestyle choices. Recently, a governmental agency clearly stated that some of the claims made by some companies regarding vitamins and some other “health products” may be quite wrong and in fact some of these products may even be harmful to patients if taken without proper physician guidance.
Advertisements are frequently guilty of a flaw in logic known as the argument from ignorance. In essence, this is a line of reasoning which suggests that “there are no ghosts . . . because I’ve never seen one” (note that according to this logic, the Washington Monument also does not exist . . . if you have not seen it!).
Promoters frequently argue that science has failed to disprove their claims. Thus, “Vitamin C can prevent the common cold, because science has never proven that it cannot!” Some studies may have suggested an activity for the product which has not been substantiated by subsequent studies. Perhaps Vitamin C can impact the onset or duration of colds. Yet, truth is truth. It does not require science to prove or disprove it. If science has failed to disprove a claim…it does NOT mean that the claim is valid.
The concept of dualism
Ours is also a society which very much believes in absolute dualism. Accordingly, one is either right or wrong. It is a view which accepts only absolute extremes with few “gray areas” in between. Thus, if science cannot disprove a claim . . . it must, therefore, exist. In this case, the actual truth probably DOES reflect one premise or the other. Yet, we are too impatient to wait for credible proof. In some cases, a theory may be formulated which proposes why a drug should be able to result in some effect. Yet, appropriate scientific and clinical evidence is clearly lacking. Nonetheless, claims are made based upon whatever evidence does exist, the theoretical suggestions, and the lack of scientific evidence to the contrary. Invariably, promotions state what people want to hear, and certainly, whatever is necessary to guarantee sales.
Many health professionals have voiced concerns about the quality of promotional practices, since advertisements rarely provide information regarding warnings and precautions. Not every drug product is appropriate for every consumer. Yet, this fact is traditionally deemphasized. Since advertisements attempt to create a demand for products, it is often theorized that consumers might ignore warnings and precautions even if they were included. Many times it is assumed by manufacturers that if they have all the “legally relevant” information in the package insert of an OTC product the consumers will read it. However, anecdotally, not all consumers read this information as carefully as it is intended to be read. It has also been observed that quite often warning statements are printed in labels of prescription medication bottles. In a related study, the authors found that most of these warnings statements were printed, using laser printer, between font size 3 (approx. 48 characte! rs per inch) font size 4 (approx. 40 characters per inch).
The normal font size used in letter is at least 12 (approx. 12 characters per inch).
This might be the reason that only slightly more than half of the participants of that study indicated that they had actually seen warning statements on the label (Chandra, 1996).
Another major category of advertising problems involves costs. Advertising is expensive. It has been estimated that as much as 50% of the cost of some products are related to advertising costs! The more a product is advertised, the more expensive it will usually be for consumers. There is no doubt in the fact that advertising, particularly television advertising, does have an impact on sales of the promoter’s product(s), and most often it is positive. This positive impact is also one of the reasons of increasing advertising costs. Lets take the example of advertising expenses during the Super Bowl. People often find out via news media the amount of advertising fee being paid by companies for a 30 second spot on television (it has been observed that most television ads are 30 seconds long).
Thus, the high advertising fee for a short time period restricts promoters to include the amount of information they can provide in a small duration of time. Obviously, manufacturers must! recover their advertising expenses, so the product costs must offset this expense. Thus, highly promoted pain medications are often far more expensive than aspirin products that are not so heavily advertised. The consumer can reach a point of diminishing return whereby the purchase price far exceeds the benefits actually derived from the purchase (at least as compared to similar products which are available).
A third category of advertising problems involves behavioral changes. Because advertisements are occasionally misleading, they may encourage consumers to misuse drug products or to make poor product selections. They may also encourage self-care at a time when a health care professional should be consulted (e.g., the promotion of OTC analgesics for arthritis).
Advertising can encourage consumers to make unhealthy health care decisions. For example, a well known laxative manufacturer has at times promoted the idea that “everyone needs a little help now and then!” Yet, laxative products are among the most misused of all OTC products (usually based on a cultural misconception regarding “normal” bowel habits) (Poe and Holloway, 1980).
Stimulant laxatives almost inevitably exceed the concept of a “little” help and should probably NEVER be the first choice in treating constipation. It has only been within the last decade or so that a dependency warning has been included on product labeling for these products (there are many elderly in our society who are now physically dependent upon stimulant laxatives!).
Anecdotally, deaths have resulted from high protein diets during the time that they were being actively promoted; many patients died from cancer when they opted for alternative OTC products instead of seeking the services of a physician; and smoking has remained a major cause of illness and death in our society, despite more than 25 years of warnings by the Surgeon General. Almost 400,000 Americans die prematurely each year from the direct or indirect effects of smoking (Mayo Clinic – How Hazardous is Smoking?, 1993).
Need for a realistic perspective
The previous discussion is not meant to suggest that all advertising is bad. It does mean that advertisements must be considered for what they are – promotions . . . not a source of factual consumer information. Some characteristics of an “ideal” drug advertisement is that they be concise, educational and truthful (Day, 1976).
To achieve these would be difficult at best. Many promotion practices, as discussed earlier, have very real space or time limitations. Thus, it is very difficult to design an advertisement that could achieve these characteristics within the constraints imposed upon them. Yet, these traits remain as valid guides for promotional practices, as well as for the assessment of promotional practices.
Realistically, most consumers are NOT sufficiently informed to assess the accuracy or truth of an advertisement. This is particularly important considering the fact that approximately 18.9% of the U.S. population of age 18 and older have not completed a high school education (Digest of Educational Statistics, 1996).
Holt et al. conducted a study regarding the readability level of 21 “popular” OTC product labels using two readability formulas (G. A. Holt et al., 1990).
These formulas used word length, word complexity and sentence lengths to compute the grade in school to which the passage difficulty corresponded. This study found that consumers needed at least a seventh grade reading ability in order to follow the instructions of most of the OTC drug products reviewed. Thus, it becomes important for health professionals to continually monitor advertisements in an effort to be aware of the cultural messages to which consumers are being exposed. Only then the health care profe! ssional will be able to identify the important information which is missing from the advertisement about which the consumer should be aware. This will also provide the basis for patient counseling regarding the appropriate assessment of products because as consumers become more enlightened, they begin to question more the advertising practices and are more likely to seek advice from health professionals as needed.
Advertisements, at times, tend to encourage consumers to evaluate products based upon actual need. For example, one popular cold product boasts that it “helps relieve 12 cold symptoms.” This seems impressive until one realizes that patients rarely have all 12 cold symptoms at one time, and 6 out of the 12 symptoms can quite often be relieved by the aspirin contained in the product (which the consumer probably already has at home, but is now purchasing again!).
The consumer is encouraged to purchase ingredients to treat symptoms that do not actually exist! Pharmaceutical promotional practices often provide little information to assist consumers in selecting specific products for specific symptoms.
Advertisements are at times written by experts in sales promotion and marketing, not by experts in health. The messages that clutter our billboards and airwaves promote wishful thinking, dissatisfaction with self (as we presently exist), and most importantly . . . sales. The dilemma of drug manufacturers is that there are relatively few drugs for any disease category which have been released for self-care use and many of the drugs which are currently available as an OTC product are really not as impressive as similar prescription drug products. And, since many companies manufacture OTC products, it is extremely difficult for a company to have a unique product on the market for very long. The result is that it contributes to the problems associated with promotional practices as manufacturers try to make their products appear to be more unique through unrealistic drug advertisements.
Advertisements tend not to promote the intelligent selection and use of OTC products (which would, in turn, promote responsible practices with prescription products, as well).
Consumers often purchase more expensive products when less expensive products work just as well (Day, 1976).
They may purchase products with multiple ingredients (thereby exposing themselves to additional adverse drug reactions, including drug interaction), when only a single ingredient was actually indicated and needed. They may be encouraged to ignore the advice of health professionals, particularly considering the fact of how expensive it is for consumers to visit health care provider, when the advertisement is providing desirable information. The misconceptions created by irresponsible advertising practices can be difficult to remove from the cultural mind-set, especially when the objective information and advice provided by health professionals is less sensational, and generally speaking, not wha! t the consumer wants to hear. Social marketing should be used to improve the health of public (Walsh et al., 1993).
It is the opinion of the authors of this article that drug marketers should always try to follow the unwritten rules of marketing ethics and consider what is best for their consumers before developing a particular advertising strategy. Increased participation of health care professionals in developing these strategies are likely going to be beneficial to all parties involved which are directly and even indirectly associated with the promotion of drug products.
References
Chandra, Ashish: 1996, `Consumer Perceptions and Beliefs as Related to Professional Communication and Counseling by Pharmacists’, Dissertation, Northeast Louisiana University, Monroe, LA, 115.
Cope, James D.: 1976, `The Charges Against OTC Medicine Advertising – Are They Deserved?’, Journal of the American Pharmaceutical Association NS16(9), 500-504. Day, Robert L.: 1976, ‘. . . Up to Eight Hours of Relief . . .’, Journal of the American Pharmaceutical Association NS16(9), 496-499, 504. Digest of Educational Statistics, National Center for Educational Statistics: 1996, U.S. Department of Education, pp. 218. Griffenhagen, George B.: 1976, `Can OTC Advertising be Justified?’, Journal of the American Pharmaceutical Association NS16(9), 495. Handbook of Nonprescription Drugs: 1993. American Pharmaceutical Association, lOth ed., pp. 1-9. Holt, Gary A., J. D. Hollon, S. E. Hughes and R.
Coyle: 1990, `OTC Labels: Can Consumers Read and Understand Them?’, American Pharmacy NS30 (November), 51-54. Kotler, Philip and Gary Anderson: 1997, Marketing: An Introduction, 4th ed. (Prentice Hall, Upper Saddle River, NJ).
Madhavan, S.: 1993 (winter), `Are We Ready for Direct-to-Consumer Advertising of Prescription Drugs?’, Pharmacy Business, 14(5).
Mathieu, Mark: 1990, New Product Development: A Regulatory Overview (PAREXEL International Corporation, Cambridge, MA), p. 240. Mayo Clinic: Family Health Book: 1993 (IVI Publishing Inc.).
Morris, L. A. and L. G. Millstein: 1984, `Drug Advertising to Consumers: Effects of Formats for
Magazine and Television Advertisements’, Food Drug Cosmetic Law Journal 39, 497-503. Poe, W D. and D. A. Holloway: 1980, Drugs and the Aged (McGraw-Hill, New York, NY), pp. 39-40. Rheinstein, Peter H. and M. B. Mazis: 1976, `Regulation of OTC Drug Advertising: The FDA “Prescription”‘, Journal of the American Pharmaceutical Association NS16(9), 505. Shuler, J.: 1984, `Liz Moench: Taking Boots Directly to Consumers’, Pharmaceutical Executive 4 (September), 22-25, 28, 32, 34, 36, 38. Waldholz, Michael R.: 1992, `Prescription Drug Advertising: A Critic’s Perspective’, Promotion of Pharmaceuticals: Issues, Trends, Option, 43-52. Walsh, D. C., R. E. Rudd, B. A. Moeykens and T. M. Moloney: 1993, `Social Marketing for Public Health’, Health Affairs 12(2), 104-119.
Ashish Chandra is an Assistant Professor of Pharmacy and Health Care Administration at Xavier University of Louisiana, New Orleans, LA 70125. Dr. Chandra has published in several peer reviewed journals and proceedings in the fields of Business, Health Care Administration, and Pharmacy Administration. He has also served as the Track Chair for the Health Care/Health & Safety Track of the 1998 Southwest Academy of Management Conference and as the Track Chair for the Professional/Health Care/Services Marketing Track of the 1998 Southwestern Marketing Association Conference. Gary A. Holt is an Associate Professor of Pharmacy Administration, Northeast Louisiana University, Monroe, LA 71209. Dr. Holt has also published extensively in the fields of Pharmacy and Health Care Administration.
Ashish Chandra, College of Pharmacy, Xavier University of Louisiana, 7325 Palmetto Street, New Orleans, LA 70125, E-mail: [email protected].
Gary A. Holt, Division of Social and Administrative Sciences, School of Pharmacy and Health Sciences, Northeast Louisiana University, Monroe, LA 71209.
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