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Faculty Insights

Following Directions on Over-the-Counter Drugs

By Wisconsin School of Business

April 27, 2017

WSB spoke with Neeraj Arora, executive director of the A.C. Nielsen Center for Marketing Research and professor of marketing at the Wisconsin School of Business, about his work on label deviations for acetaminophen, an over-the-counter pain reliever.
Pill Bottles
You have a raging headache and turn to your medicine cabinet for some pain relief. The label on the bottle says to take two pills…but you wonder if you should just take three so that you’ll feel better faster.
This scenario and others like it provide the basis for my research on consumers and how they interact with label instructions in relation to the medication acetaminophen.
WSB: What sparked your interest in this topic? 
Arora: This research was conducted by an interdisciplinary team that was formed with the intention of getting us to a better place: What can be done to limit label violations? Changes need to happen in labeling and consumer education, and we hope that what we learn here can help guide industry initiatives. Some of those initiatives are already in place.
Along with my co-authors—David Kaufman, a professor of epidemiology at Boston University, Saul Shiffman, a professor of clinical psychology at University of Pittsburgh and Pinney Associates, and Min Tian, a Ph.D. student at WSB—we wanted to develop a statistical model that helps quantify these label deviations and come away with intervention suggestions on how to prevent them.
WSB: By “deviation,” are we talking about how closely people follow the instructions on the bottle, like whether they are taking more or less of the recommended amount or changing the frequency?  
Arora: Yes, that’s correct. Label deviation is a consumer education issue and very closely tied to marketing, which is how I got interested in this topic. Taking too much acetaminophen can lead to serious health problems such as liver damage. The real harm happens at much higher doses than the 4g originally set by the FDA, but it’s an important guideline.
In the study, we looked at three specific deviations: taking the medication too soon after a previous dose, taking too much per dose, and taking a greater dose than the permissible maximum 4g per day. In all three instances, we find a relationship between pain state (the level of pain the consumer was experiencing) and the degree of deviation occurring.
WSB: So, for example, a consumer that might follow the directions to the letter in a minimal pain situation might deviate from the label if the pain level increases? 
Arora: That’s right. What we consistently find is that at a higher pain state, people tend to have a greater propensity to deviate from the labels. If you’re going to propose interventions—how to modify or better inform consumer thinking to prevent this type of label deviation—I think factoring in the pain state is extremely important. This paper uses a formal statistical model that focuses on the consumer pain state, and that is something that hasn’t been done before. For example, if you take one of the variables in the study that isn’t a risk factor, like consumption of greater than 4 drinks/week, and overlay the pain state part of it, it can become a factor. In a high pain state, consumers who drink more than four drinks per week are more likely to label deviate than those who do not.

Neeraj Arora
Neeraj Arora, professor of marketing

We also found that in the high pain state, participants who took the medication sooner than they should were also likely to take too much; in other words, we might see more than one label deviation. That is, both too soon and too much label deviations could serve as critical gateways to the more medically serious >4g label deviation. This association pattern is amplified at the higher pain state.
Looking at the level of knowledge is also key. Only 57.3% of the participants in the survey correctly identified acetaminophen in the products they consumed. Many consumers are not aware that acetaminophen is an ingredient in numerous headache and flu medications. Even when they are aware, they don’t necessarily know the correct individual dose or the correct time between doses.
A lot of what we are seeing in these label deviations is driven by knowledge, consumer attitude, and pain level—those are the big criteria. There are gender and demographic differences also, but at a behavioral level, that’s what’s going on. In terms of impact, our results reveal important insights for educational interventions such as label design change and direct to consumer messaging that highlights the need to be concerned about label deviation during periods of increased pain. Such interventions could be highly targeted based on criteria such as demographics and health profile. The results also offer guidance on factors to highlight (pain state, consumer attitudes) in the educational messages intended to curb label deviations.
WSB: Can you describe the method that you used? 
Arora: As a broader topic, I’m just fascinated by the whole notion of how we as consumers interact with label instructions. We used the diary method here, and that’s a well-known methodological approach that’s been used in everything from alcohol consumption studies to food intake and obesity studies. It’s fairly general and cuts across a lot of different contexts.
My co-authors Dave and Saul led the data collection part of the study, and it was an elaborate effort to collect these data. For example, in the data collection, we recorded all of the medications participants have in stock at home, as well as what and how much they took over a one week period. We compiled a database of more than 300 drugs nationally, and mapped the participants’ intake back to their acetaminophen consumption, both the timing and quantity aspects of it.
We are not concerned with the specific condition participants took acetaminophen for, but we do care when they take it: How often are these label deviations happening?
WSB: What are some of the marketing implications or suggestions from this study?
Arora: One avenue could be establishing educational websites. Some of this is already happening (see for example, Get Relief Responsibly). To curb label deviations, individuals searching for pain relief products using keywords such as “extreme pain” or “severe headache” could be shown educational ads during the search process, and display ads later.
Our results suggests what message to include in the ad copy that is intended to reach the high-risk consumers and pinpoint important intervention targets. Physicians, during routine visits, track some of these measures (e.g. drinking, smoking, pain level). An avenue to curb label deviations would be to encourage physicians or nurses to nudge the high-risk consumer groups during routine office visits by using educational pamphlets.
An area that warrants further study is looking at whether those experiencing higher levels of pain are open to intervention messages to the same extent as those who are experiencing lower levels of pain.
​Neeraj Arora is the executive director
of the A.C. Nielsen Center for Marketing Research and a professor in the Department of Marketing at the Wisconsin School of Business.