americans from drug marketing act, which proposed the removal of tax breaks for pharmaceutical companies who engage in dtca. franken similarly showed concerns that the industry was spending too much on marketing. in a similar move, representative rosa delauro called for a three-year moratorium on advertising of newly-approved prescription drugs. proposed display of list prices on may 8, 2019, the department of health and human services (hhs) approved a mandate for list prices to be displayed in advertising for any prescription that costs $35 or higher for 30 days of treatment. ads could also include price comparisons against competitors. phrma objected to the rule, arguing that prominent display of list prices would cause confusion because they do not reflect what patients would typically pay under insurance coverage (the rule did require display of a disclaimer stating that those with health insurance may pay a different amount). when the rule was proposed in october 2018, phrma stated that its members would commit to publishing detailed pricing information online (including possible out-of-pocket costs, and information on financial support options), and directing viewers to this information within their advertising. however, the hhs disputed their arguments, arguing that list prices would help patients calculate how much they would pay, especially if they have not yet met their insurance deductible, or the drug is not covered by their insurance. secretary of health and human services alex azar compared the proposed requirement to similar regulations involving list prices for automobiles. on july 8, 2019, shortly before it was to take effect, the rule was struck down by dc district judge amit mehta, who ruled that it overstepped the hhs' authority. reception supporters of direct-to-consumer advertising argue that advertisements increase competition which leads to lower prescription drug prices and new development, citing, for instance, that between 1997 and 2001, spending on research and development in the u.s. increased 59% while spending on promoting drugs directly to patients increased 145%. however, other experts have asserted that funding for r&d is determined by several other factors. direct-to-consumer advertising, among other patient education initiatives, can educate consumers and patients about new treatments and therapeutic options that may not have been proactively mentioned by their healthcare professional. proponents of dtca claim this provides a vital opportunity for the public to be aware of what is available to them and to engage in an educated discussion with their doctor. a study observed that direct-to-consumer advertising promotes communication between patients and their doctors about medications. thirty percent of americans indicated they talk with their doctor about a medicine they saw on tv. in addition, surveys showed that increased advertising has had a positive impact on the degree to which people adhere to a given course of treatment – but only among those who were already on medication prior to exposure to direct-to-consumer advertising. among this population, a 10% increase in exposure to drug advertising increases the rate of adherence between 1% and 2%. some studies have asserted that direct-to-consumer advertising misleads patients into demanding heavily-advertised drugs, leading to superfluous or sub-optimal treatment. doctors may feel pressured to prescribe specific brand-name medications because they were mentioned by a patient. in 2016, the centers for disease control and prevention reported that 47% of all antibiotics prescribed in the united states were unnecessary. another study of young people living in west palm beach, florida found that a 10% increase in advertising expose increased the total number of prescriptions by 5%; a higher percentage change than in denver, colorado – where dtca expenditures per person are lower. market impact it has been argued that direct-to-consumer advertising can influence the doctor–patient relationship, including patients bringing up their need for an advertised, name-brand drug as their primary concern during a doctor visit, and becoming interested in newly-introduced medications that may not have undergone sufficient postmarketing surveillance. it has been demonstrated that direct-to-consumer ads have contributed to the frequency of requests made by patients towards their physicians to prescribe analgesic drugs, including opioids. a patient's request for a specific medication dramatically increases the rate at which physicians prescribe usually more expensive, branded drugs even when treatment for existing indications does not warrant such use. pharmaceutical companies have also faced allegations of "disease mongering"—the process of promoting awareness of minor conditions such as balding and skin wrinkles in such a way that it encourages the sale of treatments for them. critics also argue that resources spent on advertising could otherwise be spent on research and development for new drugs and medical therapies. danish physician peter c. gøtzsche indicated that pharmaceutical companies will advertise for their most profitable products, many of which are unnecessary "me-too" drugs. he maintains that "there is no need for marketing, as the products should speak for themselves." drug safety advertisements generally begin within a year of drugs entering the market, before postmarketing surveillance is available to see if adverse effects emerge, which increases the risk of harm. in the early 2000s, the fda's resources to screen dtc ads were not keeping pace with the number of ads being produced, raising the risk that the inappropriate ads were not removed. vioxx was heavily marketed and was widely-prescribed after its approval in 1999. when the drug was withdrawn for safety reasons in 2004, merck, its developer, and the fda were criticized for the campaign. direct-to-consumer advertising of pharmaceuticals had long been suspected of downplaying the risk to consumers. studies by scientific american reliably found that consumers perceived the side effects of drugs to be less severe when they were presented with ads that listed both "major" and "minor" side effects, and more severe when only major side effects are listed. several dtc ads have faced criticism or fda warnings over containing depictions of activities that are part of a prescription's contraindications, such as an advertisement for the blood thinner xarelto which featured scenes of a patient spokesperson among motorcycles (despite a disclaimer stating that the spokespatient had to stop riding her motorcycle whilst taking the medication), and a print ad for the factor ix treatment idelvion containing an image of a soccer player (with the fda warning that soccer was a "moderate to dangerous high-risk activity for hemophilic patients", and that the ad falsely implied patients could engage in such activity without consequences). gender stereotypes some drug ads have "gendered" diseases in ways that do not reflect actual epidemiology. women's bodies have also been objectified to mask or distract from unpleasant aspects of diseases. the marketing of drugs for inflammatory bowel disease have been called out on both counts. similarly, the marketing of gardasil was primarily aimed at young women, when sexually transmitted diseases are carried by, and affect, both genders. parodies u.s. dtc regulations have led to drug commercials having formulaic elements that have often been parodied in popular culture, such as the juxtaposition of often-lighthearted footage with the reading of side effects. saturday night live has often featured sketches with parody commercials for drugs, many of which featuring exaggerated side effects (such as annuelle, a parody of seasonale that lets women have their period only once per-year, at the cost of having extreme pms symptoms when it does occur) or inane purposes (such as swiftamine, a medication for people who experience onset vertigo after realizing they love taylor swift). the adult swim short unedited footage of a bear similarly portrays a commercial for the fictitious medication claridryl, but the scenes slowly segue into a psychological horror narrative involving the woman portrayed in the ad.