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Hard to swallow

How to create an award-winning campaign that shocks audiences into behaviour change

Man with a rat in his mouthIn April 2009, the UK Advertising Standards Authority (ASA) ruled on a controversial campaign that had shocked cinema audiences across the country. The unusual thing in this case was that it wasn't an advertisement for a high profile consumer brand that was being judged. It was the pharmaceutical industry, with a unique campaign by Pfizer, alerting people to the dangers of counterfeit medicines.

Counterfeit medicines pose a significant threat to public health. The World Health Organisation (WHO) estimates that 10 per cent of all medicines available across the world are now counterfeit. In Europe, customs and border police have discovered unprecedented quantities of fake medicines – over 4 million items in 2007. For the counterfeiters manufacturing and selling fake medicines, the rewards are high and the risks low. However, many people remain unaware of the dangers of fake medicines and large numbers, particularly men, fuel a multi-million pound criminal business.

Pfizer's medicines have been heavily targeted by counterfeiters over the years and the company has worked extensively with regulators, law enforcement authorities and healthcare professionals to stem the tide. However, a DTC-style campaign to alert the public to the risks had never been tried. For a campaign of this nature to succeed, it was recognised that the highest level of support from stakeholders was needed, as well as a creative execution that would allow a public health message to cut through in the consumer space.

Stage one was to measure the extent of the problem and to try to understand the reasons why people were reluctant to engage with trained health professionals. Research conducted showed that a tenth of men have purchased a prescription-only medicine without a prescription. A total of 50 per cent of these were men buying online, of which nearly one third saw this behaviour as having a low or neutral risk. It's widely recognised that men are less likely to visit or engage with their GP, so this highlighted a population at significant risk from counterfeit medicines.

This new insight into why the public buys prescription medicines from illicit sources was packaged as a report entitled Cracking Counterfeit, with a foreword by respected media medic, Dr Mark Porter. Key stakeholders, including the Medicines and Healthcare products Regulatory Agency (MHRA), were pre-briefed on the report and agreed to issue a supportive media statement.

Media outreach, led by Dr Porter and Pfizer's medical director, helped create public awareness of the campaign messages.

The foundation had been laid and now it was time to bring the campaign to life. The MHRA and health stakeholders, including The Patients Association, Men's Health Forum and HEART UK, all agreed to support ongoing public awareness activities.

A creative consumer-facing road show took the Cracking Counterfeit messages to city centres across the UK. Western-style snake oil salesmen, led by Professor Chancetaker, entertained crowds with sales pitches for miracle elixirs, before delivering the patient safety message. This was supported by extensive regional media outreach, photo-calls and radio interviews in hosting cities.

With the messages firmly delivered, the next stage was to build the campaign that would shock audiences into behaviour change.

Pfizer and Red Health discussed options, and a plan was developed to use hard-hitting cinema advertising, which provided a number of opportunities. Not only did it deliver the message straight to cinemagoers, it also provided a vehicle for multi-level PR activities. An uncompromising execution by Langland was selected . . . and "Ratty" was born.

This new phase of the campaign, Get Real, Get a Prescription, upped the volume and impact of the core messages. Langland used some of the latest cinematic techniques to create a graphic advert featuring a man pulling a dead rat from his mouth (to reflect the fact that fake medicines have been found to contain rat poison).

The shock factor
Clearly, this advert was going to take pharmaceutical consumer communication into new areas and an extensive series of workshops was used to evaluate previous 'shock' campaigns, particularly those from the Department of Health. The team needed to be sure that ethical, as well as regulatory, principles were being upheld.

The plan was discussed with stakeholders, following which the MHRA, The Patients Association, Men's Health Forum and HEART UK not only agreed to support the campaign, they signed up as campaign partners.

A premiere showing was arranged at the Odeon cinema in London's Shaftesbury Avenue, to bring existing and new stakeholders together and create a sense of occasion for this groundbreaking launch. Over 70 attended from the government, law enforcement, regulatory and health sectors. Key consumer and trade media – including media affairs and advertising journalists - were invited, and stakeholders were provided with an opportunity to brief journalists on their perspectives.  

Dr Porter chaired the launch presentation and speakers from the MHRA and The Patients Association discussed campaign significance. The advert was supported by a 'making of the advert' film, which dealt with potentially difficult issues, such as the use of dead rats (which were provided by a licensed handler and would usually end up as snake food). 

An attention-grabbing media pack contained the news release, DVD and other resources to maximise media coverage, coupled with comprehensive sell-in to national, healthcare, marketing/advertising and regional media.

Behind the scenes, an exclusive ITN feature had been under development in the run-up to launch. Lawrence McGinty, ITN's science editor, used the stakeholder event to put his final interviews in place. This coverage was preceded the evening before when the story featured as the second item on the channel's 10 o'clock news programme. This was supported by a GMTV sofa interview in the morning with Jim Thomson, chair of the European Alliance for Access to Safe Medicines, which helped stimulate media interest and coverage.

A regional radio day, led by Men's Health Forum's Dr Ian Banks, increased penetration of messages at a local level and on cinema advert go-live date, the Metro carried a four-page advertorial with rat campaign images.

Digital message
Most campaigns targeting consumers now need to utilise digital channels. Get Real, Get a Prescription used a series of digital tools. The starting point was a campaign website,, which provided an online destination for audiences beyond the cinemagoers.

But we also wanted to create online buzz and excitement. The advertising imagery was designed to shock, and made excellent material for digital viral outreach. We launched a YouTube channel ( and proactive engagement with health, advertising, men's interest bloggers and social networks drove interest online.

Proactive linking with partner organisations and viral outreach through social media included Facebook, Delicious and StumbleUpon. It was a topic of online conversation and links to the advert were widely distributed by the social media community.


 The campaign video


The campaign clearly shocked a lot of people and some were motivated to complain to the ASA. In its ruling, the ASA said the advert did show images that some people might find offensive or distressing. However, because the advert was designed to highlight an important issue, the dangers of which could result in damage to health or fatality, they thought the image of a rat being regurgitated was justified.

It's still too early to ascertain the extent to which the campaign met its objective of achieving behaviour change. Analysis of men's internet habits will need to be measured in the future to see whether there has been a long-term shift in behaviour.

However, the messages were clearly understood by audiences who saw elements of the campaign. For instance, 97 per cent of men questioned leaving cinemas confirmed that the campaign would impact online behaviour.

Medicines regulators also felt the impact. The MHRA experienced a significant increase in calls to its counterfeit helpline immediately following the launch.

In the digital space, it became the number one education video and over 49,000 people had visited in the 25 days post-launch. Traditional media coverage was equally extensive, with 93 articles creating 296 million opportunities to view.

Perhaps one of the most important outcomes was that it brought leading health stakeholders in the UK to take a unified position against counterfeit medicines. The Cracking Counterfeit findings were shocking. They provided a call-to-action and the catalyst for the robust response, which was Get Real, Get a Prescription. There's now common agreement across leading health stakeholders on the need for  better education and more extensive activity to stop criminals from exploiting the public and putting people's health at risk. And that has to be a good thing.

The Author
Pat Pearson is head of ethical healthcare at Red Health
To comment on this article, email

5th October 2009


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