an audit of health products advertised for sale

8/19/2019 An Audit of Health Products Advertised for Sale

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N UDIT OF HE LTH PRODUCTS DVERTISED FOR S LE ON

HIROPR TI WE SITES IN C N D ND CONSIDER TION

OF

THESE PR CTICES

IN THE

CONTEXT

OF

C N DI N

HIROPR TI CODES

OF

ETHICS ND CONDUCT

Stacey A Page, PhD, ''' and Jaroslaw P Grod,

ABSTRACT

Objective This study describes the extent to whieh chiropractors with Web sites practicing in Canada advertise health

products for sale and considers this practice in the context of chiropractic codes of ethics and conduct.

Methods Chiropractic Web sites

in

Canada were identified using

a

public online business directory (Canada 411).

The Web sites were searched,

and an

inventory

of

the health products

for

sale

was

taken.

The

influences

of

type

of

practice and province of practice on the sale of health product were assessed. Textual comments about health product

marketing were summarized. National and provincial codes of ethics were reviewed, and the content on health product

advertising

was

summarized.

Results Two hundred eighty-seven Web sites were reviewed. Just more than half of the Web sites contained information

on health products

for

sale

(n =

158, 54%). Orthotics were advertised most often

(n = 136

practices, 47%), followed

by vitamins/nutritional supplements

(n =

53, 18%), pillows

and

supports

(n =

40, 14%),

and

exercise/rehabilitation

products (n = 20, 7%). Chiropractors in solo or group chiropractic practices were less likely to advertise health products

than those in multidisciplinary practice (P


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Audit of Health Products

Joumal of Manipulative and Physiological Therapeuti

July/August 200

The retailing of health products is an important issue that

warrants consideration when defining the professional

conduct boundaries of health care practitioners These actions

may be considered by some as being at odds with the

professionals' ethical obligations to act in patients' best

interests and avoid actions that may cause conflict of

interest.^'' Although the recommendation of health products

should be based on a clinical value that addresses a patient's

needs, a financial interest in the sale of that product might

influence the practitioner's behavior, and the patient's best

interest has the potential of being compromised. Little is

known about the current practices of retailing health

products by chiropractors in Canada.

The purpose of this study is to provide a preliminary

description of the extent to which Canadian chiropractors

are selling and marketing health products as evidenced by

advertisements or offers on Web sites. This study also

describes and discusses the guidelines offered by Canadian

national and provincial chiropractic codes of ethics and

conduct relating to health product sales and advertising.

M THO S

Consistent with the Tricouncil Policy Statement, this

study did not require ethics review [Section I.A., Article

1.1 (c)]. ' Chiropractic Web sites in Canada were identified

using a publicly available business directory, Canada 411.

This online directory provides contact information (name,

address, phone numbers) for chiropractors offering services

in the country. Chiropractors with Web sites can choose to

have their URLs listed in this directory for an additional fee.

In 2009, the Canadian Chiropractic Association stated

there were 7000 licensed chiropractors in Canada.

Searching for chiropra ctor in the Cana da 411 directory in

June of 2007 yielded 8401 listings, suggesting most

chiropractors were represented. These online listings were

reviewed to find practices with Web sites. Once identifled,

the Web addresses were recorded and the Web sites were

audited. All health products and services offered through the

practice were recorded on a standard inventory form. The

results were summarized descriptively using proportions.

The association between the type of practice and the

advertising of health products and the province of practice

(British Columbia vs other) on sale of health products was

evaluated using the j ̂ statistic. Comments made about the

products available for sale were also recorded and summar-

ized using content analysis.

The Canadian Chiropractic Association (CCA) is a

national voluntary organization that represents Canada's

licensed chiropractors. Approximately 87% (N = 6100) of

the approximately 7000 chiropractors in Canada are

members. The national code of ethics and conduct of the

CCA, available online from the CCA's Web site, was

reviewed, and its content relating to the sale of health

products was summarized. Six provincial associations have

Table . ealth

products sales on chiropractic

Web

sites in ana

Province

BC

AB

SK

MB

ON

QB

NFLD

NS

PEI

NB

Total

Chiropractic

Web

sites

identified

45

30

-

9

152

34

1

14

-

2

287

Selling

health

products

at clinic

33

(73%)

20

(67%)

-

3 (33%)

88 (58%)

3

(9%)

0

7

(50%)

-

1 (50%)

155

(54%)

Link

to a

product

site

15

7

-

4

79

4

0

4

-

1

114(40%)

BC,

British Columbia; AB, Alberta; SK, Saskatchewan; MB. Manitob

ON , Ontario; QB, Quebec; NFLD, Newfoundland; NS, Nova Scoti

NB, New Brunswick; PEI, Prince Edward Island.

developed their own codes of ethics and conduct (Britis

Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nov

Scotia), and these are also available on their Web sites. Th

Code of Ethics of Chiropractors in Quebec is found within

the Chiropractic Act (RSQ, c. C-26, S. 87) available online

The provincial codes were reviewed, and their content on th

sale of health products was summarized.

R SULTS

From the 8401 listings for chiropractors, 225 wer

nonchiropractic, leaving 8176 chiropractic listings. From

these listings, 929 Web addresses w ere found. Upon review

637 w ere nonchiropractic, duplicates, or inaccessible, leavin

292 unique active Web addresses for audit. No W eb sites wer

found using Canada 411 for either Saskatchewan o

Manitoba. For these 2 provinces, we searched the Yellow

Page print directories for the 2 larger cities in each provinc

(Saskatoon and Regina, and Brandon and Winnipeg

respectively). Nine W eb addresses were found for M anitoba

whereas none were found for Saskatchewan, resulting in

total of

3 1

Websites.

Three sites represented multiple, franchised clinics. I

was not impossible to determine who owned and operated

these clinics, nor was it possible to identify the practitioner

or products by clinic site. Therefore, these sites wer

excluded, reducing the number of practice sites reviewed t

298.

Two sites were resource or product sites fo

practitioners, not consumers, and these were also dropped

reducing the number of chiropractic sites to 296. Eleve

sites comprised clinics that were clearly owned by othe

health professionals (eg, massage therapists, physiothera

pists, naturopaths) and were dropped, leaving 285 We

sites.

In contrast, 2 Web addresses reported on 2 clinic

each, and it was possible to code practitioners and product

by site. The final tally of clinics reviewed was 287. Th

number of clinic Web sites identified for each province i

shown in Table 1.


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Table 2

Health products advertised for sale through chiropractic

practices

Table 3 Links to health product sales sites

Link to product site

Product

Orthotics

Pillows

Supports, braces

Exercise/rehabilitation equipmetit

Topical creams (tnassage oil, atialgesics)

Hot/cold packs

Sold through practice

n (%)

135 (47%)

40( 14%)

27 (9%)

20 (7%)

18 (6%)

14 (5%)

Product

Orthotics

Pillows

Supports, braces

Exercise/rehabilitation equipment

Topical creatTis (massage oil, analgesics)

Hot/cold packs

n (%)

41 (14%)

12(4.0%)

7 (2%)

6 (2%)

11 (4%)

1 (0.3%)

Other health products

Nutritional suppleme nts including: 53 (18%)

Vitamins and minerals, herbal

Supplements, hormonal

Supplements, digestive enzyrnes

Home opathic supplements 10 (3%)

Miscellaneous products for sale 34 (12%)

Brand name/custom footwear 11 (4%)

Skin care products 4

(

%)

Backpacks 3 (1%)

Other: cardiopulmonary resuscitation barriers. Sold by


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Joumal of Manipulative and Physiological Therapeutic

July/August 2009

compared the prevalence of health product advertised for

sale by chiropractors with Weh sites in British Columbia

compared with those in the remaining provinces and found

that, although those in British Columbia were more likely to

engage in health product sales generally {y ' = 8.0; P =

.005), they were less likely to sell nutritional supplements

2

C o m m e n t s A c c o m p a n y i n g P r o d u c t A d v e r t is i n g

Most comments about products for sale involved an

endorsement or recommendation. Product endorsements

varied in intensity and w ere most often made about nutritional

supplem ents. Some described their products as simply recom -

men ded, whereas others offered evaluation of products using

phrases such as award winning , highest quality pharma-

ceutical grade, and finest supplements available today in

their descriptions. One offered a personal endorsem ent stating

that clinic mem bers had personally used every product on this

page and have recommended them to our families.

T o a lesser extent, comm ents focused o n t h e effectiveness of

products. For example, general claims such as I recommend

them because they get the best results were made. Less often,

specific health claims were made (eg, our products address

health conce rns such as ..., natural solutions to the most

common conditions, a n d absolutely miraculous for... ). One

product descriptor indicated that ' 'named product could

replace prescription medications such as naproxen. Effec-

tiveness was hacked up by reference to clinical or scientific

research on a couple of sites. On one site, links to joumal

publications about a few products (ie, multivitamins, gluco-

samine, and coenzym e Q IO) were available. In contrast, one

site offered a disclaimer indicating that the information

provided with the product was for educational purposes only

and that no m edical or curative claims were implied.

A few sites comm ented on produ ct safety (eg, all Chinese

herbs available at named chiropractic centre are manufac-

tured to high quality North American standards and are very

safe ). Others pointed out the need for patient monitoring of

produc t use (eg, caution should be taken ... self-prescribing

or self-dosing is not in a patient's best interest ).

Occasionally, statements centered on the value and

affordability of products. Some Web sites offered assistance

with product access for patients, indicating that if desired

products were not seen on the Web sites, the patient could

request that the practitioners order them.

A few sites indicated the products they sold were only

available through a health practitioner's office. One Web site

clearly stated it did not offer supplements for sale because

these could be readily obtained at local stores and pharmacies.

H e a l t h P r o d u c t S a le s C h i ro p r a c t ic C o d es o f E t h i o a n d C o n d u c t a n d

F e d e r a l G u i d e l i n e s

The C CA 's C ode of Ethics and Conduct contains a general

statement that conduct in the profession of chiropractic should

be above reproach and w ill take no physical, mental, social, o

financial advan tage of a patient. The Code of Conduct expand

upon this, stating the dispensing of health products is

permissible, with certain provisions.'^ These provisions

include that dispensing such items does not create a conflic

of interest, they serve the best interests ofthe patient, clinica

value has been s hown , and the items are available at fair ma rke

price. Moreover, the code states that the chiropractor will

recommend only treatment considered essential for the well-

being of the patient. Product endorsements are permitted

provided such endorsements reflect favorably upon the

profession and that CCA's policies are upheld.

Some provincial bodies have adopted the CCA's Code of

Ethics and Conduct (Newfoundland, N ew B runswick, Prince

Edward Island), whereas others have developed unique

provincial codes (Alberta, British Columbia, Saskatchewan

Manitoba, Ontario, Quebec, Nova Scotia). The codes of these

latter provinces all contain statements similar to that of the

CCA , prohibiting the professional ft-om taking advantage o

patients, financial or otherwise, and limiting chiropractors to

the provision of treatment believed necessary for the well-

being of th e patient.

The Nova Scotia College of Chiropractors C ode of Ethics

and Conduct contains the same statement as the CCA with

respect to its position on the retailing of health products.'''

The remaining provinces vary in the extent t o which they

permit the sale of health products. The Code of Conduct of

the British Columbia College of Chiropractors was mos

restrictive, specifically prohibiting the sale or dispensing of

vitamins or food supplements, drugs, or homéopathies and

also prohibiting chiropractors from receiving any financial

remuneration or other benefit coming from the supply o

distribution of vitamins or food supplemen ts. This code also

prohibited chiropractors from engaging in any product o

service endorsement, unless it related directly to the practice

of chiropractic and limited the links that chiropractors could

have on their Web sites. W here the chiropracto r shared office

space with another health practitioner who sold or dispensed

these products, the code stated this activity must be carried

out solely by the other health practitioner and further stated

that no vitamins, food supplements, drugs, or homéopathies

may be displayed or sold in any office space or common area

occupied by the chiropractor.'

Since the time this study was undertaken, the College o

Chiropractors of British Columbia (formerly the British

Columb ia College of Chiroprators) has revised its Professiona

Conduct Handbook.''* The revised code of conduct lifts

previous restrictions imposed on chiropractors regarding h ealth

product sales. Notably, chiropractors do not appear to be

prohibited from selling, or from being associated through thei

practices with the sale of, vitamins or food supplements

Although the current professional conduct handbook does no

directly address produ ct

s les

and endorsements as the previou

code of conduct did, it does indicate the chiropractors may

reco mm end nutritional supplements for specified conditions


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4

The Ontario Chiropractic Association does not prohibit the

sale of products. H owever, it clearly defines conflict of interest

and ackn owledges that the sale of any product to a patient is a

potential conflict of interest. The Ontario Chiropractic

Association lays out clear ethical guidelines to help practi-

tioners avoid a conflict of interest. These include that the

chiropractor should not receive financial benefit from a third

party in retum for the sale of products to a patient, and that

the markup on products should have a reasonable relationship

to the expenses associated with supplying the product.

Members are cautioned to avoid engaging in commercial

activities that could improperly influence their professional

judgment. Product endorsements are not mentioned,'^

In contrast, the Code of Ethics of the College of

Chiropractors of Ontario, Canada, the province's governing

body, does not directly address health product sales. It does

state that chiropractors should avoid both flnancial conflict

of interest and the provision of unnecessary care,'*

Although the code of ethics of the Alberta College and

Association of Chiropractors does not prohibit the sale of

health products, it does have a section on product marketing

in the chiropractic office in which a number of conditions are

placed on this practice. These include that chiropractors

ensure they do not exploit the trust in the therapeutic

relationship, not misrepresent or exaggerate the value of

products, have evaluated that the therapeutic value is rational,

and make available information necessary for patients to

make an informed choice, including the availability of the

product elsewhere, '

The Code of Professional Ethics of the Chiropractor's

Association of Saskatchewan does not directly address the

retailing of health products. It does, however, state that

chiropractors shall avoid the advocacy of any product when

they are identified

a s

mem bers ofthe chiropractic profession,

^

The Manitoba Chiropractors' Association Code of Ethics

makes a general statement about not taking financial

advantage of patients and another statement about protecting

professional reputation by avoiding all situations that could

lead to a conflict of interest as defined in the Conflict of

Interest Policy'^ Although product sales per se are not

addressed within this policy, conflict of interest is clearly

defined. The policy also outlines procedures to be followed

when a conflict of interest arises; however, these apply more

to a single event rather than to an ongoing pattern of practice,

such as product retailing.

Finally, the Code of Ethics of Chiropractors in Quebec

clearly states that the chiropractor must subordinate his

personal interest to that of his patient. The Quebec code is

consistent with others, stating the chiropractor should avoid

any situation that would put him in a conflict of interest, and

it describes such a conflict as arising when, in respect of a

given act, the chiropractor finds direct or indirect, real or

possible, personal advantage therein. Like the Code of the

Manitoba Chiropractors' Association, this code does direct

the chiropractor to advise his patient of this situation once

recognized, but again, this does not seem applicable to an

ongoing pattern of practice,^

F e d e r a l G u i d a n c e a n d d v e r t is i n g o f H e a l t h P r o d u c ts

For chiropractors, the practice of selling health products is

addressed by their provincial and national codes of ethics.

Advertising of health products is also overseen by Health

Canada, A dvertising as defined u nder the Food and Drugs Act,

the Food and Drug Regulations, and the Natural Health

Products Regulations refers to any representation by any

means whatever for the purpose of promoting directly or

indirectly the sale or disposal of any food, drug, cosmetic or

device, Health Canada provides guidance on direct-to-

consumer advertising of health products including natural

health products and nonprescription drugs. Only those

products (including drugs, natural health products, medical

devices, vaccines, and biologic products) that have been

authorized for sale by the Health Products and Food Branch

may be advertised. Health products authorized for sale are

readily identified by an 8 digit identification num ber preceded

by a specific acronym (DIN, NPN, DIN-HM), Specific pro-

visions limit the type and extent of

advertising.

For example.

Health Canada does not permit the use of superlative

terminology to exaggerate therapeutic properties of a product

(eg, amazing formula ), it does not permit products to be

described as safe or free of adverse effects, and it prohibits the

advertisement of health products as treatments, preventions,

or cures for a number of specific diseases and conditions,^'

These guidelines have been developed to minimize the

health risk factors to Canadians while maximizing safety and

to promote conditions that enable Canadians to make healthy

informed choices, Noncompliance with these guidelines

could result in uninformed decision making, threatening the

well-being of the consumer.

IS USSION

This study explored the extent to which Canadian

chiropractic Web sites identified using the Canada 411

Business Directory advertised products for sale. Our findings

show that just more than half of the chiropractors with Web

sites were offering health products for sale. Most health

products related directly to promotion of musculoskeletai

health and included orthotics, pillows, braces, and exercise

equipment. Nutritional supplements were offered to a lesser

extent and were more often advertised by those in a

multidisciplinary practice setting. Practitioners in the province

with the most restrictive guideline on the sale of nutritional

supplements (British Columbia) were less likely to advertise

these products.

The codes of ethics and conduct of the national and

provincial chiropractic associations were generally permissive

ofth e practice of selling health produc ts, with the exception of

British Columbia, Conditions placed on the sale of these


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49 0 Page and Grod


Journal of Manipulative and Physiological Therapeutic

July/August 200

products included that they pose no conflict of interest, they

serve the best interest of

th e

patient, they have clinical value,

and they be made available at fair market.

C o n f l ic t o f In t e r e s t P a t i e n t B e s t I n t e r e s t s a n d F a i r M a r k e t P r ic e

The potential problem with office dispensing by health

professionals is the conflict it may create between the role of

the health practitioner as a professional performing in the best

interest of the patient and the role o f the health practitioner

a s

a

business person. The practice of retailing is viewed by some

health professionals as undermining professionalism.^'^^'^''

Health professionals have a fiduciary duty to act in their

patien ts' best interests. Implicit within the healing professions

is the commitment to serve the interests of patients; efface-

ment of self-interest is the ethical ideal.^'' A potential conflict

of interest exists when practitioners proflt from selling health

products to their patients. Some of the chiropractic codes of

ethics described above take this into account, recommending

that products be sold at fair market price (CCA ) or that

product ma rkup be reasonable in relation to expen ses incurred

(Ontario); however, these parameters are variable and subject

to individual interpretation. Th is conflict may b e magnifled if

the demand for the product does not com e from the patient and

the patient only purchases the product because of the

chiropractor's recotnmendation or endorsement.

Smith^^ sugg ests that conflict of interest represents a set of

conditions rather than a behavior. That is although the selling

of health products may not be deliberately intended to take

advantage of patients, the very fact that such products are for

sale in the office may influence practitioners' behaviors in

ways they are potentially unaware of. For example, a

practitioner may be drawn into discussions of products that

are unrelated to the patient's reason for seeking care simply

because the patient has seen the product in the office. In turn,

patients may feel compelled to purchase products because of

the practitioner's endorsement.

In addition, chiropractors arc confronted with business

advertisements, such as Retail product sales a t point of service

improve chiropractic clinic revenues and patient loyalty, ^* and

trade publications suggesting practitioners can increase their

incomes through the sale of nutritional or other products.'^'

Such advertisements may mask the potential ethical conflict

created by health product sales by making such sales appear the

norm and, therefore, acceptable within the profession.

The intentions of the practitioners, markups on the

products, and the motivations of the patients could not be

assessed from the methods used in the present study. These

are important areas of inquiry for future research.

C l i n i c a l V a l u e

In addition to the commitment of service to others,

professionalism assumes possession of

a

specialized body of

knowledge. Although chiropractors are recognized as

neuromusculoskeletal specialists, some have suggested that

the expertise of some chiropractors does not necessarily

extend to other areas of health, such as nutrition, which rnay

make it difficult for these practitioners to recommend

treatments essential for the well-being of their patients.^'^ •'

Moreover, it has been suggested that some chiropractors m ay

lack the expertise required to critically evaluate the evidence

on product safety and efficacy; therefore, decisions may no

be groun ded in science or clinical efficacy.' '•'̂ This i

particularly im portant in the area of nutritional suppleme nts

where claims of benefit lack scientific validity and research

is frequently criticized for its lack of rigor (eg, references 36

to 38). The average consumer is at an even greate

information disadvantage and may assume that, because

some chiropractors are selling such products, the products

have shown safety and efficacy.

O t h e r P r o f e s s i o n s a n d P e r s p e c t i v e s

Chiropractors are not the only group of health profes

sionals who have ventured into the health product market

place. Others, such as dentists and dermatologists, have gone

there too.^'^'''' Members of some other professions have

described the benefits of selling products to their patients

Dentists who engaged in product retailing did not believe tha

this behavior harmed the professional image of dentistry and

strongly agreed that retailing offered convenience to thei

patients. Moreover, dentists were likely to view retailing o

products as ethical if the product was backed by clinica

research.^^ Dermatologists identified trust and convenience

as the most common reasons patients purchased nonpre

scription products from them. For their part, the patient

listed physician knowledge and trust most frequently.

L i m i t a t i o n s

The sampling strategy used in this study captured a very

restricted proportion of ehiropractic practices. The sample is

limited because not all chiropractors list their Web sites with

the online directory. In addition, chiropractors who do no

have W e b sites might also sell health care products. Bias withi

this sampling strategy may have arisen because chiropractor

with advertised Web sites may be more aggressive marketer

and may, therefore, be more likely to advertise products. As

well, advertisement of a product on a Web site may no

correlate with sales of the product. For these reasons, the

estimate of chiropraetors who engage in the advertising o

health products should be interpreted with caution. Future

research should use representative samples of practitioners to

allow chiropraetors to provide their opinions of and practice

around health product retailing and to examine practitione

knowledge of their codes of conduct and ethics.

ON LUSION

Chiropractors are responsible for good practice, achieved

in part by complying with professional standards and


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regulatory mandates. The review of national and provincial

codes of ethics and conduct showed that the practice of

health product sales is generally permitted with the exception

of the restrictions in place in British Columbia at the time of

the audit. The differences are evidenced in the detail the

codes contain. Where there is less specificity, practitioners

are permitted a greater degree of subjectivity in their

interpretation and, therefore, application of these standards.

This may result in an uneven standard of practice both across

and within provinces and is illustrated in part by the range

health product advertising found in this study. The results of

this Web site audit have raised the. possibility that some

practitioners may not be aware of, or adhering to, their

professional guidelines regarding health product advertising

and sales, nor aware of the Health Canada guidelines

regarding advertising and health products.

The challenge before chiropractic is to decide if the act

of advertising and selling health products inevitably

conflicts with its code of ethics and its professional role.

Once this is determined, the profession can move toward

consistent standards of practice across the country,

complemented by appropriate guidelines and monitoring

of professional conduct.

Practical pplications

• Chiropractors professional conduct is governed in

part by their professional codes of ethics.

•

Canadian chiropractic codes of ethics vary in

their position on the sale of health products by

chiropractors.

• The sale of health products by chiropractors may be

in conflict with their professional code of ethics.

CKNOWLEDGMENT

The authors acknowledge Dr Michael King for his initial

review of the manuscript.

FUNDING SOURCES

ND POTENTI L CONFLICTS

OF INTEREST

Funding for this project was granted by the Canadian

Memorial Chiropractic College. The authors have no

conflicts of interest.

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