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Direct-to-consumer advertising

of prescription medicines:
A systematic review of the
evidence from the perspective
of the consumer
Received (in revised form): 9th October, 2006

Michael Harker
is Associate Professor in Marketing at the University of the Sunshine Coast in Queensland, Australia. He has a Bachelor of
Science (Hons) in Economics from Southampton University and MA in Marketing from Lancaster University, both in England. His
PhD in Strategic Management is from Griffith University, Brisbane, Australia and his research is concerned with social problems
and the contribution of Social Marketing in solution of these issues. His articles have appeared in Journals in the USA, Europe
and Australia. Before taking up a teaching and research position at the Australian University, he was Marketing Director for Lloyds
in Europe.

Debra Harker
is Associate Professor in Marketing at the University of the Sunshine Coast and previously worked as a Marketing Consultant with
KPMG Peat Marwick Management Consultants in England and AGB McNair in Australia. She achieved a BA (Hons) in Business
Studies at South Bank University, London, and evaluated the effectiveness of the advertising self-regulatory scheme in Australia
for her doctorate, which was awarded by Griffith University in Brisbane, Australia. She now lectures in Marketing at the University
of the Sunshine Coast in Queensland, Australia and publishes in quality journals around the world.

Keywords direct-to-consumer advertising of prescription medicines (DTCA),


consumer knowledge, attitudes and behaviour, medicalisation

Abstract Direct-to-consumer advertising of prescription medicines (DTCA) is a


controversial practice where many of the arguments for and against are not supported
by strong evidence. There is little research that considers DTCA from the consumer’s
perspective, and this paper explores consumer education, consumer protection,
medicalisation of consumer conditions and patient doctor relationships. The paper
concludes that little is known about the impact of DTCA on actual consumer behaviour
in relation to drug acquisition and use.
Journal of Medical Marketing (2007) 7, 45–54. doi:10.1057/palgrave.jmm.5050060

INTRODUCTION developed a number of techniques to


It is not so many years ago that the inform, educate, advise and warn
advertising of prescription medicines was consumers about medical conditions and
directed exclusively at doctors and other the prescription drugs that are marketed.
Michael Harker healthcare professionals. But as populations This study focuses on direct-to-consumer
University of the Sunshine
Coast age and experience longer life-spans, there advertising (DTCA) by pharmaceutical
Faculty of Business
Locked Bag 4 is increasing evidence that consumers need companies, a practice that is polemical as
Maroochydore South
Queensland 4558, Australia
to seek out more information concerning it operates at the nexus of population
Tel: (61) 7 5430 1234
Fax: (61) 7 5430 1231
their health and wellbeing.1 Governments healthcare and ‘for profit’ enterprise, and
e-mail: mharker@usc.edu.au and pharmaceutical companies have is thus still severely restricted in the

© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00 Vol. 7, 1 45–54 Journal of Medical Marketing 45
www.palgrave-journals.com/jmm
Harker and Harker

developed and developing nations of the view of the field. The contribution of
world. Interest in, and the literature on, this study is to consider DTCA from
DTCA has, however, developed apace over the perspective of the consumer.
the last decade or so, but it has tended to
reflect the positions of the ‘pro’ and ‘anti’
groups towards DTCA. There are few FINDINGS
studies that consider DTCA strictly from
the perspective of the consumer, and this Background
is the key purpose of this paper. An DTCA is only permitted in the United
additional objective of the paper is to States of America and New Zealand, but
assess the rigour of those studies that it has been considered in other developed
purport to assess the impact of DTCA nations. The DTCA debate in the
on consumer behaviour. The definition literature has concentrated on the ‘pros’
of DTCA and the methodological and ‘cons’ of the process to the virtual
approach are outlined in the next sections exclusion of evidence-based position
of the paper, and these are followed by statements. The critics express concern
sections addressing a number of consumer about consumer safety, increased costs and
issues covering consumer protection, patient–doctor relationships, while the
consumer education, consumer attitudes proponents stress patient awareness of
and behaviour, the medicalisation of conditions, treatment alternatives,
consumer conditions and consumer compliance and a heightened involvement
relationships with doctors. in their healthcare.5
The healthcare market is divided
basically into two segments, the healthy
STUDY METHOD half and the unhealthy half, suggests White
‘DTCA is any paid form of non-personal and his team;6 segments that comprise
communication of prescription medicines different people with different needs.
by manufacturers and distributors, the According to White et al.6 DTC ads are
effect of which is to induce the ‘invisible’ to the healthy half because they
prescription, supply, purchase and/or have no obvious health problems (p. 63).
use of those prescription medicines’.2 This is not necessarily the case because, as
A systematic review of all evidence will be shown, some of these people have
relating to DTCA and the consumer was health problems of which they are
undertaken. The systematic review was unaware — and they may need to be
conducted in line with the guidelines set alerted to them.
out in Khan3, and the results are presented Consumers and close carers need to
according to the guidelines laid down in search for information on healthcare issues;
the QUOROM statement (www.consor- the intensity of the search is influenced by
statement.org/QUOROM.pdf 2005). It the physical and mental condition of the
was not possible to extend the review into consumer, age, sex and income level.7
a formal statistical method syntheses or Today’s consumers are more vociferous
meta-analyses because of the heterogeneity and active in the healthcare process than
of the studies explored. in the past; the doctor is still influential
An extensive search of relevant databases in the decision process, but some
from 1987 to October 2004 coincided acquiescence to patients’ demands has
with the study by Gilbody et al.4 and a been demonstrated.8
search of the databases from October 2004 Television is a well-used medium
to June 2006 provided a more current in DTCA with problem-solution and

46 Journal of Medical Marketing Vol. 7, 1 45–54 © 2007 Palgrave Macmillan Ltd 1745-7904 $30.00
Direct-to-consumer advertising of prescription medicines

emotional appeals being most popular. about an advertised drug, while 57 per
Magazines are most popular with female cent of consumers searched for additional
consumers, but many people do not information on the internet. The top 20
bother to read all the copy and ‘skim drugs account for 58 per cent of DTCA
through’ brief summaries. The internet is expenditure in the USA.12
an important source of information, and In New Zealand, the high awareness
the integrated approach of television– levels of DTCA match those in the USA
internet has high attention and credibility. and awareness of benefits are above 80 per
Doctors are a highly credible source of cent in both countries, but risk
information.6 information recalled in New Zealand is
much lower than in the US (30 vs 80 per
Consumer protection and cent). A ‘great majority’ of New Zealand
regulation of DTCA patients, however, neither asked for, nor
It is a consumer’s right to be informed9 received, a prescription as a result of
and ‘everyone has the right to freedom of DTCA.13 Further, the surveys suggest
expression, including the freedom to seek, that consumers do not share many of
receive and impart information and the concerns raised about DTCA on
opinions of any kind’,10 but many their behalf.
countries deny consumers this right with
regard to prescribed medicines believing Educating consumers
that healthcare is primarily the province The ‘consumer welfare’ effect of DTCA,
of the healthcare professional. whereby advertising provides information
In the United States, the consumer is to consumers regarding unmet, but
protected by the government body, the medically significant, conditions, for
Food and Drug Administration (FDA), example diabetes, hypertension, oesophagus
while in New Zealand the consumer is and stomach problems and high
protected by an industry self-regulatory cholesterol, has been confirmed by a
body, the Advertising Standards Authority number of rigorous studies. Forty-three
(ASA). per cent of new diagnoses were ‘high
priority conditions’.14
The practice ‘Well informed consumers are the
The populations of industrialised nations bedrock of an efficiently operating
are ageing; the ‘boomer’ generation market’,15 and the FDA confirmed that
accounts for 80 million consumers and DTCA served public health functions by
the ‘mature’ accounts for 52 million increasing patient awareness of diseases
consumers in the United States. American that could be treated and prompted
consumers ‘buy’ on average nine thoughtful discussions with doctors.16
prescriptions each per year and by the age More than half of the adults who were
of 45 years, 50 per cent of Americans and interested in an advertisement for
over 45 per cent of New Zealanders, are medication took action after seeing the ad.
prescribed at least one prescription drug. Most consumers sought information from
Eighty per cent of Americans, however, their doctor as a result of DTCA —
feel confident about the safety of higher than any other source, and the
prescription drugs sold in the USA.11,12 doctor was the most trusted source of
Ninety-six per cent of US citizens are information at 95 per cent.6 Although ads
aware of advertised medicines and 32 were useful in initiating doctor discussions,
per cent of consumers who had seen some older consumers found them
an advertisement talked to their doctors confusing. But over 61 per cent of

© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00 Vol. 7, 1 45–54 Journal of Medical Marketing 47
Harker and Harker

consumers in a national survey in the over the year, while the price of the other
United States disagreed with the drugs rose by 9 per cent. The USGAO
statement: report concluded that advertising had
‘Ads for medications should only be in increased prescription drug utilisation
medical journals’17 which, in turn, had influenced prescription
drug expenditures rather than price.22
One of the ‘clearest and strongest’
Consumer reaction to DTCA findings of FDA research, according to
Consumer reaction to DTCA in the the FDA study, is that DTCA increases
United States is tracked through a consumers’ awareness of new drug
longitudinal study by Prevention magazine, treatments (Aikin et al.16, p. 86). Further,
confirmed by two FDA surveys. The DTCA was of value to consumers by
overall consumer attitude towards DTCA assisting them to guide their discussions
is positive and ‘consumers like DTCA’.18 with doctors and allowing them to
DTCA increases consumer awareness of become more involved in their own
new drug treatment, and 93 per cent of healthcare.16 In a special survey directed
consumers said that doctors welcomed at women, it was found that DTCA
their questions about prescription helped 75 per cent of the sample to
treatment. There was some concern discuss prescription medicines with their
from consumers about the clarity of physicians. These 1,600 women found
information in broadcast advertisements.19 that magazines were the best source of
It has also been argued that information on prescription medication.23
pharmaceutical companies charge high
prices for new drugs and those drugs are
promoted selectively. A comprehensive Consumer attitudes and
study by Anantharaman et al.20 found a behaviour and treatment
weak relationship between DTCA and the Research in the United States and New
price for 20 heavily advertised drugs, and Zealand indicates that there are few
concluded that DTCA costs ‘did not drive problems with DTCA.13,24 Detailed and
price increases’ (p. 15). Additionally, in the longitudinal research data interrogated by
last 20 years, the FDA has moved more Calfee shows that the overall attitudes
than 600 drugs from prescription to over towards DTCA were very positive and
the counter (OTC) status. It has also been some lessons can be learned from these
argued that some new drugs are more data:
expensive, as companies endeavour to
recover high research and development 1. Consumer deception is not an issue.
costs. Newer drugs are, however, more 2. DTCA provides valuable information
effective and help to lower the costs of to consumers.
non-drug spending; for example, replacing 3. DTCA motivates consumers to seek
a 15-year-old drug with a new one additional information from health
increases drug costs by US$18, but reduces professionals and other sources.
overall costs on the average by US$100.21 4. DTCA aids patient–doctor discussions.
Also, the United States General 5. Spill-over benefits for consumers from
Accounting Office has reported that the DTCA include better knowledge of the
most heavily advertised drugs outsold risks of medication, better compliance
those that were less heavily advertised by a with drug therapies and even motivation
factor of 6 to 1. The prices of the heavily to pursue lifestyle changes in the place of
advertised drugs increased by 6 per cent prescription drugs.24

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Direct-to-consumer advertising of prescription medicines

Lexchin and Mintzes25 question the to the fact that the patient might be
findings from such surveys that measured referred to a specialist, or the doctor
attitudes, beliefs and recall of past wished to monitor progress before
behaviour, indicating that this research prescribing; this was subsequently termed
ignored consumer behaviour emanating ‘minimally acceptable care for depression’.
from doctor–patient discussions. An ‘The prescription rates for ‘minimally
important study by Kravitz et al.8 took acceptable care were 56 per cent when
us into the doctor’s office to assess the the patient made no request, but over 90
prescribing behaviour of doctors as a result per cent when they made a request’.
of DTCA. The rigorous study used a Swann responded:
randomised controlled trial and engaged
‘So nearly half fell below the minimum
actors called ‘standardised patients’ (SPs) standards’.26
who presented at doctors’ offices with two
levels of depression, requesting three levels Kravitz replied ‘you might ask how did
of information for treatment from ‘no you manage to recruit such a cohort of
medication request’, through ‘a general bad doctors — but these doctors really
request’, to ‘request for a specific brand aren’t bad at all, in fact they are among
of drug’. Interestingly, ‘patients’ who made the better doctors in the various
‘brand’ requests for information, and had communities that we studied’.
either major depression or minor disorder, So how ‘good’ have doctors been found
received antidepressant prescriptions in to be when managing patient healthcare
similar proportions (53 vs 55 per cent). through the use of therapy? An exhaustive
Only 31 per cent of ‘patients’ presenting study by Choudrey produced some
with major depression, but making ‘no interesting results for patient care. The
request’, were prescribed antidepressants. researchers carried out a comprehensive
The findings of this study suggested that, systematic review to uncover 59 studies,
although patients can influence the or 62 evaluations, between 1966 and 2004
treatment that they receive, doctors that related physician knowledge to age
differed systematically in their propensity and experience. They found that 52 per
to prescribe antidepressant drugs; there was cent of evaluations reported decreasing
evidence of under-treatment of serious doctor performance with years in practice.
depression and some over-treatment of less More specifically, of the 19 studies that
serious conditions.14 looked at adherence of standards to
When discussing this study with Dr appropriate therapy, it was found that
Norman Swann of the Health Report on 14 of the 19 (74 per cent) evaluations
Australia’s Radio National, Professor Kravitz reported a negative association between
explained that the ‘patients’ who presented doctor age and adherence to appropriate
with major depression were about twice as therapy standards; for example with Beta-
likely to receive antidepressant medication blockers and lipid-lowering agents. Older
when they requested it than when no doctors, it seems, are failing to provide the
request was made. This comment was appropriate therapy for their patients and
questioned by Dr Swann: the authors of this study recommend
quality improvement interventions.27
‘So what you are telling me is that an active Younger doctors, too, are not free from
consumer, and active patient, gets better care
than somebody who is passive’.26 criticism when it comes to knowledge and
practice; it appears that anatomy teaching
Professor Kravitz went on to explain that in Australian universities is not as
possibly the low prescription rate was due comprehensive as it used to be and that

© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00 Vol. 7, 1 45–54 Journal of Medical Marketing 49
Harker and Harker

young doctors ‘do not have the basics on recent study by AusDiab has shown that
which to build their medical thinking’.28 an additional 275 Australian citizens are
Additionally, doctors are under developing diabetes every day — but not
increasing pressure for cost control and all know this fact, it appears.32
from policy changes of governments and Mintzes33 asks the question ‘does
health plans. Doctors found it increasingly DTCA broaden the domain of medicine
difficult to manage busy practices and beyond reasonable grounds?’ (p. 908).
devote adequate time to their patients.29 Significantly, the medicines that have been
Doctors found patients to be better growing most quickly in consumer
informed but were concerned with the awareness terms in the United States are
time taken to discuss patient Nexium (for reflux/ulcer ailments) and
misconceptions about conditions and Lipitor (for high cholesterol).12
treatments.30 Consumers are, however, In a spirited response to Mintzes’ stance
much more interested in their healthcare, in the medicalisation debate, Bonaccorso31
and the balance of power between doctor highlighted the epidemiological evidence
and patient is changing as consumers that showed ‘substantial under-diagnosis’ of
interrogate and become better-informed major diseases and the known risk factors
from the numerous databases available to for which treatments exist. Even when
them. Eight out of ten patients who diagnosed, the diseases are still under-
visited their doctor to discuss a condition treated and, when noncompliance is
as a result of DTCA did, in fact, suffer factored into the equation (estimated at 50
from that condition.12 per cent of prescribed medicines across all
the major chronic diseases), avoidable
The consumer and medicalisation morbidity and mortality is the result.
Medicalisation is the process by which These data ‘make the most powerful case
non-medical problems become defined for greater public awareness of the benefits
and treated as medical problems, usually of modern medicines’ (Bonaccorso and
in terms of illness and disorders. The main Sturchio31, p. 2).
factors that facilitate medicalisation are the In Australia, the medicalisation debate
processes of supply and demand. On the has been refuelled in 2005 by a paper
supply side, there is the historical power, from Dr Con Costa of the Doctors’
prestige and credibility of the medical Reform Society. He suggests that dementia
profession, which gave doctors jurisdiction and osteoporosis are a natural part of the
over all things related to illness or ageing process and that the pharmaceutical
healthcare. On the demand side, there has industry is ‘medicalising’ these
been an increase in demand for medical conditions.34 He also questions the
solutions to health problems.29 commitment by the industry to high
There has been concern in some cholesterol and impotence conditions.
quarters that consumers were being In a response to the claim by Costa that
persuaded, by DTCA, that non-medical osteoporosis and dementia are ‘newly
conditions have become defined and manufactured’ by the pharmaceutical
treated as medical conditions,25 for industry, Kieran Schneemann rebuts the
example toe nail fungus, baldness and argument. He points out that many of the
erectile dysfunction. Other researchers drugs available today are ‘discovered,
have highlighted the epidemiological researched, manufactured, trialled,
evidence showing ‘substantial under- registered, supported and marketed by
diagnosis’ of major diseases and the known pharmaceutical companies’. It is totally
risk factors for which treatments exist.31 A appropriate that continuing education

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Direct-to-consumer advertising of prescription medicines

about new and existing drugs be patients. On the other hand, a well-
supported by the companies that know researched study by Wazana has
most about them (Schneemann35, p. 23). demonstrated that drug-company
As evidence Schneemann directs Costa to sponsored continuing medical education
a new website by the International programs and funding for travel and
Federation of Pharmaceutical accommodation were associated with
Manufacturers and Associations, which has increased prescription rates of the sponsors’
more than 250,000 links to clinical trials drugs by attending doctors. Apparently
around the world. ‘gifts matter’, and a number of
The medicalisation concept was organisations and government departments
introduced into the literature in the 1990s, have developed guidelines to ‘modulate
since when there have been significant the interaction between physicians and
changes in the pharmaceutical industry. the pharmaceutical industry’ (Wazana38,
The medical profession used to dominate p. 379).
the industry, but now consumers and Doctors are expected to be ‘life-long
advocacy groups, providers (doctors, learners’ in addition to running a business,
hospitals), payers (insurance companies and managing staff, completing forms from
governments) and buyers (companies that demanding bureaucracies, and this in a
buy health insurance for workers) all technically complex and rapidly changing
compete for power and influence over healthcare environment. As populations
healthcare. But if there has been an age, surgeries are busier, subsidised
increase of medicalisation through rising consultation times are shorter and doctors
consumerism and industry zeal, insurers are under pressure ‘to meet customer
and governments have acted quickly to needs’.29
correct the balance.36 Before DTCA and the internet, the
local doctor was the first point of call and
DTCA and the doctor–patient probably the sole custodian of key aspects
relationship of health data. The patient trusted the
The healthcare landscape is complex and knowledge and experience of the doctor
dynamic and is being influenced by a who acted as an intermediary between
number of factors, all of which impact on two unknowns — the patient’s condition
the doctor–patient relationship. The and the innovative but distant providers of
influencing factors are the rise of wonder drugs. Today, the patient is armed
consumerism, increasing litigation, direct- with vast quantities of data from numerous
to-consumer promotion of drugs and easy sources concerning conditions, treatments,
access to a multitude of sources about test data on latest ‘blockbuster’ drugs, and
medical conditions, for-profit healthcare the medical profession struggles to keep
and the relentless pursuit of cost up to date with the latest advances in
containment by health plans and treatments, drugs and ‘bed-side’ manners.29
government departments.29 But the doctor is still the most valuable
It has been argued that DTCA may source of healthcare information,6 and the
adversely affect the doctor–patient most trusted, according to a study where
relationship and lead to less than doctors rated a 98 per cent trust rating
satisfactory health outcomes. Apart from from consumers.39 A number of studies
the ‘philosophical’ concern and the have suggested that DTCA encouraged
information asymmetry argument,37 there consumers to seek medical help and to
is evidence that DTCA can affect the increase the flow of traffic into doctors’
kind, and costs, of prescriptions given to surgeries. DTCA does not, however, seem

© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00 Vol. 7, 1 45–54 Journal of Medical Marketing 51
Harker and Harker

to have interfered with the doctor–patient CONCLUSIONS


relationship since prescription choice was The systematic review of the literature
still decided primarily by the doctor once that was undertaken for this study into
patients made the surgery visit.12 DTCA from the consumer’s perspective
In countries where DTCA is not demonstrates that much of the research
permitted, however, attitudes are less in this area has been descriptive in nature.
positive and there are behavioural Valuable as this is, the research has failed
differences between doctors and patients. to answer some key questions.
In the UK, doctors and hospital specialists The Prevention studies, research
were highly opposed to the ‘concept and undertaken by Mintzies, Kravitz and
likely overall impact of DTC advertising’. Calfee in the United States and Canada,
Further, these same doctors were also and the work of Eagles and Hoek and
not in favour of recently introduced ‘see colleagues in New Zealand have been
your doctor’ campaigns when 50 per cent valuable as they provide information of
of the sample was unaware of the trends in consumer awareness, knowledge
campaigns even though they had been and attitudes over time. These studies were
running for four years.40 An Australian also confirmed by FDA work in 1999 and
study showed that consumers who had 2002. Such descriptive studies have value
‘high knowledge’ of prescription in that they explore the ‘who’, ‘what’,
advertising and drug regulation had a ‘when’ and ‘where’ questions. But they are
more negative attitude towards DTCA unable to answer the important questions
than those consumers with ‘low of ‘why’ and ‘how’; the research studies
knowledge’.41 Other research, however, have not explored in any depth the basic
found that 50 per cent of Australians felt behavioural issues, that is ‘why do
that DTCA would be a useful source of consumers do what they do and what
information for consumers and would influences this behaviour’.
increase public awareness of prescription The studies that have been evaluated
medicines; they also thought that DTCA in this systematic review of the DTCA
would increase the price of prescription literature and consumers have provided
medicines.42 valuable insights into the nature, extent
A rigorous study by Mintzes and and effects of DTCA of prescription
her colleagues demonstrated that medicines:
American doctors in Sacramento were
more likely to prescribe an advertised • Some consumers are better educated about
drug than their Canadian counterparts conditions and treatments.
in Vancouver. Seven per cent of • Some consumers are better prepared for
Sacramento patients requested an doctor discussions.
advertised drug as opposed to 3 per cent • DTCA can facilitate the compliance process
in Vancouver, and physicians fulfilled 78 with older consumers.
per cent of requests for the advertised • DTCA appears to increase the demand for
drug in Sacramento as compared to treatments and medicines.
72 per cent in Vancouver.43 • Consumers need more information about the
DTCA has not significantly impacted risks of prescription medicines.
adversely on the patient–doctor
relationship, but it seems to be a It has been said that ‘the absence of
contributor in affecting the balance of evidence is not evidence of absence’44, but
power in discussions in the consulting the effects of DTCA on consumers have
room.36 yet to be summarised in a relevant and

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rigorous manner.4 Although this study has regulatory approaches and consumer responses. Int. J.
Advertising 23(2), 197–227.
indicated that consumers have an 14 Berndt, E. R. (2005). The United States’ experience
increasing need for information about with direct-consumer advertising of prescription drugs:
health issues and treatments, the authors what have we learned, Paper presented at the
International Conference on Pharmaceutical
were unable to find significant studies that Innovation, Institute of Economics, Academia Sinica,
actually demonstrated the impact of Grand Hotel, Taipei, Taiwan, May 25–27, Session B4,
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and Quality in the Health Care Industry. (1998).
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by Kravitz and Mintzes but much more Available from http://www.hcqualitycommission.gov/
final/append_a.html accessed 9th October 2006.
needs to be done.
16 Aikin, K. J., Swasey, J. L. & Braman, A. C. (2004).
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associated with DTC promotion of prescription drugs
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