Since the late 1970s, DTCA of prescription drugs has become important in the United States. It takes two main forms: the promotion or creation of a disease out of a non-pathologic physical condition or the promotion of a medication. The rhetorical objective of direct-to-consumer advertising is to directly influence the patient-physician dialogue. Many patients will inquire about, or even demand a medication they have seen advertised on television. In the United States, recent years have seen an increase in mass media advertisements for pharmaceuticals. Expenditures on direct-to-users advertising almost quadrupled in the seven years between 1997 and 2005 since the FDA changed the guidelines, from $1.1 billion in 1997 to more than $4.2 billion in 2005, a 19.6% annual increase, according to the United States Government Accountability Office, 2006). The mass marketing to users of pharmaceuticals is banned in over 30 industrialized nations, but not in the US and New Zealand, which is considering a ban. Some feel it is better to leave the decision wholly in the hands of medical professionals; others feel that users education and participation in health is useful, but users need independent, comparative information about drugs (not promotional information). For these reasons, most countries impose limits on pharmaceutical mass marketing that are not placed on the marketing of other products. In some areas it is required that ads for drugs include a list of possible side effects, so that users are informed of both facets of a medicine. Canada's limitations on pharmaceutical advertising ensure that commercials that mention the name of a product cannot in any way describe what it does. Commercials that mention a medical problem cannot also mention the name of the product for sale; at most, they can direct the viewer to a website or telephone number operated by the pharmaceutical company. Reynold Spector has provided examples of how positive and negative hype can affect perceptions of pharmaceuticals using examples of certain cancer drugs, such as Avastin and Opdivo, in the former case and statins in the latter. Drug coupons In the United States, pharmaceutical companies often provide drug coupons to consumers to help offset the copayments charged by health insurers for prescription medication. These coupons are generally used to promote medications that compete with non-preferred products and cheaper, generic alternatives by reducing or eliminating the extra out-of-pocket costs that an insurers typically charge a patient for a non-preferred drug product. Economics