The Upside of the Downturn The restrictions imposed by the floundering global economy are prompting pharmaceutical executives to seek creative ways to adjust their marketing strategies. The difficult economic environment of the past year has impacted businesses across the globe, and the pharmaceutical industry is no different. Pharma companies have been plagued by declining sales, constrained resources, and shrinking work forces. by Carolyn Gretton “Patients are making fewer doctor visits and some patients are not filling or refilling prescriptions as directed by their physicians," notes Deirdre Connelly, president, North American pharmaceuticals, for GlaxoSmithKline (GSK). “Given the challenging economic environment we’ve seen over the last year, we’ve increased our focus on being more efficient and effective in delivering value to our customers in every interaction we have." Meaghan Onofrey, president of MBS/Vox, part of CommonHealth, concurs that the current recession has altered the landscape dramatically. “Discussions of cost within the healthcare professional-patient dialogue have become more and more common," she says. “Interestingly enough, physicians are just as likely to raise this topic as are patients. The topic is no longer taboo, and the playing field is more level. Our culture is slowly shifting into one that puts an emphasis on value. Healthcare professionals and patients can align on the need to save money whenever possible." Ms. Onofrey says fostering an appropriate healthcare professional-patient dialogue about value, and how to deal with cost beyond cut-backs, can ensure that patients stay on their medications. (For more information related to cost vs. value in the healthcare environment, please turn to page 21.) In some cases, experts observe, the downturn has simply accelerated marketing shifts that already were in progress. “As an industry, we’ve always been keenly aware of our responsibilities to the various constituencies who depend on us," says Walt Johnson, VP of marketing for Astellas US. “Today’s environment has accelerated our activity to increase value in the form of successful treatments, and in terms of affordability." “I think the downturn has caused companies to reduce expenses more quickly than they might otherwise have done," says Josh Franklin, VP, sales and marketing, at Cornerstone Therapeutics. “The downsizing may have been inevitable in some areas, but it might not have happened so quickly if the economic downturn had not occurred." According to Joe Meadows, VP, marketing and creative services, at Catalina Health Resource, one of the most significant changes in pharmaceutical marketing has been the realization that there’s more to the marketer’s job than just finding new patients and battling for market share. “Most businesses learn the value of holding on to existing customers quickly, but the rising tide that brought us last decade’s blockbuster products made pharma slow to invest in this area to the extent it deserves," he says. “The industry is reallocating significant resources away from patient acquisition as the sole goal of brand marketers, toward a more balanced approach that places greater emphasis on keeping patients both adherent to therapy and loyal to a brand." (For more information related to adherence-driven marketing by bringing balance to the brand, please turn to page 18.) One way in which pharma marketing has changed in these leaner times is by shifting away from simple brand identity reinforcement toward strong, clear communications emphasizing the product’s value and benefits to patients and their communities. These communications may be contributing to an improvement in the industry’s public image; according to Harris Interactive’s annual survey on corporate reputation, pharma was the only industry that showed a significant improvement in reputation in 2008, with 31% of respondents giving the industry a positive rating — pharma’s highest percentage in five years. According to Chris Mario, VP, marketing and commercial development, for Neuropharm, pharma companies are currently taking a more stringent view of spending and placing a stronger emphasis on utilization of technologies that allow for more precise targeting. “Branded and targeted promotional initiatives have become the mainstay," Ms. Mario says. “In many instances, this has prompted a reevaluation of tactical spending and alignment with strategic intent, key objectives, and critical success factors, with an eye toward eliminating random acts of marketing." One way to avoid these marketing miscues, especially when it comes to the creative process, which is often less linear and more subjective than we like to think, may be to have more open, honest, face-to-face collaborations, in spite of budgetary constraints, according to Abby Mansfield, VP/creative director, Topin & Associates. “At some point it’s critical for multinational, multidisciplinary teams to be able to review, comment, and approve the agency’s creative work," she says. “In our experience, in-person global team meetings at key points are vital to a collaborative, efficient creative process. Bringing the marketing and scientific teams together for a concentrated input session allows the agency to ask questions, clarify data, and begin to see the compelling insights in the brand." (To learn more about better global branding, please turn to page 28.) Some companies have managed to not only survive, but thrive despite the sluggish economy. “We’ve been fortunate in that we haven’t felt the negative impacts of the downturn as strongly as other companies might have; in fact, it’s allowed us to be a little more aggressive in our own growth strategies," Mr. Franklin says. He notes that cuts at other pharma companies have made more salesforce talent available to companies like Cornerstone, which has doubled its salesforce size in recent months to handle its expanding product portfolio. In addition, the reduction in large primary-care salesforces is creating opportunities for niche companies like Cornerstone, which specializes in respiratory therapies. “There are only a fixed number of details that physicians are willing to accept, and now there are fewer representatives vying for those detail slots," Mr. Franklin observes. Ms. Mario says that Neuropharm operates as a virtual company by design, pulling in subject matter expertise on an as-needed basis. “Due to the relatively large-scale multicompany downsizing, I have found there to be a stronger, high-performing pool of talent willing to work on a consulting basis than may have been available in the past," she says. “This, in turn, allows smaller companies to find more cost-effective expertise and scalable solutions." At Cephalon, Mike Derkacz, VP, U.S. marketing, CNS, says the downturn is being viewed as an opportunity for the company to become more innovative with its approach and seek out ways to effectively and efficiently maximize resources. The company is examining innovative ways to strengthen its dialogue with patients and physicians using technological tools such as on-demand Webcasts. “This new technology means our representatives can play a more strategic role while still maximizing resources," he says. “It increases our reach and results in a richer dialogue and customized physician engagement." Safely Navigating Social Networking Most experts agree that social networking tools such as Twitter, Facebook, and MySpace will become an integral part of the next wave of marketing strategies. But companies so far have remained reluctant to do more than dip a toe into the social media pool, in part because of its lack of clear-cut regulatory boundaries. “I think that over time, social networking will become a part of the marketing mix and the communication strategy for pharmaceutical products, but it’s going to be driven by some of the industry leaders mapping out what’s acceptable," Mr. Franklin says. “There’s so much risk in having a dialogue that is not regulated, so everyone is shy to be the first to go all the way down that road. There’s going to have to be a group that works together — either from within pharma or some other entity — to outline an approach that is consistent with the regulatory guidance that governs what we do within this media." “GSK continually examines how healthcare providers and patients seek and access information, and social networking tools may provide us with an opportunity to listen and connect with customers in new ways and better provide them with the type of information they value, when they want it, where they want it," Ms. Connelly says. “The risk for the industry will come if those communications are not done with fair balance and in accordance with all relevant regulations." Mr. Derkacz agrees that the opportunity for education and engagement provided by social networking tools comes with the responsibility to ensure that a company looks closely at the ways in which they will interact with their most important constituents. “Before implementing social networking initiatives, it’s important that companies have a broad understanding of the space — not just in the marketing department, but also legal and regulatory," he says. “We need a deep understanding of both the opportunities and the latest regulations to engage physicians and patients through social media channels in an appropriate and effective manner." Other experts believe that social networking should be viewed as just another tool in the communications toolbox, rather than an exotic and potentially dangerous alternative to traditional marketing media. “Given the expanding utility of vehicles like Twitter and Facebook, I’m not even sure the term ‘social’ networking remains descriptive," Ms. Mario says. “To me, these communication platforms are much like other consumer channels and as such should be considered for potential inclusion in the marketing mix on a case-by-case basis." Mr. Johnson concurs: “As in all other areas of life and society today, social networking’s major contribution to our industry will be to facilitate sharing of information and ideas and the building of relationships at a pace and at a scale not previously possible." Ms. Mario emphasizes that the inherent challenges to maintaining the integrity of social media-delivered communications from a regulatory perspective still need to be sorted out. “With that said, as a consumer, I would always fight to have access and the option to have a two-way communication with any manufacturer of a product I use," she says. “Therefore, I believe finding a way to make this work is both worthwhile and imperative." Sharpening the Salesforce The continued cutbacks in pharma salesforces occurring over the past year have apparently paid off. Reps have been forced to hone their approach and increase their flexibility, and rep fatigue seems to have subsided now that armies of salespeople from the same company are no longer beating on physicians’ doors. The result, according to a recent Cutting Edge Information study, is that doctors are not only more open to visits from reps, but are willing to spend more time with them when they come calling. Surveys and interviews with top-performing pharmaceutical and biotech companies revealed that reps now earn more time with their physician targets and have more developed and consultative relationships with them. The reps are also more accountable for their territories, the study notes. As part of GSK’s continuing efforts to ensure every interaction with healthcare professionals has value, Ms. Connelly says the company is moving some of its sales representatives from primary care to specialty care and scaling its business to meet the needs of the market. “Given the changes we are making, I’m confident that we’re on the right track to deliver the value our customers expect and deserve," she says. Mr. Derkacz believes the overall industry shift away from the large-scale, less-personalized salesforce model toward a more personalized approach is having a positive impact on the dialogue between the physician and sales representative, and is central to education and continued treatment innovation. “At Cephalon, this is a much less dramatic shift because our company model has always centered on a small salesforce and commitment to one-on-one interaction between the physician and representative," he says. “We haven’t seen the need to reduce our salesforce and have also started to leverage contract salesforces to allow for greater flexibility while ensuring proper reach and engagement." Smaller, more specialized companies like Cornerstone have actually stepped up their salesforce efforts in recent months as a result of the widening talent pool created by big pharma’s continued cutbacks. “We might not have grown as quickly as we did if so much talent wasn’t available, or if we hadn’t seen greater access within the high-decile primary-care targets," Mr. Franklin says. Mr. Franklin observes that large company salesforces, with their mirrored teams and pods, made it difficult for reps and physicians to form strong relationships. “Physicians who have six representatives from different divisions of one company selling the same product to them for different indications have a weaker bond with those representatives and that company, in my opinion," he says. “The days of multiple sales representatives calling on one physician are gone," Mr. Johnson agrees. “Now it’s all about targeting that resource, and targeting is more about bringing value in the form of clinical expertise and customized messaging." To that end, Mr. Johnson says Astellas has realigned its hospital unit to address the changing landscape and is using technology to maintain strategic alignment among its field sales organization and maximize its in-field time and effectiveness. “Physicians will continue to become more selective about which representatives they will see," he predicts. “Those representatives who not only know their products inside and out, but also have a thorough understanding of the specific nuances of each clinician’s practice, a firm grasp of the managed care market and its influence nationally as well as locally, and solid disease state knowledge, will be the select few that get time in front of the healthcare provider." Gina Clark, senior VP, marketing and business development for AmerisourceBergen Specialty Group, concurs that the managed care component of the continuum will become even more important, and as such it’s going to be more important than ever to open a dialogue between physicians and payers to achieve common goals: cost-efficient treatment, equitable reimbursement, and superior patient care. She believes managed care companies may believe that some products are no longer cost-effective at their current reimbursement levels. “Without adequate reimbursement, prescribing physicians may not be able to continue administering some products," Ms. Clark says. (For more information about improving the physician-payer interaction, please turn to page 16.) Michael Ball, Ph.D., VP, marketing and product management, and Amy Weickert, director of product marketing, at InfoMedics, believe by supporting brands throughout their life cycle in a manner that raises the confidence levels of the prescribing physicians and their patients, pharma companies can help to ensure sustained brand loyalty in the face of economic and regulatory challenges. These patient feedback experts believe the combined program should continually build and leverage brand equity throughout all stages of the product life cycle, including disease state awareness, early experience programs, branded launch campaigns, market share growth initiatives and patient adherence programs. (For more information related to supporting brands throughout the life cycle, please turn to page 22.) Ms. Mario believes the tough economic environment and subsequent downsizing have forced management to take an even harder look at salesforce strategy and implementation and have served as catalysts for the development of better, more sustainable business practices. “To survive, a pharma sales representative must prove be an asset to the company as well as to the community of practitioners who prescribe a manufacturer’s product, and be capable of doing this in a way that is in compliance with ever-expanding regulatory requirements," she says. “This is a much harder job than it used to be and I applaud those who do it well." The Code, One Year Later A year ago the Pharmaceutical Research and Manufacturers of America (PhRMA) set the pharma marketing sector on its ear with its updated Code on Interaction with Healthcare Professionals, which included a recommended ban on the distribution of promotional items such as pens and mugs with physician details. The revised code formally took effect in January 2009, and marketing experts say that so far, the changes have all been for the better. GSK was one of the companies that participated in the committee that defined the updated PhRMA code. Ms. Connelly notes that even before the revisions were made, GSK had implemented some of the suggested practices, such as having full independence between the company’s continuing medical education (CME) grant-making function and its sales and marketing functions. “In fact, some of our current practices go beyond what is required by the updated PhRMA code; for instance, we have eliminated all non-educational items — not just for healthcare provides, but also for patients and consumers," she says. “We have firm rules in place that prohibit offering or providing healthcare professionals anything that would be an inappropriate influence on prescribing or purchasing practices or that would be an inappropriate inducement to prescribe or purchase GSK products." Mr. Derkacz believes the PhRMA changes have had a positive impact on the way the pharma industry is perceived. “Our goal has always been to increase awareness and understanding of our medicines to help physicians and patients make treatment decisions," he says. “When Cephalon representatives enter a physician’s office, they are there to talk about lifesaving or life-enhancing medicines and where those medicines fit into the overall treatment discussion." “With the new PhRMA guidelines, the role of the representative has evolved; those reps that can bring value to their customers will stand out," Mr. Johnson says. “Like all pharma companies, we’ve moved away from any promotional item that is not educational in orientation. And, of course, we have modified our peer-to-peer or speaker programs to fit within all of the new guidelines." Mr. Franklin says the code has simply changed where companies make their promotional investments, not the level of spending itself. “The focus is now where it should be — educational and clinical resources — but it hasn’t significantly altered the nature of our business or the way we market our products," he says. “We don’t give away pens and pads anymore; that doesn’t change the nature of the interaction between our sales professionals and the clinicians." Brighter Economic Skies Ahead Marketing executives say that despite the signs that a rebound in the U.S. economy is imminent, they do not expect the current constraints in the marketing environment to ease anytime soon. “I think that a year is a pretty short window of time to look at when one thinks about all of the turbulence that we’ve had recently," Mr. Franklin says. “I would expect that we’re going to continue to see the same type of activity that we’ve seen recently for awhile yet — consolidation, acquisition, companies struggling to replace revenue from blockbusters that are losing their patent protection." While Mr. Derkacz agrees that the pharma landscape will probably remain relatively unchanged over the next 12 months, he believes there will likely be a significant transformation over the longer term. “Both technology and emerging media will become better leveraged by the industry, which will have a great deal of influence on the pharmaceutical marketing business model and will likely result in new ways to effectively engage at both the physician and patient level," he says. “I don’t see highly radical changes occurring over the next few years," Ms. Mario predicts. “The most significant change might be around becoming more disciplined in evaluating promotional investments, in using new technology more efficiently to make decisions/evaluate ROI, and in managing expanding regulatory reporting requirements." “I do believe over the long term we’ll see a stronger push for innovation in operations," Ms. Mario continues. “We are well behind many of our peers in other industries who have used this to strategic advantage." Ms. Connelly forecasts that there will be greater transparency in how pharmaceuticals are marketed and a greater emphasis by the industry in providing value to healthcare providers and patients. Mr. Franklin believes that over the long term, the use of product samples to market products will become more efficient. “As technologies and expertise grow, we will, as an industry, get better at correlating the relationship between product sampling and product sales," he says. “And the net result of that will be less sampling, which I think will be well-received on all sides." Steve Gransden, VP, technical marketing, at J. Knipper and Co., agrees that additional technology-driven and delivered marketing methodologies have produced even broader solutions such as CRM database tracking systems that allow for multiple e-marketing and e-sampling efforts over finite periods. “This allows brand teams to track and adjust, in real-time, their marketing efforts related to sample orders and associated scripts," he says. “FDA guidelines now allow for e-signatures that in turn make it possible for physicians to use a virtual sample closet to get information about pharmaceutical products on their preferred schedule." (For more information related to why e-sampling is no longer an alternative solution, please turn to page 24.) Mr. Johnson says that as salesforces continue to evolve, companies will look to employ more technologically based training tools, and that distance learning and virtual meetings will become the norm. “The relationships between sales representatives and clinicians will become more of a partnership focused on improving efficiency and clinical outcomes," Mr. Johnson notes. “Marketing departments will be working more with their sales teams to collect information from the field that can be used to further refine and individualize messaging. And newer forms of technology involving Internet, PDAs, and the like, will be employed to supplement the efforts of the sales teams." Collecting information from the field is one important way to conduct market research, Allen Stegall and Bob Costanza, both partners at Scout Marketing, believe it’s also imperative to consider and discuss the meaning of the research in the broader context of the brand’s marketing challenges. Brand teams should realize that while market research is invaluable, it can’t replace judgment, the two experts agree, adding that market research reports probably don’t factor in the competitive environment, the difficulty in breaking through and registering a message, the size of the budget versus the competitor’s, where the brand is in its life cycle, or any of a hundred other important considerations. (For more information related to how to maintain creative integrity during market research, please turn to page 26.) Marketing and Healthcare Reform As Congress and the Obama Administration work to hammer out the details of a healthcare reform package, the pharma industry has remained actively involved in the process and communicated the message that it wants to be part of a solution that benefits patients, providers, pharma, and physicians alike. Despite these efforts, recent research by Harris Interactive indicates that pharma’s reputation continues to suffer in relation to the subject of healthcare reform. Results of an online Harris survey conducted in August 2009 show that the health insurance and pharmaceutical industries are the most widely blamed for problems with the current healthcare system in the United States. According to the survey, 84% of adults blame the pharmaceutical industry, with 53% responding that it deserves a “great deal" of the blame. Still, pharma companies continue to incorporate public service as part of their efforts to promote the benefits the industry brings to the overall healthcare package. Some have taken specific steps to help relieve the economic burden faced by patients and remove some of the obstacles to healthcare access. For example, this year Cephalon established the nonprofit CephalonCares Foundation to manage its long-established patient assistance programs. “With CephalonCares, we can help more patients gain access to our medicines by ensuring that cost is not a barrier to treatment," Mr. Derkacz says. “For some Cephalon products we are also able to provide co-pay assistance for those patients with insurance coverage, and we also contribute to programs such as the Leukemia & Lymphoma Society co-pay assistance program to help patients access the treatments they need." Astellas also has expanded its initiatives to help alleviate the cost burden of medications on qualified patients, notes Mr. Johnson. As to what kind of impact healthcare reform might have on pharma product marketing plans, most experts agree that it’s too soon to tell. “I think that there’s so much variability in the form that healthcare reform could take that it would be probably premature to attempt to give an answer to that question," Mr. Franklin says. “My best guess would be that it won’t significantly affect the way that sales and marketing occur within the industry, because even if the reform causes some type of price pressure or price controls, it’s going to create access for more patients, so the total market size is not likely to change by a great magnitude." According to Brian Doherty, executive VP, director of client services of Ferguson, part of CommonHealth, among the few certainties of healthcare reform will be the goal of reducing the cost of treatment by private health insurance providers and the indirect acceleration in shifting costs toward patients. “An obvious outcome will be the increased filling of prescriptions with generics and protocols that demand step-edits," he says. “Looking just a little deeper and further ahead, we can also expect a significant increase in the use of over-the-counter (OTC) medications. Since there can be no actual self-care policy, OTC usage is expected to continue to grow with healthcare reform, as the system, and the impending dearth of medical professionals, will have difficulty covering “minor" ailments, thus pushing treatment efforts back onto the consumer." (For more information on OTC marketing in the future, please turn to page 20.) PharmaLinx LLC, publisher of the VIEW, welcomes comments about this article. E-mail us at [email protected]. Given the challenging economic environment we’ve seen over the last year, we’ve increased our focus on being more efficient and effective in delivering value to our customers in every interaction we have. Deirdre Connelly GlaxoSmithKline thought leaders n Deirdre Connelly. President, North American ­Pharmaceuticals, GlaxoSmithKline Plc., one of the world’s leading research-based pharmaceutical and healthcare companies. For more information, visit gsk.com. n Mike Derkacz. VP, U.S. Marketing, CNS, Cephalon Inc., an ­international biopharmaceutical company dedicated to the discovery, development, and commercialization of many unique products in four core therapeutic areas: central nervous system, inflammatory diseases, pain, and oncology. For more information, visit cephalon.com. n Josh Franklin. VP, Sales and Marketing, Cornerstone ­Therapeutics Inc., a specialty company focused on medications for ­respiratory disorders, For more information, visit crtx.com. n Walt Johnson. VP of Marketing, Astellas US LLC, an affiliate of Astellas Pharma Inc., which is dedicated to improving the health of people around the world through the provision of innovative and reliable ­pharmaceutical products. For more information, visit us.astellas.com. n Chris Mario. VP, Marketing and Commercial Development, ­Neuropharm Inc., the U.S. division of Neuropharm Group Plc., a specialty company focused on developing medicines for neuro-developmental ­disorders. For more information, visit neuropharm.co.uk. We need a deep understanding of both the opportunities and the latest regulations to engage physicians and patients through social media channels in an appropriate and effective manner. Mike Derkacz Cephalon Over time, social networking will become a part of the marketing mix and the communication strategy for pharmaceutical products, but it’s going to be driven by some of the industry leaders mapping out what’s acceptable. Josh Franklin Cornerstone Therapeutics Pharma has been working hard to rehabilitate its image through improved communication of the benefits it provides, and recent study results suggest that public perception of pharma in the United States may be improving as a result. In the 10th Annual Harris Interactive Reputation Quotient (RQ): Study of the 60 Most Visible Companies, the pharmaceutical industry was the only industry to register a significant positive change in 2008, with 31% positive ratings — pharma’s highest in five years — compared with 26% in 2007. In terms of individual companies, Johnson & Johnson reclaimed the top spot from Google with a score of 82.39, the highest individual company score since 2001. An RQ score of 80 and above is considered excellent. J&J also ranked in the top five with five of the six reputation dimensions: emotional appeal, financial performance, products and services, social responsibility, and workplace environment. Respondents to the Harris RQ study also rated companies on vision and leadership. “While the overall reputation of corporate America has never been worse in the eyes of the general public, greater understanding of and credit for working diligently to build and maintain a good reputation has never been stronger," Robert Fronk, senior VP, senior consultant, reputation strategy at Harris Interactive, said in a prepared statement announcing the study’s release earlier this year. According to Mr. Fronk, the RQ study also validates that both corporate behavior and corporate communication play a major role in how a company is perceived. Sincerity, correctness and accuracy of information, and consistency are the corporate communication measures that have the greatest influence on overall reputation, the study noted. Other communications measures included in the study were transparency of communications, providing consistent messages, ease of recognition, and having a common look and feel. As important as sincerity is to overall reputation, on average, only 52% of survey respondents gave the most visible companies a positive sincerity rating. Responses also indicate that companies need to do a better job in providing company information to stakeholders; only 26% of respondents gave positive ratings for transparency of information. In terms of individual companies, J&J ranked first and second, respectively, in these categories, with 76% of respondents giving the company a positive rating for sincerity and 37% giving it a positive rating for transparency. The picture isn’t quite so rosy across the Atlantic. In Europe, 86% of pharma marketers in a recent survey revealed that they believe their communications to customers could be healthier. The survey, commissioned by the European Association of Communications Agencies’ recently formed Health Communications Council (HCC) and conducted by Praxis Research, showed that the majority of pharma marketers polled think that the pharma industry needs to be more active in defending its reputation. The HCC represents all major agency networks with a broad base across European markets and works to help the pharmaceutical industry build healthier communication across Europe. “Health agencies are rarely in the spotlight, and the value they bring to society and the pharmaceutical industry is often underestimated," says HCC Chairman Michel Nakache, worldwide managing partner at Euro RSCG Life. “Empowering citizens to live healthy lives is one of the thorny issues European societies are struggling with, and we want to be part of the solution." Source: Annals of Family Medicine, Lack of Impact of Direct-to-Consumer Advertising on the Physician-Patient Encounter in Primary Care: A SNOCAP Report. For more information, visit annfammed.org. Companies rated “excellent" in terms of reputation Rank Company Reputation Quotient 1. Johnson & Johnson 82.39 2. Google 81.89 3. Sony 81.71 4. Coca-Cola 80.63 5. Kraft Foods 80.54 6. amazon.com* 80.13 *New to RQ 2008 study and/or not measured in the RQ 2007 study Source: Harris Interactive, 10th Annual Harris Interactive Reputation Quotient (RQ): Study of the 60 Most Visible Companies. For more information, visit harrisinteractive.com. The days of multiple sales representatives calling on one physician are gone. Now it’s all about targeting that resource, and targeting is more about bringing value in the form of clinical expertise and customized messaging. Walt Johnson Astellas US Branded and targeted promotional initiatives have become the mainstay. In many instances, this has prompted a reevaluation of tactical spending and alignment with strategic intent, key objectives, and critical success factors, with an eye toward eliminating random acts of marketing. Chris Mario Neuropharm

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