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Married with three children, Mary Ellen lives in the Bronx, N.Y., and likes hiking in the Adirondacks. But until she learned how to manage her Type 2 diabetes, she was tired and hungry all the time.

Mary Ellen tried insulin injections and then switched to the Lantus SoloStar insulin pen, which has a push-button system with a small, thin needle. "I found the pen easier to use and much more discreet," she confides in a video clip at

The health site - run by the pharmaceutical company Sanofi-Aventis - portrays Mary Ellen as a typical middle-aged woman who put her family's health before her own.

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But the website does not clarify that Mary Ellen and other patients featured in its "insulin success stories" are paid spokespersons for the drug company, according to a formal complaint submitted in November to the U.S. Federal Trade Commission.

Prepared by four separate watchdog groups, the 144-page report cites dozens of examples of pharmaceutical marketing on the Web that "threatens consumer privacy and engages in unfair and deceptive practices."

In June, the British Medical Journal cited the report in an article that suggests Big Pharma's online marketing activities pose a threat to public health.

Direct-to-consumer advertising that includes the name of a prescription drug, health claim and contraindications is prohibited in Canada and highly regulated in the United States.

But transparency has become murky on the Internet, says Jeff Chester, co-author of the complaint to the FTC and executive director of the Washington, D.C.-based Center for Digital Democracy.

Pharmaceutical companies are using stealth marketing tactics by eavesdropping on patients' discussions on social networks and tracking patients' "digital footprints" online to target them for advertising, Mr. Chester says.

He adds that drug companies are misleading the public by setting up unbranded health sites that obscure their Big Pharma funding and paying seemingly independent health bloggers to rave about their products without revealing the exchange - a practice prohibited by the FTC.

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"These are very powerful tools in the hands of pharma marketers, designed to drive up drug sales, without providing adequate information to patients who are often in a vulnerable state," Mr. Chester says.

Earlier this year, WebMD - one of the most visited health sites on the Internet - came under fire for promoting an online depression test sponsored by Eli Lilly, maker of the antidepressant Cymbalta. According to a report from CBS's, the test was rigged to yield the same results no matter which of the 10 questions were answered "yes": "You may be at risk for major depression." (The questionnaire has since been changed.)

The pharmaceutical industry's growing presence online coincides with a pivotal shift in health care, Mr. Chester says.

As many as 80 per cent of Internet users go online to find health information, according to a 2011 report published by the non-profit Pew Research Center in Washington, D.C. And almost 20 per cent go online to find others with similar health problems.

Big Pharma is gearing up to "friend" and "tweet" them., a pharmaceutical marketing website, lists more than 350 examples of online health forums and YouTube, Twitter and Facebook pages run by drug companies.

According to a 2010 report in Pharma Marketing News, there may be hundreds of patients in social networks earning thousands of dollars from drug companies to provide "real patient stories" as part of online branded drug or disease-awareness campaigns.

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The article describes these "online opinion leaders" as "pharma's 'secret sauce' for social media marketing."

And unless drug companies comply with FTC regulations, consumers have no way of knowing which online "friends" are on the payroll.

Consumers who use Google to search a specific condition are liable to stumble on unbranded health sites and "patient communities" that do not declare their pharmaceutical affiliations. For example, has a cutesy pink home page that looks like it was designed in a home office, and a banner that suggests this "gathering place" for incontinent women was created by urologist Raymond A. Bologna. But the "education" section redirects readers to a site for Medtronic's InterStim Therapy for bladder control - and Dr. Bologna turns out to be a "partner" of Medtronic.

Big Pharma's social media ventures give the impression of empowerment and mutual cooperation, Mr. Chester says, "but who is pulling the strings?"

Pharmaceutical companies such as Novartis argue that social media provides an important channel to "better understand the needs" of patients, according to a company statement, which adds, "we will continue to act responsibly and in accordance with regulatory authorities' guidance on the appropriate ways to use online and social channels."

Nevertheless, Novartis has been slapped on the wrist for including a Facebook "share" button on a website for its Tasigna leukemia medication. The U.S. Federal Drug Administration ruled the Facebook widget provided "misleading" shared content because it failed to disclose serious risks associated with the drug.

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In Canada, drug companies are "really trying to take a cautious approach" to social media, says Joanne Kennedy, communications director for Sanofi-Aventis Canada. All of Sanofi-Aventis Canada's online initiatives will meet Canadian advertising standards, she says, but declined to speak on behalf of Sanofi-Aventis's U.S. company, which features patient testimonial at

Ms. Kennedy acknowledges that Canadians have access to U.S. health sites that do not conform to Canadian regulations. "That's the function of our information age," she says, adding that consumers should consult their doctors about prescription drugs.

But brand recognition plays a major role in doctors' offices, points out Barbara Mintzes, a specialist in direct-to-consumer advertising at the University of British Columbia's Centre for Health Services and Policy Research.

Her research and a 2005 study by Richard Kravitz at the University of California suggest that when patients ask for a medication by name, they have a 50- to 75-per-cent chance of walking out of the doctor's office with a prescription for that drug - often despite physicians' ambivalence about the treatment choice.

Canadians have been exposed to a heavy dose of cross-border ads through satellite television, print media and the Internet since the late 1990s, Dr. Mintzes notes. But there have been no fines in Canada for illegal marketing activities by drug companies since the mid 1970s.

Health Canada officials tend to raise the technical challenges of regulating the Internet, "but it's technically very easy," Dr. Mintzes says, pointing to websites in Australia and Britain that routinely block Canadian viewers.

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"In Canada, the problem is that we don't enforce the law properly."

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