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Natural Cycles has launched a hugely successful marketing campaign, incorporating targeted advertising and social media influencers. The app, which has digitised fertility awareness based methods of contraception, was approved as a medical device in Europe in 2017. After being subject to advertising by Natural Cycles ourselves, we were concerned that some of their claims were vulnerable to misinterpretation, and may have contravened the UK Code of Non-broadcast Advertising and Direct & Promotional Marketing (CAP code). We felt uneasy about the impact of this advertising on young women’s contraceptive choices, and the potential consequences of using an app that may not be suitable for their needs or lifestyle. As a result, we filed a complaint with the Advertising Standards Authority (ASA) in January 2018 expressing our concerns. While waiting for the ASA to respond, we wrote a piece summarising the campaign management and content and the UK regulations of such campaigns which was published in this journal in July 2018.1 On 29 August the ASA upheld our complaint against Natural Cycles and concluded that their claims of ‘highly accurate contraceptive app’ and ‘clinically tested alternative to birth control methods’ were misleading.2 The ASA noted that as so few women achieved perfect use of the app, and so contributed to the perfect use Pearl Index, it was misleading to quote this figure in the accuracy claim. They concluded that Natural Cycles broke four separate rules of the CAP code, including exaggeration, and misleading advertising. Natural Cycles were warned not to “exaggerate the efficacy of the app in preventing pregnancies” and were informed that “the ad must not appear again in the form complained about”.2
There are several important implications to this ASA ruling. They have stated that the typical use Pearl Index is the most relevant information for accuracy claims, so it is likely Natural Cycles will have to present both perfect and typical use Pearl Indexes in any future campaigns. The consequences of an independent regulator validating many concerns in the press3 about the content and ramifications of the Natural Cycles campaign should also not be overlooked and may lead to further proactive steps taken by Natural Cycles to dissipate the negative media coverage. Generally, they have stated that they removed the ad in question when they were informed about the investigation, and they respect the outcome of the complaint.4 However, they have not responded to requests for information about how much control they exert over the content of influencer posts.5 The ASA did not comment on and cannot regulate the use of social media influencers by Natural Cycles. They cannot prevent influencers from putting the Pearl Indexes at the bottom of long captions, which means that they can be scrolled past without being seen. They also cannot prevent Natural Cycles from using influencers that do not have the lifestyle that suits the app, or being outside the age bracket that their research was based on. Although Natural Cycles have recently said they will only use influencers over 25 who are in relationships,6 they have not removed posts from influencers before the instigation of this policy.
Our complaint to the ASA joined some others, the first of which was actually submitted over a year ago, in July 2017. There was a significant time delay between submitting a complaint and action which is not unique to this complaint. Margaret McCartney noted recently that a complaint about an advertisement of private non-evidence based screening tests took months to be upheld and resolved.7 It is clear that tighter regulations and more efficient investigations by the ASA are needed, especially when dealing with issues of health and safety.
Two weeks before the announcement of the ASA ruling, the US Food and Drug Administration approved marketing of Natural Cycles as a method of contraception.8 The ASA may be able to restrict Natural Cycles from certain advertising content in the UK but it cannot influence strategies overseas. People have the right to know all of the current and most accurate information about contraceptive methods, and marketing is a powerful tool that may influence decisions people make about their reproductive health. Currently conversations about Natural Cycles are mainly directed by advertising and media coverage. Information about contraception should be unbiased, free from commercial incentives, and transparent about effectiveness as well as other potential benefits or harms. As regulatory policy has difficulty keeping up with the quick-changing environments of the internet and social media, we cannot rely on bodies like the ASA to ensure that this is the case. Natural Cycles should allow independent evaluations to be conducted, with freedom over publication regardless of the results. In terms of their advertising, they should also ensure that typical rather than perfect use Pearl Indexes are presented. A multifaceted approach of comprehensive sex and relationships education, ethical commercial policy and informed clinicians is required to help deliver accurate and clear information.
Contributors AH and MB contributed equally.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.