In early 2000, we conducted a study to understand the herbal market from the perspective of the retail pharmacist. Many of the facts are based on the study completed with a representative sample of more than 200 pharmacists. The survey used was 11 pages in length and very comprehensive. Key respondent demographics include:

• Average pharmacist age was 45 years
• 75% male, 25% female
• Pharmacists averaged 20 years experience and worked an average 45 hours/week
• Pharmacy location mix: 45% suburban, 31% urban, 24% rural

The herbal study covered a broad range of topics. The topics that were selected are as follows:

I. Product knowledge, familiarity and awareness
II. Recommendation frequency, habits and patient inquiries
III. Educational needs to enhance pharmacist knowledge
IV. Perceptions of efficacy, manufacturers and product quality
V. General market issues

Highlights of topic I – IV will be presented in this article. Based on our findings, our company has concluded that the retail pharmacist is underutilized, underequipped and undertrained to handle the current growth in the herbal market. These shortcomings, however, present a significant opportunity for manufacturers and retailers that could benefit both sales and their relationship with pharmacists.

An Herbal Market Snapshot
The nutraceutical supplement industry has been producing strong product sales over the last decade, particularly in the past several years. According to F-D-C Reports/The Hartman Group, the herbal market alone grew from $1.3 billion in 1994 to almost $4 billion in 1998. Although the herbal market is one piece of the entire nutraceutical category, it represents a significant manufacturing opportunity for manufacturers and a sales opportunity for retailers.

Outlets for herbal product distribution includes specialty shops, direct mail including Internet sites and retail outlets such as food, mass merchandiser and chain and independent pharmacies. Retailers with in-store pharmacies are seizing the opportunity for additional herbal product sales by placing them within immediate periphery of the pharmacy in eye-catching kiosks, etc. The strategy appears to be effective. Our report shows that almost half (46%) of all pharmacists surveyed believe the herbal market will have rapid or even greater growth in the future.

The herbal category is simply immense, with individual herbal ingredients numbering in the thousands. Many herbals are obscure and therefore currently represent little commercial value. In the research we cite, 18 of the more popular herbals in terms of sales and manufacturing were included. Table 1 shows sales of the top 15 herbals, many of which were included in the 18 we studied.

The herbals listed above and the herbals included in our research cover a broad range of therapeutic categories. Major categories include arthritis/anti-inflammatory, depression, cold, cardiovascular, circulatory and sexual dysfunction. Not surprisingly, these same categories represent tremendous sales in the Rx and OTC business.

Report Highlights by Topic
Section I: Product knowledge, familiarity and awareness. In general, the trend for purchasing herbal products is increasing. In some cases, the demand for herbal remedies has led to more inquiries of pharmacists for information. Our study reveals that herbal product knowledge varies widely from herbal to herbal.

Figure 1 shows that St. John's Wort ranks highest among herbals included in the survey in terms of familiarity. The scale was from 1 to 5, with 1="totally unfamiliar" and 5="familiar with ALL medical properties and interactions with OTC and Rx products."

Note that only one (St. John's Wort) of 18 herbals had an average rating higher than 4. Interestingly, while 55% of the pharmacists surveyed personally use an herbal product, only 7% use St. John's Wort compared to the 30% that use echinacea. A majority of pharmacists are "totally unfamiliar" or "unfamiliar" with guarana (79%), horse chestnut (71%), and dong quai (56%).

Also explored in this report section were pharmacists' perceptions of dangerous interactions. Perhaps one of the reasons only 7% of pharmacists personally use St. John's Wort is that fully 80% stated it is potentially dangerous to a person's health when used in combination with some Rx and OTC products. Ma huang (61%) and yohimbe (50%) were noted as second and third. An interesting but dichotomous finding was that 36% of the pharmacists consider ginseng as potentially dangerous while 31% consider it not dangerous. This sixth most popular herbal according to sales demonstrates the lack of clear understanding among pharmacists with herbal products.

Section II: Recommendation frequency, habits and patient inquiries. As the herbal market grows, particularly in the retail segment, so does the likelihood of both consumer inquiries and pharmacist recommendations. In virtually every case, however, recommendations for each herbal are exceeded by inquiries. Although we cannot be certain, this relationship suggests that pharmacists are consciously not recommending the purchase of an herbal with each inquiry.

Our study shows that pharmacists have doubts and concerns about recommending herbal products to their customers. Almost 70% of the pharmacists sometimes (check-off option) recommend the customer use an OTC product or speak to their physician about an Rx instead of using of an herbal remedy. Ironically, more than 50% of the pharmacists said that physicians are referring patients with questions about herbals to pharmacists. This is an obvious professional dilemma of "who is the expert?" When we asked about their confidence level for providing medically satisfactory advice for herbals, only 27% stated "confident" or "very confident." These statistics once again support the argument that by and large, pharmacists are positioned to help further the growth of herbals, but are stymied by inadequate information.

Approximately 40% of the surveyed pharmacists do not recommend an herbal manufacturer or brand for herbals when making a purchasing recommendation to a customer. In fact, our survey yielded a total of 42 different manufacturer names that were recommended by pharmacists. Seventy-five percent of the recommendations included 10 manufacturers. The top three were PhytoPharmica, Sundown and Nature's Bounty. We determined that there was tremendous fragmentation in the marketplace and also that brand/label name and manufacturer were commonly confused. For example, Nature's Bounty is a brand label for NBTY. The biggest winner for manufacturer/brand recommendation was the store brand.

Prior to making an herbal recommendation, about 45% of pharmacists ask the inquiring customer about his or her current Rx use. The list of Rx drug classes that prompt pharmacists to ask patients included as many as 32 classes. The top three mentioned were:

1. Psychotherapeutics (29%)
2. Anti-coagulants (26%)
3. Cardiovasculars (23%)

For those pharmacists consulting with the customer, over 50% spend 1-3 minutes discussing the herbal and 30% spend more than three minutes. More than 75% of the pharmacists surveyed think their customers are not able to make good and appropriate choices of herbals without the consultation of a pharmacist, physician or healthcare specialist.

For this report section, our data led us to conclude that pharmacists see themselves as central to the herbal decision making process. It remains clear, however, that there is a need for improved information to boost recommendation confidence.

Section III: Educational needs to enhance pharmacist knowledge. Informational needs led us to this next section. Many pharmacists simply did not receive formal training in herbal pharmacology. Few schools of pharmacy require herbal pharmacology for a Pharm. D. degree. Perhaps with the rise in natural medicine, we will see an increase in formal training. In the meantime, pharmacists must rely on publications, articles and other literature read on their own time to stay informed about the latest in herbal news.

Almost 80% of the pharmacists surveyed received educational material on the 18 herbals in the past three months. Yet, although pharmacists are receiving material for herbals, it may not be well used or absorbed. Figure 2 is evidence of the fact that pharmacists still do not have confidence in responding to customer questions.

In a busy pharmacy environment, customer questions may not be well timed with a pharmacist's ability to answer them. Having an herbal reference guide or system to refer to would be time saving and potentially increase the accuracy of the information given. Although 99% have a manual or reference book, only 10% have an in-pharmacy computer database on herbal products. For those that DO have such a database, 59% use it at least once daily. There is a real need to have an in-pharmacy database for both pharmacists and customers alike.

Section IV: Perceptions of efficacy, manufacturers and product quality. This section revealed both interesting and unexpected results. Since pharmacists are well positioned to either help or hinder herbal product sales, their perceptions of product efficacy, manufacturers and product quality are critical.

Pharmacist opinions of efficacy vary considerably among the 18 herbals we studied. Garlic, glucosamine and St. John's Wort led in pharmacists' ratings, each receiving either a "definitely efficacious" or "likely to be efficacious" by more than 80% of pharmacists. Figure 3 details the findings of the herbals studied; totals do not equal 100% due to pharmacist having "No Opinion."

Nearly 70% of pharmacists think there are significant differences in quality among various manufacturers of herbal products. However, only 30% of pharmacists think their customers place manufacturing quality as a top priority in selecting one herbal over another. When pharmacists were asked, unaided, to list their top three manufacturers in terms of product quality, Pharmavite (Brand name: "Nature Made," "Nature's Resource") topped the list. Oddly, Rexall Sundown (1998 sales of $245 million) was rated second, despite having sales more than triple that of Pharmavite. In fact, Pharmavite placed first not only in perceptions of product quality, but also in "product sales" and "marketing support."

It appears that pharmacists are not entirely sold on the clinical claims made by the manufacturers of herbal products. We expect that pharmacists are simply accustomed to having FDA approval for Rx drugs with substantiated safety and efficacy.

The tepid response by pharmacists on claims is probably rooted in the fact that 75% believe that herbal products should undergo increased regulation. Professionals at this level desire security in their customer recommendations by having some degree of clinical proof.

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With the rapid growth of the herbal market, pharmacists have become critical in disseminating information to the consumer. Pharmacists appear content to adopt the professional responsibility of helping consumers make sound herbal choices. Our study suggests, however, that pharmacists are skeptical of the quality and accuracy of the information they receive on herbals and their own ability to provide appropriate information to consumers. Retailers and manufacturers need to build their relationship with pharmacists by providing better information tools, offering more training through CE programs, giving better in-store support and differentiating their brand(s) from others.

Many opportunities for herbal sales growth exist with the retail pharmacist. Companies serious about a long-term relationship with pharmacists will no doubt be winners in this billion dollar market. NW

About the author:
Mr. Little is president of Delta Marketing Dynamics, a survey and marketing research firm with 29 years of experience conducting thousands of qualitative and quantitative marketing research studies for the healthcare industry. Mr. Little can be reached at 4207 Taylor Road, Jamesville, NY 13078; 315-492-2905;
E-mail: wrlittle@deltamktgdyn.com; Website: www.deltamktgdyn.com.