Q&A: Expert on Social Media’s Normalization of Lifestyle Drugs
Luke Turnock, PhD, MSc, discussed current trends in the promotion of lifestyle enhancement drugs for populations they are not approved for.
Luke Turnock, PhD, MSc, has done extensive research on prescription drug markets and how these products have been promoted on social media in recent history. He’s specifically versed in the promotion of weight-loss medications, testosterone replacement therapy (TRT), and sexual enhancement products. Throughout his research, he and his colleagues have uncovered an alarming normalization of these products that can potentially lead to poor outcomes for many consumers globally.
We had a chance to catch up with Turnock, who began his discussion touching on glucagon-like peptide-1 (GLP-1) drugs for weight loss.
“The [weight-loss drugs] people are buying [are] semaglutide, which is Ozempic and Wegovy; tirzepatide, which is Mounjaro; and liraglutide, which is Saxenda,” said Turnock. “Those tend to be the ones that are getting promoted and those have been approved as prescription-only medicines that you can access through your doctor if you need them for weight-loss purposes. It's designed for those who need that type of drug to control that weight. What we've seen since about 2021-2022 is just an explosion of interest from people who don't fit within those categories.
Turnock and his colleagues have uncovered an alarming normalization of various lifestyle-enhancing drugs on social media. | image credit: YouraPechkin / stock.adobe.com
In part 1 of our interview with Turnock, he dove deep into insights he and his colleagues provided in their article titled “Semaglutide, testosterone, and sildenafil advertising on social media: the normalization of lifestyle enhancement drugs.” He discussed the normalization of GLP-1s, TRT, and sexual enhancement drugs like sildenafil and tadalafil.
READ MORE: Semaglutide, TRT Advertising Contributing to Normalization of Use
Drug Topics: With your expertise in enhancement drugs, as well as your work on published articles like “Semaglutide, testosterone, and sildenafil advertising on social media: the normalization of lifestyle enhancement drugs,” what exactly is going on right now regarding these drugs and their circulation throughout social media?
Luke Turnock: Starting with the GLP-1 medicines, so semaglutide, tirzepatide. Those obviously started off as they were prescribed for treating diabetes, and there's been a recent shift, as we've understood, these are very good for weight loss. In the UK, a couple of them were approved for weight loss. There [are] others that aren't yet approved, like retatrutide, but the ones people are buying [are] semaglutide, which is Ozempic and Wegovy; tirzepatide, which is Mounjaro; and liraglutide, which is Saxenda. Those tend to be the ones that are getting promoted and those have been approved as prescription-only medicines that you can access through your doctor if you need them for weight-loss purposes. That's for people on prescription with a high BMI. I think it's 30 off the top of my head, but it's designed, obviously, for those who need that type of drug to control that weight.
What we've seen since about 2021-2022 is just an explosion of interest from people who don't fit within those categories. And of course, this is prior to them being approved for weight loss. Them being approved for weight loss came about a year after this explosion where there was a trend on a lot of social media sites, particularly TikTok, where people were coming to the realization these were really effective for weight management. A lot of the people who were promoting these were not people who would fall in that high level of BMI. They were people who just perceived themselves as slightly overweight or wanted to get in better shape for summer or whatever. There was just this explosion. You probably remember some of the articles around that time saying there's been shortage of diabetes medicines because so many people have started seeking them out because of social media.
That's kind of the background to this explosion. As this awareness of these drugs got everywhere, we then saw a rise in advertising. There are so many companies in that article, I listed a few of them. They are promising and they're putting out paid advertisements on places like YouTube and Facebook saying, ‘We sell this for X amount of money.’ Now, technically a prescription medicine in the UK, you can't say ‘You can buy this from us for this amount.’ That's not how prescription works, but these companies are doing it. And then for the influencer culture, there's a lot of beauty pages, fitness pages, this sort of thing. They often are sponsored by more of illicit company to sell. These peptide sellers and so on will have influencers who they give free product to and they perhaps have a referral link; you click their link and they get a kickback. Those are essentially selling potentially quite sketchy products when you buy from them because they're often not actual prescription medicines. Even if they appear to be, they're very likely produced in China in powder form, not necessarily the highest quality. Ashraf and colleagues did some research on this, checking, ordering semaglutide over the internet, and they found quite a big degree of variation in what's underdosed, what's overdosed. Some of it was as much as 39% overdosed, which, of course, presents a risk. And that's being shipped to, for instance, the UK, where it's often then being drawn up into insulin syringes, after being reconstituted and just sent out in an insulin syringe with perhaps handwritten instructions on this is the doses you should be using, which, of course, has a lot of potential for harm.
There are quite a few difficulties with just the prevalence of this. And also, do consumers necessarily know what is legitimate pharmaceutical product versus, ‘Oh, this is sold by this beauty page’ and they have no idea that actually that [may] not [be] safe to use. Even if it is, does the dosing information being given by that seller even reflect what the clinical dosing protocols should be, because you're meant to titrate up GLP-1 medicines. Whether users know that, we've certainly got examples. The BBC have reports on some examples where people have been hospitalized, have been put into hyperglycemic comas from using these drugs. So that's kind of the background to the GLP medicines.
In terms of testosterone. Again, it's kind of two-fold in that you have this illicit market and you have the TRT market. You've long had bodybuilders and so on use testosterone and use steroids. With the rise in gym and fitness accounts and fitness influencers, quite a few of these are either directly selling or they're showing links to people who are selling illicit testosterone, being a scheduled drug, a Class C drug in Britain, obviously higher classification in the US. Those are premised around getting big, getting ripped, getting shredded, and it's mostly these male fitness influencers. What we're also seeing is the rise of these TRT services, where some of that is by fitness-type influencers, but some of it is more general advertising that's going out everywhere, on Instagram, TikTok, Facebook, YouTube, even. That's for the ‘check your testosterone levels,’ ‘buy our home testing kit.’ They'll generally list a range of symptoms and things that they say could be associated with low testosterone to encourage people to try their testing kits and then hopefully be paying them for prescription tests.
So obviously, TRT, testosterone replacement therapy, that traditionally has been for older men, when your natural testosterone levels start to decline. Potentially, as they say about the male menopause, it can be used as a treatment for that. It might also be used for men with hypogonadism or specific medical conditions. But with these recent trends in advertising, a lot of them seem to be targeting a younger demographic. If you look at some of the men in the adverts, they'll be using guys in their late ‘20s, for instance—not traditionally a market who particularly needs TRT. They should—unless they have a specific medical condition, or maybe if they messed around with a lot of steroids when younger and tank their testosterone levels—they shouldn't really be the market for this. But some of the language that's used to promote it, there's some posts about ‘Testosterone levels are declining worldwide, your grandfather [had] much higher testosterone levels than you do, get your levels checked.’ Some of it's to do with if you're feeling down, if you're feeling fatigued, if you struggle to concentrate, you probably have low testosterone. And some of it is also based around libido and sexual performance, which I'll probably come to in a second because that ties in with the third example I want to use of the sexual enhancers.
All these claims very much frame it around if you have this condition or you have this concern, or potentially even in that kind of broader masculinity, testosterone levels are declining population wide. It's all very much targeted to your problems now are the result of low testosterone, so you need to get on this. As I said, the men they're primarily marketing to are not the men who most need TRT. So with the low-libido adverts, there's one example we used in the article that said, ‘Sex isn't everything, said the man with low testosterone.’ It's playing on this idea that you need testosterone for sexual performance, and if you don't have peak sexual performance, it's probably because you have low testosterone and you should buy our kits, get tested, get a prescription.
Now, Andrew Richardson's done some interesting work around this area. Essentially, what's happening, very much as with the gym and fitness culture, everything's moving towards this enhanced idea of these guys on steroids are setting the norm for sex. It seems to be that the porn consumption is so prevalent that a lot of guys are looking at that thinking that's what sex is supposed to look like. ‘If I don't have porn star performance, that means there's something wrong with me.’ And so, companies advertising testosterone prey on that, but so potentially do the ones that are selling these sexual enhancers.
Drugs like tadalafil (Cialis), sildenafil (Viagra), those are being promoted again to young men, not the population who medically tends to need them. It's generally older men who suffer from clinical erectile dysfunction, but they're being promoted as these more recreational drugs. Blue Chew was like the big one that I remember several years ago, back in 2018, and various podcasts have promoted it. You've got a bunch of guys in their late ‘20s, early ‘30s, saying about, ‘Oh, Blue Chew is so good. It helps with your sexual performance.’ A range of influencers [are] promoting it, and obviously, mainly targeting men in their ‘20s. Now, again, with advertisements, the problem is, if you're promoting these drugs to people who wouldn't necessarily clinically need them, but you're leading them to believe you need them because you don't have this porn star sexual performance, the problem is, you can create psychological dependency from using these drugs. That’s being sold as this recreational thing, and just have more fun sex, and your sex will be better using this. Obviously, that can then lead to actual erectile dysfunction occurring once they become dependent psychologically on them.
READ MORE: The Rise in Direct-to-Consumer Advertising of Prescription Drugs
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