Cosmetic business mechanics in London: A cross-sectional analysis and audit of ASA compliance

Introduction: The proliferation of providers and practitioners of cosmetic botulinum toxin and dermal filler has profound public health implications. The Advertising Standards Authority (ASA) regulates the use of advertising materials in the United Kingdom and prohibits the promotion of prescription-only medicines. Aims: We aim to perform a cross-sectional analysis of the practitioners in London, UK to evaluate the distribution of clinics within Greater London, prices advertised for interventions, and compliance with the ASA code. We also aim to identify whether there are any differences in cost of botulinum toxin or dermal filler between the boroughs. Methods: Between December 2021 and January 2022, we performed a systematic search using the internet search engine Google. Five searches were performed (1) [london] botox, (2) [london] botulinum toxin, (3


| INTRODUC TI ON
The proliferation of providers and practitioners of cosmetic botulinum toxin and dermal filler has profound public health implications.
The size of the market is estimated to be growing at a compound annual growth rate of 12.4% globally from 2022 to 2030. 1 The growth of the market could be assessed using a simple supply and demand analysis whereby, the demand for injectable interventions continues to grow with supply of practitioners growing to match or keep up with demand. The rapid growth in demand has been attributed to a variety of factors including convenience, low downtime, perceived minimal risk, social factors through networks, price points, and increase in marketing. 2 A more granular assessment of the market could be performed using Michael Porter's five forces model assessing 3 : supplier power, buyer power, threat of new entrants, threat of substitutes, and intrinsic industry rivalry. Each of these five elements have become a staple and formative analytical starting point across business schools and businesses globally. Buyer power in this industry is significant as patients have low to no switching costs, can influence price sensitivity, and due to buyer and supplier concentration are able to move to a different provider with relative ease. The supplier power is related to how well aesthetic practitioners can differentiate their product, which explains why practitioners try to innovate the delivery or assessment of their interventions. Some practitioners utilize add-ons and supplementary interventions and complementary products such as extra creams and skin care. Threat of substitution includes a spectrum of interventions including non-invasive to more invasive surgical interventions. The threat of new entrants is assessed by understanding requirements such as relatively low capital requirements to set up a practice, relative to for example a surgical practice.
In addition, due to the low switching costs and price sensitivity, price differentiation may result in a potential strategic advantage. In addition, government or legal regulation is often a significant barrier to entry, however, there is little to no regulation in terms of provision of non-surgical aesthetics. The final facet of Porter's five forces is industry rivalry, which through continually increasing in size suggests continued growth.
To further understand industry rivalry, we leverage Jerome McCarthy's 4Ps framework, which describes Product, Place, Price, and Promotion. The products being considered are both botulinum toxin and dermal fillers. While their administration is aimed to be standardized and is licensed for specific indications by the Medicines Health Regulatory Agency (MHRA) in the United Kingdom, the overall consideration and use is where practitioners often seek to differentiate themselves through novel techniques of administration or purported differential understandings of achieving 'facial harmony'. 4,5 Place or location of a clinic is often perceived as a signal of competence and quality, and no address exemplifies this better than Harley Street, in London, 6 which for over 200 years has been associated with high-end specialist care. However, overcrowding and an increased density of providers drives competition leading to some practitioners having to look to differentiate or promote themselves further. Furthermore, given the potential small differences in the product offering, patients may go to a more local provider for convenience.
Price is a further form of signaling which influences how costs are determined. While a variety of pricing strategies exist including value-based and cost-based pricing, patients often use price as a signal of quality. While previously considered a luxury, 7 the precise definition of cosmetic interventions as either an elastic or inelastic product is subject to controversy and debate with changing patterns of purchasing noted. 8 More work will need to be done, particularly in the current economic climates to understand whether skincare and aesthetics are now considered an essential product, and therefore become price inelastic.
The final element of McCarthy's framework is Promotion, some aspects of which have already been discussed above relating to product, place, and price. Promotion is challenging in a crowded market, and marketers often take novel and innovative steps to promote their work. Studies have shown a variety methods leveraged to market cosmetics including drawing attention to physical flaws, 'playing on femininity and sensuality', referencing natural appearance, promises of improved self-image and quality of life and financial packages/incentive. 9 The internet and social media have significantly changed the landscape of marketing and this has had profound implications for practitioners, with some authors criticizing the ineffective use of such platforms in obtaining greater exposure and subsequent patient interest. 10 Conclusion: This paper demonstrates poor compliance with the ASA/CAP guidelines and further provides an insight into the industry mechanics associated with aesthetic injectables in a major UK city, identifying regional variance in price and clinic density.
The advertising of prescription-only medication may pose a potential risk to patients and will be an important consideration in proposed legislation to introduce licensing to the industry.

| Aims
We aim to perform a cross-sectional analysis of the practitioners in London, UK, to evaluate place, price, and promotion. Specifically, we will be assessing the distribution of clinics within the Greater London area across London boroughs, prices advertised for interventions, and compliance with the ASA/CAP code.
We also aim to identify whether there were any differences in cost of botulinum toxin or dermal filler between the boroughs.

| ME THODS
Between December 2021 and January 2022, we performed a systematic search using the internet search engine Google using an adaption of a validated methodology previously described. 12 In Inclusion criteria included websites relating to services in the UK, offering specifically aesthetic interventions to the face.
Exclusion criteria included any non-injectable intervention. There

Number of clinics
Westminster 113 Kensington and Chelsea 28 City of London 9 Wandsworth 8 Camden 7 Tower Hamlets 5 Lambeth 5 Hammersmith and Fulham 5

| RE SULTS
A total of 500 websites were visited and evaluated. After the removal of duplicates, a total of 233 independent clinics were identified in Greater London, and the surrounding areas Sussex, Essex, and Surrey ( Table 1)

| Dermal fillers
The overall average cost per mL of dermal filler was £330.89 with variation of costs per regions in Tables 2 and 3 and Figure 2. In evaluating the costs of dermal fillers, we included treatments described as: cheek filler, dermal filler, filler, filler injections, and lip fillers.
The data presented only include the treatments offered where both price and quantity (mL) were available (Tables 2 and   3, Figure 2).

| Botulinum Toxin
The overall average cost per mL of Botulinum Toxin was £284.45.
In evaluating the costs of Botulinum Toxin, we included treatments

| Compliance with ASA/CAP
A total of 206 out of the 233 clinics were sampled and of these, it was found that 88% were in direct infringement of the enforcement notice through advertising a prescription medicine. Excluding

F I G U R E 1 Heatmap of clinics per Greater London borough.
Clinics per Borough 0-2 2-5 3-10 10-13 those who likely attempted to circumvent the regulation by using anti-wrinkle, a total of 142 clinics (61%) directly used the terms Botulinum Toxin and its various brand names.

| DISCUSS ION
This is the first paper to perform a cross-sectional analysis of a major city and specific to the UK, assess compliance with the ASA/CAP regulations. The selection of a major city such as London was deliberate to represent an urban center. Furthermore, with a population of 8.92 million this provides valuable insights into the behaviors of a densely populated center. 13 Within this study, the most significant and concerning finding was the lack of compliance with the ASA/CAP regulations -promotion.
The authors initially considered that these data may be an aberrant snapshot due to the nature with which it was collected at a single Furthermore, we have previously described the role of price as a signal for quality and this may be a further consideration applied. Of note is the fact that the borough density of clinics map did not align TA B L E 2 Average cost of dermal filler per mL per region/ borough.

Region/Borough Average cost of filler per mL (£)
Richmond where despite being cheaper in terms of rent, a lack of competition in the region enables the practitioners to charge a higher rate. It is important to note, however, that these findings are limited by both the methodology and the lack of representation of all London boroughs so may be subject to bias. Further future analysis may find uniformity across London and that these outlier values are accounted for by the need to justify higher marketing budgets.
However, within the limitations of the methodology, a striking finding of this cross-sectional analysis was the proportion of clinics located in the London Borough of Westminster -'place' analysis. A notable proportion of these clinics was located in and around Harley Street.
The density of clinics decreased the further out from the center one F I G U R E 2 Average cost of dermal filler per mL per borough. Whether this signal truly translates to quality needs future study.
Further analysis may find that some inexperienced/under-qualified individuals look to leverage this prime location for their own gain.

| Limitations
As stated above, it is important to note that the findings of this should be interpreted within the context of the methodology. Given

| CON CLUS ION
This paper demonstrates poor compliance with ASA/CAP guidelines with unique insights into the industry mechanics associated with aesthetic injectables in the UK's capital city and regional pricing variances. Advertising prescription-only medication may pose a potential risk to patients and will be an important consideration in proposed legislation to introduce licensing to the industry.
TA B L E 5 A one-way ANOVA test was performed on data where cost per mL of Botulinum Toxin was available however no significance (p = 0.058) was demonstrated in the variance of market price between boroughs/regions.

FU N D I N G I N FO R M ATI O N
The work was supported by a research grant from QUAD A, a notfor-profit organization in the United States that works to standardize and improve the provision of healthcare facilities and care quality.
The funding sources played no part in the design and conduct of the study, analyses, or interpretation of the data.

CO N FLI C T O F I NTER E S T S TATEM ENT
All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any other organization for the submitted work; the research presented was sponsored by QUAD A -see below, no other relationships or activities that could appear to have influenced the submitted work

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are openly available on the search engine Google, with the search strings provided in the body of the text.

E TH I C S S TATEM ENT
The authors confirm that the ethical policies of the journal, as noted on the journal's author guidelines page, have been adhered to. No ethical approval was required as this is a review article with no original research data.