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Psychology of Addictive Behaviors 2009 American Psychological Association 2009, Vol. 23, No. 2, 373–379 DOI: 10.1037/a0015695 Beliefs and Attitudes About Bupropion: Implications for Medication Adherence and Smoking Cessation Treatment Lisa M. Fucito and Benjamin A. Toll Yale University School of Medicine Stephanie S. O'Malley Yale University School of Medicine Beliefs about medication are associated with treatment adherence and outcome. This is a secondaryanalysis of the role of beliefs and attitudes about bupropion in treatment adherence and smoking cessationoutcomes using data from a smoking cessation trial of open-label sustained-release (SR) bupropiontherapy reported previously (Toll et al., 2007). Positive beliefs and attitudes were positively correlatedwith intentions, desire, confidence, and motivation to quit smoking; expectation of quitting success;perceived benefits of quitting; and perceived disadvantages of smoking. Positive beliefs were alsoassociated with greater medication adherence, an increased likelihood of completing treatment and beingcontinuously abstinent, and a delayed latency to smoking lapse. These findings provide preliminarysupport that positive beliefs and attitudes about bupropion are associated with positive attitudes towardquitting, better treatment adherence, and potentially better treatment response.
Keywords: beliefs, attitudes, bupropion, adherence, smoking Sustained-release (SR) bupropion, an antidepressant approved include bupropion (reviewed in Fiore et al., 2000; Hughes, Stead, for smoking cessation, has been shown to double quit rates relative & Lancaster, 2007).
to placebo (e.g., Gonzales et al., 2002; Hall et al., 2002; Hurt et al., Limited long-term smoking cessation outcomes may be due to 1997; Jorenby et al., 1999; Simon, Duncan, Carmody, & Hudes, poor adherence to bupropion treatment. Higher rates of bupropion 2004; Tønnesen et al., 2003). Bupropion may promote abstinence adherence are associated with an increased likelihood of smoking by blocking nicotine effects (Warner & Shoaib, 2005), alleviating abstinence (Killen et al., 2004; Mooney, Sayre, Hokanson, Stotts, withdrawal (Cryan, Bruijnzeel, Skjei, & Markou, 2003), or reduc- & Schmitz, 2007; Schmitz, Stotts, Mooney, DeLaune, & Moeller, ing negative affect (Lerman et al., 2002; Shiffman et al., 2000).
2007; Swan, Javitz, Jack, Curry, & McAfee, 2004). Many smok- There is also evidence that bupropion is efficacious for smokers ers, however, demonstrate poor adherence by taking inadequate with comorbid medical and psychiatric conditions (e.g., Cox et al., doses or stopping use prematurely (Hurt et al., 1997; Lam, Abdul- 2004; Evins et al., 2005; Hertzberg, Moore, Feldman, & Beckham, lah, Chan, & Hedley, 2005; reviewed in Waldroup, Gifford, & 2001; Tashkin et al., 2001; Tonstad et al., 2003; Wagena, Knips- Kalra, 2006). Moreover, adherence appears to decrease progres- child, Huibers, Wouters, & van Schayck, 2005). Nevertheless, sively over time (Waldroup et al., 2006). Gifford, Antonuccio, only 15 to 30% of smokers achieve long-term abstinence with Kohlenberg, Hayes, and Piasecki (2002) showed that bupropion bupropion or other effective smoking cessation treatments that adherence rates were 75% within the first few weeks of treatmentbut declined to 20% by Week 10.
These findings may be partially attributable to smokers' beliefs Lisa M. Fucito, Benjamin A. Toll, and Stephanie S. O'Malley, Depart- and attitudes about bupropion. According to social cognitive mod- ment of Psychiatry, Yale University School of Medicine; Peter Salovey, els, behavior is guided by an individual's knowledge and attitudes Department of Psychology, Yale University.
about the behavior, beliefs in one's ability to perform the behavior, This research was supported in part by National Institutes of Health and perceived social norms about the behavior (Ajzen, 1991; Grants P50 –DA13334, P50 –AA15632, K12–DA000167, K05– Bandura, 1977; Kirsch, 1999). Thus, individuals are more likely to AA014715, R25–DA020515, and T32–AA015496, the Department of Vet- perform behaviors that they feel skilled in, expect will result in eran Affairs, and the State of Connecticut, Department of Mental Healthand Addictions Services. The content is solely the responsibility of the positive outcomes, and perceive to be acceptable to others (Ajzen, authors and does not necessarily represent the official views of the National 1991; Bandura, 1977). These cognitive factors are purported to Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug play a role in medication adherence (Horne & Weinman, 1999).
Abuse, or the National Institutes of Health. We thank Nathan Hansen and Among patients with chronic illnesses, perceiving medication to be Ralitza Gueorguieva for their assistance in data analyses.
necessary for health maintenance is associated with greater adher- Correspondence concerning this article should be addressed to Lisa M.
ence whereas maintaining strong beliefs about the adverse effects Fucito, Yale University School of Medicine, Department of Psychiatry, 1Long Wharf Drive, Box 18, New Haven, CT 06511. E-mail: lisa.fucito@ of medication is linked to poor adherence (Horne & Weinman, FUCITO, TOLL, SALOVEY, AND O'MALLEY The role of beliefs about smoking pharmacotherapies in adher- cigarettes per day for a mean of 25.00 (SD ⫽ 2.06) years, and had ence and smoking cessation outcomes has also been explored.
a mean Fagerstro¨m Test for Nicotine Dependence (FTND) score of Beliefs that nicotine replacement therapy (NRT) will facilitate 5.37 (SD ⫽ 2.06) (Heatherton, Kozlowski, Frecker, & Fagerstro¨m, quitting are associated with greater use and intended use of NRT 1991). Fifty-two participants (20.9%) had prior experience using as well as stronger motivation to quit smoking (Etter & Perneger, bupropion to quit smoking.
2001; Juliano & Brandon, 2004). There is also preliminary evi-dence that smokers' knowledge and attitudes about NRT can be modified and that these changes may contribute to smoking ces-sation outcomes (Fucito & Juliano, 2007; Mooney, Leventhal, & All participants received bupropion SR therapy (300 mg/day) Hatsukami, 2006; Tate, Stanton, Green, & Schmitz, 1994).
for a 7-week period (1-week prequit and 6-weeks postquit) and In light of these findings, smokers' beliefs and attitudes about were randomly assigned to receive messages emphasizing either bupropion may influence adherence and the overall effectiveness the benefits of quitting (gain framed) or the costs of continued of bupropion for smoking cessation. Poor attitudes about bupro- smoking (loss framed). After their quit date, participants attended pion may be associated with decreased bupropion utilization and biweekly research appointments for 6 weeks. Beliefs were as- adherence and may be self-fulfilling (Juliano & Brandon, 2004). It sessed the day before participants quit smoking, which was 1 week has been proposed that a significant portion of all antidepressant after bupropion pretreatment.
responses is due to placebo effects (Kirsch & Sapirstein, 1999).
Thus, maintaining negative beliefs about bupropion may contrib-ute to poorer outcomes. Relatively little is known, however, about the role of smokers' beliefs and attitudes about bupropion in Beliefs and attitudes about bupropion. This six-item measure treatment adherence and smoking cessation outcomes.
assessed smokers' confidence in bupropion as a smoking cessation This report investigated smokers' beliefs and attitudes about aid (two items), general expectancy that bupropion helps people bupropion and their association with: (a) beliefs about smoking stop smoking (one item), perceived utility/importance of bupro- and quitting, (b) treatment adherence, and (c) smoking cessation pion for smoking cessation (two items), and confidence that they outcomes. Positive beliefs about bupropion were anticipated to be would adhere to bupropion as indicated (one item) on a 5-point associated with positive beliefs about quitting and abstinence, Likert scale ranging from 1 (not at all) to 5 (extremely). Two-item greater treatment adherence, a greater likelihood of smoking ab- subscale scores were derived by summing individual items. A stinence, and a longer latency to smoking lapse.
principal components analysis with varimax rotation performed onthe six items confirmed this four-factor solution and revealed four components with eigenvalues greater than 1, accounting for93.31% of the total variance. Only items that loaded .40 on one factor and less than .40 on all other factors were assigned to factors This is a secondary analysis of data from a randomized con- (Hatcher, 1994). Factor 1 contained two items, r(244) ⫽ .74, p ⬍ trolled trial of message framing for smoking cessation with open- .01; Factor 2 contained one item, Factor 3 had two items, r(244) ⫽ label bupropion SR therapy (300 mg/day) reported previously .85, p ⬍ .01; and Factor 4 contained one item. The items and factor (Toll et al., 2007). Eligibility requirements included being at least loadings are shown in Table 1.
18 years of age, smoking at least 10 cigarettes per day for at least Other baseline self-report measures included the Perceived Risks 1 year, and having a baseline expired air carbon monoxide (CO) and Benefits Questionnaire (PRBQ; McKee, O'Malley, Salovey, level of at least 10 parts per million (ppm). Participants were Krishnan-Sarin, & Mazure, 2005), a 40-item measure of the perceived excluded for current serious neurologic, psychiatric, or medical risks and benefits associated with smoking cessation; the Thoughts illness and current alcohol dependence. Two hundred forty-nine About Abstinence Scale (TAAS; Hall, Havassy, & Wasserman, participants in the treatment seeking sample (129 women, 120 1991), a 6-item measure of commitment to abstinence, motivation, men) were primarily White (81.9%), had a mean age of 42.65 desire, and confidence to quit smoking, and expected outcomes of (SD ⫽ 11.54) years, smoked an average of 22.61 (SD ⫽ 9.32) quitting; Decisional Balance for Smoking–Short Form (DBS–SF; Table 1Rotated Four-Factor Matrix for Beliefs and Attitudes About Bupropion Scale 1. How important will it be for you to use Zyban to help you stop smoking? 2. How helpful will it be for you to use Zyban to help you stop smoking? 3. Zyban can help people stop smoking.
4. How confident are you that Zyban can help you quit smoking? 5. How confident are you that Zyban will be useful to you as you quit smoking? 6. How confident are you that you will use Zyban as indicated by your doctor? Note. N ⫽ 249. Varimax rotation method was used. Underlined figures were assigned to factors.
BELIEFS AND ATTITUDES ABOUT BUPROPION Velicer, DiClemente, Prochaska, & Bradenburg, 1985), a 6-item tic regression analyses were used to test the relationships among measure of perceived costs and benefits of smoking; and a 2-item bupropion beliefs, treatment adherence, and abstinence outcomes, measure, designed for this study, to assess intentions to quit smoking controlling for message framing condition (gain vs. loss framed).
within the next 6 weeks and 6 months (5-point Likert scale; from 1 ⫽ Cox regression analysis was also conducted to evaluate if beliefs not at all strong to 5 ⫽ extremely strong).
were associated with latency to smoking lapse (range 1 to 42 days), Bupropion SR adherence was evaluated controlling for condition. Regression models were fitted in steps.
using electronic drug exposure monitor caps (APREX, Union City, Message framing condition was entered in Step 1. Beliefs and CA) that recorded the time and day that the pill bottle was opened.
attitudes about bupropion or treatment adherence variables were Percentage adherence was defined as the number of cap openings then entered in Step 2. Similar models were also tested without divided by 95 (the total number of times bupropion should have controlling for the effect of framing condition. Linear and logistic been taken over the treatment period; Kastrissios & Blaschke, regression analyses were also conducted to evaluate treatment 1997). The number of treatment sessions attended and whether adherence variables as potential mediators of the relationship be- participants completed treatment was also recorded.
tween bupropion beliefs and smoking outcomes. The relationship Smoking behavior. Timeline followback (TLFB; Brown et al., between beliefs and smoking outcomes was evaluated for the full 1998; Sobell & Sobell, 1992; 2003) methodology was used to sample (N ⫽ 249) and the subsample of treatment completers (N ⫽ assess the number of cigarettes smoked per day. Abstinence was 170) in line with recent theoretical and statistical advances that defined by self-reports of no smoking (not even a puff) and an suggest supplementary analyses accounting for treatment adher- expired air CO level less than or equal to 10 ppm (SRNT Sub- ence may be of value and should be reported (Armitage, 1998; committee on Biochemical Verification, 2002). Participants who Pocock & Abdalla, 1998). Armitage (1998) contended that the dropped out or missed multiple appointments were coded as smok- intention to treat analysis often underestimated the "true" treat- ing. Data for a single missed appointment were coded abstinent if ment effect, as nonadherent participants will attenuate whatever participants reported not smoking and had expired air CO levels less effect may have been shown in adherent participants.
than or equal to 10 ppm at the sessions before and after the missedappointment. The following smoking outcomes were examined: (a) continuous 6-week abstinence from the quit date, (b) point prevalenceabstinence over the last 7 days of treatment, (c) latency to first Experience With Bupropion smoking lapse during treatment, and (d) 7-day point prevalence smok-ing abstinence at 3- and 6-month follow-up appointments.
Beliefs about the importance/utility of bupropion as a smoking cessation aid, confidence that bupropion would facilitate quitting,expectancies that bupropion helps people quit smoking, and perceived confidence that one would use bupropion as indicated did not statis- To examine if beliefs and attitudes about bupropion signifi- tically differ by prior experience using bupropion for a quit attempt.
cantly differed by prior experience using bupropion for a quitattempt, t tests were conducted. Pearson correlations were calcu- Beliefs About Smoking and Quitting lated to examine associations between beliefs and attitudes aboutbupropion and beliefs about smoking (i.e., DBS–SF) and quitting As shown in Table 2, beliefs and attitudes about bupropion (i.e., TAAS, PRBQ, intentions to quit smoking). Linear and logis- were positively associated with desire to quit smoking, expec- Table 2Correlation Matrix for Beliefs and Attitudes About Bupropion Scale and Other Smoking and Quitting Cognitions confidence factor 1. Desire to quit smoking 2. Expectation of success in quitting 3. Perceived difficulty remaining abstinent 4. Confidence will be able to quit smoking 5. Motivation to quit smoking 1. Perceived risks of quitting smoking 2. Perceived benefits of quitting smoking 1. Costs of smoking 1. Intentions to quit smoking within next 6 weeks 2. Intentions to quit smoking within next 6 months Note. N ⫽ 249. Underlined figures reflect significant correlation coefficients. TAAS ⫽ Thoughts About Abstinence Scale; PRBQ ⫽ Perceived Risks andBenefits Questionnaire; DBS–SF ⫽ Decisional Balance for Smoking–Short Form.
p ⬍ .05. ⴱⴱ p ⬍ .01.
FUCITO, TOLL, SALOVEY, AND O'MALLEY tation of quitting success, quitting confidence, motivation to quit, perceived benefits of quitting, perceived costs of smoking, and intentions to quit smoking and were negatively associated with expected difficulty remaining abstinent and perceived risks of quitting.
Beliefs and attitudes about bupropion were significantly asso- ciated with treatment adherence. Greater confidence that one p 2 ␹ ⬍ 249) would use bupropion as indicated was significantly associated with a greater mean percentage of cap openings, ⌬R2 ⫽ .04, ⌬F(1, 239) ⫽ 8.77, p ⫽ .003, ␤ ⫽ .19; a greater number of treatment sessions attended, ⌬R2 ⫽ .02, ⌬F(1, 241) ⫽ 5.71, p ⫽ .02, ␤ ⫽ .15; and an increased likelihood of completing treatment, Nagelkerke R2 ⫽ .03, ␹2(1, N ⫽ 244) ⫽ 4.22, p ⫽ .04, Wald ⫽ 4.18, odds ratio (OR) ⫽ 1.55, 95% confidence interval (CI) ⫽ 1.02 to 2.36; after controlling for message framing condition. Other beliefs and attitudes about bupropion were unrelated to adherence, attendance, or the likelihood of completing treatment. Similar results were obtained without controlling for message framing Smoking Outcomes Among all participants (N ⫽ 249), logistic regression analyses demonstrated that the mean percentage of cap openings, the num- ber of sessions attended, and the likelihood of completing treat- ment were significantly related to an increased odds of smoking abstinence and a delayed latency to smoking lapse (see Table 3).
Beliefs and attitudes about bupropion were unrelated to smoking outcomes among all participants. Among treatment completers (N ⫽ 170), however, greater beliefs about the importance/utility of bupropion as a smoking cessation aid were significantly related to an increased likelihood of continuous smoking abstinence, Nagelkerke R2 ⫽ .06, ␹2(1, N ⫽ 168) ⫽ 4.73, p ⫽ .03, OR ⫽ 1.28, 95% CI ⫽ 1.02 to 1.60; and a delayed latency to smoking lapse over the 6-week treatment period, ␹2(1, N ⫽ 168) ⫽ 4.74, p ⫽ .03, ⫽ (1,2 p OR ⫽ 1.18, 95% CI ⫽ 1.01 to 1.37; after controlling for message framing condition. Greater confidence that one would use bu- propion as indicated was also nonsignificantly related to an increased likelihood of continuous abstinence, Nagelkerke R2 ⫽ .05, ␹2(1, N ⫽ 168) ⫽ 2.91, p ⫽ .088, OR ⫽ 1.59, 95% CI ⫽ 2 ␹ ⬍ 249) .001.
.93 to 2.72; and 6-week point prevalence abstinence, Nagelkerke R2 ⫽ .03, ␹2(1, N ⫽ 168) ⫽ 2.88, p ⫽ .098, OR ⫽ ⫽ Step .56, (1, 1.62, 95% CI ⫽ 0.91 to 2.89; after controlling for treatment condition. Other bupropion beliefs were unrelated to smoking outcomes. Similar results were obtained for all analyses without controlling for condition.
The potential mediating effects of the mean percentage of cap openings, number of sessions attended, and likelihood of com- ⫽ 2: 19.82, 1: p pleting treatment on the relationship between bupropion beliefs and smoking outcomes were also examined among the full sample and subsample of treatment completers but yielded no significant results. Similarly, treatment adherence variables were also examined as mediators of the associations between other smoking and quitting cognitions (i.e., TAAS, PRBQ, DBS–SF) and smoking outcomes. None of these analyses were BELIEFS AND ATTITUDES ABOUT BUPROPION experience with the medication because there is evidence thatbeliefs interact with pharmacological effects to produce medi- Positive beliefs about bupropion were related to greater inten- cation responses (Kirsch, 1999). Thus, smokers' beliefs may tions, motivation, confidence, and desire to quit smoking, stron- have been influenced by the experience of side effects or a ger perceived benefits of quitting and disadvantages of smok- perceived lack of effect on smoking motivation, thereby reduc- ing, greater expectation of quitting success, and better treatment ing the association between positive beliefs and better smoking adherence. These results lend support to previous studies that outcomes. In addition, bupropion beliefs only accounted for a showed positive NRT expectancies were associated with greater small percentage of the variance in adherence and smoking quit intentions, NRT utilization, and adherence (Etter & Per- outcomes. Bupropion beliefs appear to be important but other neger, 2001; Juliano & Brandon, 2004) and expand on this factors may have stronger associations with adherence and research by demonstrating that positive bupropion beliefs were smoking outcomes. Future research should investigate factors also related to better smoking cessation outcomes. Moreover, related to bupropion adherence to identify additional targets for such results provide preliminary support for the convergent and intervention. Beliefs were also not directly manipulated and predictive validity of the beliefs and attitudes about bupropion therefore it is not possible to draw conclusions about their scale used in the present study. In addition, greater treatment potential causal role in adherence or smoking outcomes.
adherence was associated with an increased likelihood of being This is the first study to provide preliminary support for the abstinent and a longer latency to smoking lapse. This finding is hypothesis that positive beliefs and attitudes about bupropion are consistent with prior research that has shown positive associa- associated with more positive attitudes about quitting and better tions between bupropion adherence and smoking cessation out- treatment adherence and response. More research is needed to comes (Killen et al., 2004; Mooney et al., 2007; Schmitz et al., better understand the role that beliefs about bupropion (and 2007; Swan et al., 2004). In accordance with social cognitive other smoking pharmacotherapies such as varenicline) play in models of behavior, smokers who expect positive outcomes perceived drug effects, medication adherence, and smoking from using bupropion (i.e., that bupropion will facilitate quit- cessation outcomes.
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