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Mersha, A.G.; Gould, G.S.; Bovill, M.; Eftekhari, P. Nicotine Replacement Therapy. Encyclopedia. Available online: https://encyclopedia.pub/entry/3562 (accessed on 19 June 2024).
Mersha AG, Gould GS, Bovill M, Eftekhari P. Nicotine Replacement Therapy. Encyclopedia. Available at: https://encyclopedia.pub/entry/3562. Accessed June 19, 2024.
Mersha, Amanual Getnet, Gillian Sandra Gould, Michelle Bovill, Parivash Eftekhari. "Nicotine Replacement Therapy" Encyclopedia, https://encyclopedia.pub/entry/3562 (accessed June 19, 2024).
Mersha, A.G., Gould, G.S., Bovill, M., & Eftekhari, P. (2020, December 15). Nicotine Replacement Therapy. In Encyclopedia. https://encyclopedia.pub/entry/3562
Mersha, Amanual Getnet, et al. "Nicotine Replacement Therapy." Encyclopedia. Web. 15 December, 2020.
Nicotine Replacement Therapy
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Poor adherence to nicotine replacement therapy (NRT) is associated with low rates of smoking cessation. Hence, this study aims to identify and map patient-related factors associated with adherence to NRT using the capability, opportunity, motivation, and behaviour (COM-B) model. Methods: A systematic review was conducted by searching five databases (MEDLINE, Scopus, EMBASE, CINAHL, and PsycINFO) and grey literature on 30 August 2020. Data were extracted, thematically analysed, and mapped to the COM-B model. The Joanna Briggs Institute (JBI) critical appraisal tool was utilised to assess the quality of studies. Results: A total of 2929 citations were screened, and 26 articles with a total of 13,429 participants included. Thirty-one factors were identified and mapped to COM-B model: psychological capability (forgetfulness, education), physical capability (level of nicotine dependence, withdrawal symptoms), reflective motivation (perception about NRT and quitting), automatic motivation (alcohol use, stress, depression), physical opportunity (cost), and social opportunity (social support). The most prominent element associated with adherence was reflective motivation followed by physical capability and automatic motivation. Conclusions: Multiple personal, social, and environmental factors affect NRT adherence. Hence, it is recommended to implement a multifaceted behavioural intervention incorporating factors categorised under the COM-B model, which is the hub of the behaviour change wheel (BCW) to improve adherence and quitting.

adherence COM-B model factors nicotine replacement therapy smoking cessation

1. Introduction

Tobacco smoking is one of the main public health concerns that the world has ever faced [1]. Since the adoption of the World Health Organisation (WHO) Framework Convention on Tobacco Control (FCTC) in 2003, tremendous efforts have been made to scale-up tobacco control [2][3][4]. Smoking cessation is one of the most important and cost-effective preventive health measures to reduce the risk of mortality and morbidity [5][6]. Smoking cessation is associated with substantial positive health outcomes, and evidence suggests that smoking cessation medications are offered in addition to behavioural therapy [7].

One factor that has been shown to have a direct effect on the success of smoking cessation treatment is adherence to smoking cessation medications [8]. A review conducted in 2020 by Mersha et al. showed that adherence to nicotine replacement therapy (NRT) doubles the success of smoking cessation (OR = 2.17, 95% CI, 1.34–3.51) [9]. A literature review conducted by Pacek et al. which included participants utilising any type of smoking cessation medications such as varenicline, bupropion, and NRT, classified factors associated with adherence to smoking cessation medications into preventable and non-preventable factors. The non-preventable factors include sociodemographic, medical comorbidities, genetic, and personality factors [10]. Male sex [11][12], older age [8][13], and greater educational status [14] were found to increase the level of adherence to smoking cessation medications. Low socioeconomic status and having depressive symptoms were found to reduce the level of adherence in most of the studies [15][16][17]. Preventable factors associated with adherence to smoking cessation medications include belief about the safety and efficacy of smoking cessation medications [18].

In the behaviour change wheel (BCW), which is broadly utilised to design and implement successful behavioural change interventions, the capability, opportunity, motivation, and behaviour (COM-B) model is at the hub of the wheel. The COM-B model suggests that behaviour is the result of an interaction between three components: capability, opportunity, and motivation. These components are further divided into six subcomponents: psychological capability, physical capability, social opportunity, physical opportunity, automatic motivation, and reflective motivation [19]. The components of the COM-B model are encircled by nine intervention functions (education, persuasion, incentivisation, coercion, training, restriction, environmental restructuring, modelling, enablement) and seven policy categories (communication, guidelines, fiscal, regulation, legislation, environmental/social planning, and service provision) in the BCW [20]. This representation in the BCW makes suggestion of possibly effective strategies easy and targeted to components of the COM-B model.

Among the smoking cessation medications, NRT has the lowest half-life, especially nicotine gum and spray, with a maximum of two to three hours; whereas, the half-life of bupropion and varenicline is 22 and 24 h to ease adherence as compared to NRT [21][22]. Moreover, the rates of adherence were 63 and 74% for varenicline and bupropion, respectively [23][24]. Adherence to NRT is inconsistent between 26 to 61%, given the difficulty of the dosing schedule [9]. Although, a literature review conducted in 2018 aimed at classifying factors as preventable and nonpreventable [10], the current review utilised the COM-B model to understand factors and BCW to discuss and suggest interventions [20].

A detailed understanding of the barriers and facilitators of adherence to NRT is crucial for the development of comprehensive and effective interventions that can improve the success of smoking cessation. This systematic review aims to identify barriers and facilitators of adherence to NRT and to map the identified factors into the six sub-components of the COM-B model. As the COM-B model is the heart of the BCW, it will guide researchers and policymakers to develop targeted strategies that may improve adherence to NRT and smoking cessation [20]

2. Discussion

This review identifies factors using a predefined behavioural model, the COM-B model, which is at the hub of the BCW that was effectively used to design and implement behavioural change strategies. Hence, the intervention functions and policy categories in the BCW are used to recommend and discuss the findings [25].

Strategies that aimed at addressing intervention functions of the BCW such as enablement, education, and training were found to be effective in improving psychological capability of an individual towards adherence to smoking cessation medications [19][26]. For instance, a double-blind randomised controlled trial conducted in the UK evaluated the effect of a mobile application (NRT2Quit) among adult smokers. The application provided comprehensive information about quitting and NRT, daily tips as well as a reminder about the medications. The intervention group had a higher level of treatment adherence and 4 weeks biochemically verified smoking cessation rate (25%) compared to the control group (8%). This study supports our findings on the importance of an individual’s ability to remember and comprehend the necessary information and instructions about NRT use [27].

In this review, except for the level of nicotine dependence, all other factors mapped under physical capability were consistently associated with either a high or low level of adherence to NRT. Studies that reported an inverse relationship between the level of dependence and adherence to NRT also reported relapse to smoking and dropout from the study, which may have contributed to the inverse relationship between the two variables [28]. Prescribing higher doses of NRT and early initiation were found to improve the level of adherence to NRT [29]. This can be explained by the fact that higher doses are more effective in alleviating withdrawal symptoms from quitting than low dose preparations leading to better adherence. This is represented as enablement in the intervention function and guideline in the policy category of the BCW [25].

Furthermore, withdrawal symptoms were one of the most commonly reported causes for nonadherence in the category of physical capability. When attempting to quit smoking, experiencing greater levels of withdrawal symptoms could become a barrier to abstinence, which also applies to NRT aided smoking cessation [30]. This explains why, when participants attempt to quit smoking “cold turkey” (unaided) or delay initiation of NRT, they often fail to quit or adhere to NRT [31]. To minimise withdrawal symptoms, the dose of NRT should be adjusted according to one’s dependence and severity of withdrawal symptoms [32][33].

Medication-related beliefs and expectations were the main factors categorised under the reflective motivation subcomponent of the COM-B model. A randomised factorial study also found a significant positive effect of additional medication-related face-to-face counselling and automated phone calls directed to improve knowledge about NRT [34]. Establishing realistic expectations are also vital during quit attempt. A study conducted by Tucker et al. in 2017 [35] reported a higher adherence rate to NRT among participants who received additional information on the extent of withdrawal symptoms and urges and how NRT would reduce them in order to develop realistic expectations.

Motivation improves once ability to cope up with withdrawal symptoms and improves the appropriate consumption of NRT [36]. Psychological symptoms and alcohol use reduced the rate of motivation to quit and adherence to NRT. This could be explained by the risk of resuming smoking among participants who have developed the above mental issues [36][37]. There is a close link between smoking and drinking. Alcohol intake may trigger cravings to smoke cigarettes [38]. Alcohol may affect adherence to NRT by increasing the risk of resuming smoking [39]. As alcohol intake is often cited as a major precipitant of smoking relapse [40], current clinical guidelines for smoking cessation also suggest reducing or avoiding drinking during quit attempt [41]. The rewarding effect of smoking is enhanced in smokers with alcoholic disorders. Hence, smokers with alcohol use disorders tend to experience intense withdrawal symptoms and craving leading to resuming smoking and medication nonadherence [42].

The rate of adherence to NRT was improved among clinical trial participants for whom associating medication with regular activities such as taking other medications, with meals, and watching preferred TV shows were achieved with the help of therapists [43]. Being able to identify and prevent personal triggers reduces the risk of relapse and adherence to NRT. This finding is similar with a randomised trial that aimed at identifying and avoiding temptations to smoke, which helped improve adherence at eight weeks as well as self-reported abstinence rates [35].

Factors categorised under opportunity component of the COM-B model can be improved by addressing the fiscal measures and legislation elements in the BCW that advocate access to NRT [25]. Although most countries subsidise the cost of NRT and provide the medication over the counter, it may still be difficult to get a preferred or combination of forms of NRT. NRT may only be prescribed for a shorter period, which may not be enough to support cessation leading to premature discontinuation of NRT [44]. Greater social support increases adherence to nicotine patches, which may be explained by the effect of having someone to remind the participant to take the medications, motivate them to stay quit, and provide financial support to refill medications [45]. Additionally, having greater social support may improve the mental health status of an individual during a quit attempt [46].

2.1. Strength and Limitations of the Study

Our search strategy was broad and comprehensive and was developed with the help of an experienced librarian. As only one study was conducted in a developing country, caution should be taken during interpreting the findings especially in developing countries; there were also some inconsistencies in the direction of the association between some factors. Moreover, the COM-B model did not distinguish intentional and unintentional nonadherence. Despite these limitations, this systematic review is the first to evaluate enablers and facilitators of adherence to NRT using the theoretical framework of the COM-B model.

2.2. Implications for Policy, Research, and Practice

Health care providers are recommended to provide adequate information about withdrawal symptoms and NRT, address safety concerns, and establish realistic expectations. Individuals are recommended to boost their motivation and mental health by having social connections, physical activity, and managing stress. It is also recommended for patients to visit health care providers, smoking cessation support services, or access a Quitline for psychological support and counselling.

Subsidisation of smoking cessation medications and care are advocated and recommended to improve adherence to NRT and the success of smoking cessation attempts. It is recommended to advocate policies and strategies that can enhance motivation to quit smoking through the promotion of the health benefits of smoking cessation and smoking cessation supports.

Additionally, as the review illustrated the importance of factors at multiple levels, implementation and evaluations of trials addressing multiple components of the COM-B level are recommended.

More studies, especially among special population groups, such as pregnant women, individuals with psychiatric disorders, and socially disadvantaged individuals, are recommended to develop more tailored approaches. In addition, as gender is an important factor for adherence and successful quitting, future research should include gender-based analysis.

3. Conclusions

The current review demonstrated the importance of personal, social, and environmental factors affecting adherence to NRT using a comprehensive predefined theoretical framework (COM-B model). Most of the identified factors were mapped under the category of the reflective motivation component of the COM-B model followed by physical capability, and automatic motivation. Hence, reflective motivation is the most crucial element for adherence to NRT out of the six sub-components of the COM-B model. However, it should be noted that all sub-components of the COM-B model are essential in moderating an individual’s behaviour concerning adherence to NRT. For instance, motivation cannot provide opportunity, and if these are missing, then according to the COM-B model, behaviours have to be engaged with to increase or seek out opportunities, which may be beyond an individual’s control.

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