Asthma medication in athletes: a qualitative investigation of adherence, avoidance and misuse in competitive sport

Abstract

Objectives:The purpose of this qualitative study was to utilize the Capability, Opportunity, Motivation -Behavior model (COM-B) to: (1) evaluate athlete knowledge and understanding of current asthma-related anti-doping regulations, (2) explore the impact of environmental and societal influences on athletes with asthma, and (3) examine athlete perception of asthma medication use in competitive sport. Methods: Semi-structured interviews were conducted with ten competitive endurance athletes (five athletes with asthma and five without asthma). Interviews were guided by the COM-B model and transcripts were analyzed inductively and deductively using reflexive thematic analysis. Results: Mapping the experiences and perceptions of athletes against an established behavioral framework identified that: (1) athletes' possess limited knowledge and understanding of the World Anti-Doping Agency (WADA) Prohibited List and Therapeutic use exemption (TUE) policy with respect to asthma medication; (2) the use of sub-optimal diagnostic methods is commonplace and increases the risk of misdiagnosis and unnecessary inhaler therapy; (3) negative media portrayal of high-profile asthma-related doping allegations impacts public opinion and contributes to the perception of wrongdoing within the sporting community. Conclusion:The novel application of behavioral science highlights several factors that may contribute to asthma medication avoidance and promote misuse in competitive sport. The findings from this study provide a foundation for the development and implementation of targeted education programmes, and it is hoped that employing this approach will ultimately improve overall perceptions of asthma treatment in athletes, which is necessary to maintain respiratory health, optimize performance and protect the integrity of sport.

Prevalence of lower airway dysfunction in athletes: a systematic review and meta-analysis by a subgroup of the IOC consensus group on ‘acute respiratory illness in the athlete’

“…Indeed, large retrospective studies in this area reveal a consistent prevalence of lower airway dysfunction (ie, asthma medication use) of approximately 8% in Olympic-level athletes over sequential major competitions (1996–2004) 12 13. The reason this figure is lower than the overall prevalence in our analysis is unclear, but certainly challenges the widely held supposition that many athletes report ‘asthma symptoms’ or use inhalers to potentially enhance performance87–89; that is, studies objectively confirming lower airway dysfunction actually suggest that a greater number of athletes should be using inhaler therapy to optimise and maintain their respiratory health.…”

“…Historically, many studies that report the prevalence of lower airway dysfunction in Olympic athletes have arisen from mandatory evidence of inhaled beta-2 agonist use when TUE certificates were required for this type of medication (for review see Allen et al 87). Indeed, large retrospective studies in this area reveal a consistent prevalence of lower airway dysfunction (ie, asthma medication use) of approximately 8% in Olympic-level athletes over sequential major competitions (1996–2004) 12 13.…”

Annual banned‐substance review: Analytical approaches in human sports drug testing 2020/2021

“…Asthma medication, more specifically the use of β 2 -agonists, has required distinct considerations in anti-doping due to the prevalence of asthma-related conditions within the general as well as the elite athletic population and the necessity of maintaining respiratory health while protecting the integrity of sport. 138 Agreement appears to exist among scientists about the performance-enhancing potential of β 2 -agonists, particularly concerning short and largely anaerobically conducted athletic performance, and anabolic as well as lipolytic activities. 88 In 2020/2021, especially, salmeterol was the subject of indepth anti-doping investigations as the drug's permissive use is limited to 200 μg per 24 h, 24 but, in contrast to salbutamol and formoterol, no urinary threshold or reporting level has been defined.…”

“…Asthma medication, more specifically the use of β 2 ‐agonists, has required distinct considerations in anti‐doping due to the prevalence of asthma‐related conditions within the general as well as the elite athletic population and the necessity of maintaining respiratory health while protecting the integrity of sport 138 . Agreement appears to exist among scientists about the performance‐enhancing potential of β 2 ‐agonists, particularly concerning short and largely anaerobically conducted athletic performance, and anabolic as well as lipolytic activities 88 .…”

Fighting fair: community perspectives on the fairness of performance enhancement in esports

“…Consequently, athletes that may actually need an inhaler refuse therapy in order to avoid being stigmatized. Thus there is a urgent need to change the perception among the athletes with regards to asthma medication, to maintain respiratory health ( 32 ). It is possible that athletes may falsely report their symptoms to get access to medically unnecessary prescriptions, and an unjustified medical use exemption.…”