*Purpose: Medication non-adherence is associated with poor outcomes in transplant recipients. It can be challenging to identify candidates at risk for medication non-adherence. The simplified medication adherence questionnaire (SMAQ) is an instrument designed to assess medication adherence. The aim of this study was to evaluate factors associated with medication adherence in thoracic transplant candidates.

*Methods: A questionnaire, including the SMAQ, was mailed to waitlisted thoracic transplant candidates at 6 transplant centers. Recruitment occurred from 9/16/2015 to 11/19/2019. Medication adherence or non-adherence by SMAQ is binary. Medication non-adherence is defined as a positive response to any of the qualitative SMAQ questions, missing more than two doses of any scheduled medication over the preceding week, or missing more than two cumulative days of all medications over the preceding 3 months. A chi² test was performed to examine the relation between demographic factors and medication adherence. The association of positive attitude, as defined by a positivity ratio of >2.9 on the Positive and Negative Affect Schedule, and medication adherence was also examined using chi². Self-management ability, as assessed by the Self-Management Ability Scale (SMAS-30), was compared in medication adherent and non-adherent candidates using a t-test. We set an alpha level of 0.05.

*Results: Questionnaires were completed by 314 candidates (77.5% participation). 179 (57.0%) respondents were medication non-adherent: 96 (60.8%) heart transplant, 81 (54.0%) lung transplant, and 2 (33.3%) combined heart-lung transplant candidates. Male candidates (p=0.05), candidates with at least some college (p=0.05), and obese candidates (p=0.05) were more likely to be medication non-adherent. In contrast, candidates with a positive attitude were more likely to be medication adherent (p=0.02). While the SMAS-30 total score was similar in medication adherent (74.24 + 13.40) compared to medication non-adherent (69.94 + 12.24, p=0.08) candidates, medication non-adherent candidates had lower mean investment behavior SMAS sub-scores (68.67 + 18.24) compared to medication adherent (73.81 + 18.88, p=0.02) candidates.

*Conclusions: Male sex, obesity, and higher education were associated with medication non-adherence. Candidates with positive attitude and more investment behaviors were more likely to be adherent. Given the importance of medication adherence following thoracic transplant, these characteristics can be used to identify and provide appropriate resources to candidates that may be at risk for medication non-adherence.

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