Overcoming patient resistance to using a free e-cigarette to support smoking reduction in a primary care trial

Problem

Almost everyone with a serious smoking-related disease tries to stop smoking on diagnosis, but relapse is common, and many are unable or unwilling to quit. Many people with chronic disease receive repeated advice to quit smoking but harm reduction may offer a more appropriate alternative. Harm reduction reduces exposure to the harmful constituents in tobacco smoke by providing nicotine though less harmful sources. E-cigarettes have now become the most popular non-tobacco system of obtaining nicotine, with 42% of smokers using this method to support quit attempts. The MaSC trial investigated whether clinicians could deliver advice about e-cigarettes and offer support to smokers with chronic disease who had declined standard stop smoking support. Primary care clinicians gave brief advice about e-cigarettes, offered a free starter kit to their eligible patients, and discussed switching a few cigarettes for an e-cigarette. In this study we used recordings from the trial, aiming to identify how clinicians responded to patients who were resistant to the offer of an e-cigarette and the communication strategies used to attempt to overcome that resistance.

Approach

We used conversation analytic methods to analyse 164 audio-recordings from the MaSC trial. We focussed on cases where patients were initially resistant to using an e-cigarette, but subsequently accepted the offer. We aimed to identify any common persuasive strategies and resources clinicians drew on to reach acceptance including grammar, action, sequence, and prosody. We then compared the interactional features of these ‘turnaround’ cases with cases where turnarounds were not forthcoming, and considered the differences.

Findings

Of 164 patients, 29 initially displayed negative views of e-cigarettes, and were subsequently persuaded to accept. Clinicians achieved these ‘turnarounds’ by eliciting the patient’s perspective on e-cigarette acceptability, prior to making a direct offer. This sequence trajectory allowed patients to display resistance to using e-cigarettes in general, without explicitly rejecting the clinician’s offer. Clinicians then countered the basis for resistance (e.g. potential for harm), through a series of incremental steps, providing information tailored to the patient’s concerns. When the offer of a free e-cigarette was subsequently made, patients would usually accept, as their prior concerns had been allayed. Some clinicians did not do this and were met with further resistance.

Consequences

Obtaining patient’s perspectives on the acceptability of e-cigarettes prior to making a direct offer was instrumental in allowing bases for resistance to be elicited and addressed, and subsequent offers to be accepted. Prior to recommending e-cigarettes clinicians should first assess patients’ perspectives and address concerns that may prevent uptake. This work adds to a growing body of evidence that a more cautious approach, eliciting a patient’s perspective before offering something that has the potential to be received negatively is useful in supporting informed uptake.