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Introduction Financial incentive programs promote smoking cessation. However, the incentive amount which should be provided—and how this may interact with other program characteristics—is unknown. The objective of this study was to evaluate the influence of the design of incentive programs for smoking cessation on current smokers’ perceptions of programs and willingness to enroll. Method An online discrete choice experiment was conducted amongst adult current smokers residing in the United Kingdom (N = 430). Hypothetical incentive programs were described using five attributes (incentive amount, incentive type, frequency of sessions, reward schedules, program location). Participants responded to a series of choice sets comprised of two hypothetical programs. For each set, participants selected their preferred program. They then specified whether they would enroll in their preferred program if it were available. Analyses also considered the effect of participant income on preferences. Results Overall, participants preferred higher amounts over lower amounts, cash over vouchers, healthcare settings over workplaces, and consistent amounts over an escalating schedule. One session per week was the most preferred session frequency. Willingness to enroll increased quadratically with the incentive amount, although this increase slowed for higher amounts. Although middle- and high-income smokers preferred slightly higher amounts (cf. low-income participants), enrollment choices did not differ by income. Conclusion The characteristics of incentive programs influence smokers’ perceptions of programs and willingness to enroll. Higher amounts may encourage greater enrollment rates, but there will likely be a ceiling point beyond which increasing the incentive amount does not meaningfully increase enrollments. Implications There is increasing evidence incentive programs aid smoking cessation. Yet, the variety in previous program designs means how to best structure programs, including optimal incentive amount and the impact of the design on potential enrollment rates, remains unclear. This study suggests enrollments may be highest when incentive amounts are higher, rewards of a consistent amount in cash are provided, and sessions occur once per week in a healthcare setting. Although higher-income participants may desire higher incentive amounts compared to lower-income participants, this may not translate into differences in willingness to enroll.

Objective: To evaluate the adherence to asthma evidence‐based guidelines before and after a quality improvement process. Design: A controlled trial was conducted at two regional hospitals (intervention and control hospitals). We performed a retrospective pre‐intervention audit, followed by a post‐intervention audit 1 year after the implementation of evidence‐based guidelines. Setting: Emergency departments of two neighbouring hospitals serving regional and rural North West Tasmania. Participants: All children (

Objective: Investigate the smoking-related outcomes and feasibility of a pharmacy led financial incentive program for smoking cessation. Design: Multi-site single-arm trial of the Tobacco Free Communities program. Setting: Community pharmacies within the Glamorgan Spring Bay (Site 1) and George Town (Site 2) municipalities of Tasmania. Participants: Adult smokers. Based on funding, the recruitment target was 76 smokers. Interventions: Pharmacy staff provided quitting advice through 7 sessions over 3 months. At 6 sessions, abstinent participants (no cigarettes in the previous week and expired carbon monoxide ≤4 ppm) were rewarded with AU$50 vouchers. Main outcome measures: Smoking-related outcomes were decreased smoking (self-reported cigarettes per day and carbon monoxide levels) and abstinence rates. Feasibility outcomes were meeting the recruitment target, participant retention and participants' views of the program (measured by interview data from Site 2). Results: Ninety individuals enrolled. Sixty-two participants were included in analyses; remaining participants were excluded from analyses because they did not consent to use of their data within this study or had carbon monoxide ≤4 ppm at enrolment. Smoking (carbon monoxide and cigarettes per day) significantly decreased between enrolment and the first financial incentive session. Twelve participants (19.35%) were abstinent at the end of the program. Yet retention was poor; only 13 participants (20.97%) attended all sessions. Interviews suggested participants found the program beneficial. Conclusions: Providing financial incentive within rural community pharmacies could be a viable method of encouraging smoking reductions and quit attempts. Additional work is needed to increase retention and compare effects to usual care pharmacy practices.

This article presents an analysis of interviews with Australian women who had smoked or were currently smoking during pregnancy. It explores how they spoke about their experiences of smoking, cessation and harm minimisation during pregnancy. Eighteen women underwent a single in-depth interview, these were analysed using an iterative thematic method. We found that smoking, cessation and harm minimisation by pregnant women are complex social practices. Participants viewed smoking as a potential risk to fetal health and as an actual risk to their own health and described feeling embarrassed and ashamed of smoking when pregnant. Their opinions about the relative seriousness of health risks posed by smoking when pregnant were often informed by their own personal observations and experiences. Participants used this knowledge to engage in lay epidemiological processes as they rationalised and made sense of the relative risks of smoking, quitting or cutting down. They also sought legitimacy for their claims about the safety of quitting or cutting down in two potentially contradictory ways. These were personal experience/observations and medical advice. Our findings contribute to sociological understanding about lay responses to medical advice on smoking in pregnancy and will be of value to healthcare professionals who work with pregnant women.

Context The significant symptom burden in advanced renal disease is often poorly recognized by clinicians. Recently, the Integrated Palliative Outcome Score (IPOS)–renal survey was developed from pre-existing tools to capture these symptoms and other common concerns. Objectives We studied the validity and reliability of the IPOS-renal survey (patient and staff versions) in an Australian population. Methods Adult patients with advanced renal disease and nurses caring for them were participated. We initially administered the IPOS-renal survey simultaneously with other validated surveys and then retested the IPOS-renal after seven to 14 days. We tested the construct validity of 1) IPOS-renal patient version in relation to the Edmonton Symptom Assessment Survey–revised and the Kidney Diseases quality of life–short form version 1.3 questionnaire and 2) IPOS-renal staff version in relation to the Support Team Assessment Schedule survey. Results Eighty-one patients (65 hemodialysis, 10 peritoneal dialysis, and six on supportive care; average age 64.9 years) and 53 nurses (average renal nursing experience 10.9 years) were participated. Intraclass coefficients for test-retest reliability were >0.7 for most queries; Cronbach's alphas for internal consistency were 0.84 (patient version) and 0.91 (staff version). In tests of construct validity, Spearman's coefficient of correlation between surveys and their comparators for similar questions was significant, at 0.61 to 0.77 (patients) and 0.24 to 0.76 (staff). As expected, symptom scores and total symptom burden were negatively correlated with summary scores of quality of life. Conclusion The IPOS-renal surveys, patient and staff versions, have good test-retest reliability, internal consistency, and construct validity in patients with advanced kidney disease and their nurses. We recommend their use in symptom assessment.

In this article, we use qualitative data to examine the shape and nature of the online ‘moral outrage’ that was directed at a research trial that used financial incentives to encourage pregnant mothers to quit smoking. Mai Frandsen developed the research trial in Tasmania, a small island state in Australia characterised by high rates of smoking in pregnancy. In this article, we draw on data from 121 online text comments posted in relation to three Australia-wide media stories relating to the research trial in 2015. Two of the online stories came from popular Australian independent ‘mummy’ website ‘Mamamia’. We found that the intense negative moral judgement directed at the programme and the women it benefited was driven by an individualised risk discourse drawing on ideologies of the ‘good’ and ‘intensive’ mother. We argue in this article that the over-emphasis on risk in relation to pregnancy produces a conservative morality that demonise women, fails to account for the social determinants of health and diminishes care for the Other. We argue that the research programme with its incentive component was a useful alternative to more punitive risk approaches as it promoted reward rather than blame and shame and acknowledged the importance of including emotions and morality in analysing the relationship between risk, health and society.

Introduction: Smoking remains the single-most significant preventable cause of poor pregnancy outcomes, yet around 12% of Australian women smoke during pregnancy. Many women are motivated to quit when they find out they are pregnant, yet few are successful. While previous studies have examined the profile of the maternal smoker compared to her nonsmoking counterpart (Aim 1), little is known about what differentiates women who quit during pregnancy to those who do not (Aim 2). Here, we present results from a study investigating the characteristics of women who were able to quit during pregnancy. Methods: Data were drawn from the Tasmanian Population Health database of women who had received antenatal care between 2011 and 2013 (n = 14300). Data collected included age, relationship status and ethnicity of expectant mothers, antenatal details, mental health conditions, and drug use. Independent samples t tests were used to compare differences between women who had, and those who had not, quit during pregnancy. The 19.4% of women who self-reported as smoking in the first half (first 20 weeks) of their pregnancy were further grouped and analyzed comparing those who reported still smoking in the second half of their pregnancy (smokers: n = 2570, 92.4%) to those who quit (quitters: n = 211, 7.6%). Results: Quitters (57.8%) were more likely to be in a relationship than their non-quitting counterparts (49.6%, p = .022) and were less likely to suffer from postnatal depression (2.4% vs. 6.0%, p = .029). No other differences between quitters and smokers were observed. Conclusions: Determining the profile of women who are able to quit during pregnancy may be important to improve the relatively poor cessation rates among maternal smokers and may assist in more effectively targeting at-risk women. Implications: Smoking cessation interventions have traditionally targeted socially disadvantaged women, for good reason: the majority of smoking pregnant women fall into this category. However, despite the significant attention and resources dedicated to antenatal smoking cessation interventions, most are ineffective with only 7.6% of the present sample quitting smoking during pregnancy. This paper may assist in developing more effective antenatal smoking cessation interventions by more clearly describing the profile of maternal smokers who successfully quit during pregnancy. Specifically, this paper highlights the need to acknowledge and address women’s relationship status and mental health in order to promote smoking cessation in pregnancy.

Aim We investigated the symptom burden in adults on haemodialysis; the recognition of symptoms by nurses and nephrologists; and the relationship between symptoms and quality of life. Methods In this cross-sectional observational study, symptoms and quality of life in hemodialysis patients were determined using validated surveys. Nurses and nephrologists independently estimated their patients’ symptoms, and these estimates were compared with patient responses (sensitivity; kappa values for inter-rater agreement). Associations between symptoms and quality of life were assessed using multi-level regression. Results 43 patients, 18 nurses and 3 nephrologists participated. The commonest symptoms (95%CI) reported by patients were: weakness, 69%(53 to 82); poor mobility, 44%(29 to 60); and drowsiness,44%(29 to 60). Sensitivity less than 50% was seen towards 11 of 17 symptoms in nurse ratings compared to 15 of 17 in nephrologist ratings. Agreement with patient symptom ratings was mostly “fair” (0.21 - 0.4), with nurses’ scores showing greater agreement than nephrologists’. Physical, mental and kidney disease component summary scores of quality of life were negatively associated with total symptom score and the number of ‘major’ symptoms (r2 values 0.3-0.36); while with multivariate regression, 50 to 60% of the variance in these scores was accounted for by parsimonious models containing symptoms such as pain and poor mobility. Conclusion Symptom burden worsened quality of life scores in hemodialysis patients. Clinician recognition of symptom burden was inaccurate, although nurses were more accurate than nephrologists. Using patient-completed surveys or including dialysis nurse feedback in routine outpatient settings may help improve symptom recognition by nephrologists. This article is protected by copyright. All rights reserved.

Background Older patients on dialysis may not have optimal outcomes, particularly with regards to quality of life. Existing research is focused mainly on survival, with limited information about other outcomes. Such information can help in shared decision-making around dialysis initiation; it can also be used to improve outcomes in patients established on dialysis. We used qualitative research methods to explore patient perspectives regarding their experience and outcomes with dialysis. Methods Semi-structured interviews with participants aged ≥70, receiving dialysis at a regional Australian hospital, were recorded and transcribed. From participants’ responses, we identified descriptive themes using a phenomenological approach, with verification by two researchers. Factors affecting outcomes were derived reflexively from these themes. Results Seventeen interviews were analysed prior to saturation of themes. Participants (12 on haemodialysis, 5 on peritoneal dialysis) had spent an average of 4.3 years on dialysis. There were 11 males and 6 females, with mean age 76.2 years (range 70 to 83). Experiences of dialysis were described across four domains - the self, the body, effects on daily life and the influences of others; yielding themes of (i) responses to loss (of time, autonomy, previous life), (ii) responses to uncertainty (variable symptoms; unpredictable future; dependence on others), (iii) acceptance / adaptation (to life on dialysis; to ageing) and (iv) the role of relationships / support (family, friends and clinicians). Conclusions Older patients experience the effects of dialysis across multiple domains in their lives. They endure feelings of loss and persistent uncertainty, but may also adapt successfully to their new circumstances, aided by the support they receive from family, health professionals and institutions. From these insights, we have suggested practical measures to improve outcomes in older patients.

Introduction: Gender differences in smoking behavior have been proposed to account for poorer outcomes among women attempting to quit. Specifically, it has been suggested that women’s smoking behavior is less motivated by nicotine-seeking and more driven by environmental cues. To date, however, few real-world studies have examined the hypothesis that women’s smoking is under greater stimulus control. Methods: One hundred and ninety four daily smokers (men = 107; women = 87) completed 3 weeks of ecological momentary assessment (EMA) monitoring that provided data on real-world smoking behavior by reporting on situational contexts shown by previous research to influence smoking behavior (including social setting, cigarette availability, alcohol consumption, and mood). Results: Analyses of particular cues found few gender differences; however, men’s smoking increased to a greater extent compared with women’s when they were with others who were smoking. Idiographic analyses that allow individual subjects to have different directions of linkage to situational cues also were conducted to assess how predictable subjects’ smoking was from a range of contextual characteristics. Compared with women, men’s smoking was significantly more closely tied to food/alcohol consumption and tended to be more closely tied to social context. No other gender differences were found. Conclusions: EMA analyses suggest that men and women are similarly influenced by cues, including mood. Where there were gender differences, it was men rather than women whose smoking behavior was more influenced by cues. The data contradict the hypothesis that women’s smoking is more influenced by cues.

Background and Aims Modelling the population impact and cost-effectiveness of smoking cessation aids is limited by lack of knowledge about how the use of aids changes across quit attempts. Here we test whether the quit method used in a previous attempt influences (i) future decisions to quit and/or (ii) treatment/s used during subsequent attempts. Design and Setting Data came from the Smoking Toolkit Study, a United Kingdom national household survey. Participants and Measures Smokers (n = 5489) who completed a baseline and 6-month follow-up questionnaire. Respondents were asked what treatment/s, grouped as: prescription medication/s [bupropion, varenicline or nicotine replacement therapy (NRT)], over-the-counter NRT or unaided that they had used in their most recent quit attempt (at baseline), and any use of treatment/s for a quit attempt in the last 3 months at follow-up. Results Smokers who had tried to quit at baseline were more likely to report having tried to quit again prior to follow-up [all odds ratios ≥ 2.19 relative to no attempt at baseline, P

Introduction:Results from observational studies suggest that smoking-related cues play a role in triggering relapse. Coping strategies are among the most commonly used cessation strategies, but little is known about how they aid quitting.Aims:The aim of this pilot study was to evaluate the effect of a suite of selected coping techniques on alleviating cue-induced cravings.Methods:Thirty-seven daily smokers (Intervention: 20; Control: 17) participated in two laboratory cue-reactivity sessions, separated by approximately one week, during which craving was assessed before and after exposure to smoking-related cues. Following the first session, participants in the Intervention Group were taught a suite of coping strategies. During the second session, participants in the Intervention Group were encouraged to use these strategies.Results:Participants in the Intervention Group reported a slight decrease in craving following the acute exposure manipulation at the second session, compared to an increase in craving among participants in the Control Group. Intervention Group participants also reported a decrease in craving following prolonged exposure to the smoking cues (compared to an increase in craving among Control Group participants). In both cases, the difference between groups was more pronounced among smokers who responded to the cue-reactivity manipulation. The observed differences were not significant.Conclusions:The results of this pilot study suggest that coping techniques may be beneficial in alleviating both the initial spike in craving observed following acute cue exposure, and aid recovery during prolonged exposure. These findings need to be replicated in a larger study.

ObjectivesThis review summarises the information available for clinicians counselling older patients with kidney failure about treatment options, focusing on prognosis, quality of life, the lived experiences of treatment and the information needs of older adults.DesignWe followed the Joanna Briggs Institute Methodology for Scoping Reviews. The final report conforms to the PRISMA-ScR guidelines.Data sourcesPubMed, PsycINFO, CINAHL, Embase, Scopus, Web of Science, TRIP and online repositories (for dissertations, guidelines and recommendations from national renal associations).Eligibility criteria for inclusionArticles in English studying older adults with advanced kidney disease (estimated glomerular filtration rate 2); published between January 2000 and August 2018. Articles not addressing older patients separately or those comparing between dialysis modalities were excluded.Data extraction and synthesisTwo independent reviewers screened articles for inclusion and grouped them by topic as per the objectives above. Quantitative data were presented as tables and charts; qualitative themes were identified and described.Results248 articles were included after screening 15 445 initial results. We summarised prognostic scores and compared dialysis and non-dialytic care. We highlighted potentially modifiable factors affecting quality of life. From reports of the lived experiences, we documented the effects of symptoms, of ageing, the feelings of disempowerment and the need for adaptation. Exploration of information needs suggested that patients want to participate in decision-making and need information, in simple terms, about survival and non-survival outcomes.ConclusionWhen discussing treatment options, validated prognostic scores are useful. Older patients with multiple comorbidities do not do well with dialysis. The modifiable factors contributing to the low quality of life in this cohort deserve attention. Older patients suffer a high symptom burden and functional deterioration; they have to cope with significant life changes and feelings of disempowerment. They desire greater involvement and more information about illness, symptoms and what to expect with treatment.

Introduction: The aim of the present study was to explore the viability of using social media as a recruitment tool in a clinical research trial. Sociodemographic data and smoking characteristics were assessed in 266 participants recruited to investigate the effectiveness of a behavioral support program for smoking cessation. Methods: For analysis, participants were separated into two groups based on whether they were recruited either using traditional means (flyers, word of mouth, or newspaper advertisement; n = 125, 47.0%) or by advertisements in online social media ( n = 138, 51.9%). Results: Participants recruited via social media were significantly younger, but there were no differences in other socioeconomic variables or smoking characteristics compared with participants recruited via other traditional means. Conclusions: The findings of the present study suggest that using online social media is a viable recruitment method for smoking studies and compliments other more traditional recruitment methods.

Since its launch as a smoking cessation aid, varenicline use has been linked to a number of serious adverse events, notably the exacerbation of pre-existing psychiatric illness, depressed mood and suicidal ideation. Regulators’ fears have been somewhat allayed by varenicline's status as a prescription only medication. The purpose of this study was to examine the care provided by physicians – or general practitioners – and pharmacists to varenicline users under real-world conditions. Participants were 141 patients who had filled a prescription for varenicline at a participating pharmacy within the previous six-months. Identified patients were mailed a survey to complete that included items on interactions with their physician and pharmacy staff, and knowledge of treatment side-effects. Most participants reported that their physician encouraged them to set a quit date (82.5%) and provided additional cessation materials (57.2%). While most (79.0%) physicians discussed whether varenicline was appropriate for the patient, fewer asked about psychiatric illness (40.1%), or asked to be informed about mood or behaviour change during treatment (48.1%). Participants (78.4%) reported that their physician had discussed a follow-up consultation, but only 59.4% of patients who had finished treatment at the time of the survey reported having one. Most reported discussing potential drug side-effects with their physician (71.0%) and or pharmacist (52.9%); when probed, knowledge was variable. These results suggest that many patients do not receive the level of support that physicians and pharmacists are assumed to provide.

Nicotine dependence is a construct used to classify a cluster of symptoms and behaviors, a syndrome. It is typically associated with heavy consumption of tobacco products, compulsive use, tolerance, regulation of intake, and withdrawal. Nicotine withdrawal and its associated symptoms, which emerge when nicotine consumption is reduced or ceased (ie, during a quit attempt), are typically regarded by smokers as the greatest barrier to quitting. Indeed, nicotine dependence, nicotine withdrawal, as well as the finding that most smokers attempting to quit fail to do so demand further understanding to enable improved treatment approaches and outcomes. This chapter provides an overview of how nicotine dependence develops, its clinical manifestations, the multifaceted nature of withdrawal, and the influential role of negative affect.

We investigated the symptom burden in adults on haemodialysis, the recognition of symptoms by nurses and nephrologists, and the relationship between symptoms and quality of life.In this cross-sectional observational study, symptoms and quality of life in haemodialysis patients were determined using validated surveys. Nurses and nephrologists independently estimated their patients' symptoms, and these estimates were compared with patient responses (sensitivity; kappa values for interrater agreement). Associations between symptoms and quality of life were assessed using multi-level regression.Forty-three patients, 18 nurses and 3 nephrologists participated. The commonest symptoms (95%CI) reported by patients were weakness, 69% (53 to 82); poor mobility, 44% (29 to 60); and drowsiness, 44% (29 to 60). Sensitivity less than 50% was seen towards 11 of 17 symptoms in nurse ratings compared with 15 of 17 in nephrologist ratings. Agreement with patient symptom ratings was mostly 'fair' (0.21-0.4), with nurses' scores showing greater agreement than nephrologists'. Physical, mental and kidney disease component summary scores of quality of life were negatively associated with total symptom score and the number of 'major' symptoms (rSymptom burden worsened quality of life scores in haemodialysis patients. Clinician recognition of symptom burden was inaccurate, although nurses were more accurate than nephrologists. Using patient-completed surveys or including dialysis nurse feedback in routine outpatient settings may help improve symptom recognition by nephrologists.

Modelling the population impact and cost-effectiveness of smoking cessation aids is limited by lack of knowledge about how the use of aids changes across quit attempts. Here we test whether the quit method used in a previous attempt influences (i) future decisions to quit and/or (ii) treatment/s used during subsequent attempts.Data came from the Smoking Toolkit Study, a United Kingdom national household survey.Smokers (n = 5489) who completed a baseline and 6-month follow-up questionnaire. Respondents were asked what treatment/s, grouped as: prescription medication/s [bupropion, varenicline or nicotine replacement therapy (NRT)], over-the-counter NRT or unaided that they had used in their most recent quit attempt (at baseline), and any use of treatment/s for a quit attempt in the last 3 months at follow-up.Smokers who had tried to quit at baseline were more likely to report having tried to quit again prior to follow-up [all odds ratios ≥ 2.19 relative to no attempt at baseline, P0.001]. Smokers who tried to quit using pharmacological aids were more likely to try to quit again at follow-up (all ORs ≥ 2.19 relative to no attempt at baseline, P0.001). Smokers tended to re-try aids used in baseline attempts in future attempts (all ORs ≥ 1.48 relative to no attempt at baseline, P0.01).Smokers who have tried to quit in the past year are more likely to try to quit again within 6 months regardless of whether they used a pharmacological aid, and they are more likely to re-try aids they had used previously.

Introduction: Arguably, the greatest advantage of ecological momentary assessment (EMA) studies is that data are collected repeatedly in real-time and real-world situations, which reduces recall and situational biases and thus improves the accuracy and validity of the data collected. However, the validity of EMA data is contingent upon compliance rates. If participant characteristics are related to missing data, analyses should control for these factors, or they should be targeted in EMA training sessions. This study evaluates the impact of demographic and smoking-related participant characteristics on compliance to an EMA smoking study protocol. Methods: Prequit day data were taken from the control arm of an ongoing randomized controlled trial of a smoking-cessation program. After training, N = 119 participants were asked to carry a mobile device with them at all times for ~6 days and log every cigarette they smoked in addition to completing randomly scheduled assessments. Different types of compliance were assessed: the percentage of completed random prompts (signal-contingent compliance), the percentage of logged cigarettes per day compared to a timeline follow-back measure, and the correlation between logged cigarettes and a carbon monoxide assessment 2 hr later (both event-contingent compliance). Results: Overall compliance rates were 78.48% for event-contingent and 72.17% for signal-contingent compliance. None of the demographic or smoking-related participant characteristics predicted signal-contingent compliance; however, female participants showed higher event-contingent compliance than male participants, and Caucasian participants showed higher eventcontingent compliance than non-Caucasian participants. Conclusions: Compliance did not depend on smoking-related characteristics. EMA is a valid method to assess smoking behavior in real-time and real-world settings.

Introduction Older adults constitute the largest group of patients on dialysis in most parts of the world. Management of advanced renal disease in the older adult is complex; treatment outcomes and prognosis can be markedly different from younger patients. Clinical teams caring for such patients are often called on to provide information regarding prognosis and outcomes with treatment—particularly, the comparison between having dialysis treatment versus not having dialysis. These discussions can be difficult for clinicians because they have to contend with incomplete or nascent data regarding prognosis and outcomes in this age group. We aim to summarise the currently available information regarding the prognosis and outcomes of advanced renal disease in the older adult by means of a scoping review of the literature. This article discusses our protocol. Methods This scoping review will be undertaken in accordance with the Joanna Briggs Institute's methodology for scoping reviews. A directed search will look for relevant articles in English (within electronic databases and the grey literature), written between 2000 and 2016, which have studied older patients with advanced renal disease (estimated glomerular filtration rate

Introduction Emotive health messages are widely used tools in tobacco control. However, under some circumstances, they can be less effective than desired by eliciting defensive responses in smokers. Aims This study tests whether enhancing a currently used emotive graphic smoking health warning with a self-affirmation component reduces cigarette consumption and whether potential effects are stronger in heavier smokers, as suggested by previous research. Methods Participants (n = 265) were randomly allocated to a self-affirmation (reflecting on personal values and positive traits using a questionnaire) or matched control condition before viewing an emotive graphic health message from a current Australian government public health campaign. The primary outcome (cigarettes per day [CPD]) was assessed both before and a week following the intervention. Results No main effect of self-affirmation on smoking, but as hypothesized, a significant interaction between baseline smoking and self-affirmation was found that showed that heavier smokers (>21 CPD) who self-affirmed significantly reduced CPD compared to nonaffirmed smokers. Conclusions These findings support the use of self-affirmation to enhance smoking awareness campaigns in heavier smokers. Implications This study shows that enhancing emotive graphic smoking health messages with self-affirmation (the act of reflecting on positive aspects of oneself) increases their effectiveness in heavier smokers. This suggests that self-affirmation might be a particularly useful tool for health promotion targeting heavier smokers. This study adds to previous research in that it is the first to test the add-on effects of self-affirmation to current graphic health messages on smoking rather than smoking-related cognitions.