Abstract
Background
Promoting smoke-free homes (SFHs) in Armenia and Georgia is timely given high smoking and secondhand smoke exposure (SHSe) rates and recent national smoke-free policy implementation. This study examined theoretical predictors (e.g. motives, barriers) of SFH status, and among those without SFHs, past 3-month SFH attempts and intent to establish SFHs in the next 3 months.
Methods
Multilevel logistic regression analyzed these outcomes using 2022 survey data from 1467 adults (31.6% past-month smokers) in Armenia (n = 762) and Georgia (n = 705). Correlates of interest included SHSe reduction behaviors and SFH motives and barriers; models controlled for country, community, age, sex, smoking status and other smokers in the home.
Results
In this sample, 53.6% had SFHs (Armenia: 39.2%; Georgia: 69.2%). Among those without SFHs, one-fourth had partial restrictions, no smokers in the home and/or recent SFH attempts; 35.5% intended to establish SFHs; and ∼70% of multiunit housing residents supported smoke-free buildings. We documented common SHSe reduction behaviors (opening windows, limiting smoking areas), SFH motives (prevent smell, protect children/nonsmokers) and barriers (smokers’ resistance). Correlates of SFHs were being from Georgia, other smokers in the home, fewer SHSe reduction behaviors, greater motives and fewer barriers. Among participants without SFHs, correlates of recent SFH attempts were other smokers in the home, greater SHSe reduction behaviors and SFH motives, and fewer barriers; correlates of SFH intentions were being female, greater SHSe reduction behaviors, greater motives, and fewer barriers.
Conclusions
SFH interventions should address motives, barriers and misperceptions regarding SHSe reduction behaviors. Moreover, smoke-free multiunit housing could have a great population impact.
Introduction
Secondhand exposure (SHSe) is linked to several adverse health outcomes (e.g. respiratory infections, cardiovascular disease, multiple cancer types, low birthweight, child morbidity and mortality) and causes >600 000 deaths (1% of deaths) annually worldwide—experienced disproportionately among women and children.1 Effective interventions for reducing SHSe include establishing smoke-free policies at work and in public places. The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC; Article 8) encourages 100% smoke-free laws applying to all indoor workplaces and public places,2 which has prompted increasing numbers of countries to adopt such smoke-free policies.1,2
Private areas, such as homes and vehicles, are prominent sources of SHSe, particularly among children and women.1,3 Additionally, children in homes that allow smoking are more likely to initiate smoking themselves, while smokers with smoke-free homes (SFHs) are more likely to quit or try quitting and consume fewer cigarettes.3 Thus, creating and maintaining SFHs is critical.3 The FCTC does not address SFHs, but public smoke-free policies have implications for SHSe in homes.4,5 Some theories and research have suggested that public smoking restrictions may displace smoking to private places, thus increasing SHSe at home.6,7 However, a preponderance of research suggests that public smoking restrictions lead to increases in voluntary restrictions in private settings like homes.4,5,8
Although some home environments can be protected through government policies, such as those mandated for conventional public housing in the USA, or by voluntary policies established in multiunit housing, SFHs are primarily voluntarily implemented by household members. Thus, understanding what may influence individuals to implement SFHs is crucial.
Health behavior theories, such as Social Cognitive Theory, underscore the importance of cognitive and environmental determinants of behavior.9 For example, one’s outcome expectancies play a crucial role in shaping behavior.9 In the case of SFHs, whether one implements an SFH—or the extent to which they have tried or intend to—likely depends on the extent to which they perceive the consequences of SHSe in the home to be harmful or of implementing SFH rules to reduce harm or have benefits (i.e. motives).10–12 In addition, outcome expectancies might include the perceived difficulty of a behavior—and whether one believes they can navigate related challenges (i.e. self-efficacy). In terms of SFHs, greater perceived barriers to establishing and maintaining an SFH likely reduce the odds of doing so, while greater perceived barriers to smoking in the home may reduce cigarettes smoked or promote quit attempts among smokers.12–14 Another outcome expectancy relates to misperceptions regarding the benefits of behaviors (e.g. perceived harm reduction) that are shown to lack benefit. Thus, it is critical to dispel myths about the effectiveness of behaviors to reduce SHSe (e.g. running a fan, opening a window, restricting smoking to certain sections of the home)12,14 as such misperceptions may reduce the perceived importance of SFHs.9
Addressing SHSe in the home is particularly important in settings where the smoking prevalence is high, such as in many low- and middle-income countries (LMICs), which are disproportionately impacted by tobacco- and SHSe-related diseases and deaths.1 Armenia and Georgia represent LMICs where tobacco use and SHSe are especially prominent. Smoking rates among men are among the top 10 highest in men globally (56.1% and 49.5%, respectively), but much lower (2.6% and 8.5%) among women.15,16 Moreover, SHSe rates in Armenia and Georgia are concerning—with estimates of past-month SHSe of 74.2% (79.5% in Armenia, 68.9% in Georgia) and daily SHSe of 24.4%—and SHSe rates are high even where smoking is prohibited.17,18 Although Armenia and Georgia ratified the FCTC in 2004 and 2006, respectively, progress in advancing tobacco control, including smoke-free policy, has lagged. However, both countries have made substantial advances in implementing public smoke-free policies, effective in Georgia since 2018 and in Armenia since 2022. Despite this progress, 2018 data indicated that smoking is allowed in >75% of homes in Armenia and ∼50% of homes in Georgia.18 With the recent implementation of national smoke-free policies, understanding theoretical factors (e.g. outcome expectancies, perceived barriers) related to implementing SFHs is crucial for deterring potential displacement of smoking behaviors to private settings and capitalizing on a critical period for promoting SFHs.4,5
Despite the rich literature regarding the impact of SFHs, there has been less research examining theoretical predictors of SFH adoption or interventions to promote SFHs,11,19–31 particularly among households in LMICs14,24,26 or during the pivotal time when national smoke-free policies are being implemented—and potentially shifting societal norms and raising awareness of SHSe-related harms.4,5 This study examined the nature of smoking restrictions in the home, recent attempts to implement SFH restrictions and intent to establish SFHs among adults in Armenia and Georgia, as well as theoretical predictors (e.g. outcome expectancies, perceived barriers) of SFH status and related factors.
Methods
Study overview
This study (launched in Fall 2018) used a matched-pairs community randomized controlled trial involving 28 communities (i.e. municipalities) in Armenia and Georgia to examine the effectiveness of local coalitions in promoting smoke-free air and reducing SHSe.31 The Institutional Review Boards of Emory University (#IRB00097093), the National Academy of Sciences of the Republic of Armenia (#IRB00004079), the American University of Armenia (#AUA-2017-013) and the National Center for Disease Control and Public Health of Georgia (#IRB00002150) approved this study.
Data collection
In each of the 28 communities (intervention and control), we conducted population-level surveys at baseline in October-November 2018 and at follow-up in May-June 2022. Current analyses focused on the 2022 survey data. Sampling strategies were different across countries because of the availability of household data in Armenia (but not Georgia) and the utility of ‘clusters’ (i.e. geographically defined areas of 150 households) in Georgia (but not Armenia). In both countries, we obtained census data for households within the municipality limits, then used the KISH method32 to identify target participants (i.e. ages 18–64) in each household to reach target recruitment (n = 50/city).33,34
In Armenia, addresses in each city were randomly ordered (using a random number generator); assessments began at the beginning of the list and continued until recruitment targets were reached. In 2022, 1140 households were visited; of the 890 (78.1%) eligible, 756 (86.1%) participated. In Georgia, 5 clusters per city were identified, then 15 households per cluster were selected using a random walking method.35 In 2022, 916 households were visited; of the 839 (91.6%) eligible, 705 (84.0%) participated. All participants provided informed consent before participating in this study.
Measures
Supplementary table S1 provides details on each measure.
Primary outcomes
To assess SFH restrictions, participants were asked, ‘Which of the following statements best describes the smoking rules in your home: allowed, generally not allowed with certain exceptions, never allowed, or there are no rules about smoking?’36,37 We also asked those with at least some SFH restrictions, ‘Does this rule also ban the use of: e-cigarettes? heated tobacco products like IQOS? marijuana?’ We also asked, ‘In what room or rooms is smoking allowed? Family/living room; Kitchen; Bathroom(s); Participant’s bedroom; Other adult’s bedroom(s); Children’s bedroom(s); Balcony or garden; or Staircases’ (response options: allowed, not allowed, not applicable).10–12,14
Among those without a complete SFH, we assessed recent attempts to establish an SFH by asking, ‘In the last 3 months, has anyone tried to establish a smoke-free rule in your current home?’ We also assessed readiness to establish an SFH by asking, ‘Are you thinking about making a rule that your home is smoke-free within the: next 6 months? next 30 days?’ and ‘In the next year, how likely are you to implement a rule in your home banning—or continuing to ban—the indoor use of: cigarettes? e-cigarettes? heated tobacco products like IQOS?’ (response options: 1 = not at all to 7 = extremely).
Primary correlates of interest
To assess SHSe reduction strategies, participants were instructed, ‘To reduce secondhand smoke in your home, please indicate how often you or any smoker have done the following in your home’. They responded to 11 items (e.g. ‘smoked near a running fan’; a complete list is given in table 3; response options: 1 = never to 5 = almost always [or not applicable]).10–12,14
Table 3.
Recent attempts to establish an SFH, intentions to establish an SFH, strategies used to reduce SHSe in the home, motives for SFH and barriers to implementing SFH by SFH status (complete vs. no/partial ban) and by whether smokers reside in the home among those with no/partial ban
| SFH status |
No/partial ban |
||||||
|---|---|---|---|---|---|---|---|
|
Total
N = 1467 (100%) |
Complete ban
N = 787 (53.6%) |
No/partial ban
N = 680 (46.4%) |
Smokers in the home
a
N = 508 (74.7%) |
No smokers in the home
N = 172 (25.3%) |
|||
| Variables | M (SD) or N (%) | M (SD) or N (%) | M (SD) or N (%) | P | M (SD) or N (%) | M (SD) or N (%) | P |
| Attempted to establish SFH, past 3 months, N (%) | − | − | 164 (24.4) | − | 130 (25.8) | 34 (20.1) | 0.134 |
| Readiness for SFH, N (%) | |||||||
| Next 6 months | − | − | 271 (43.1) | − | 189 (40.0) | 82 (52.6) | 0.006 |
| Next 30 days | − | − | 224 (35.5) | − | 155 (32.4) | 69 (45.4) | 0.003 |
| Likely in the next year to establish SFH including… M (SD) b | |||||||
| Cigarettes | 4.97 (2.55) | 6.00 (2.02) | 3.77 (2.58) | <0.001 | 3.56 (2.54) | 4.41 (2.61) | <0.001 |
| E-cigarettes | 4.89 (2.64) | 5.66 (2.34) | 3.99 (2.69) | <0.001 | 3.84 (2.68) | 4.44 (2.68) | 0.011 |
| Heated tobacco products | 4.93 (2.64) | 5.64 (2.36) | 4.11 (2.70) | <0.001 | 3.95 (2.70) | 4.58 (2.66) | 0.009 |
| Marijuana | 5.33 (2.57) | 5.70 (2.34) | 4.89 (2.76) | <0.001 | 4.92 (2.76) | 4.80 (2.76) | 0.637 |
| Strategies used to reduce SHSe in the home, M (SD) c | |||||||
| Opened the window to let the smoke escape | 4.24 (1.39) | 3.75 (1.72) | 4.53 (1.04) | <0.001 | 4.56 (0.99) | 4.41 (1.23) | 0.141 |
| Left the room to have a cigarette | 3.68 (1.60) | 3.94 (1.70) | 3.49 (1.49) | <0.001 | 3.42 (1.45) | 3.74 (1.62) | 0.038 |
| Talked about making home smoke-free | 3.22 (1.68) | 3.49 (1.68) | 2.98 (1.64) | <0.001 | 2.93 (1.61) | 3.20 (1.71) | 0.098 |
| Only smoked in certain rooms | 2.98 (1.83) | 2.22 (1.80) | 3.42 (1.70) | <0.001 | 3.32 (1.69) | 3.82 (1.71) | 0.005 |
| Reduced number of cigarettes smoked inside the home | 2.72 (1.65) | 2.66 (1.83) | 2.75 (1.54) | 0.439 | 2.60 (1.47) | 3.45 (1.68) | <0.001 |
| Only smoked indoors when no one is home | 2.41 (1.56) | 1.88 (1.51) | 2.75 (1.50) | <0.001 | 2.81 (1.48) | 2.47 (1.60) | 0.050 |
| Only smoked indoors when the children were gone | 2.37 (1.64) | 1.79 (1.50) | 2.76 (1.61) | <0.001 | 2.76 (1.57) | 2.77 (1.78) | 0.976 |
| Used an air freshener to get rid of the smoke or smell | 2.23 (1.62) | 1.98 (1.56) | 2.42 (1.64) | <0.001 | 2.38 (1.60) | 2.60 (1.76) | 0.201 |
| Smoked near a running fan | 2.10 (1.56) | 1.81 (1.54) | 2.29 (1.54) | <0.001 | 2.20 (1.46) | 2.65 (1.81) | 0.009 |
| Used nicotine replacement therapy like nicotine gum or patch | 1.25 (0.83) | 1.26 (0.87) | 1.25 (0.80) | 0.874 | 1.21 (0.74) | 1.39 (1.01) | 0.032 |
| SHS reduction behaviors index score (average rating) | 2.70 (1.08) | 2.42 (1.31) | 2.88 (0.87) | <0.001 | 2.82 (0.81) | 3.19 (1.11) | 0.004 |
| Motives for SFH, M (SD) c | |||||||
| Keep the home smelling fresher and cleaner | 4.73 (0.77) | 4.86 (0.50) | 4.57 (0.98) | <0.001 | 4.51 (1.03) | 4.75 (0.78) | 0.007 |
| Keep everyone’s clothes from smelling like cigarettes | 4.65 (0.81) | 4.77 (0.64) | 4.52 (0.95) | <0.001 | 4.47 (1.00) | 4.66 (0.76) | 0.023 |
| Protect children from SHS, which can make children sick | 4.65 (0.88) | 4.84 (0.59) | 4.43 (1.09) | <0.001 | 4.34 (1.15) | 4.68 (0.84) | 0.001 |
| Prevent bothering children’s/nonsmokers’ eyes, throat, lungs | 4.53 (0.95) | 4.73 (0.67) | 4.29 (1.16) | <0.001 | 4.19 (1.22) | 4.58 (0.89) | <0.001 |
| Set good example; keep children/teenagers from starting to smoke | 4.49 (1.04) | 4.69 (0.77) | 4.24 (1.24) | <0.001 | 4.13 (1.30) | 4.58 (0.99) | <0.001 |
| Reduce child risk of bronchitis, ear infections, worsening asthma in children | 4.44 (1.04) | 4.69 (0.74) | 4.15 (1.25) | <0.001 | 4.03 (1.30) | 4.50 (1.02) | <0.001 |
| Reduce nonsmokers’ risk of heart disease and cancer | 4.41 (1.07) | 4.66 (0.79) | 4.12 (1.26) | <0.001 | 4.02 (1.31) | 4.43 (1.04) | <0.001 |
| Reduce amount smokers smoke | 4.21 (1.29) | 4.57 (0.93) | 3.79 (1.51) | <0.001 | 3.68 (1.52) | 4.12 (1.43) | 0.001 |
| Keep pets healthy | 3.96 (1.41) | 4.24 (1.21) | 3.59 (1.57) | <0.001 | 3.47 (1.56) | 3.97 (1.53) | 0.003 |
| Make it easier for smokers to quit smoking | 3.72 (1.51) | 4.21 (1.22) | 3.17 (1.61) | <0.001 | 3.03 (1.58) | 3.59 (1.64) | <0.001 |
| SFH motives index score (average rating) | 4.40 (0.83) | 4.63 (0.58) | 4.08 (1.00) | <0.001 | 3.95 (1.05) | 4.46 (0.69) | <0.001 |
| Barriers to adopting SFH, M (SD) c | |||||||
| You have friends, family, or visitors who want to smoke inside | 2.72 (1.74) | 1.77 (1.31) | 3.74 (1.57) | <0.001 | 3.91 (1.48) | 3.24 (1.73) | <0.001 |
| A smoker does not want to quit smoking nowd | 2.79 (1.81) | 1.92 (1.48) | 3.57 (1.72) | <0.001 | 3.90 (1.57) | 1.93 (1.48) | <0.001 |
| A smoker does not want a band | 2.53 (1.78) | 1.64 (1.30) | 3.35 (1.76) | <0.001 | 3.60 (1.68) | 2.31 (1.73) | <0.001 |
| A smoker may have a hard time breaking habit of smoking insided | 2.47 (1.73) | 1.57 (1.20) | 3.32 (1.73) | <0.001 | 3.54 (1.68) | 2.31 (1.59) | <0.001 |
| A smoker would probably ignore rulesd | 2.37 (1.72) | 1.47 (1.11) | 3.21 (1.76) | <0.001 | 3.41 (1.72) | 2.24 (1.66) | <0.001 |
| Difficult to find a place to smoke outside in bad weather or at night | 2.29 (1.61) | 1.67 (1.25) | 2.92 (1.70) | <0.001 | 3.01 (1.69) | 2.67 (1.70) | 0.028 |
| Not head of household, can’t make rules | 1.98 (1.59) | 1.73 (1.39) | 2.24 (1.73) | <0.001 | 2.31 (1.74) | 2.05 (1.67) | 0.104 |
| No good place to smoke outside (e.g. apartment with no porch/yard) | 1.64 (1.29) | 1.45 (1.09) | 1.84 (1.45) | <0.001 | 1.84 (1.46) | 1.84 (1.42) | 0.977 |
| A smoker can’t go outside to smoke because of childrend | 1.52 (1.18) | 1.37 (0.99) | 1.67 (1.33) | <0.001 | 1.71 (1.38) | 1.48 (1.08) | 0.140 |
| SFH barriers index score (average rating) | 1.90 (1.02) | 1.35 (0.75) | 2.45 (0.97) | <0.001 | 2.57 (0.94) | 1.84 (0.87) | <0.001 |
Notes: N = number, M = mean, SD = standard deviation. P values based on t-tests and one-way analysis if variance for continuous variables and chi-square tests for categorical variables.
Participant reports current cigarette use or other smokers in the home.
On a scale of 1 = not at all likely to 7 = extremely likely.
All on a scale of 1 = not at all to 5 = very much; n/a; Cronbach’s alpha for SHSe reduction strategies, motives for SF home rules, and barriers to adopting a SF home were 0.875, 0.925, and 0.891, respectively.
Smoker in the home (you or someone else).
To assess SFH motives, participants were also instructed, ‘People who have made their home smoke-free may have done so for many reasons. For those who haven’t made their home smoke-free, different reasons may be more important than others for considering it. Please indicate the extent to which each item below represents a reason that you have made your home smoke-free or would consider making your home smoke-free. Smoke-free homes help…’ Participants responded to 10 items [e.g. ‘keep the home smelling fresher and cleaner’; a complete list is given in table 3; response options: 1 = not at all to 5 = very much (or not applicable)].10–12,14
To assess SFH barriers, participants were instructed, ‘People who have made their home smoke-free may have faced challenges in doing so or in keeping them enforced. For those who haven’t made their home smoke-free, there could be challenges that make it difficult to consider or do. Please indicate the extent to which each of the items below represents a challenge you’ve faced or could face in making your home smoke-free’. Participants responded to nine items [e.g. ‘you have friends, family, or visitors who want to smoke inside’; the complete list is given in table 3; response options: 1 = not at all to 5 = very much (or not applicable)].10–12,14
Covariates and descriptors
Current analyses included the following sociodemographics: age, sex, education level, employment status, marital status, housing type (single unit/detached house, townhome/duplex, apartment/condo/multiunit complex, other), and household composition.
We assessed tobacco use characteristics, specifically the number of days participants smoked cigarettes in the past 30 days, and among past-month smokers, cigarettes smoked per day, importance and confidence in quitting (0 = not at all to 10 = extremely, respectively), past-year quit attempts (any vs. no quit attempts) and readiness to quit (i.e. in the next 30 days, in the next 6 months, never).
Smoking restrictions in household vehicles were assessed using measures similar to those assessing SFH status (i.e. level of restrictions, whether restrictions covered e-cigarettes, etc.).36,37
Among those living in multiunit housing, we asked, ‘Can you sometimes smell tobacco smoke from another apartment or unit in your own unit?’; ‘Would you like to live in a smoke-free building where no one is allowed to smoke inside the building, except for inside their own apartment or unit?’; ‘Would you like to live in a smoke-free building where no one is allowed to smoke inside the building at all, including inside their own apartment or unit?’; and ‘Would you want to move if your building became smoke-free?’.
We also assessed SHSe by asking, ‘In the past 30 days, on how many days did you breathe the smoke from someone else’s smoking?’36,37 To assess smoking in the home and car, we asked, ‘In the past 30 days, on how many days did you breathe the smoke from someone smoking tobacco products: in your home? in your car?’36,37 Additionally, we asked, ‘Who are the primary sources of secondhand smoke you inhale? (Check up to 3.): Spouse/partner/significant other; Parents; Siblings; Children; Extended family; Friends; People at work; Other’.18
Data analysis
Descriptive analyses were conducted to characterize participants. Then, bivariate analyses (chi-square tests for categorical variables, t-tests and one-way analysis of variance for continuous variables) were used to examine differences in correlates of interest between (i) those with vs. without complete SFHs and (ii) among those without SFHs, those with vs. without smokers in the home.
Next, we conducted multilevel logistic regression analyses (accounting for clustering within communities) to identify correlates of (i) complete SFH vs. no/partial restrictions (referent group) and (ii) among those without SFHs: (a) attempts to establish an SFH in the past 3 months and (b) readiness to establish an SFH in the next 30 days. Models included correlates of interest (SHSe reduction behaviors, SFH motives and barriers), as well as sociodemographics, current smoking status and other smokers in the home. Analyses were conducted in SPSS v.27, and alpha was set at 0.05.
Results
SFH characteristics
In this sample (avg. age = 42.92, 48.6% male), 53.6% had complete SFHs (39.2% in Armenia; 69.2% in Georgia); additionally, 19.3% had partial SFH restrictions, and 27.1% had no restrictions (table 1). Among those with any restrictions, almost all (87.9–89.7%) included e-cigarettes, heated tobacco products and marijuana in their restrictions (table 2). The spaces/rooms in which smoking was most commonly allowed included balconies/gardens (62.5%), staircases (54.1%), and children’s bedrooms (45.8%). Notably, >50% of those who reported having SFHs indicated that smoking occurred within balconies/gardens or staircases, and roughly one-third indicated other rooms in the home where smoking may occur. Among vehicle owners, 46.3% reported complete car restrictions, 14.5% partial and 39.2% no restrictions; >80% of those with at least some vehicle restrictions also applied them to e-cigarettes, heated tobacco products and marijuana.
Table 1.
Participant characteristics by SFH status (complete vs. no/partial ban) and by whether smokers reside in the home among those with no/partial ban
| SFH status |
Among those with no/partial ban |
||||||
|---|---|---|---|---|---|---|---|
|
Total
N = 1467 (100%) |
Complete ban
N = 787 (53.6%) |
No/partial ban
N = 680 (46.4%) |
Smokers in the home
a
N = 508 (74.7%) |
No smokers in the home
N = 172 (25.3%) |
|||
| Variable | M (SD) or N (%) | M (SD) or N (%) | M (SD) or N (%) | P | M (SD) or N (%) | M (SD) or N (%) | P |
| Sociodemographics | |||||||
| Armenia, N (%) | 763 (52.0) | 299 (38.0) | 464 (68.2) | <0.001 | 346 (68.1) | 118 (68.6) | 0.904 |
| Age, M (SD) | 42.92 (13.55) | 43.14 (14.02) | 42.67 (13.00) | 0.505 | 42.01 (12.79) | 44.62 (13.43) | 0.023 |
| Male, N (%) | 713 (48.6) | 364 (46.3) | 349 (51.3) | 0.053 | 292 (57.5) | 57 (33.1) | <0.001 |
| High school or more, N (%) | 1073 (73.1) | 570 (72.4) | 503 (74.0) | 0.506 | 376 (74.0) | 127 (73.8) | 0.963 |
| Employed, N (%) | 899 (61.3) | 509 (64.7) | 390 (57.4) | 0.004 | 288 (56.7) | 102 (59.3) | 0.550 |
| Married/living with partner, N (%) | 976 (66.5) | 531 (67.5) | 445 (65.4) | 0.658 | 342 (67.3) | 103 (59.9) | 0.190 |
| Lives in multiunit housing (e.g. apartment) | 733 (50.0) | 357 (45.4) | 376 (55.3) | <0.001 | 277 (54.5) | 99 (57.6) | 0.490 |
| Household composition, N (%) | |||||||
| Other smokers | 585 (39.9) | 251 (31.9) | 334 (49.1) | <0.001 | 334 (65.7) | − | − |
| Spouse/partner | 913 (62.2) | 500 (63.5) | 413 (60.7) | 0.270 | 328 (64.6) | 85 (49.4) | <0.001 |
| Children <18 years old | 724 (49.4) | 393 (49.9) | 331 (48.7) | 0.630 | 256 (50.4) | 75 (43.6) | 0.124 |
| Parents | 553 (37.7) | 291 (37.0) | 262 (38.5) | 0.540 | 210 (41.3) | 52 (30.2) | 0.010 |
| Siblings | 222 (15.1) | 115 (14.6) | 107 (15.7) | 0.550 | 86 (16.9) | 21 (12.2) | 0.142 |
| Extended family | 139 (9.5) | 73 (9.3) | 66 (9.7) | 0.779 | 58 (11.4) | 8 (4.7) | 0.010 |
| No one else | 6 (0.4) | 1 (0.1) | 5 (0.7) | 0.102 | 3 (0.6) | 2 (1.2) | 0.605 |
| Tobacco use characteristics | |||||||
| Current smoking status, N (%) | 464 (31.6) | 191 (24.3) | 273 (40.1) | <0.001 | 273 (53.7) | − | − |
| Among current smokers | |||||||
| Number of days of smoking, M (SD) | 28.57 (5.01) | 28.35 (5.34) | 28.73 (4.77) | 0.414 | 28.73 (4.77) | − | − |
| Cigarettes smoked/day, M (SD) | 20.86 (10.16) | 18.69 (9.33) | 22.40 (10.46) | <0.001 | 22.40 (10.46) | − | − |
| Importance of quitting, M (SD)b | 5.88 (3.58) | 5.92 (3.44) | 5.85 (3.69) | 0.851 | 5.85 (3.69) | − | − |
| Confidence in quitting, M (SD)b | 4.10 (3.09) | 4.19 (2.93) | 4.03 (3.21) | 0.583 | 4.03 (3.21) | − | − |
| Past-year quit attempt, N (%) | 167 (36.5) | 70 (37.0) | 97 (36.1) | 0.831 | 97 (36.1) | − | − |
| Readiness to quit, next 30 days, N (%) | 60 (13.8) | 37 (20.2) | 23 (9.2) | 0.001 | 23 (9.2) | − | − |
Notes: N = number, M = mean, SD = standard deviation. P values based on t-tests and one-way analysis of variance for continuous variables and chi-square tests for categorical variables.
Participant reports current cigarette use or other smokers in the home.
On a scale of 0 = not at all to 10 = extremely.
Table 2.
SHSe, rules in private settings, and related factors by SFH status (complete vs. no/partial ban) and by whether smokers reside in the home among those with no/partial ban
| SFH status |
Among those with no/partial ban |
||||||
|---|---|---|---|---|---|---|---|
|
Total
N = 1467 (100%) |
Complete ban
N = 787 (53.6%) |
No/partial ban
N = 680 (46.4%) |
Smokers in the home
a
N = 508 (74.7%) |
No smokers in the home
N = 172 (25.3%) |
|||
| Variable | M (SD) or N (%) | M (SD) or N (%) | M (SD) or N (%) | P | M (SD) or N (%) | M (SD) or N (%) | P |
| SHSe b | |||||||
| Any SHSe, past 30 days, N (%) | |||||||
| Overall | 1007 (69.2) | 435 (55.6) | 572 (85.0) | <0.001 | 461 (91.5) | 111 (65.7) | <0.001 |
| In the home | 465 (32.0) | 28 (3.6) | 437 (65.5) | <0.001 | 372 (75.0) | 65 (38.0) | <0.001 |
| In the car | 303 (36.5) | 92 (21.2) | 211 (53.3) | <0.001 | 184 (60.9) | 27 (28.7) | <0.001 |
| Number of days of SHSe, past 30 days, M (SD) | |||||||
| Overall | 10.69 (11.85) | 5.77 (8.85) | 16.39 (12.32) | <0.001 | 19.56 (11.55) | 6.95 (9.37) | <0.001 |
| In the home | 4.80 (9.82) | 0.16 (1.52) | 10.27 (12.34) | <0.001 | 13.03 (12.85) | 2.28 (5.40) | <0.001 |
| In the car | 4.58 (8.78) | 2.15 (6.21) | 7.24 (10.27) | <0.001 | 8.70 (10.87) | 2.57 (6.06) | <0.001 |
| Primary sources of SHS, N (%) | |||||||
| Friends | 776 (52.9) | 378 (48.0) | 398 (58.5) | <0.001 | 307 (60.4) | 91 (52.9) | 0.083 |
| People at work | 360 (24.5) | 197 (25.0) | 163 (24.0) | 0.638 | 125 (24.6) | 38 (22.1) | 0.505 |
| Spouse/partner/significant other | 239 (16.3) | 88 (11.2) | 151 (22.2) | <0.001 | 139 (27.4) | 12 (7.0) | <0.001 |
| Extended family | 112 (7.6) | 40 (5.1) | 72 (10.6) | <0.001 | 54 (10.6) | 18 (10.5) | 0.952 |
| Siblings | 96 (6.5) | 27 (3.4) | 69 (10.1) | <0.001 | 50 (9.8) | 19 (11.0) | 0.651 |
| Children | 96 (6.5) | 30 (3.8) | 66 (9.7) | <0.001 | 58 (11.4) | 8 (4.7) | 0.010 |
| Parents | 95 (6.5) | 27 (3.4) | 68 (10.0) | <0.001 | 60 (11.8) | 8 (4.7) | 0.007 |
| Home smoking rules, N (%) | <0.001 | <0.001 | |||||
| Allowed/no rules | 397 (27.1) | − | 397 (58.4) | 322 (63.4) | 75 (43.6) | ||
| Partial ban | 283 (19.3) | − | 283 (41.6) | 186 (36.6) | 97 (56.4) | ||
| Complete ban | 787 (53.6) | 787 (100.0) | − | − | − | ||
| Among those with at least some rules: rules cover, N (%) | |||||||
| E-cigarettes | 941 (87.9) | 736 (93.5) | 205 (72.4) | <0.001 | 137 (73.7) | 68 (70.1) | 0.526 |
| Heated tobacco products | 942 (88.0) | 738 (93.8) | 204 (72.1) | <0.001 | 137 (73.7) | 67 (69.1) | 0.415 |
| Marijuana | 960 (89.7) | 752 (95.6) | 208 (73.5) | <0.001 | 139 (74.7) | 69 (71.1) | 0.515 |
| Rooms in which smoking allowed, N (%)c | |||||||
| Family/living room | 436 (41.2) | 291 (37.5) | 145 (51.4) | <0.001 | 95 (51.4) | 50 (51.5) | 0.975 |
| Kitchen | 439 (41.5) | 296 (38.1) | 143 (50.9) | <0.001 | 95 (51.6) | 48 (49.5) | 0.732 |
| Bathroom(s) | 455 (43.0) | 297 (38.2) | 158 (56.2) | <0.001 | 104 (56.5) | 54 (55.7) | 0.891 |
| Participant’s bedroom | 453 (42.8) | 294 (37.9) | 159 (56.4) | <0.001 | 107 (57.8) | 52 (53.6) | 0.496 |
| Other adult’s bedroom(s) | 449 (43.1) | 286 (37.4) | 163 (59.1) | <0.001 | 114 (62.6) | 49 (52.1) | 0.092 |
| Children’s bedroom(s) | 418 (45.8) | 268 (29.4) | 150 (65.5) | <0.001 | 104 (68.0) | 46 (60.5) | 0.264 |
| Balcony or garden | 644 (62.5) | 520 (68.8) | 124 (45.3) | <0.001 | 73 (40.3) | 51 (54.8) | 0.022 |
| Staircases | 513 (54.1) | 425 (59.5) | 88 (37.4) | <0.001 | 59 (38.1) | 29 (36.3) | 0.785 |
| Car smoking rules, N (%) | <0.001 | <0.001 | |||||
| Allowed/no rules | 321 (39.2) | 88 (19.9) | 233 (62.0) | 203 (68.8) | 30 (37.0) | ||
| Partial ban | 119 (14.5) | 57 (12.9) | 62 (16.5) | 48 (16.3) | 14 (17.3) | ||
| Complete ban | 379 (46.3) | 298 (67.3) | 81 (21.5) | 44 (14.9) | 37 (45.7) | ||
| Don’t own a car | 642 (43.9) | 341 (43.5) | 301 (44.5) | − | 210 (41.6) | 91 (52.9) | − |
| Among those with at least some rules: rules cover, N (%) | |||||||
| E-cigarettes | 413 (82.9) | 313 (88.2) | 100 (69.9) | <0.001 | 59 (64.1) | 41 (80.4) | 0.042 |
| Heated tobacco products | 416 (83.5) | 317 (89.3) | 99 (69.2) | <0.001 | 60 (65.2) | 39 (76.5) | 0.163 |
| Marijuana | 407 (81.7) | 306 (86.2) | 101 (70.6) | <0.001 | 62 (67.4) | 39 (76.5) | 0.254 |
| Among those in multiunit housing, N (%) | |||||||
| Can smell smoke from another apartment/unit | 160 (22.4) | 69 (19.4) | 91 (25.1) | 0.067 | 61 (22.9) | 30 (31.3) | 0.107 |
| Would like smoke-free building, except in units | 505 (70.7) | 274 (79.2) | 231 (62.8) | <0.001 | 158 (58.1) | 73 (76.0) | 0.002 |
| Would like smoke-free building, including in units | 486 (68.2) | 277 (80.3) | 209 (56.8) | <0.001 | 135 (49.6) | 74 (77.1) | <0.001 |
| Would want to move if building became smoke-free | 122 (17.1) | 43 (12.4) | 79 (21.5) | 0.001 | 71 (26.4) | 8 (8.2) | <0.001 |
Notes: N = number, M = mean, SD = standard deviation. P values based on t-tests and one-way analysis of variance for continuous variables and chi-square tests for categorical variables.
Participant reports current cigarette use or other smokers in the home.
Reports breathing secondhand smoke.
Excluding those for whom this setting is not applicable.
Additionally, 22.4% of participants who lived in multiunit housing indicated that they could smell smoke from another unit, and the majority reported that they would like to live in a smoke-free building that either did or did not include individual units (68.2% and 70.7%, respectively). Only 17.1% reported that they would move if the building became smoke-free.
Common SHSe reduction behaviors were opening windows, limiting smoking to certain rooms, and discussing SFH rules (table 3). Highly endorsed motives were to prevent smell, protect children and nonsmokers, and set an example for children. Smokers’ resistance to SFHs was the major barrier.
Correlates of SFHs
In bivariate analyses, those with complete SFHs were more likely from Georgia (P < 0.001), employed (P = 0.004), not living in multiunit housing (P < 0.001), living without other smokers in the home (P < 0.001) and nonsmokers (P < 0.001; table 1). Among current smokers, those with complete SFHs smoked fewer cigarettes per day (P < 0.001) and were more likely to be ready to quit in the next 30 days (P = 0.001). Those with complete SFHs were less likely to experience past-month SHSe overall and in the home and car, and were more likely to apply their restrictions to e-cigarettes, heated tobacco products, marijuana, and the broad range of spaces/rooms within the home, to have complete restrictions in their vehicles, and to support smoke-free multiunit housing policies (P’s < 0.001; table 2). Bivariate analyses also indicated that those with complete SFHs reported fewer SHSe reduction behaviors, greater motives and fewer barriers (table 3). Multilevel binary logistic regression analyses (table 4) indicated that correlates of SFHs included fewer SHSe reduction behaviors [adjusted odds ratio (aOR) = 0.66, 95% confidence interval (CI): 0.53–0.82; P < 0.001], greater motives (aOR = 2.47, 95% CI: 1.97–3.09; P < 0.001) and fewer barriers (aOR = 0.28, 95% CI: 0.28–0.33; P < 0.001), as well as being from Georgia (aOR = 3.83, 95% CI: 2.02–7.25, P < 0.001) and not having other smokers in the home (aOR = 0.67, 95% CI: 0.50–0.91, P = 0.006).
Table 4.
Multilevel logistic regression models examining correlates of having a complete SFH among all participants, and of past 3-month attempts to establish an SFH and readiness to implement an SFH in the next 3 months among participants without an SFH
| Among participants without complete SFH |
|||||||||
|---|---|---|---|---|---|---|---|---|---|
| Complete SFH rules |
Prior attempt to implement SFH, past 3 months |
Readiness to implement SFH, in the next 30 days |
|||||||
| Variables | aOR | 95% CI | P | aOR | 95% CI | P | aOR | 95% CI | P |
| Intercept | 0.94 | 0.25–3.60 | 0.927 | 0.04 | 0.01–0.24 | 0.001 | 0.04 | 0.01–0.26 | 0.001 |
| Sociodemographics | |||||||||
| Georgia (ref: Armenia) | 3.83 | 2.02–7.25 | <0.001 | 0.49 | 0.20–1.04 | 0.063 | 0.43 | 0.18–1.04 | 0.062 |
| Age | 1.00 | 0.99–1.10 | 0.788 | 1.00 | 0.99–1.02 | 0.874 | 1.01 | 0.99–1.02 | 0.354 |
| Female (ref: male) | 0.92 | 0.64–1.33 | 0.667 | 0.78 | 0.43–1.39 | 0.392 | 2.03 | 1.11–3.70 | 0.021 |
| Current smoker (ref: no) | 0.69 | 0.46–1.03 | 0.066 | 0.89 | 0.48–1.63 | 0.702 | 0.54 | 0.28–1.02 | 0.056 |
| Other smokers in home (ref: no) | 0.67 | 0.50–0.91 | 0.009 | 2.19 | 1.39–3.46 | 0.001 | 1.39 | 0.88–2.21 | 0.161 |
| SFH-related factors | |||||||||
| SHS reduction behavior index | 0.66 | 0.53–0.82 | <0.001 | 1.72 | 1.28–2.33 | <0.001 | 1.86 | 1.37–2.53 | <0.001 |
| SFH motives index | 2.47 | 1.97–3.09 | <0.001 | 1.52 | 1.10–2.10 | 0.012 | 1.85 | 1.33–2.59 | <0.001 |
| SFH barriers index | 0.28 | 0.24–0.33 | <0.001 | 0.62 | 0.49–0.78 | <0.001 | 0.47 | 0.36–0.60 | <0.001 |
Note: Bold indicates significant findings.
Subanalysis among those without SFHs
Among those without SFHs, 25.3% had no smokers in the home, 24.4% reported past 3-month SFH attempts, and 35.5% reported intending to establish SFHs in the next 30 days (table 3). Those without smokers in the home reported lower SHSe (any and number of days overall and in the home and car), were more likely to have smoke-free vehicles, were more likely to have favorable attitudes to smoke-free multiunit housing (table 2), reported greater readiness for SFHs in the next 6 months (P = 0.006) and 30 days (P = 0.003) and reported greater likelihood of establishing an SFH including cigarettes (P < 0.001), e-cigarettes (P = 0.011) and heated tobacco products (P = 0.009; table 3). They were also more likely to engage in a number of SHSe reduction behaviors, reported higher average motives for SFHs and fewer barriers (see table 3).
Multilevel regression analyses (table 4) indicated that correlates of recent SFH attempts among participants without SFHs were greater SHSe reduction behaviors (aOR = 1.72, 95% CI: 1.28–2.33, P < 0.001) and SFH motives (aOR = 1.52, 95% CI: 1.10–2.10; P = 0.012), and fewer barriers (aOR = 0.62, 95% CI: 0.49–0.78, P < 0.001), as well as having other smokers in the home (aOR = 1.29, 95% CI: 1.39–3.46, P = 0.001). Correlates of SFH intentions were greater SHSe reduction behaviors (aOR = 1.86, 95% CI: 1.37–2.53, P < 0.001), greater motives (aOR = 1.85, 95% CI: 1.33–2.59, P < 0.001) and fewer barriers (aOR = 0.47, 95% CI: 0.36–0.60, P < 0.001), as well as being female (aOR = 2.03, 95%CI: 1.11–3.70, P = 0.021).
Discussion
Current findings add to the literature by examining SFH adoption and related theoretical determinants among homes in two LMICs with high smoking prevalence and the recent implementation of national smoke-free public policies—Armenia and Georgia.15,16 The proportion of homes with SFH rules has increased from 2018 to 2022, from ∼25% to ∼40% in Armenia and ∼50% to ∼70% in Georgia.18 These differences and differential increases are likely related to the earlier implementation of the national smoke-free policy in Georgia (2018) relative to Armenia (2022) and align with research suggesting that public restrictions lead to increases in SFHs.4,5,8 These results also underscore the potential benefits of having SFHs.12–14 For example, those with SFHs were more likely to apply their restrictions to the broad range of tobacco products and spaces in the home and vehicle and were less likely to experience past-month SHSe (overall and in the home or car). Further, smokers with SFHs smoked fewer cigarettes per day and were more likely ready to quit. However, even those with SFHs failed to consistently apply them to all settings (e.g. about one-third allowed smoking in certain rooms), underscoring opportunities to strengthen existing SFH rules.
Also noteworthy, one-third of participants without SFHs had some restrictions, one-fourth tried establishing SFHs in the past 3 months, over one-third intended to establish SFHs in the next month and one-fourth of homes that allowed smoking had no smokers in the home—indicating opportunities to promote SFHs during this critical period.4,5 Additionally, while only ∼15% of those living in multiunit housing indicated that they would move if the building became smoke-free, ∼70% supported smoke-free building policies (including for individual units)—suggesting the timeliness and potential of intervening within multiunit housing.17,18 However, two important concerns related to SHSe among children must be addressed: (i) among the spaces/rooms in which smoking was most commonly allowed were children’s bedrooms (∼50% of households) and (ii) less than half of vehicle owners banned smoking in vehicles.
Additionally, theory-based factors were associated with SFH-related outcomes. Reporting greater SFH motives (e.g. prevent smell, protect children/nonsmokers, set an example for children) and fewer SFH barriers (e.g. smokers’ resistance to SFHs) was associated with having SFHs—and recent SFH attempts and intention to establish SFHs among those without SFHs. These findings align with theory9 and prior empirical findings.10–12 SHSe reduction behaviors positively correlated with allowing smoking in the home, which could reflect common misperceptions about the effectiveness of these behaviors12,14 and thus the need to correct such misperceptions, as they undermine the perceived importance of SFHs.9 However, this finding may also reflect the need/desire to exercise such reduction efforts in situations where establishing an SFH is particularly challenging. This might be likely, as reporting greater SHSe reduction behaviors was also associated with being more likely to report recent SFH attempts and intent to establish SFHs. These findings may relate to shifting social norms regarding smoking and smoke-free restrictions, as well as increased awareness of the harms of SHSe that coincide with the implementation of public smoke-free policies.4,5,8,38,39 Furthermore, having other smokers in the home was associated with not having SFHs but related to recent SFH attempts, and women were more likely to report intent to establish SFHs. These findings likely imply the importance of barriers to SFHs, such as resistance to SFHs among smokers who are predominantly men in Armenia and Georgia.
Current findings have implications for research and practice. First, intervening to promote SFHs is timely in Armenia and Georgia. Interventions to prevent or reduce SHSe in the home have been shown to be effective in various populations (e.g. those with small children,19–22,40 those from low-income backgrounds11,28–31), often address theory-based predictors of behavior change (e.g. outcome expectancies regarding the benefits of SFHs to increase motivation, skills to address barriers),11,19–31 have used various strategies (e.g. home visits, telephone counseling),11,19–31 have recruited via various settings/channels (e.g. clinical settings) and have shown potential scalability and sustainability.11,20,28–31 Thus, these approaches may lend themselves to adaptation and delivery in Armenia and Georgia. Moreover, examining the process of adaptation and implementation of evidence-based interventions may have significant implications not only for population health in these countries but also for other countries where such interventions could be adapted and disseminated.
Limitations
This sample may not represent the general adult populations of these countries; while the cities in this study account for about one-third of each country’s population, they do not include the two largest cities (Yerevan, Tbilisi), or more rural areas, which show different rates of smoking among men and women.15,16 Additionally, sampling/recruitment methods across countries differed by necessity and yielded different compositions by sex and smoking status. Finally, the cross-sectional nature and self-reported assessments limit the ability to make causal attributions or account for bias.
Conclusions
A substantial proportion of homes in Armenia and Georgia still allow SHSe among children and nonsmokers, although the proportion of SFHs has increased in both countries. Moreover, promoting SFHs is timely, as one-third of participants without complete SFHs had some type of restrictions and/or intended to establish SFHs in the near future, and one-fourth either recently tried to establish an SFH and/or had no smokers in the home. Multiunit housing also provides the potential to have high reach and impact, given that 70% of residents supported smoke-free multiunit housing. Finally, findings indicate the potential of theory-based SFH interventions, given the associations between related outcome expectancies and barriers with SFH status and indicators of potential SFH adoption.
Supplementary Material
Acknowledgements
We would like to thank our community partners for their participation in the ongoing study and its execution.
Contributor Information
Carla J Berg, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Cancer Center, George Washington University, Washington, DC, USA.
Ana Dekanosidze, Georgia National Center for Disease Control and Public Health, Tbilisi, Georgia.
Varduhi Hayrumyan, Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia.
Cassidy R LoParco, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington Cancer Center, George Washington University, Washington, DC, USA.
Arevik Torosyan, National Institute of Health named after academician S. Avdalbekyan, MOH, Yerevan, Armenia.
Lilit Grigoryan, National Institute of Health named after academician S. Avdalbekyan, MOH, Yerevan, Armenia.
Alexander Bazarchyan, National Institute of Health named after academician S. Avdalbekyan, MOH, Yerevan, Armenia.
Regine Haardörfer, Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Michelle C Kegler, Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Supplementary data
Supplementary data are available at EURPUB online.
Funding
This work was supported by the US Fogarty International Center/National Institutes of Health (NIH) (R01TW010664, MPIs: C.J.B., M.C.K.). C.J.B. was also supported by other US NIH funding, specifically from the National Cancer Institute (R01CA215155, PI: C.J.B.; R01CA239178, MPIs: C.J.B., Levine; R21CA261884, MPIs: C.J.B., Arem; R01CA278229, MPIs: C.J.B., M.C.K.; R01CA275066, MPIs: Yang, C.J.B.), the National Institute of Environmental Health Sciences/Fogarty (D43ES030927, MPIs: C.J.B., Caudle, Sturua), Fogarty (D43TW012456, MPIs: C.J.B., Paichadze, Petrosyan), and the National Institute on Drug Abuse (R01 DA054751, MPIs: C.J.B., Cavazos-Rehg).
Conflicts of interest: None declared.
Data availability
Limited data sets are available upon reasonable request.
Key points.
The proportion of smoke-free homes in Armenia and Georgia has increased in the past 4 years.
Yet, a substantial proportion of homes in these countries still allow secondhand smoke exposure among children and nonsmokers.
There is great potential to promote smoke-free homes, given the proportion with some restrictions and interest in establishing smoke-free homes.
Theory-based interventions may catalyze smoke-free home adoption during this pivotal time in these countries.
The vast majority of people living in multiunit housing supported smoke-free buildings, indicating one avenue with high potential reach and impact.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Limited data sets are available upon reasonable request.
Key points.
The proportion of smoke-free homes in Armenia and Georgia has increased in the past 4 years.
Yet, a substantial proportion of homes in these countries still allow secondhand smoke exposure among children and nonsmokers.
There is great potential to promote smoke-free homes, given the proportion with some restrictions and interest in establishing smoke-free homes.
Theory-based interventions may catalyze smoke-free home adoption during this pivotal time in these countries.
The vast majority of people living in multiunit housing supported smoke-free buildings, indicating one avenue with high potential reach and impact.