Among the disparities faced by populations in low- and middle-income countries are those
related to tobacco use and secondhand smoke exposure. Two countries particularly impacted
by tobacco use and secondhand smoke exposure are Armenia and Georgia, which represent the
11th and 6th highest smoking rates in men globally (51.5% and 55.5%, respectively).
However, smoking prevalence is much lower among women (1.8% and 7.8%). Notably, a primary
source of secondhand smoke exposure among children and most nonsmoking adults in many
low- and middle-income countries, including Armenia and Georgia, is the home. Smoke-free
homes can reduce secondhand smoke exposure, promote cessation, and possibly disrupt
initiation; however, 61.4% of households in Armenia and Georgia allow smoking in the
home. Thus, promoting smoke-free homes may be an innovative and relatively untapped
strategy for chronic disease prevention in these countries - and in other low- and
middle-income countries with high smoking rates. Research focused on implementing
evidence-based interventions offers unique opportunities to address the pressing needs in
low- and middle-income countries and to examine key barriers in the adoption, scale-up,
and sustainment of evidence-based interventions in low-resource settings. This study
builds on ongoing collaborations among George Washington University, Emory, the Georgia
National Center for Disease Control, the Armenia National Institute of Health, and the
American University of Armenia that have established: 1) a strong community-based
infrastructure for implementing public health programs using local coalitions in 14
communities, developed in our current Fogarty-funded R01; and 2) a theory-based
smoke-free homes intervention, designed to be brief and adaptable and shown to be
effective, generalizable, scalable, and cost-effective among low-income households in the
US. The current study will strategically capitalize on these partnerships with national
public health agencies, local community mobilization infrastructure, and smoke-free homes
evidence-based intervention to address the specific aims. Aim 1 involves adapting the
smoke-free homes intervention to be culturally appropriate for the Armenia and Georgia
populations, using a community-engaged approach and robust adaptation frameworks and
methods, and develop in-country capacity for intervention dissemination (via local
coalitions) and delivery (via national quitlines). Aim 2 involves examining the
effectiveness of the adapted intervention (vs. control) on smoke-free home adoption
(primary outcome) among households in Armenia and Georgia, using a type 1 hybrid
effectiveness-implementation randomized clinical trial (n=550 participants; 275/country),
with follow-up assessments at 3 and 6 months. Aim 3 will assess intervention reach,
adoption, implementation, and maintenance potential, as well as related contextual
influences, using a mixed-methods process evaluation. The research team (including
national public health agencies) will use these findings to develop a sustainability and
dissemination plan (e.g., intervention packaging for scale-up). This work will provide a
robust model for adapting and implementing this evidence-based intervention for Armenia
and Georgia, which could then be used for this intervention in other countries and/or for
other behavioral targets and evidence-based interventions in Armenia, Georgia, and
elsewhere. This work will advance the knowledge base informing strategies to reduce
tobacco-related disparities globally and the implementation and scale-out of
evidence-based interventions in low- and middle-income countries.
