An interventional study of Intervention Condition in Smoking, sponsored by Emory University. Completed at 2 sites in 2 countries. Open to participants aged 18 Years to 65 Years, including healthy volunteers. Per ClinicalTrials.gov, last updated 2023-10-17.
Sponsored by Emory University · Not applicable, Interventional, and Prevention
This is a matched-pairs community randomized controlled trial (CRCT) to examine the impact of coalitions promoting smoke-free air policies on individual secondhand smoke exposure (SHSe).
This proposal will build the capacity of Georgia (GE) and Armenia (AM) researchers to conduct high-quality mixed methods tobacco research and test the Community Coalition Action Theory (CCAT) as a framework for impacting local community-driven policy change to inform such processes for the region more broadly. Researchers from the GE National Center for Disease Control (NCDC) and AM National Institute of Health (NIH) will collaborate with Emory to execute the proposed research, train tobacco control researchers within their organizations and partnering universities, and train practitioners within local communities to build local coalitions for tobacco control policy.
Twenty-eight communities (14 per country) will participate in the population-level tobacco survey at baseline and follow-up. Within each country, 7 communities will be randomized to the intervention condition and 7 to the control condition (14 communities per condition). In the intervention communities, public health center staff will form a coalition by recruiting partner organizations from civil society and other government sectors (e.g., health care, education), conduct situational assessment, and develop and implement action plans to promote the adoption and enforcement of smoke-free policies primarily in indoor and outdoor public places (e.g., worksites, hospitality). The GE NCDC and AM NIH will establish subcontracts with the local public health centers in the randomly selected communities to provide funding for local staff to develop local coalitions and to support program activities. The 14 communities assigned as controls will participate in the population-level survey and be provided with a site-specific summary of findings but will not participate in any aspects of the intervention. Additionally, to examine potential contamination in the control communities, a follow-up interview will be conducted with public health center leaders to assess any local coalition or grassroots actions regarding tobacco control that may have naturally occurred or be influenced by coalition activity in other communities.
Public health efforts in low- and middle-income countries (LMICs) could be catalyzed by bolstering ways to optimally leverage local talents and resources, such as civil society. Developing effective models for aligning civil society and governmental public health at the local level in LMICs has the potential to impact a range of chronic diseases and risk factors, including tobacco use. Local coalitions have been a dominant strategy in tobacco control in the US, with well-documented success in establishing smoke-free policies specifically. However, this approach has not been widely leveraged or well-studied in LMICs or those with less democratic traditions than the US. Instead, in many LMICs, smoke-free policy progress is largely initiated at the national level. Parallel civil society movements at the local level may be needed to build support for and compliance with policies. Given their sociopolitical histories and high tobacco use and secondhand smoke exposure (SHSe) rates, Georgia (GE) and Armenia (AM) are two strategic settings for the proposed work. The smoking prevalence is 57.7% and 52.3% in men (6th and 11th highest in the world) and 5.7% and 1.5% in women, respectively. Moreover, previous findings indicate extremely high rates of SHSe. However, there is also documented high receptivity to public smoke-free policies despite high use rates.
In this matched-pairs community randomized controlled trial (CRCT), the impact of coalitions promoting smoke-free air policies on individual secondhand smoke exposure (SHSe) will be examined. The Emory team will lead the oversight of the research design and execution of all components of the research. This proposal will build the capacity of Georgia (GE) and Armenia (AM) researchers to conduct high-quality mixed methods tobacco research and test the Community Coalition Action Theory (CCAT) as a framework for impacting local community-driven policy change to inform such processes for the region more broadly. Researchers from the GE National Center for Disease Control (NCDC) and AM National Institute of Health (NIH) will collaborate with Emory to execute the proposed research, train tobacco control researchers within their organizations and partnering universities (Tbilisi State Medical University, American University of Armenia), and train practitioners within local communities to build local coalitions for tobacco control policy.
This study aims to:
Twenty-eight communities (14 per country) will participate in the population-level tobacco survey at baseline and follow-up. Within each country, 7 communities will be randomized to the intervention condition and 7 to the control condition (14 communities per condition). In the intervention communities, public health center staff will form a coalition by recruiting partner organizations from civil society and other government sectors (e.g., health care, education), conduct situational assessment, and develop and implement action plans to promote the adoption and enforcement of smoke-free policies in primarily in indoor and outdoor public places (e.g., worksites, hospitality). The GE NCDC and AM NIH will establish subcontracts with the local public health centers in the randomly selected communities to provide funding for local staff to develop local coalitions and to support program activities. The 14 communities assigned as controls will participate in the population-level survey and be provided with a site-specific summary of findings but will not participate in any aspects of the intervention. Additionally, to examine potential contamination in the control communities, a follow-up interview will be conducted with public health center leaders to assess any local coalition or grassroots actions regarding tobacco control that may have naturally occurred or be influenced by coalition activity in other communities.
The GE NCDC and AM NIH will conduct cross-sectional population-level surveys in Year 1 (baseline) and in Years 4/5 (follow-up) in the intervention and control communities. A multi-stage, clustered sample design will be used to select 50 participants within each municipality. The most recent census data for each country and the respective municipalities will be used to establish the sampling frame.
Community Level Inclusion Criteria:
Exclusion Criteria:
Fourteen communities will be assigned to the intervention.
Behavioral: Intervention Condition
The 14 communities assigned as controls will participate in the population-level survey and will be provided with a site-specific summary of findings but will not participate in any aspects of the intervention. To examine potential contamination in the control communities, a follow-up interview will be conducted with public health center leaders to assess any local coalition or grassroots actions regarding tobacco control that may have naturally occurred or be influenced by coalition activity in other communities.
The intervention approach will be informed by the Community Coalition Action Theory (CCAT) developed by Butterfoss and Kegler. CCAT posits that coalitions form due to a threat, opportunity, or mandate. Public health center staff will form a coalition by recruiting partner organizations from civil society and other government sectors (e.g., health care, education), conduct situational assessment, and develop and implement action plans to promote the adoption and enforcement of smoke-free policies in public indoor and and outdoor spaces.
Secondhand Smoke Exposure
The frequency of secondhand smoke (SHS) exposure in the past 30 days was assessed by asking the respondent to report the number of days they were exposed to SHS.
Time frame: Baseline, Follow-up (approximately 44 months post-baseline)
Attitude Regarding Secondhand Smoke Exposure
Attitudes regarding Secondhand Smoke Exposure (SHSe) were examined by assessing the degree to which the respondent believes that smoke causes illnesses. Participants were asked "Based on what you know or believe, does breathing other people's smoke cause serious illness in non-smokers?" Possible responses are 1 = "not at all", 2 = "a little", 3 = "somewhat", or 4 = "a lot".
Time frame: Baseline, Follow-up (approximately 44 months post-baseline)
Attitude Regarding Smoke-Free Environments
To assess attitudes regarding smoke-free environments, respondents were asked whether they think smoking should or should not be allowed in places such as workplaces, indoor areas on school grounds, outdoor events, restaurants, and bars. Participants indicated how much the supported or opposed complete cigarette smoking bans on a 4-point scale where 1 = strongly oppose and 4 = strongly support.
Time frame: Baseline, Follow-up (approximately 44 months post-baseline)
Count of Participants Agreeing With Certain Home Policies
Smoke-free home policies at baseline and follow-up were assessed by asking about rules about smoking inside of the participant's home. Possible responses included: smoking is allowed, smoking is not allowed but there are exceptions, smoking is never allowed, or there are no rules about smoking in the home.
Time frame: Baseline, Follow-up (approximately 44 months post-baseline)
Count of Participants With Certain Workplace Policies
Among participants employed in a workplace with an indoor setting, workplace policies at baseline and follow-up were measured by asking, "Which of the following best describes the indoor smoking policy where you work? Smoking is allowed anywhere, smoking is allowed only in some indoor areas, smoking is not allowed in any indoor areas, or there is no policy."
Time frame: Baseline, Follow-up (approximately 44 months post-baseline)
Enforcement of Smoke-Free Policies
Changes in enforcement of smoke-free policies in various settings will be measured by asking, "In the past 7 days, how many times have you seen someone using tobacco in a location where it is prohibited?"
Time frame: Baseline, Follow-up (approximately 44 months post-baseline)
Secondhand Smoke Exposure in Various Locations
The frequency of secondhand smoke (SHS) exposure in the past 30 days will be assessed by asking the respondent to report the number of days they were exposed to SHS in the home, in vehicles, at work, in indoor public places, and in outdoor public places. The frequency of exposures is evaluated as the number of days in the past 30 days the participant was exposed to SHS in the home, in vehicles, at work, in indoor public places, and in outdoor public places
Time frame: Baseline, Follow-up (approximately 44 months post-baseline)
Participants were from communities in Tbilisi, Georgia and Yerevan, Armenia. Community member participation began October 1, 2018 and the follow-up assessments occurred in Spring and Summer of 2022 (approximately 44 months after the start of community member participation in the baseline surveys). Follow-up assessments were completed by June 30, 2022.
| Milestone | Intervention Condition | Control Condition |
|---|---|---|
| Started | 1481 | 1443 |
| Community members who completed the baseline survey | 732 | 724 |
| Community members who completed the follow-up survey | 749 | 719 |
| Completed | 1481 | 1443 |
| Not completed | 0 | 0 |
The frequency of secondhand smoke (SHS) exposure in the past 30 days was assessed by asking the respondent to report the number of days they were exposed to SHS.
| days with SHS exposure | Intervention Condition | Control Condition |
|---|---|---|
| Baseline | 11.70 ± 12.14 | 12.08 ± 12.35 |
| Follow-up | 10.86 ± 11.77 | 10.51 ± 11.92 |
Attitudes regarding Secondhand Smoke Exposure (SHSe) were examined by assessing the degree to which the respondent believes that smoke causes illnesses. Participants were asked "Based on what you know or believe, does breathing other people's smoke cause serious illness in non-smokers?" Possible responses are 1 = "not at all", 2 = "a little", 3 = "somewhat", or 4 = "a lot".
| score on a scale | Intervention Condition | Control Condition |
|---|---|---|
| Baseline | 2.53 ± 0.70 | 2.53 ± 0.68 |
| Follow-up | 3.44 ± 0.81 | 3.37 ± 0.82 |
To assess attitudes regarding smoke-free environments, respondents were asked whether they think smoking should or should not be allowed in places such as workplaces, indoor areas on school grounds, outdoor events, restaurants, and bars. Participants indicated how much the supported or opposed complete cigarette smoking bans on a 4-point scale where 1 = strongly oppose and 4 = strongly support.
| score on a scale | Intervention Condition | Control Condition |
|---|---|---|
| Baseline - In restaurants, cafes, and cafeterias | 3.36 ± 0.88 | 3.32 ± 1.02 |
| Baseline - On the outdoor terrace of restaurants, cafes, and cafeterias | 2.39 ± 1.12 | 2.60 ± 1.21 |
| Baseline - In bars, pubs, or nightclubs | 3.05 ± 1.05 | 3.08 ± 1.17 |
| Baseline - On the outdoor terrace of bars, pubs, or nightclubs | 2.33 ± 1.14 | 2.49 ± 1.24 |
| Baseline - Indoor common areas of apartment or condominium complexes (hallways, lobbies, stairwells) | 3.26 ± 0.96 | 3.21 ± 1.05 |
| Baseline - Outdoor common areas of apartment or condominium complexes (playgrounds, park benches) | 3.10 ± 0.98 | 3.04 ± 1.07 |
| Baseline - Within individual apartment or condo units within a complex | 3.17 ± 1.00 | 3.06 ± 1.14 |
| Baseline - Private vehicles when children under age 18 are present | 3.84 ± 0.47 | 3.77 ± 0.61 |
| Baseline - Parks and beaches | 2.93 ± 1.04 | 2.91 ± 1.09 |
| Baseline - Other public outdoor areas, such as open stadiums | 2.86 ± 1.11 | 2.77 ± 1.18 |
| Follow-up - In restaurants, cafes, and cafeterias | 3.36 ± 0.98 | 3.33 ± 1.00 |
| Follow-up - On the outdoor terrace of restaurants, cafes, and cafeterias | 2.59 ± 1.15 | 2.49 ± 1.12 |
| Follow-up - In bars, pubs, or nightclubs | 3.26 ± 1.04 | 3.32 ± 1.00 |
| Follow-up - On the outdoor terrace of bars, pubs, or nightclubs | 2.59 ± 1.16 | 2.49 ± 1.12 |
| Follow-up -Indoor common areas of apartment or condominium complexes (hallways, lobbies, stairwells) | 3.24 ± 1.01 | 3.17 ± 1.04 |
| Follow-up - Outdoor common areas of apartment or condominium complexes (playgrounds, park benches) | 2.97 ± 1.10 | 2.92 ± 1.08 |
| Follow-up - Within individual apartment or condo units within a complex | 3.06 ± 1.14 | 2.96 ± 1.20 |
| Follow-up - Private vehicles when children under age 18 are present | 3.62 ± 0.79 | 3.62 ± 0.80 |
| Follow-up - Parks and beaches | 2.74 ± 1.08 | 2.64 ± 1.07 |
| Follow-up - Other public outdoor areas, such as open stadiums | 2.82 ± 1.09 | 2.68 ± 1.08 |
Smoke-free home policies at baseline and follow-up were assessed by asking about rules about smoking inside of the participant's home. Possible responses included: smoking is allowed, smoking is not allowed but there are exceptions, smoking is never allowed, or there are no rules about smoking in the home.
| Participants | Intervention Condition | Control Condition |
|---|---|---|
| Baseline — Smoking is allowed | 91 | 110 |
| Baseline — Smoking is not allowed but there are exceptions | 209 | 177 |
| Baseline — Smoking is never allowed | 298 | 263 |
| Baseline — There are no rules about smoking in the home | 131 | 172 |
| Baseline — No response | 3 | 2 |
| Follow-up — Smoking is allowed | 95 | 90 |
| Follow-up — Smoking is not allowed but there are exceptions | 147 | 136 |
| Follow-up — Smoking is never allowed | 418 | 369 |
| Follow-up — There are no rules about smoking in the home | 88 | 124 |
| Follow-up — No response | 1 | 0 |
Among participants employed in a workplace with an indoor setting, workplace policies at baseline and follow-up were measured by asking, "Which of the following best describes the indoor smoking policy where you work? Smoking is allowed anywhere, smoking is allowed only in some indoor areas, smoking is not allowed in any indoor areas, or there is no policy."
| Participants | Intervention Condition | Control Condition |
|---|---|---|
| Baseline — Smoking is allowed anywhere | 32 | 38 |
| Baseline — Smoking is allowed only in some indoor areas | 51 | 28 |
| Baseline — Smoking is not allowed in any indoor areas | 217 | 173 |
| Baseline — There is no policy | 40 | 68 |
| Follow-up — Smoking is allowed anywhere | 9 | 7 |
| Follow-up — Smoking is allowed only in some indoor areas | 46 | 42 |
| Follow-up — Smoking is not allowed in any indoor areas | 266 | 233 |
| Follow-up — There is no policy | 21 | 11 |
Changes in enforcement of smoke-free policies in various settings will be measured by asking, "In the past 7 days, how many times have you seen someone using tobacco in a location where it is prohibited?"
No measurements were reported for this outcome.
The frequency of secondhand smoke (SHS) exposure in the past 30 days will be assessed by asking the respondent to report the number of days they were exposed to SHS in the home, in vehicles, at work, in indoor public places, and in outdoor public places. The frequency of exposures is evaluated as the number of days in the past 30 days the participant was exposed to SHS in the home, in vehicles, at work, in indoor public places, and in outdoor public places
| days with SHS exposure | Intervention Condition | Control Condition |
|---|---|---|
| Baseline - Exposure in the home | 6.83 ± 11.48 | 7.18 ± 11.53 |
| Baseline - Exposure in vehicles | 3.87 ± 8.15 | 3.93 ± 8.36 |
| Baseline - Exposure in indoor work areas | 4.16 ± 8.66 | 4.44 ± 8.85 |
| Baseline - Exposure in indoor public areas | 1.74 ± 4.71 | 2.00 ± 5.17 |
| Baseline - Exposure in outdoor public areas | 5.34 ± 8.86 | 4.83 ± 8.79 |
| Follow-up - Exposure in the home | 4.88 ± 9.83 | 4.72 ± 9.83 |
| Follow-up - Exposure in vehicles | 4.43 ± 8.27 | 4.74 ± 9.27 |
| Follow-up - Exposure in indoor work areas | 2.91 ± 7.70 | 3.06 ± 7.68 |
| Follow-up - Exposure in indoor public areas | 1.66 ± 5.21 | 1.15 ± 3.89 |
| Follow-up - Exposure in outdoor public areas | 6.78 ± 9.68 | 6.49 ± 9.02 |
Collected over Information on adverse events was collected while community member participants were completing the Baseline or Follow-up survey (approximately 44 months post-baseline), which was completed within one hour on their single day of study participation.. Non-serious events are listed at a 0% frequency threshold.
| Group | Deaths | Serious | Other |
|---|---|---|---|
| Intervention Condition | 0/1,481 (0%) | 0/1,481 (0%) | 0/1,481 (0%) |
| Control Condition | 0/1,443 (0%) | 0/1,443 (0%) | 0/1,443 (0%) |
The baseline analysis population includes community members who completed the baseline assessment.
| Age, Continuous(years) | Intervention Condition | Control Condition | Total |
|---|---|---|---|
| Mean | 42.52 ± 13.71 | 44.19 ± 13.22 | 43.35 ± 13.49 |
| Sex: Female, Male(Participants) | Intervention Condition | Control Condition | Total |
|---|---|---|---|
| Female | 429 | 452 | 881 |
| Male | 303 | 272 | 575 |
| Ethnicity (NIH/OMB)(Participants) | Intervention Condition | Control Condition | Total |
|---|---|---|---|
| Hispanic or Latino | 0 | 0 | 0 |
| Not Hispanic or Latino | 732 | 724 | 1456 |
| Unknown or Not Reported | 0 | 0 | 0 |
| Race (NIH/OMB)(Participants) | Intervention Condition | Control Condition | Total |
|---|---|---|---|
| American Indian or Alaska Native | 0 | 0 | 0 |
| Asian | 0 | 0 | 0 |
| Native Hawaiian or Other Pacific Islander | 0 | 0 | 0 |
| Black or African American | 0 | 0 | 0 |
| White | 732 | 724 | 1456 |
| More than one race | 0 | 0 | 0 |
| Unknown or Not Reported | 0 | 0 | 0 |
| Region of Enrollment(Participants) | Intervention Condition | Control Condition | Total |
|---|---|---|---|
| Armenia | 351 | 354 | 705 |
| Georgia | 381 | 370 | 751 |
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Emory University