Sociocultural Barriers to Reduce Children’s Exposure to SHS in Georgia: A Technical Report

Sociocultural Barriers to Reduce Children’s Exposure to SHS in Georgia: A Technical Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Sociocultural Barriers to Reduce Children’s Exposure to SHS in Georgia: A Technical Report Nino Gamtkitsulashvili This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9193937/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite the success of Georgia’s 2017 comprehensive tobacco control legislation in public spaces, the home remains the primary setting for children’s exposure to secondhand smoke (SHS), driven by deeply rooted cultural norms and misconceptions regarding protective smoking practices. This study explores parental smoking behaviors and their underlying determinants, with a focus on how clinical cues to action during routine pediatric visits may influence the adoption of strict indoor smoking bans. Methods An exploratory qualitative study was conducted in Tbilisi, Georgia, using stratified purposive sampling to recruit 16 smoking parents of children under 18. Two semi-structured focus group discussions were held, supported by a brief demographic questionnaire adapted from the Global Adult Tobacco Survey. Data were transcribed verbatim and analyzed using qualitative content analysis with inductive coding, while descriptive severity ratings were used to contextualize perceived risk. The Health Belief Model (HBM) guided the interpretation of behavioral determinants. Findings Phase I findings (2020) reveal a widespread reliance on pseudo-protective behaviors, such as smoking near open windows, under kitchen exhaust fans, or on balconies, based on the belief that these measures eliminate risk. This sensory-based logic overlooks the persistence of thirdhand smoke (THS), a toxic residue that remains on surfaces and contributes to continued exposure. This study identifies pediatric health consultations as a critical cue to action, with parents expressing a high willingness to adopt smoke-free home rules when provided with clear, child-specific clinical guidance. Conclusion These findings suggest that interventions focusing on clinical communication strategies, including frameworks such as the 5 A’s and CEASE, may support the reduction of SHS exposure in domestic settings. Phase II (2026) is currently underway to assess the stability of these behavioral patterns over time. Preventive Medicine Epidemiology secondhand smoke (SHS) thirdhand smoke (THS) children smoke-free homes tobacco control Georgia Introduction Secondhand smoke (SHS), also called passive or environmental tobacco smoke, has been recognized as a major public health issue for decades. The 1972 U.S. Surgeon General’s report was the first to acknowledge the health dangers of involuntary tobacco smoke exposure formally. ( 1 ) Despite significant progress in tobacco control, SHS remains a major cause of preventable illness and death worldwide. The World Health Organization (WHO) estimates that SHS causes around 1.3 million early deaths globally each year, and notably, children are disproportionately affected, with nearly 40% exposed worldwide. ( 2 ) The home remains the main place of exposure, with parental smoking identified as the primary source of children’s SHS exposure. ( 3 ) According to the U.S. Department of Health and Human Services (2014), children are particularly vulnerable due to their smaller airways, developing lungs, and immature immune systems. Exposure has been clearly linked to higher risks of lower respiratory infections, bronchitis, bronchiolitis, asthma attacks, ear infections, and sudden infant death syndrome (SIDS). ( 4 ) In Georgia, the legislative landscape underwent a significant shift after the ratification of the WHO Framework Convention on Tobacco Control (FCTC) and the implementation of comprehensive smoke-free laws in 2018. ( 5 ) While these laws significantly improved air quality in public spaces and on transportation, private homes are not subject to these legal restrictions. Consequently, the home remains the main place of exposure, with parental smoking identified as the primary source. WHO STEPS (2016) indicates that 43.2% of Georgian teens aged 13–15 reported SHS exposure at home. ( 6 ) Reducing SHS in private homes relies on voluntary behavioral changes by parents and caregivers. However, research indicates that social relationships and traditional norms largely drive domestic exposure in Georgia. [7] There is a critical lack of research on how Georgian parents perceive these risks or how these perceptions shape household rules. This report analyzes Phase I findings and introduces Phase II (2026), which is currently underway to study parents' current misperceptions about SHS and their behaviors in the modern legislative landscape. Methods Ethical Considerations This study was conducted in accordance with ethical standards for human research. Ethical approval was obtained from the Institutional Review Board of the National Center for Disease Control and Public Health, Georgia (IRB0000215). Participation was voluntary, and all participants received written and verbal study information before providing informed consent. Confidentiality was maintained throughout the study, and identifying information was removed during transcription to ensure anonymity. Study Design An exploratory qualitative design with embedded descriptive elements was employed to examine parental perceptions, sociocultural influences, and household smoking practices related to children’s exposure to SHS. Qualitative content analysis enabled the systematic identification of patterns, while descriptive severity ratings provided contextualization of perceived risk. The Health Belief Model (HBM) informed the interpretation, highlighting perceived susceptibility , severity , benefits , cues to action , and the identification of Sociocultural Barriers . Inductive coding guided the initial analysis to preserve data-driven insights. Setting and Participants The Phase I study took place in Tbilisi, Georgia. Participants were recruited via stratified purposive sampling to ensure variation in age, gender, and educational attainment among smoking parents. Eligibility criteria included: ( 1 ) Age over 18 years, ( 2 ) Current smoker, and ( 3 ) Parent or primary caregiver of at least one child under 18 years. Sixteen participants were enrolled and divided into two focus groups (n = 8; n = 8). Conducting two groups allowed for a comparison of emergent patterns and an assessment of thematic recurrence, thereby supporting analytic depth. Data Collection Demographic Questionnaire : Before discussions, participants completed a brief structured questionnaire adapted from the Global Adult Tobacco Survey (GATS). It captured age, gender, education, employment, number of children, and household smoking rules. Focus Group Discussions : Two semi-structured focus groups were conducted in Georgian, each lasting approximately 1 hour and 30 minutes. Participants independently rated the perceived severity of children's SHS exposure on a 0–10 scale before discussions to reduce conformity bias. Sessions were led by a primary researcher trained in qualitative methods. Audio recordings were transcribed verbatim in Georgian with identifying information removed. Current Phase Following the thematic analysis of Phase I, Phase II (2026) is currently underway to study parents' current misperceptions about SHS and their smoking behaviors in the modern context. This ongoing phase specifically validates the prevalence and persistence of pseudo-protective smoking behaviors among caregivers in Tbilisi. Results: Thematic Findings and HBM Mapping The thematic analysis of the focus group discussions revealed three primary domains influencing parental smoking behaviors and children’s SHS exposure in Tbilisi: conceptualizations of smoke drift, the impact of sociocultural norms on household rules, and the efficacy of external health communications. Table 1 below maps the qualitative findings from the Tbilisi focus groups to the specific constructs of the HBM , illustrating the drivers of continued domestic exposure. Table 1 Summary of Qualitative Themes and HBM Mapping HBM Construct Qualitative Finding (Thematic Analysis) Illustrative Evidence / Parent Perspective Perceived Susceptibility Low : Misconception that partial ventilation (windows/balconies) eliminates all risk. "I never smoke directly in front of my child... I believe the smoke goes outside". Perceived Severity High (General) / Low (Specific) : Awareness of SHS danger, but lack of awareness regarding THS persistence. Baseline awareness of SHS as a public health issue. Perceived Barriers High: The Burden of Hospitality —social pressure makes it difficult to restrict guests or elders. Social obligations and etiquette override health concerns. Cues to Action Clinical Trust : pediatric medical services are the most effective trigger for behavior change. Parents report readiness to adopt strict rules if a doctor links smoking to their child's health. These targeted adaptations of the 5 A’s framework, aligned with CEASE protocols, can help address barriers identified in Phase I and strengthen clinical interventions aimed at reducing children’s exposure to SHS in Georgia. 1. Conceptualizing Exposure: Misconceptions and Perceived Susceptibility A primary finding was that parents held significant misconceptions about the physical behavior of tobacco smoke in indoor environments. Although there was a baseline awareness that SHS is harmful, the physical visibility of smoke largely governed the understanding of exposure. This led to a Low Perceived Susceptibility among parents who believed their children were safe if smoke was not visible or smellable. The Reliance on Partial Ventilation : Most parents believed that smoking near an open window, on a balcony with the door closed, or in a kitchen with an exhaust fan provided an absolute barrier to child exposure. Spatial Separation and the THS Blind Spot : Participants frequently felt their child was only "exposed" if they were in the same room at the exact moment of smoking. There was little to no awareness of thirdhand smoke (THS) —the toxic residue that remains on hair, clothes, and furniture long after the cigarette is extinguished. 2. Sociocultural Barriers: The Burden of Hospitality A significant obstacle to behavior change is identified in the High Perceived Barriers created by traditional Georgian hospitality. Social Obligations vs. Health Concerns : Participants reported that social obligations often take precedence over health concerns, making it difficult to ask guests or elders to smoke outside. The Structural Barrier of Etiquette : The desire to be a "good host" acts as a barrier to enforcing safety rules. Parents feel that asking visitors to change their behavior is socially awkward or disrespectful, particularly when it involves guests rather than family members. Response to External Cues and Healthcare Engagement Participants discussed how they interact with existing tobacco control measures and where they seek credible health information. Avoidance Tactics : Although cigarette packs in Georgia feature graphic health warnings, participants described them as largely ineffective or easily ignored. Most reported active avoidance strategies, such as placing the pack face down or using a decorative cover, are used to mitigate the emotional discomfort without changing their behavior. The Credibility of Pediatricians : There was a strong, unanimous sentiment that pediatricians are the most trusted sources of health advice. However, participants noted a significant "missed opportunity" in clinical settings, reporting that doctors rarely ask detailed questions about household smoking or provide specific strategies for creating a smoke-free home. Discussion This study provides the first qualitative insight into how smoking parents in Georgia conceptualize children’s exposure to SHS within private domestic environments. Consistent with global evidence that the home remains the primary site of exposure ( 2 , 3 ), participants described smoking practices occurring within enclosed household spaces despite general awareness of smoking-related harms. While the 2017 law successfully denormalized smoking in public spaces, the home remains an "unprotected" environment where children are still exposed to SHS. This suggests that Legislative progress does not automatically result in changes in household behavior. The Persistence of Pseudo-protective Behaviors A central finding is the reliance on "pseudo-protective" strategies, such as smoking by open windows or on balconies. These behaviors stem from a Low Perceived Susceptibility , as parents assume the environment is clean when smoke is not visible, overlooking thirdhand smoke. This toxic residue persists on surfaces and clothing. The current study is consistent with findings from multiple studies highlighting persistent parental misperceptions and knowledge gaps regarding secondhand and thirdhand smoke. ( 8 ) Effective interventions should go beyond general SHS warnings and raise awareness among families about the invisible, persistent nature of THS. Overcoming the Burden of Hospitality The High Perceived Barriers identified as the hospitality burden represent a unique sociocultural challenge in Georgia. The traditional role of the "good host" often overrides health concerns, making it socially difficult for parents to enforce smoke-free rules with guests - findings that are consistent with the qualitative study by Dekanosidze et al. (2024) ( 9 ), which highlights how hospitality norms discourage restricting guests’ smoking in the home. Our findings suggest that new public health messaging is needed to provide parents with the practical tools to navigate these social pressures. The Role of Clinical Authority Given the high level of trust parents place in clinical guidance for their children’s health, this creates an important opportunity to introduce targeted interventions. Evidence suggests that structured, specific clinical guidance can help bridge the gap between general awareness of harm and the adoption of tobacco-free home practices.( 10 ) Therefore, one can assume that when healthcare providers frame a smoke-free home as a clinical necessity rather than a personal preference, it may serve as a powerful Cue to Action . Future Directions: Phase II (2026) As Georgia continues to evolve its tobacco control strategies, it is essential to determine whether these domestic misconceptions persist. Phase II is currently underway to study parents' current misperceptions about SHS and their smoking behaviors nowadays. This data will be instrumental in validating whether the "protective" patterns identified in 2020 remain a barrier to protecting the next generation of Georgian children in their own homes. Strengths and Contributions A major strength of this study is its methodological triangulation , which uses the Health Belief Model to provide a structured analysis of both qualitative narratives and descriptive background data. This approach is particularly relevant for the Georgian context, where tobacco research has historically been limited to quantitative surveys. Key contributions include: Foundation for Future Research : Findings serve as a reliable baseline for larger studies in Georgia. Sociocultural Insight : The study extends understanding beyond simple statistics to the normative processes—such as "social pressure"—that sustain exposure within private homes. Interactive Data : Focus group discussions allowed for the exploration of the interactive nature of parental beliefs. Limitations Generalizability Several limitations should be considered when interpreting the findings of this study. First, the small, purposive sample of 16 caregivers from a single urban center (Tbilisi) limits the generalizability of the results to the broader Georgian population. However, the primary goal of this qualitative inquiry was not statistical representation but a deep, thematic exploration of the cognitive and cultural barriers to smoke-free homes Social Desirability Bias The reliance on self-reported behaviors may mean that participants minimized their smoking habits to align with perceived social norms. To mitigate this, non-judgmental, open-ended prompts were used to establish rapport and encourage honest dialogue about the practical challenges of rule enforcement. Clinical Recommendations: The 5 A’s Framework To reduce Children’s Exposure to Secondhand Smoke in Georgia, clinical practice should move beyond general inquiries toward a focused, evidence-based intervention approach. Integrating the 5 A’s framework (Ask, Advise, Assess, Assist, Arrange) with the CEASE (Clinical Effort Against Secondhand Smoke) protocols can help ensure actionable guidance for parents. ( 11 , 12 ) Phase I findings indicate that parents rarely cited healthcare settings as a source of information, yet they placed the highest trust in healthcare providers. Table 2 demonstrates how the 5 A’s framework can be employed to reduce children’s SHS exposure at home. For example, under the Ask stage, parents may underreport smoking due to social stigma or reliance on “balcony-only” smoking logic. Targeted questioning—such as, “Do you have a 100% smoke-free rule at home, including balconies and windows?”—can improve accuracy. During the Advice stage, linking parental smoking directly to the child’s respiratory health provides concrete motivation for behavior change. In the Assess stage, employing the CEASE approach can help identify whether social pressure from guests contributes to noncompliance with home rules. At the Assist stage, healthcare professionals may provide scripted strategies to support parents in enforcing smoke-free rules with guests and older family members. Finally, at the Arrange stage, the electronic health record (EHR) can prompt discussion at the next wellness check. Table 2 Clinical Implementation of the 5 A’s for Promoting Smoke-Free Homes Stage Standard Definition Recommended Intervention Ask Systematically identify all tobacco users. Ask specifically: “Do you have a 100% smoke-free rule at home, including balconies and windows?” This phrasing ensures clarity and reduces underreporting. Advise Strongly urge all smokers to quit and/or maintain a smoke-free home. Link smoking directly to the child’s specific respiratory health during the visit, providing concrete reasons for behavior change. Assess Determine willingness to make a change. Employing the CEASE to assess household social determinants contribute to noncompliance with smoke-free home rules. Assist Help the patient develop a tobacco-free plan. Provide scripted strategies to help parents confidently enforce smoke-free home rules with guests and older family members. Arrange Schedule follow-up contact. Flag “Inconsistent Home Rules” in the electronic health record (EHR) to prompt discussion at the next wellness check. These targeted adaptations of the 5 A’s framework, aligned with CEASE protocols, can help address barriers identified in Phase I and strengthen clinical interventions aimed at reducing children’s exposure to SHS in Georgia. Conclusion While Georgia’s 2017 legislation successfully reclaimed public spaces from tobacco smoke, this study reveals that the home remains a critical gap in child health protection. Findings indicate that parental efforts to protect children are systematically undermined by a reliance on pseudo-protective smoking behaviors (e.g., balcony or window smoking) and sociocultural pressures. Using the Health Belief Model , this study emphasizes the need for future interventions to move beyond general awareness and focus on addressing low perceived susceptibility , particularly concerning the invisible and persistent nature of THS . The high level of trust in pediatricians establishes the clinical setting as the primary venue for change. Standardizing the 5 A’s and CEASE frameworks may help healthcare professionals to provide parents with guidance that supports them in enforcing rules, even when cultural norms make it difficult. As Phase II (2026) continues to evaluate evolving parental behaviors, this report provides the evidence base for a clinical shift. Closing the domestic exposure gap requires a transition from legislative success to clinical empowerment, ensuring Georgian homes become authentic tobacco-free environments for the next generation. References U.S. Department of Health and Human Services (1986) The health consequences of involuntary smoking: A report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control World Health Organization (2023) WHO report on the global tobacco epidemic, 2023: Protect people from tobacco smoke. World Health Organization Orton S, Jones LL, Cooper S, Lewis S, Coleman T (2014) Predictors of children's secondhand smoke exposure at home: a systematic review and narrative synthesis of the evidence. PLoS ONE, 9(11), e112690 U.S (2014) Dept of Health and Human Services. U.S. Dept of Health and Human Services World Health Organization (2018), March 21 Georgia launches communication campaign to support new tobacco control legislation . World Health Organization Regional Office for Europe World Health Organization. STEPS 2016: Georgia. National Center for Disease Control and Public Health. November 12, 2018. Accessed October 25, 2021. https://extranet.who.int/ncdsm… Berg CJ, Smith SA, Bascombe TM, Maglakelidze N, Starua L, Topuridze M (2016) Smoke-Free Public Policies and Voluntary Policies in Personal Settings in Tbilisi, Georgia: A Qualitative Study. Int J Environ Res Public Health 13(2):156 Published 2016 Jan 25. 10.3390/ijerph13020156 Vanzi V, Marti F, Cattaruzza MS (2023) Thirdhand Smoke Knowledge, Beliefs and Behaviors among Parents and Families: A Systematic Review. Healthc (Basel Switzerland) 11(17):2403. https://doi.org/10.3390/healthcare11172403 Dekanosidze A, Gegenava V, Liluashvili L, Sturua L, Kegler MC, Baramidze L, Kiladze N, Berg CJ (2024) A Qualitative Study Exploring Facilitators and Barriers to Implementing Smoke-free Homes in Georgia. GBMN Georgian biomedical news 2(4). 10.52340/gbmn.2024.01.01.89 Hovell MF, Zakarian JM, Matt GE et al (2009) Counseling to reduce children's secondhand smoke exposure and help parents quit smoking: a controlled trial. Nicotine Tob Res 11(12):1383–1394. 10.1093/ntr/ntp148 Winickoff JP, Hipple B, Drehmer J et al (2012) The Clinical Effort Against Secondhand Smoke Exposure (CEASE) Intervention: A Decade of Lessons Learned. J Clin Outcomes Manag 19(9):414–419 United States Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General [Internet]. Washington (DC): US Department of Health and Human Services (2020) Chapter 6, Interventions for Smoking Cessation and Treatments for Nicotine Dependence. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555596/ Additional Declarations The authors declare no competing interests. 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The 1972 U.S. Surgeon General\u0026rsquo;s report was the first to acknowledge the health dangers of involuntary tobacco smoke exposure formally. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Despite significant progress in tobacco control, SHS remains a major cause of preventable illness and death worldwide. The World Health Organization (WHO) estimates that SHS causes around 1.3\u0026nbsp;million early deaths globally each year, and notably, children are disproportionately affected, with nearly 40% exposed worldwide. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe home remains the main place of exposure, with parental smoking identified as the primary source of children\u0026rsquo;s SHS exposure. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) According to the U.S. Department of Health and Human Services (2014), children are particularly vulnerable due to their smaller airways, developing lungs, and immature immune systems. Exposure has been clearly linked to higher risks of lower respiratory infections, bronchitis, bronchiolitis, asthma attacks, ear infections, and sudden infant death syndrome (SIDS). (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn Georgia, the legislative landscape underwent a significant shift after the ratification of the WHO Framework Convention on Tobacco Control (FCTC) and the implementation of comprehensive smoke-free laws in 2018. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) While these laws significantly improved air quality in public spaces and on transportation, private homes are not subject to these legal restrictions. Consequently, the home remains the main place of exposure, with parental smoking identified as the primary source. WHO STEPS (2016) indicates that 43.2% of Georgian teens aged 13\u0026ndash;15 reported SHS exposure at home. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e Reducing SHS in private homes relies on voluntary behavioral changes by parents and caregivers. However, research indicates that social relationships and traditional norms largely drive domestic exposure in Georgia. [7] There is a critical lack of research on how Georgian parents perceive these risks or how these perceptions shape household rules. This report analyzes Phase I findings and introduces Phase II (2026), which is currently underway to study parents' current misperceptions about SHS and their behaviors in the modern legislative landscape.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eEthical Considerations\u003c/p\u003e \u003cp\u003e This study was conducted in accordance with ethical standards for human research. Ethical approval was obtained from the Institutional Review Board of the National Center for Disease Control and Public Health, Georgia (IRB0000215). Participation was voluntary, and all participants received written and verbal study information before providing informed consent. Confidentiality was maintained throughout the study, and identifying information was removed during transcription to ensure anonymity.\u003c/p\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003cp\u003eAn exploratory qualitative design with embedded descriptive elements was employed to examine parental perceptions, sociocultural influences, and household smoking practices related to children’s exposure to SHS. Qualitative content analysis enabled the systematic identification of patterns, while descriptive severity ratings provided contextualization of perceived risk. The \u003cb\u003eHealth Belief Model (HBM)\u003c/b\u003e informed the interpretation, highlighting \u003cb\u003eperceived susceptibility\u003c/b\u003e, \u003cb\u003eseverity\u003c/b\u003e, \u003cb\u003ebenefits\u003c/b\u003e, \u003cb\u003ecues to action\u003c/b\u003e, and the identification of \u003cb\u003eSociocultural Barriers\u003c/b\u003e. Inductive coding guided the initial analysis to preserve data-driven insights.\u003c/p\u003e \u003cp\u003eSetting and Participants\u003c/p\u003e \u003cp\u003eThe Phase I study took place in Tbilisi, Georgia. Participants were recruited via stratified purposive sampling to ensure variation in age, gender, and educational attainment among smoking parents. Eligibility criteria included: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) Age over 18 years, (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) Current smoker, and (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) Parent or primary caregiver of at least one child under 18 years. Sixteen participants were enrolled and divided into two focus groups (n = 8; n = 8). Conducting two groups allowed for a comparison of emergent patterns and an assessment of thematic recurrence, thereby supporting analytic depth.\u003c/p\u003e \u003cp\u003eData Collection\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDemographic Questionnaire\u003c/b\u003e: Before discussions, participants completed a brief structured questionnaire adapted from the Global Adult Tobacco Survey (GATS). It captured age, gender, education, employment, number of children, and household smoking rules.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFocus Group Discussions\u003c/b\u003e: Two semi-structured focus groups were conducted in Georgian, each lasting approximately 1 hour and 30 minutes. Participants independently rated the perceived severity of children's SHS exposure on a 0–10 scale before discussions to reduce conformity bias. Sessions were led by a primary researcher trained in qualitative methods. Audio recordings were transcribed verbatim in Georgian with identifying information removed.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eCurrent Phase\u003c/p\u003e \u003cp\u003eFollowing the thematic analysis of Phase I, \u003cb\u003ePhase II (2026)\u003c/b\u003e is currently underway to study parents' current misperceptions about SHS and their smoking behaviors in the modern context. This ongoing phase specifically validates the prevalence and persistence of \u003cb\u003epseudo-protective smoking behaviors\u003c/b\u003e among caregivers in Tbilisi.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results: Thematic Findings and HBM Mapping","content":"\u003cp\u003eThe thematic analysis of the focus group discussions revealed three primary domains influencing parental smoking behaviors and children’s SHS exposure in Tbilisi: conceptualizations of smoke drift, the impact of sociocultural norms on household rules, and the efficacy of external health communications.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e below maps the qualitative findings from the Tbilisi focus groups to the specific constructs of the \u003cb\u003eHBM\u003c/b\u003e, illustrating the drivers of continued domestic exposure.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Qualitative Themes and HBM Mapping\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eHBM Construct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eQualitative Finding (Thematic Analysis)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eIllustrative Evidence / Parent Perspective\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003ePerceived Susceptibility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e: Misconception that partial ventilation (windows/balconies) eliminates all risk.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\"I never smoke directly in front of my child... I believe the smoke goes outside\".\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003ePerceived Severity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eHigh (General) / Low (Specific)\u003c/b\u003e: Awareness of SHS danger, but lack of awareness regarding THS persistence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBaseline awareness of SHS as a public health issue.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003ePerceived Barriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eHigh: The Burden of Hospitality\u003c/b\u003e —social pressure makes it difficult to restrict guests or elders.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSocial obligations and etiquette override health concerns.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eCues to Action\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eClinical Trust\u003c/b\u003e: pediatric medical services are the most effective trigger for behavior change.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eParents report readiness to adopt strict rules if a doctor links smoking to their child's health.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThese targeted adaptations of the 5 A’s framework, aligned with CEASE protocols, can help address barriers identified in Phase I and strengthen clinical interventions aimed at reducing children’s exposure to SHS in Georgia.\u003c/p\u003e\u003cp\u003e1. Conceptualizing Exposure: Misconceptions and Perceived Susceptibility\u003c/p\u003e\u003cp\u003eA primary finding was that parents held significant misconceptions about the physical behavior of tobacco smoke in indoor environments. Although there was a baseline awareness that SHS is harmful, the physical visibility of smoke largely governed the understanding of exposure. This led to a \u003cb\u003eLow Perceived Susceptibility\u003c/b\u003e among parents who believed their children were safe if smoke was not visible or smellable.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eThe Reliance on Partial Ventilation\u003c/b\u003e: Most parents believed that smoking near an open window, on a balcony with the door closed, or in a kitchen with an exhaust fan provided an absolute barrier to child exposure.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSpatial Separation and the THS Blind Spot\u003c/b\u003e: Participants frequently felt their child was only \"exposed\" if they were in the same room at the exact moment of smoking. There was little to no awareness of \u003cb\u003ethirdhand smoke (THS)\u003c/b\u003e—the toxic residue that remains on hair, clothes, and furniture long after the cigarette is extinguished.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e2. Sociocultural Barriers: The Burden of Hospitality\u003c/p\u003e\u003cp\u003e \u003cb\u003eA significant obstacle to behavior change is identified in the\u003c/b\u003e High Perceived Barriers \u003cb\u003ecreated by traditional Georgian hospitality.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSocial Obligations vs. Health Concerns\u003c/b\u003e: Participants reported that social obligations often take precedence over health concerns, making it difficult to ask guests or elders to smoke outside.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eThe Structural Barrier of Etiquette\u003c/b\u003e: The desire to be a \"good host\" acts as a barrier to enforcing safety rules. Parents feel that asking visitors to change their behavior is socially awkward or disrespectful, particularly when it involves guests rather than family members.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eResponse to External Cues and Healthcare Engagement\u003c/p\u003e\u003cp\u003eParticipants discussed how they interact with existing tobacco control measures and where they seek credible health information.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eAvoidance Tactics\u003c/b\u003e: Although cigarette packs in Georgia feature graphic health warnings, participants described them as largely ineffective or easily ignored. Most reported active avoidance strategies, such as placing the pack face down or using a decorative cover, are used to mitigate the emotional discomfort without changing their behavior.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eThe Credibility of Pediatricians\u003c/b\u003e: There was a strong, unanimous sentiment that pediatricians are the most trusted sources of health advice. However, participants noted a significant \"missed opportunity\" in clinical settings, reporting that doctors rarely ask detailed questions about household smoking or provide specific strategies for creating a smoke-free home.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides the first qualitative insight into how smoking parents in Georgia conceptualize children’s exposure to SHS within private domestic environments. Consistent with global evidence that the home remains the primary site of exposure (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e), participants described smoking practices occurring within enclosed household spaces despite general awareness of smoking-related harms.\u003c/p\u003e \u003cp\u003eWhile the 2017 law successfully denormalized smoking in public spaces, the home remains an \"unprotected\" environment where children are still exposed to SHS. This suggests that Legislative progress does not automatically result in changes in household behavior.\u003c/p\u003e \u003cp\u003eThe Persistence of Pseudo-protective Behaviors\u003c/p\u003e \u003cp\u003eA central finding is the reliance on \"pseudo-protective\" strategies, such as smoking by open windows or on balconies. These behaviors stem from a \u003cb\u003eLow Perceived Susceptibility\u003c/b\u003e, as parents assume the environment is clean when smoke is not visible, overlooking thirdhand smoke. This toxic residue persists on surfaces and clothing. The current study is consistent with findings from multiple studies highlighting persistent parental misperceptions and knowledge gaps regarding secondhand and thirdhand smoke. (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e) Effective interventions should go beyond general SHS warnings and raise awareness among families about the invisible, persistent nature of THS.\u003c/p\u003e \u003cp\u003eOvercoming the Burden of Hospitality\u003c/p\u003e \u003cp\u003eThe \u003cb\u003eHigh Perceived Barriers\u003c/b\u003e identified as the hospitality burden represent a unique sociocultural challenge in Georgia. The traditional role of the \"good host\" often overrides health concerns, making it socially difficult for parents to enforce smoke-free rules with guests - findings that are consistent with the qualitative study by Dekanosidze et al. (2024) (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e), which highlights how hospitality norms discourage restricting guests’ smoking in the home. Our findings suggest that new public health messaging is needed to provide parents with the practical tools to navigate these social pressures.\u003c/p\u003e \u003cp\u003eThe Role of Clinical Authority\u003c/p\u003e \u003cp\u003e Given the high level of trust parents place in clinical guidance for their children’s health, this creates an important opportunity to introduce targeted interventions. Evidence suggests that structured, specific clinical guidance can help bridge the gap between general awareness of harm and the adoption of tobacco-free home practices.(\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e) Therefore, one can assume that when healthcare providers frame a smoke-free home as a clinical necessity rather than a personal preference, it may serve as a powerful \u003cb\u003eCue to Action\u003c/b\u003e.\u003c/p\u003e\n\n\n\n \u003cp\u003e\u003c/p\u003e"},{"header":"Future Directions: Phase II (2026)","content":"\u003cp\u003eAs Georgia continues to evolve its tobacco control strategies, it is essential to determine whether these domestic misconceptions persist. \u003cb\u003ePhase II\u003c/b\u003e is currently underway to study parents' current misperceptions about SHS and their smoking behaviors nowadays. This data will be instrumental in validating whether the \"protective\" patterns identified in 2020 remain a barrier to protecting the next generation of Georgian children in their own homes.\u003c/p\u003e"},{"header":"Strengths and Contributions","content":"\u003cp\u003eA major strength of this study is its \u003cb\u003emethodological triangulation\u003c/b\u003e, which uses the \u003cb\u003eHealth Belief Model\u003c/b\u003e to provide a structured analysis of both qualitative narratives and descriptive background data. This approach is particularly relevant for the Georgian context, where tobacco research has historically been limited to quantitative surveys. Key contributions include:\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFoundation for Future Research\u003c/b\u003e: Findings serve as a reliable baseline for larger studies in Georgia.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSociocultural Insight\u003c/b\u003e: The study extends understanding beyond simple statistics to the normative processes—such as \"social pressure\"—that sustain exposure within private homes.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInteractive Data\u003c/b\u003e: Focus group discussions allowed for the exploration of the interactive nature of parental beliefs.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e"},{"header":"Limitations","content":"\u003cp\u003e \u003cstrong\u003eGeneralizability\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eSeveral limitations should be considered when interpreting the findings of this study. First, the small, purposive sample of \u003cb\u003e16 caregivers\u003c/b\u003e from a single urban center (Tbilisi) limits the \u003cb\u003egeneralizability\u003c/b\u003e of the results to the broader Georgian population. However, the primary goal of this qualitative inquiry was not statistical representation but a deep, thematic exploration of the cognitive and cultural barriers to smoke-free homes\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSocial Desirability Bias\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThe reliance on self-reported behaviors may mean that participants minimized their smoking habits to align with perceived social norms. To mitigate this, non-judgmental, open-ended prompts were used to establish rapport and encourage honest dialogue about the practical challenges of rule enforcement.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e "},{"header":"Clinical Recommendations: The 5 A’s Framework","content":"\u003cp\u003eTo reduce Children’s Exposure to Secondhand Smoke in Georgia, clinical practice should move beyond general inquiries toward a focused, evidence-based intervention approach. Integrating the 5 A’s framework (Ask, Advise, Assess, Assist, Arrange) with the CEASE (Clinical Effort Against Secondhand Smoke) protocols can help ensure actionable guidance for parents. (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e Phase I findings indicate that parents rarely cited healthcare settings as a source of information, yet they placed the highest trust in healthcare providers. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates how the 5 A’s framework can be employed to reduce children’s SHS exposure at home. For example, under the \u003cb\u003eAsk\u003c/b\u003e stage, parents may underreport smoking due to social stigma or reliance on “balcony-only” smoking logic. Targeted questioning—such as, “Do you have a 100% smoke-free rule at home, including balconies and windows?”—can improve accuracy. During the \u003cb\u003eAdvice\u003c/b\u003e stage, linking parental smoking directly to the child’s respiratory health provides concrete motivation for behavior change. In the \u003cb\u003eAssess\u003c/b\u003e stage, employing the \u003cb\u003eCEASE\u003c/b\u003e approach can help identify whether social pressure from guests contributes to noncompliance with home rules. At the \u003cb\u003eAssist\u003c/b\u003e stage, healthcare professionals may provide scripted strategies to support parents in enforcing smoke-free rules with guests and older family members. Finally, at the \u003cb\u003eArrange\u003c/b\u003e stage, the electronic health record (EHR) can prompt discussion at the next wellness check.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Implementation of the 5 A’s for Promoting Smoke-Free Homes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eStandard Definition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eRecommended Intervention\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eAsk\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSystematically identify all tobacco users.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAsk specifically: “Do you have a 100% smoke-free rule at home, including balconies and windows?” This phrasing ensures clarity and reduces underreporting.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eAdvise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStrongly urge all smokers to quit and/or maintain a smoke-free home.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLink smoking directly to the child’s specific respiratory health during the visit, providing concrete reasons for behavior change.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eAssess\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDetermine willingness to make a change.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEmploying the \u003cb\u003eCEASE\u003c/b\u003e to assess household social determinants contribute to noncompliance with smoke-free home rules.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eAssist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHelp the patient develop a tobacco-free plan.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProvide scripted strategies to help parents confidently enforce smoke-free home rules with guests and older family members.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eArrange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSchedule follow-up contact.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFlag “Inconsistent Home Rules” in the electronic health record (EHR) to prompt discussion at the next wellness check.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThese targeted adaptations of the 5 A’s framework, aligned with CEASE protocols, can help address barriers identified in Phase I and strengthen clinical interventions aimed at reducing children’s exposure to SHS in Georgia.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile Georgia\u0026rsquo;s 2017 legislation successfully reclaimed public spaces from tobacco smoke, this study reveals that the \u003cb\u003ehome remains a critical gap\u003c/b\u003e in child health protection. Findings indicate that parental efforts to protect children are systematically undermined by a reliance on \u003cb\u003epseudo-protective smoking behaviors\u003c/b\u003e (e.g., balcony or window smoking) and sociocultural pressures.\u003c/p\u003e \u003cp\u003eUsing the \u003cb\u003eHealth Belief Model\u003c/b\u003e, this study emphasizes the need for future interventions to move beyond general awareness and focus on addressing \u003cb\u003elow perceived susceptibility\u003c/b\u003e, particularly concerning the invisible and persistent nature of \u003cb\u003eTHS\u003c/b\u003e. The high level of trust in pediatricians establishes the clinical setting as the primary venue for change. Standardizing the \u003cb\u003e5 A\u0026rsquo;s and CEASE frameworks\u003c/b\u003e may help healthcare professionals to provide parents with guidance that supports them in enforcing rules, even when cultural norms make it difficult.\u003c/p\u003e \u003cp\u003eAs \u003cb\u003ePhase II (2026)\u003c/b\u003e continues to evaluate evolving parental behaviors, this report provides the evidence base for a clinical shift. Closing the domestic exposure gap requires a transition from legislative success to clinical empowerment, ensuring Georgian homes become authentic tobacco-free environments for the next generation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eU.S. Department of Health and Human Services (1986) The health consequences of involuntary smoking: A report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2023) WHO report on the global tobacco epidemic, 2023: Protect people from tobacco smoke. World Health Organization\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrton S, Jones LL, Cooper S, Lewis S, Coleman T (2014) Predictors of children's secondhand smoke exposure at home: a systematic review and narrative synthesis of the evidence. PLoS ONE, 9(11), e112690\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S (2014) Dept of Health and Human Services. U.S. Dept of Health and Human Services\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2018), March 21 \u003cem\u003eGeorgia launches communication campaign to support new tobacco control legislation\u003c/em\u003e. World Health Organization Regional Office for Europe\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. STEPS 2016: Georgia. National Center for Disease Control and Public Health. November 12, 2018. Accessed October 25, 2021. https://extranet.who.int/ncdsm\u0026hellip;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerg CJ, Smith SA, Bascombe TM, Maglakelidze N, Starua L, Topuridze M (2016) Smoke-Free Public Policies and Voluntary Policies in Personal Settings in Tbilisi, Georgia: A Qualitative Study. Int J Environ Res Public Health 13(2):156 Published 2016 Jan 25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph13020156\u003c/span\u003e\u003cspan address=\"10.3390/ijerph13020156\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanzi V, Marti F, Cattaruzza MS (2023) Thirdhand Smoke Knowledge, Beliefs and Behaviors among Parents and Families: A Systematic Review. Healthc (Basel Switzerland) 11(17):2403. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/healthcare11172403\u003c/span\u003e\u003cspan address=\"10.3390/healthcare11172403\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDekanosidze A, Gegenava V, Liluashvili L, Sturua L, Kegler MC, Baramidze L, Kiladze N, Berg CJ (2024) A Qualitative Study Exploring Facilitators and Barriers to Implementing Smoke-free Homes in Georgia. GBMN Georgian biomedical news 2(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.52340/gbmn.2024.01.01.89\u003c/span\u003e\u003cspan address=\"10.52340/gbmn.2024.01.01.89\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHovell MF, Zakarian JM, Matt GE et al (2009) Counseling to reduce children's secondhand smoke exposure and help parents quit smoking: a controlled trial. Nicotine Tob Res 11(12):1383\u0026ndash;1394. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ntr/ntp148\u003c/span\u003e\u003cspan address=\"10.1093/ntr/ntp148\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinickoff JP, Hipple B, Drehmer J et al (2012) The Clinical Effort Against Secondhand Smoke Exposure (CEASE) Intervention: A Decade of Lessons Learned. J Clin Outcomes Manag 19(9):414\u0026ndash;419\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited States Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General [Internet]. Washington (DC): US Department of Health and Human Services (2020) Chapter 6, Interventions for Smoking Cessation and Treatments for Nicotine Dependence. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK555596/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK555596/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Essex","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"secondhand smoke (SHS), thirdhand smoke (THS), children, smoke-free homes, tobacco control, Georgia","lastPublishedDoi":"10.21203/rs.3.rs-9193937/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9193937/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite the success of Georgia\u0026rsquo;s 2017 comprehensive tobacco control legislation in public spaces, the home remains the primary setting for children\u0026rsquo;s exposure to secondhand smoke (SHS), driven by deeply rooted cultural norms and misconceptions regarding protective smoking practices. This study explores parental smoking behaviors and their underlying determinants, with a focus on how clinical cues to action during routine pediatric visits may influence the adoption of strict indoor smoking bans.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn exploratory qualitative study was conducted in Tbilisi, Georgia, using stratified purposive sampling to recruit 16 smoking parents of children under 18. Two semi-structured focus group discussions were held, supported by a brief demographic questionnaire adapted from the Global Adult Tobacco Survey. Data were transcribed verbatim and analyzed using qualitative content analysis with inductive coding, while descriptive severity ratings were used to contextualize perceived risk. The Health Belief Model (HBM) guided the interpretation of behavioral determinants.\u003c/p\u003e\u003ch2\u003eFindings\u003c/h2\u003e \u003cp\u003ePhase I findings (2020) reveal a widespread reliance on pseudo-protective behaviors, such as smoking near open windows, under kitchen exhaust fans, or on balconies, based on the belief that these measures eliminate risk. This sensory-based logic overlooks the persistence of thirdhand smoke (THS), a toxic residue that remains on surfaces and contributes to continued exposure. This study identifies pediatric health consultations as a critical cue to action, with parents expressing a high willingness to adopt smoke-free home rules when provided with clear, child-specific clinical guidance.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese findings suggest that interventions focusing on clinical communication strategies, including frameworks such as the 5 A\u0026rsquo;s and CEASE, may support the reduction of SHS exposure in domestic settings. Phase II (2026) is currently underway to assess the stability of these behavioral patterns over time.\u003c/p\u003e","manuscriptTitle":"Sociocultural Barriers to Reduce Children’s Exposure to SHS in Georgia: A Technical Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 07:27:05","doi":"10.21203/rs.3.rs-9193937/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba5ccfd2-7183-4774-803a-c7cbf5881e4e","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64930047,"name":"Preventive Medicine"},{"id":64930048,"name":"Epidemiology"}],"tags":[],"updatedAt":"2026-03-24T07:27:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 07:27:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9193937","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9193937","identity":"rs-9193937","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}