There are an estimated 1.3 billion adult smokers among the world's six billion people, with increases anticipated [1]. Cigarette smoking is the second leading risk factor for death worldwide [2–4]. More than six million people die every year as a consequence of tobacco smoking [5]. In 2000, an estimated 4.83 million deaths were attributed to cigarette smoking globally. Tragically, almost half of those deaths occur in the developing world [2, 3]. In fact, four-fifths of current smokers live in low- and middle-income counties (LMICs) [5]. Many LMICs are still in early stages of the tobacco epidemic; thus, the number of smoking-related deaths in these nations is likely to increase [3, 6, 7]. Based on current trends, mortality will increase to 8.3 million a year by 2030, and 80% of these deaths will occur in LMICs [5].

One high-risk region for tobacco use is the area of the former Soviet Union [8]. In a study of eight former Soviet Union countries, almost 80% of men reported a history of smoking [8]. Rates of current smoking ranged from 43.3% in Moldova to 65.3% in Kazakhstan. There are drastically different smoking rates among men and women in these regions, with men having a much higher prevalence of smoking. In general, men from rural areas, of lower education and income, had higher rates of smoking, while women in urban areas and of higher education and income had higher smoking prevalence rates [8, 9].

The Republic of Georgia, one former Soviet Union country and a lower middle-income country [10, 11], has shown a record decrease in population over recent years, mainly attributed to premature mortality and migration [12]. The tobacco-related death toll in Georgia is estimated to be around 11,000 deaths per year [12]. Among Georgian men, estimated 54.9% are current daily smokers, 17.0% are less than daily smokers, and 28.1% are nonsmokers (past and never smokers) [12]. Among Georgian women, an estimated 12.2% are current daily smokers, 6.4% are less than daily smokers, and 81.4% are nonsmokers [12]. Similar to the trends of the other former Soviet Union countries, smoking prevalence is higher among men with lower education and lower income and among those who live in smaller settlements [12], whereas the smoking prevalence among women is higher among the more educated and affluent and those who live in larger cities. This may be a sign of the growing tobacco epidemic among Georgian women, such that rates of smoking among women grew from roughly 24% in 1997 to 34% in 2007 in Tbilisi, with the greatest increases among those under 40 years of age [12]. Given the growing tobacco use epidemic in Georgia, strides are being made to curtail this epidemic. In December 2005, Georgia ratified the Framework Convention on Tobacco Control (FCTC), which mandates that nations that ratify the FCTC implement policies including smoke-free public policies and regulation of tobacco advertising, among other tobacco control policies.

The Socioecological Model (SEM) [13–15] is a framework to examine the multiple effects and interrelatedness of environmental, contextual, and social factors on individual behavior. The SEM involves a comprehensive approach that integrates multiple levels of influence that impact health behavior and ultimately health outcomes. Those levels of influence include intra- and interpersonal factors, community and organizational factors, and public policies [13–15]. For example, some variables that might influence smoking may be intrapersonal factors such as sociodemographics, substance use behaviors, and attitudes toward smoking and smoking-related policies; interpersonal factors such as social exposure to smokers; community or organizational factors such as prevalence of smoking in their community, social norms within their community, or exposure to tobacco advertising; or public policies including those that regulate advertising, taxation, or smoke-free policies in public places. Drawing from this perspective, the current study focuses on individual-level factors including nonmodifiable factors such as sociodemographic characteristics as well as modifiable factors including substance use behaviors and involvement in activities with the potential for social influence on smoking initiation and maintenance among youth in Tbilisi, Georgia. These factors are impacted by the cultural context and social norms related to tobacco use in this understudied, high-risk country.

In terms of substance use behaviors, a large amount of literature has documented the association between cigarette use and alcohol use [16–18], as well as smoking and marijuana use [19, 20]. However, little research has documented these findings among youth in LMICs or specifically in Georgian youth. In particular, alcohol is a major concern among Georgian youth. One 2009 survey [21] found that more than 90% of youth have had drunk alcohol at least once, and more than 43% have had their last drink at home. This suggests a cultural acceptance of alcohol use in the Georgian society and within Georgian families. Given the high prevalence of both tobacco use and alcohol use in this context, the comorbid nature of behaviors perceived to be high risk in other cultures may not be associated among youth in Georgia.

Additionally, activity involvement may indicate specific risk or protective influences related to smoking behavior. For example, social factors have been found to play a particularly important role in smoking initiation and maintenance in other countries. Family influences, such as parents' smoking [22–25], and peer and school influences, such as peers' smoking [24, 26–28], are well- documented predictors of youth smoking. On the other hand, being married and having a family have been associated with lower likelihood of smoking in young adulthood in developed countries [29, 30]. In addition, low academic achievement [26, 31] and low school commitment or attachment [31] has been found to be risk factors for smoking among youth in developed countries. Additionally, engagement in sports or physical activity has been documented protective factors against smoking among youth [32, 33] as well as predictive of tobacco use [34, 35]. Finally, Internet use among youth has been a factor more recently examined and may indicate risk for exposure to tobacco advertising, as the Internet provides tobacco companies with a highly active environment to advertise their products in increasingly regulated countries [36, 37].

Despite the literature regarding risk factors for smoking among youth, limited research has documented these associations in LMICs or in Georgia in particular. Given the limited tobacco control policy adoption and enforcement in these countries including Georgia, the social norms regarding smoking may be more conducive to smoking initiation or may have little differential impact given the pervasive nature of tobacco use in the community and social networks of youth. Moreover, the pervasiveness of tobacco use may also impact the perceived harm of cigarette smoking, such that youth will perceive the threat to be lower [16, 38]. Thus, examination of social factors impacting smoking among youth in LMICs is critical in informing approaches aimed at smoking prevention and cessation.

Given the aforementioned literature, the specific aims of this study are to examine sociodemographics, other substance use, perceived risk of smoking, and engagement in various social and academic activities in relation to lifetime use of cigarettes and current (past 30 day) cigarette use among lifetime cigarette users in a sample of 15–18-year-old secondary school students and 18–24-year-old postsecondary school students in Tbilisi, Georgia. We hypothesize higher lifetime and current cigarette smoking rates among the older age group, males, alcohol and marijuana users, those perceiving less harm related to cigarette smoking, and those who more frequently engage in activities where social influence might promote smoking.