title: A Multifaceted Strategy to Implement Brief Smoking Cessation Counseling During Antenatal Care in Argentina and Uruguay: A Cluster Randomized Trial.
abstract: BACKGROUND
  Argentina and Uruguay have a high prevalence of smoking during pregnancy. However, and despite national recommendations, pregnant women are not routinely receiving cessation counseling during antenatal care (ANC). We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who received a brief smoking cessation counseling based on the 5As (Ask, Advise, Assess, Assist, and Arrange).
  
  
  METHODS
  We randomly assigned (1:1) 20 ANC clusters in Buenos Aires, Argentina and Montevideo, Uruguay to receive a multifaceted intervention to implement brief smoking cessation counseling into routine ANC, or to receive no intervention. The primary outcome was the frequency of women who recalled receiving the 5As during ANC at more than one visit. Frequency of women who smoked until the end of pregnancy, and attitudes and readiness of ANC providers towards providing counseling were secondary outcomes. Women's outcomes were measured at baseline and at the end of the 14- to 18-month intervention, by administering questionnaires at the postpartum hospital stay. Self-reported cessation was verified with saliva cotinine. The trial took place between October 03, 2011 and November 29, 2013.
  
  
  RESULTS
  The rate of women who recalled receiving the 5As increased from 14.0% to 33.6% in the intervention group (median rate change, 22.1%), and from 10.8% to 17.0% in the control group (median rate change, 4.6%; P = .001 for the difference in change between groups). The effect of the intervention was larger in Argentina than in Uruguay. The proportion of women who continued smoking during pregnancy was unchanged at follow-up in both groups and the relative difference between groups was not statistically significant (ratio of odds ratios 1.16, 95% CI: 0.98-1.37; P = .086). No significant changes were observed in knowledge, attitudes, and self-confidence of ANC providers.
  
  
  CONCLUSIONS
  The intervention showed a moderate effect in increasing the proportion of women who recalled receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention.
  
  
  CONCLUSIONS
  No implementation trials of smoking cessation interventions for pregnant women have been carried out in Latin American or in middle-income countries where health care systems or capacities may differ. We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who receive brief smoking cessation counseling based on the 5As in Argentina and Uruguay. We found that the intervention showed a moderate effect in increasing the proportion of women receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention.
authors.affiliation: Mother and Child Health Research Department, Institute for Clinical Effectiveness and Health Policy (IECS) , Buenos Aires , Argentina.
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
authors.affiliation: Division of Reproductive Health, Montevideo Clinical and Epidemiological Research Unit , Montevideo , Uruguay.
authors.forename: Alicia
authors.initials: A
authors.lastname: Alemán
authors.affiliation: Mother and Child Health Research Department, Institute for Clinical Effectiveness and Health Policy (IECS) , Buenos Aires , Argentina.
authors.forename: Mabel
authors.initials: M
authors.lastname: Berrueta
authors.affiliation: Mother and Child Health Research Department, Institute for Clinical Effectiveness and Health Policy (IECS) , Buenos Aires , Argentina.
authors.forename: Paola
authors.initials: P
authors.lastname: Morello
authors.affiliation: Mother and Child Health Research Department, Institute for Clinical Effectiveness and Health Policy (IECS) , Buenos Aires , Argentina.
authors.forename: Luz
authors.initials: L
authors.lastname: Gibbons
authors.affiliation: Division of Reproductive Health, Montevideo Clinical and Epidemiological Research Unit , Montevideo , Uruguay.
authors.forename: Mercedes
authors.initials: M
authors.lastname: Colomar
authors.affiliation: Division of Reproductive Health/National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention , Atlanta, GA.
authors.forename: Van T
authors.initials: VT
authors.lastname: Tong
authors.affiliation: Division of Reproductive Health/National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention , Atlanta, GA.
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Dietz
authors.affiliation: Division of Reproductive Health/National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention , Atlanta, GA.
authors.forename: Sherry L
authors.initials: SL
authors.lastname: Farr
authors.affiliation: Division of Reproductive Health, Montevideo Clinical and Epidemiological Research Unit , Montevideo , Uruguay.
authors.forename: Alvaro
authors.initials: A
authors.lastname: Ciganda
authors.affiliation: Mother and Child Health Research Department, Institute for Clinical Effectiveness and Health Policy (IECS) , Buenos Aires , Argentina.
authors.forename: Agustina
authors.initials: A
authors.lastname: Mazzoni
authors.affiliation: Hospital de Clínicas, Facultad de Medicina, Universidad de la Republica , Montevideo , Uruguay.
authors.forename: Laura
authors.initials: L
authors.lastname: Llambí
authors.affiliation: Mother and Child Health Research Department, Institute for Clinical Effectiveness and Health Policy (IECS) , Buenos Aires , Argentina.
authors.forename: Ana
authors.initials: A
authors.lastname: Becú
authors.affiliation: Division of Reproductive Health/National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention , Atlanta, GA.
authors.forename: Ruben A
authors.initials: RA
authors.lastname: Smith
authors.affiliation: Global Community Health and Behavioral Sciences, Tulane School of Public Health and Tropical Medicine , New Orleans, LA.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Johnson
authors.affiliation: Mother and Child Health Research Department, Institute for Clinical Effectiveness and Health Policy (IECS) , Buenos Aires , Argentina.
authors.forename: José M
authors.initials: JM
authors.lastname: Belizán
authors.affiliation: Global Community Health and Behavioral Sciences, Tulane School of Public Health and Tropical Medicine , New Orleans, LA.
authors.forename: Pierre M
authors.initials: PM
authors.lastname: Buekens
mesh_terms: D000328:Adult; D001118:Argentina; D003376:Counseling / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D011295:Prenatal Care / Q000379:methods / Q000706:statistics & numerical data; D016540:Smoking Cessation / Q000379:methods / Q000706:statistics & numerical data; D014583:Uruguay