A Multifaceted Strategy to Implement Brief Smoking Cessation Counseling During Antenatal Care in Argentina and Uruguay: A Cluster Randomized Trial

Abstract

Introduction 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. Implications 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.

Barriers and facilitators to smoking cessation in pregnancy and in the post‐partum period: The health care professionals’ perspective

“…This should also help improve the consistency of health messages around smoking delivered to pregnant smokers. Training of antenatal staff can increase the assessment of smoking and provision of support to pregnant women (Althabe et al ., 2016), even when part of opt‐out referral pathways (Campbell et al ., 2017). …”

“…Professionals commonly report feeling that they lack the skills, confidence, motivation, and the time to address, discuss, and advise on smoking (Colomar et al ., 2015; Flemming et al ., 2016; Herberts & Sykes, 2012). These are not clearly addressed by training in brief advice (Althabe et al ., 2016). Health care professionals, particularly midwives, also express concern that discussing smoking could negatively affect the therapeutic relationship between them and their clients (Flemming et al ., 2016; Herberts & Sykes, 2012; Reardon & Grogan, 2016).…”

Brief Counseling on Secondhand Smoke Exposure in Pregnant Women in Argentina and Uruguay

“…This is a secondary analysis of the main paper called “A multifaceted strategy to implement brief smoking cessation counseling during antenatal care in Argentina and Uruguay: a cluster randomized trial” [ 14 ]. The primary study was a two-arm parallel cluster randomized trial with baseline and follow-up cross-sectional measurements.…”

“…World Health Organization (WHO) guidelines released in 2013 strongly recommend that antenatal care (ANC) providers, at minimum, screen all pregnant women for both tobacco use and SHS exposure, provide brief tobacco cessation counseling, provide education regarding the harms of SHS and offer strategies to reduce SHS exposure at home [ 13 ]. To increase adherence to these recommendations in Argentina and Uruguay, we designed and evaluated a multifaceted strategy to promote screening for tobacco exposure, counseling for tobacco cessation and reduction of SHS exposure for pregnant women in ANC clinics in Buenos Aires and Montevideo [ 14 ]. This intervention showed a statistically significant absolute increase in the rates of screening for SHS exposure of 24% within the home and of 33% at work, compared to the control group.…”

Tabaquismo y género: conocimiento sobre enfermedades tabaco-dependientes en la mujer, entre usuarias hospitalizadas en hospitales públicos de Montevideo 2017

“…(2) Consistentemente, en las mujeres embarazadas que se asisten en instituciones privadas en Uruguay se detecta un 9.8% de consumo de tabaco durante el embarazo, mientras que alcanza un 26,3% entre aquellas que se asisten en instituciones públicas. (4,5) Existen estudios previos realizados en embarazadas de sectores vulnerables que muestran la existencia de mitos o desconocimiento que actúan barreras a la motivación para dejar de fumar. (6) A nivel global, el tabaquismo en las mujeres era muy infrecuente en la primera mitad del siglo XX.…”