{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T20:10:27Z","timestamp":1791231027808,"version":"4.1.0"},"reference-count":76,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2024,12,30]],"date-time":"2024-12-30T00:00:00Z","timestamp":1735516800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction<\/jats:title>\n<jats:p>Smokeless tobacco use is a growing public health concern, with potential adverse implications for foetal outcomes if consumed during pregnancy. Birth weight is an important predictive measure for health outcomes of a child throughout their lifespan. Despite extensive literature, it is unclear whether smokeless tobacco consumption during pregnancy has an adverse effect on birth weight. Hence, this review was conducted to determine whether an association exists between maternal smokeless tobacco consumption during pregnancy and birth weight of infants.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>Systematic literature search was performed in Medline (via PubMed), Embase, Scopus, and CINAHL with no restrictions on language or time until May 2024. All observational studies that examined the relationship between maternal smokeless tobacco use and low birth weight of infants were eligible for inclusion. Methodological quality of included studies was assessed using the Newcastle Ottawa Scale.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Thirty-three studies were eligible for the review, including twenty-eight cohort, three case-control and two cross-sectional studies. A statistically significant association between use of smokeless tobacco and low birth weight was reported in thirteen studies. Eleven studies reported a statistically significant reduction in mean birth weight in maternal smokeless tobacco users. Pooled estimates of eighteen studies with 733,061 participants showed that there was a statistically significant association (OR = 2.25 [1.63, 3.11] P&lt;0.001); between maternal smokeless tobacco use during pregnancy and low birth weight. Subgroup analysis found a significant association between mishri consumption during pregnancy and low birth weight (n = 646 participants, OR = 10.98 [2.03, 59.34], P = 0.005), but not betel nut (n = 8007 participants, OR = 1.02 [0.84, 1.25]), betel quid (n = 483 participants, OR = 1.51 [0.47, 4.89]) or khat (n = 475 participants, OR = 1.41 [0.64\u20133.09]).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>This review presents an association between maternal smokeless tobacco use and low birth weight, and reduction in mean birth weight. It is suggested that cessation and reduction of maternal smokeless tobacco use should receive specific attention within routine prenatal care.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec005\">\n<jats:title>Implications<\/jats:title>\n<jats:p>The results of this study highlight the need for further preventive public health campaigns to create awareness about detrimental effects of smokeless tobacco on foetal outcomes. Patient education in the primary care setting will aid in promoting smokeless tobacco cessation prior to pregnancy.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0312297","type":"journal-article","created":{"date-parts":[[2024,12,30]],"date-time":"2024-12-30T18:31:51Z","timestamp":1735583511000},"page":"e0312297","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":7,"title":["The invisible enemy: A systematic review and meta-analysis of maternal smokeless tobacco use as a risk factor for low birth weight"],"prefix":"10.1371","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7299-8717","authenticated-orcid":true,"given":"Akanksha","family":"Mahajan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bhawna","family":"Gupta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Tong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,12,30]]},"reference":[{"key":"pone.0312297.ref001","article-title":"Low birthweight (LBW) estimates","author":"WHO, UNICEF","year":"2023"},{"key":"pone.0312297.ref002","author":"WHO.","year":"2024","journal-title":"ICD-11 for Mortality and Morbidity Statistics- World Health Organisation"},{"key":"pone.0312297.ref003","article-title":"Global nutrition targets 2025: low birth weight policy brief.","author":"Department of Nutrition for Health and Development WHO.","year":"2014"},{"issue":"3","key":"pone.0312297.ref004","doi-asserted-by":"crossref","first-page":"647","DOI":"10.1093\/ije\/dyq267","article-title":"Birthweight and mortality in adulthood: a systematic review and meta-analysis","volume":"40","author":"KR Risnes","year":"2011","journal-title":"International Journal of Epidemiology"},{"issue":"7","key":"pone.0312297.ref005","doi-asserted-by":"crossref","first-page":"942","DOI":"10.1017\/PHN20062005","article-title":"Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics\/WHO international growth reference: implications for child health programmes","volume":"9","author":"M de Onis","year":"2006","journal-title":"Public Health Nutr."},{"issue":"2","key":"pone.0312297.ref006","doi-asserted-by":"crossref","first-page":"e063836","DOI":"10.1136\/bmjopen-2022-063836","article-title":"Weighting of risk factors for low birth weight: a linked routine data cohort study in Wales, UK.","volume":"13","author":"A Bandyopadhyay","year":"2023","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0312297.ref007","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1186\/s12916-020-01677-9","article-title":"Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries.","volume":"18","author":"K Siddiqi","year":"2020","journal-title":"BMC Medicine"},{"issue":"5","key":"pone.0312297.ref008","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1136\/thorax.58.5.435","article-title":"Health effects associated with smokeless tobacco: a systematic review","volume":"58","author":"JA Critchley","year":"2003","journal-title":"Thorax"},{"issue":"4","key":"pone.0312297.ref009","doi-asserted-by":"crossref","first-page":"e61743","DOI":"10.1371\/journal.pone.0061743","article-title":"Toxicological Effects of the Different Substances in Tobacco Smoke on Human Embryonic Development by a Systems Chemo-Biology Approach","volume":"8","author":"BC Feltes","year":"2013","journal-title":"PLOS ONE"},{"issue":"2","key":"pone.0312297.ref010","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1016\/j.toxlet.2013.10.032","article-title":"Exposure to ethanol and nicotine induces stress responses in human placental BeWo cells","volume":"224","author":"K. 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