Unseen Threats: Mapping the Global Prevalence of Smokeless Tobacco Use in Pregnancy-A Systematic Review and...

Smokeless tobacco (SLT) use during pregnancy remains a significant yet underrecognized public health concern, particularly in low- and middle-income countries. Despite its wide prevalence and potential for adverse maternal and foetal outcomes, SLT has received comparatively less attention than smoking in prenatal health initiatives. This systematic review and meta-analysis aimed to estimate the global and regional prevalence of SLT use among pregnant women and examine associated sociodemographic patterns.

We systematically searched PubMed, Embase, Scopus, and regional databases for studies reporting the prevalence of SLT use during pregnancy up to 31 January 2025. Cross-sectional, cohort, and survey-based studies were eligible for inclusion. Two reviewers independently screened articles, extracted data, and assessed study quality. Pooled prevalence estimates were calculated using a random-effects meta-analysis model due to anticipated heterogeneity. Subgroup analyses were conducted based on geography, rural versus urban setting, and education level.

Thirty-four studies encompassing data from over 9 509 590 pregnant women across Asia, Africa, Europe, North America, and Oceania were included. The pooled prevalence of SLT use during pregnancy was 8% (95% CI: 7%-10%), with a significant heterogeneity (I² = 100%, P < .001), indicating substantial variation across studies. There was a wide regional variation, from <1% in Scandinavian countries to >60% in rural Indonesia and Palau. Higher prevalence was consistently observed among women from lower socioeconomic backgrounds, with limited education, and residing in rural settings. Cultural normalization and habitual use were common reasons for SLT use in these populations.

SLT use during pregnancy is prevalent in several parts of the world, especially among socioeconomically disadvantaged populations. These findings underscore the urgent need for targeted tobacco control interventions, maternal health education, and region-specific policy strategies addressing SLT use during pregnancy. Increased awareness, regulatory action, and integration of SLT screening in antenatal care services are warranted.