The Consequences of Prenatal Tobacco Exposure: A Systematic Review of Birth Outcomes and Developmental Trajectories

Prenatal tobacco exposure remains a significant and preventable public health concern worldwide. Maternal smoking during pregnancy has been associated with adverse perinatal outcomes and long-term developmental consequences. This systematic review aimed to evaluate the association between prenatal tobacco exposure and birth and developmental outcomes in offspring. A systematic review was conducted in accordance with PRISMA 2020 guidelines. Six electronic databases were searched for observational studies published between June 1, 2014, and June 1, 2025. Studies assessing maternal tobacco exposure during pregnancy and reporting quantitative associations with birth or developmental outcomes were included. Risk of bias was assessed using the ROBINS-I tool, and the certainty of evidence was evaluated using the GRADE approach. Twelve studies met the inclusion criteria. Prenatal tobacco exposure was consistently associated with increased risk of low birth weight, with adjusted odds ratios ranging from 2.24 to 2.91. Reported reductions in birth weight ranged from approximately 230 g to over 300 g among exposed infants. Biomarker-validated studies confirmed reductions in birth weight and head circumference. Developmental outcomes demonstrated impairments in attention, executive function, fine motor skills, and academic performance. Increased risks of psychiatric disorders, including attention-deficit/hyperactivity disorder and disruptive behavior disorder, were observed in longitudinal cohorts. Most studies were rated as having a moderate risk of bias. Certainty of evidence was graded as moderate for low birth weight and neurodevelopmental outcomes, and low for psychiatric outcomes and smokeless tobacco exposure. Prenatal tobacco exposure is consistently associated with reduced fetal growth and adverse neurodevelopmental and psychiatric outcomes extending into later life. Evidence regarding smokeless tobacco exposure remains limited. These findings support the continued prioritization of smoking cessation interventions during pregnancy to reduce preventable adverse child health outcomes.