title: Smokeless tobacco use in pregnancy: an integrative review of the literature.
abstract: OBJECTIVE
  To systematically critique and summarise the available evidence on the outcomes of smokeless tobacco use in pregnancy to inform the public health response.
  
  
  METHODS
  In March 2013, a search was conducted of observational studies where the exposure to smokeless tobacco during pregnancy and maternal, placental and/or neonatal outcomes was assessed. Two reviewers extracted data and completed quality assessment of the literature utilizing the Agency for Healthcare Research and Quality criteria (West et al. 2002).
  
  
  RESULTS
  The search resulted in 211 articles, 21 (10%) of which met the final criteria for integrative review. Ten (10) of the studies are from India, seven (7) from Sweden, two (2) from Alaska and one (1) each from South Africa and Pakistan.
  
  
  CONCLUSIONS
  Many studies lacked sufficient power to estimate precise risks. Most reports were hindered by imprecise measures of exposure and lack of confounding variable control. However, there were indications that maternal smokeless tobacco use increases rates of stillbirth, low birth weight and alters the male:female live birth ratio. Maternal smokeless tobacco use may not be safe for mother or foetus.
authors.affiliation: Queensland Health and School of Nursing and Midwifery, The University of Queensland, Brisbane, Australia, angela.ratsch@health.qld.gov.au.
authors.forename: Angela
authors.initials: A
authors.lastname: Ratsch
authors.forename: Fiona
authors.initials: F
authors.lastname: Bogossian
mesh_terms: D000328:Adult; D005260:Female; D014943:Global Health; D006801:Humans; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D008297:Male; D008425:Maternal Behavior; D064887:Observational Studies as Topic; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000209:etiology*; D011297:Prenatal Exposure Delayed Effects / Q000453:epidemiology / Q000209:etiology*; D011634:Public Health / Q000706:statistics & numerical data*; D012307:Risk Factors; D012744:Sex Ratio; D050497:Stillbirth / Q000453:epidemiology; D014030:Tobacco, Smokeless / Q000009:adverse effects* / Q000706:statistics & numerical data; D055815:Young Adult