Smokeless Tobacco Use and Risk of Stillbirth

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Abstract
Background: Maternal cigarette smoking has been causally associated with an increased risk for stillbirth. Preliminary reports suggest an increased risk for stillbirth with smokeless tobacco use during pregnancy. Methods: We conducted a population-based prospective cohort study to investigate this association by using a house-to-house approach to recruit 1217 women who were between 3 and 7 months' gestation. Of these, 96% were contacted after delivery to determine the pregnancy outcome. Demographic and maternal variables which were apparently associated either with stillbirth or with smokeless tobacco use (OR ≥ 1.5) were included as potential confounders. Stillbirth was defined as any delivery of a dead fetus after 20 completed weeks of gestation. We used time-to-event methods to analyze the risk of stillbirth. Results: Overall occurrence of stillbirth among singleton deliveries in this population was 4.1%. Smokeless tobacco use was reported by 17% of women; 8.9% of smokeless tobacco users had a stillbirth compared with 3.1% among nonusers (life-table adjusted hazard ratio = 3.1; 95% confidence interval = 1.7–5.6). After adjustment by the Cox proportional hazards procedure for age, educational and socioeconomic background, working status of mother, parity, prenatal care variables, and place of delivery, the risk for stillbirth in users was 2.6 (95% confidence interval-1.4–4.8). Most women used mishri (a pyrolyzed tobacco product often used as dentifrice), and there was a dose–response relationship between the daily frequency of use and stillbirth risk. The risk of stillbirth associated with smokeless tobacco use was greater in earlier gestational periods. Conclusions: Smokeless tobacco use during pregnancy increases stillbirth risk, with a risk at least as great as that associated with maternal cigarette smoking.