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Introduction Smokeless tobacco (SLT) use is a growing and significant public health issue in low- and middle-income countries. SLT consumption impairs nutrient absorption, particularly iron, leading to poor nutritional status and reduced hemoglobin levels. The study aimed to assess the association between SLT consumption and hemoglobin levels (Hb) among 6 to 12-year-old school-going children in rural Matiari, Pakistan. Methods An analytical cross-sectional study was conducted over 40 days (August-September 2024) in four schools in Matiari, Pakistan. Children aged 6-12 years from classes I-V who provided assent and parental consent were included. Those with hematological diseases, nutritional deficiencies, or a history of intestinal worm infestation were excluded. A systematic sampling strategy was employed to enroll at least 14 students per class and a minimum of 70 children per school. Data on SLT use, dietary habits, and health-related factors were collected using a structured, pre-tested questionnaire via REDCap software. SLT use was defined as consuming any SLT product for at least five minutes per day within the last 30 days. Hemoglobin (Hb) levels (g/dL) were measured using the HemoCue Hb 301 system device, while height (cm) and weight (kg) were recorded using a digital scale. Data were analyzed using Stata version 17.0. Result Among 283 participants, 34 (12.01%) reported SLT use. The median hemoglobin level among SLT users was 10.8 g/dL (IQR: 9.8-11.7) compared to 11.2 g/dL (IQR: 10.1-12.2) among non-users. The difference in hemoglobin levels was not statistically significant (p = 0.17). 151 (53.36%) were boys, and the median age was 8.06 years (IQR: 7-9). In multivariable analysis, SLT use was associated with a - 0.40 g/dL change in hemoglobin (95% CI: - 0.97 to 0.17) (p = 0.28). Most of the children used SLT for 1-3 days in the past 30 days (79.41%). Conclusion SLT users had lower hemoglobin levels, although the results were not statistically significant. Overall, children have lower hemoglobin levels, and most of them used SLT for the first time before age 6 or between ages 7 and 8, which is a major public health concern. Keywords: Smokeless tobacco, Hemoglobin, Children, Public health, Pakistan

Introduction Smokeless tobacco (SLT) use is a growing and significant public health issue in low- and middle-income countries. SLT consumption impairs nutrient absorption, particularly iron, leading to poor nutritional status and reduced hemoglobin levels. The study aimed to assess the association between SLT consumption and hemoglobin levels (Hb) among 6 to 12-year-old school-going children in rural Matiari, Pakistan. Methods An analytical cross-sectional study was conducted over 40 days (August–September 2024) in four schools in Matiari, Pakistan. Children aged 6–12 years from classes I–V who provided assent and parental consent were included. Those with hematological diseases, nutritional deficiencies, or a history of intestinal worm infestation were excluded. A systematic sampling strategy was employed to enroll at least 14 students per class and a minimum of 70 children per school. Data on SLT use, dietary habits, and health-related factors were collected using a structured, pre-tested questionnaire via REDCap software. SLT use was defined as consuming any SLT product for at least five minutes per day within the last 30 days. Hemoglobin (Hb) levels (g/dL) were measured using the HemoCue Hb 301 system device, while height (cm) and weight (kg) were recorded using a digital scale. Data were analyzed using Stata version 17.0. Result Among 283 participants, 34 (12.01%) reported SLT use. The median hemoglobin level among SLT users was 10.8 g/dL (IQR: 9.8–11.7) compared to 11.2 g/dL (IQR: 10.1–12.2) among non-users. The difference in hemoglobin levels was not statistically significant ( p  = 0.17). 151 (53.36%) were boys, and the median age was 8.06 years (IQR: 7–9). In multivariable analysis, SLT use was associated with a − 0.40 g/dL change in hemoglobin (95% CI: − 0.97 to 0.17) ( p  = 0.28). Most of the children used SLT for 1–3 days in the past 30 days (79.41%). Conclusion SLT users had lower hemoglobin levels, although the results were not statistically significant. Overall, children have lower hemoglobin levels, and most of them used SLT for the first time before age 6 or between ages 7 and 8, which is a major public health concern.