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Key points We analyzed 27 brain MRI studies (15,913 participants) comparing offspring exposed to tobacco in pregnancy versus unexposed controls. Exposed offspring showed structural differences, including a thinner cortex and smaller frontal, parietal, and temporal volumes. Altered brain activity within the frontal, parietal, and temporal lobes of the exposed offspring were consistently identified. Our meta-analysis found a reduced activity in the right inferior frontal gyrus of the tobacco-exposed offspring. Maternal smoking during pregnancy may alter brain development in the offspring, but more research is needed on real-world impacts

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