WTS seems to be a more popular method of tobacco smoking compared to cigarette smoking among Palestinian university students in our study sample (24.4% vs. 18.0%). In comparison to other studies in the oPt, our reported WTS prevalence was considerably higher than the prevalence reported by PCBS among enrolled university students (17–25 years old), which increased from 0.5% in 2000 to 2.0% in 2010. This finding could be due to the fact that PCBS estimates are based on proxy self-reported smoking. As for the reported prevalence of ‘other tobacco products,’ mainly attributed to WTS, among Palestinian health students, our current WTS prevalence fell within the documented range of 12.3% to 30.9% (2007) .
In relation to documented WTS prevalence among university students elsewhere, our results were overall consistent with other studies. For instance, our WTS prevalence surpassed the reported current WTS prevalence of 5.6% in the United Arab Emirates (2005) . Additionally, it was lower than the current WTS prevalence of 36.3% reported among university students in Saudi Arabia (2010) , the 40.0% among university students in South Africa (2013) and the 37.8% among women university students in Egypt (2007) [29, 30]. In comparison to the prevalence of WTS in Western countries, a study among U.S. university students had a lower reported WTS prevalence of 12.5% compared to our reported prevalence (2011) . Another study among medical students in the U.K. reported a WTS prevalence of 11.0% and a 6.3% cigarette smoking prevalence , both of which were lower than our reported prevalence for WTS and cigarette smoking, respectively. This evidence reveals varying degrees of WTS use and popularity in different contexts, which could partially be due to existing tobacco laws and in part due to the social and cultural acceptability of WTS among youth [33, 34]. In addition, when considering the higher reported prevalence of WTS among our study sample in comparison with the prevalence in countries such as the U.S. and the U.K., it is worth pointing out that WTS has been linked to social class and prestige in the Middle Eastern culture, while the opposite was true in Western countries [8, 9, 19, 35,36,37,38]. Some studies in the U.S. have also found a higher WTS prevalence among university students from Arab or Middle Eastern decent in comparison to students from other backgrounds [31, 39]. These studies grant support to both the cultural and symbol status associated with WTS among Middle Eastern students. Regular monitoring of WTS among young people, especially from Middle Eastern backgrounds, needs to be in place to curb the WTS prevalence from escalating.
Among our study sample, the higher prevalence of WTS compared to cigarette smoking supports the increased popularity of WTS among youth, as an acceptable alternative to cigarette smoking. This is also supported by the tolerability of WTS among families in the Arab culture [8, 9]. The higher prevalence of WTS could also reflect an emerging WTS epidemic among youth in the Eastern Mediterranean Region. In the oPt, results from the 2015 youth survey revealed that 50.0% of the sample (15–29 years old) believes that the major health issues they face are induced by behaviors such as tobacco smoking . Still, many youth perceive WTS as less harmful than cigarette smoking and show a lack of intent to quit [40,41,42]. These findings could elicit an alarm towards an increased risk of continuation of WTS into adulthood, thus contributing to the WTS epidemic.
The smoking profile and patterns of our study sample were overall consistent with the published literature [8, 9, 43]. For instance, age of initiation of WTS was slightly higher than for cigarette smoking. The age of initiation coincides with a transitional period from high school to university, a period thought to involve many behavioral changes, including tobacco smoking [44,45,46]. Our study design did not allow us to study this transitional period, thus future research should target youth during this phase. The average WTS duration among our study sample of 63 min fell within the range reported in other studies [8, 9, 33, 47]. The long duration of a WTS session can be due to the cultural aspect of WTS where it is viewed as a pleasurable social activity that brings together family and friends. In some studies, participants expressed that the waterpipe availability in restaurants and cafes at an affordable cost further encourages them to smoke waterpipe. In addition, others brought attention to the role of sensory qualities of WTS and innovative designs of the waterpipe instrument in encouraging continued practice of WTS. These testimonies could support the longer duration of a WTS session in comparison to cigarette smoking, which is viewed as an individualistic and habitual practice with no ties to any social or cultural aspect [8, 9, 33, 37, 47, 48].
Consistent with other studies [9, 17, 49, 50], the gender-gradient of WTS and cigarette smoking was evident among our study sample, with a higher smoking prevalence among men in comparison to women. This could be explained by the socio-cultural beliefs about tobacco smoking, in which there still exists a distinction between men and women smoking habits; this finding was corroborated during our interviews. However, our results also reflect a smaller gender gap in WTS compared to cigarette smoking; some studies have indeed alluded that the gender gap for WTS is absent or diminishing [9, 17, 49, 50]. Among our study sample, while men were about 11 times more likely to be current cigarette smokers compared to women, for WTS, men were about 4 times more likely to be current waterpipe tobacco smokers compared to women. This finding could be due to the cultural perception that WTS is more tolerated for women compared to cigarette smoking [8, 9]. Qualitative studies have addressed the various social attitudes surrounding women’s WTS such as, “expression of eagerness for more liberal choices,” which could also explain the changing gender gap in WTS . These findings call for tailored WTS-interventions for men and women and a re-assessment of the social attitudes surrounding men and women smoking behaviors.
Our finding that students who live in the West Bank had higher odds of being current waterpipe and cigarette tobacco smokers compared to those from the Gaza Strip was consistent with some studies that observed regional variation in the prevalence of tobacco smoking [10, 51,52,53]. Among our study sample, the cultural aspect of WTS, which is characterized by social, cultural and familial acceptability or, lack thereof, could explain the regional variation in the practice of WTS. In addition, the presence and differential access to WTS cafes around universities in different areas of the oPt could also explain the observed regional variation in the prevalence of WTS. In our study sample, 57.1% indicated that during their last WTS session, they had smoked waterpipe at a restaurant or coffee-shop. This finding was also corroborated during our interviews, highlighting the presence of single-gendered and student-friendly cafes in different geographic areas of the oPt. When considering the results in the Gaza Strip, caution should be taken into account when comparing the prevalence of WTS between the West Bank and Gaza Strip. Many studies, including two in the oPt, have linked exposure to conflict and violence to an increased risk of tobacco smoking [54,55,56,57]. However, due to a dearth of documentation on the recent impact of the Gaza war on the smoking behavior of Gaza Strip residents, there is a need for further research to accurately interpret the results.
As for university-related characteristics among our study sample, students at the faculties of arts and humanities had higher odds of being waterpipe and cigarette tobacco smokers compared to those studying at the faculties of sciences and health sciences. This could be viewed in light of the type of education that students in the sciences and health sciences receive about smoking [9, 43]; further research is needed to assess the level of knowledge among students on the health risks associated with WTS. In addition, this finding supports the important role of the educational system in incorporating the effect of WTS on health in the curriculum , especially that a study among Palestinian youth revealed a lack of awareness on health issues, including smoking . Furthermore, the finding that students with a low self-reported academic achievement had higher odds of being current waterpipe and cigarette tobacco smokers is consistent with the literature [53, 59, 60]. This could be due to the social network of friends that is created through WTS, which encourages smoking, indirectly shifting attention from studies.
Strengths and limitations
The current study provided invaluable information on the higher prevalence of WTS compared to cigarette smoking, marking WTS as a potential public health concern among university students in the oPt. To the best of my knowledge, this is the first study on the prevalence of WTS among university students in both the West Bank and Gaza Strip and the first study to compare the prevalence and associated factors between WTS and cigarette smoking. The prevalence results can thus act as a baseline for future studies. In addition, this study is the first to utilize the core questions from the GATS, which can support future local and regional comparisons. The current exploratory study had some limitations inherent in its cross-sectional design, which is not intended for generalizations. The study has only provided a glimpse into the factors which contribute to WTS and cigarette smoking among Palestinian university students. Given our objective to explore the WTS prevalence and behavior among selected universities, it was also not our intention to select a representative sample from the university student population where the results could be generalized outside the participating universities. With the equal sample strategy, the study focused on shedding light on the current situation of WTS behavior among a sample of Palestinian university students. In addition, the use of a cross-sectional design hampers the ability to make any causal links between our outcome variables and associated factors. Lastly, participation in the study was based on self-selection, which has an inherent bias in the characteristics of the non-respondents.