INTRODUCTION
Over one billion people frequently smoked tobacco in 2020, with men making up the majority compared to women1. Smoking tobacco has a variety of forms, with cigarettes, the traditional form, being the most popular form, followed by waterpipe and electronic cigarettes (e-cigarettes) or vape (non-traditional forms)2. Some studies attempted to describe non-traditional tobacco smoking’s prevalence and highlighted its popularity3,4. Non-traditional tobacco smoking has become increasingly popular globally, particularly among school and university students3-5. Waterpipe, also known as hookah, shisha, and nargile, is quite popular worldwide, particularly in the Middle East3. Moreover, e-cigarettes have become more prevalent in recent years, especially among university students6. This popularity is a result of its use as a tool to assist smokers in quitting traditional smoking7. However, studies have revealed that e-cigarettes contribute to the relapse of former smokers, and some have even linked it to smoking initiation8,9 Many factors also contribute to the increased prevalence of waterpipe smoking, including family members and peer pressure4,5. Most importantly, there is misperception about the negative consequences of waterpipe tobacco smoking on health and a mistaken belief that it is less harmful than cigarette smoking10.
The north of the West Bank has become the site for growing tobacco production and consumption11. Traditional tobacco smoking, or cigarette smoking, has shown a sharply increased prevalence among Palestinian males over the last decade in Palestine11. The Palestinian Central Bureau of Statistics (PCBS) announced in 2021 that the percentage of tobacco smoking in the West Bank reached 40.1%, and the results vary based on age, gender, and the governorate11. However, in the last decade, the local epidemiological trend of tobacco smoking has undergone alarming changes, particularly in waterpipe tobacco smoking12,13. A study conducted in 2021 revealed that cigarettes were the most commonly used by daily smokers (58.9%), followed by waterpipe (23.6%) and e-cigarettes (17.5%)14. Other studies revealed that waterpipe smoking was more common among males, younger age groups, those with a lower education level12,13 and as an alternative to cigarettes smoking15. A recent study in 2023 described the epidemiology of e-cigarette smoking among Palestinians and indicated that e-cigarette smoking is prevalent among university students (13.3%)16, while the PCBS indicated that 4% of individuals aged ≥18 years in the West Bank were e-cigarette smokers11. Another study reported a high prevalence of tobacco smoking among Palestinian refugee men and linked their use with eating behaviors and obesity17. Moreover, waterpipe smoking was inversely associated with increased body mass index17. All previous research indicates that smoking is a growing problem among young Palestinians, particularly university students, and that waterpipe and e-cigarettes are emerging as significant hazards in the West Bank15,18-20. However, most of these studies focused on university students. The high rates of waterpipe smoking among young people in Palestine are concerning and could have serious health consequences in the future. Therefore, this study aimed to estimate the prevalence of non-traditional tobacco smoking (waterpipe and e-cigarettes) and compare it to cigarette smoking among men in the West Bank. In addition, the study aimed to investigate possible factors associated with waterpipe smoking and its association with obesity among male Palestinians in the general population.
METHODS
Study design and setting
A cross-sectional study was held in 2022 in the largest three governorates in the north of the West Bank: Nablus, Tulkarm, and Jenin. We aimed to cover all geographical and demographic categories of the Palestinian population in the north of the West Bank.
Population, sample size, and sampling techniques
The targeted population was males, adolescents, and adults (aged ≥16 years) from the three governorates in the north of the West Bank. There are 954000 residents in these governorates, which is 78% of the population of the north of the West Bank. In order to give subjects an equal chance to participate in this study, the study area was stratified based on the governorates and then into three locations: cities, villages, and camps. Each location was divided into four substrata: east, west, north, and south. A proportional sample size was chosen based on the governorate, the location, and then on the sub-strata of the location. Subjects were recruited to participate in this study through social media, flyers, and public announcements. Flyers were posted near or in hospitals, restaurants, municipalities, schools, and telecommunication centers. Stations and locations to meet the subjects were announced. In refugee camps, the stations were in the Committee Services for Refugee Camps. A convenience sampling technique was then used to choose the recruited subjects. The target sample size was 217 from each governorate. Those who did not consent or incompletely filled in the questionnaires, were excluded. The minimum age of selected participants was 15 years, as daily smoking often begins at this age21. This study was approved by the Institutional Review Board of An-Najah National University (ANNU) in Palestine with archived number 12 for the protocol. The study was completely anonymous, with no disclosure of personal details. Informed consent was obtained from all the participants before filling out the questionnaire.
Variables measurement
A self-administered questionnaire to report background information and variables related to general health and tobacco smoking was described elsewhere14. Briefly, the questionnaire consisted of four parts. Part one was for general information and sociodemographic data, including age, location, marital status, work status, and education level. Part two was data related to tobacco smoking, including frequency, pattern, and number of units per day. Part three was data regarding other related substance intakes: energy drinks, coffee, black and green tea, and chocolate. Part four was data related to body weight, height, and waist circumferences that were recorded by the investigators. Tobacco smoking was divided into two types: traditional and non-traditional. The traditional type included cigarette smoking, and the non-traditional type included waterpipe and e-cigarette smoking. A current smoker is defined as someone who has smoked a particular type of tobacco at least in the last 30 days. A heavy smoker was a participant who smoked >20 cigarettes per day22. Bodyweight was measured with minimal clothing and without shoes on a calibrated digital scale to the nearest 0.1 kg. The standing height without shoes was measured with a wall meter to the nearest 0.1 cm. Body Mass Index (BMI) was calculated as weight (kg) divided by height (m) squared. The waist circumference, or central obesity, was measured to the nearest 1.0 cm using a non-elastic tape. These measurements were taken following World Health Organization recommendations15. Waist circumference was measured halfway between the thoracic cage’s inferior edge and the iliac crest’s superior border23. According to the International Diabetes Federation (IDF), a waist circumference ≥94 cm is considered high24.
Data analysis
The whole process of analysis was performed using IBM SPSS Statistics for Mac, version 22 (IBM Corp., Armonk, NY, USA). Percentages were used to represent categorical variables. An adjusted binary logistic regression model was used to generate the odds ratios (OR) and 95% confidence intervals (CI) for risk factors. To account for various factors associated with waterpipe smoking, the model was adjusted for age, marital status, location, job, and other substance use, such as cigarette, e-cigarettes, chocolate, coffee, tea, energy drinks, and alcohol. Similarly, for factors associated with increased waist circumferences, the model was adjusted for age, work, BMI, and other substance use, including cigarette, e-cigarettes, chocolate, coffee, tea, and energy drinks. Next, the interaction between confounders was tested. Finally, a comparison of significant differences between groups was made. A p<0.05 was used as the significance level.
RESULTS
Characteristics of participants
In total, 1241 male subjects agreed to participate, and 37 questionnaires were excluded as they had incomplete information. The final number of participants was 1204 males aged 16–58 years. Most of the participants were singles (58.9%), with an education level of high school or lower (95.9%), had work (80.4%), and 33.4% were working students. The majority were young adults (69.4%), followed by adolescents (22.1%) and late adults (8.4%). The location of residence was closely distributed between the city (37.1%), village (34.3%), and camp (28.6%) (Table 1).
Table 1
Characteristics of participants, a cross-sectional study, West Bank, 2022 (N=1204)
Prevalence and pattern of tobacco smoking and other substance use
The prevalence of cigarette smoking was 67.5%, with 53.9% smoking more than 20 cigarettes (pack) per day with a median duration of 7.00 years. The prevalence of waterpipe smoking was 35.3%, with a median duration of 5.00 years. The majority (58.1%) were smoking on average 0.5 to one head per day. For e-cigarettes, the prevalence was 15.0%, with 52.5% having more than 30 puffs on average per day. The prevalence of other substances was as follows: coffee (78.0%), tea (57.1%), and energy drinks (46.3%) (Table 2).
Table 2
Frequencies and patterns of tobacco smoking and other substance use, a cross-sectional study, West Bank, 2022 (N=1204)
Univariate analysis of waterpipe use based on different factors
Table 3 represents the associations between waterpipe tobacco smoking and different factors. The univariate analysis shows that the prevalence of waterpipe smoking is significantly higher among cigarette smokers (p<0.001) and e-cigarette smokers (p<0.001) than non-smokers, among singles (37.7%) than married (31.9%) (p=0.04), among students without work (46.6%) than worker students (37.1%) and workers (31.4%) (p=0.003), and among adolescents (41.0%) than young adults (34.8%) and late adults (24.8%) (p=0.012).
Table 3
Univariate analysis for waterpipe use based on different factors, a cross-sectional study, West Bank, 2022 (N=1204)
Factors associated with increased waterpipe smoking
Table 4 shows the factors that were associated with increased waterpipe smoking. Adjusted logistic regression results revealed that factors that were associated with increased waterpipe smoking were cigarette smoking (AOR=0.23; 95% CI: 0.175–0.313, p<0.001), energy drink intake (AOR=1.62; 95% CI: 1.237–2.134, p<0.001), non-working students (AOR=1.95; 95% CI: 1.089–3.497, p=0.025), young adults (AOR=2.15; 95% CI: 1.145–4.032, p=0.017), working student (AOR=2.73; 95% CI: 1.318–5.650, p=0.007), and e-cigarette smoking (AOR=3.29; 95% CI: 2.301–4.70, p<0.001).
Table 4
Adjusted binary logistic regression for factors associated with waterpipe smoking*, a cross-sectional study, West Bank, 2022 (N=1204)
| Covariates | Categories | OR | 95% CI | p |
|---|---|---|---|---|
| Age (years) | Adolescents | 1.170 | 0.833–1.644 | 0.366 |
| Young adults | 2.149 | 1.145–4.032 | 0.017 | |
| Adults ® | 1 | |||
| Marital status | Single | 0.842 | 0.534–1.327 | 0.459 |
| Married ® | 1 | |||
| Location | Refugee camp | 0.894 | 0.602–1.328 | 0.579 |
| City | 0.917 | 0.618–1.359 | 0.666 | |
| Village ® | 1 | |||
| Work status | None working student | 1.952 | 1.089–3.497 | 0.025 |
| Worker | 1.277 | 0.848–1.924 | 0.241 | |
| Working student | 2.729 | 1.318–5.650 | 0.007 | |
| No work ® | 1 | |||
| Cigarette smoking | Yes* | 0.234 | 0.175–0.313 | <0.001 |
| E-cigarette smoking | Yes* | 3.287 | 2.301–4.696 | <0.001 |
| Energy drink intake | Yes* | 1.624 | 1.237–2.134 | <0.001 |
| Coffee intake | Yes* | 1.111 | 0.805–1.532 | 0.522 |
| Tea intake | Yes* | 1.146 | 0.842–1.560 | 0.385 |
Increased central obesity associated with smoking
Table 5 displays the odds of increased central obesity associated with smoking. Adjusted logistic regression results revealed that waterpipe smoking was associated with increased odds of central obesity (AOR=2.15; 95% CI: 1.97–5.12, p=0.038). Other factors that were associated with an increased odds of increased central obesity were age (AOR=1.61; 95% CI: 1.38–2.00, p=0.006) and increased body mass index (AOR=2.43; 95% CI: 1.87–3.14, p<0.001). Coffee consumption showed an inverse association with central obesity (AOR=0.44; 95% CI: 0.27–0.87, p=0.015).
Table 5
Adjusted binary logistic regression for the risk of increased waist circumference* associated with e-cigarette smoking, a cross-sectional study, West Bank, 2022 (N=1204)
DISCUSSION
In this study, cigarette and waterpipe smoking were highly prevalent among Palestinians in the West Bank (67.5% and 35.3%, respectively). These results are higher than the estimated global percentage (32.6%)1, and even those of previous local studies14,17. These results indicate that cigarette and waterpipe smoking has increased in recent years. Moreover, the prevalence of e-cigarette smoking (15%) was high compared to neighboring countries25. The lack of previous studies to compare e-cigarette results in the general population is one of the constraints of this study. Therefore, there is a need for further research in the area of study.
In this study, the majority of e-cigarette (68.5%) and waterpipe (50.8%) smokers were cigarette smokers, which indicates dual traditional and non-traditional smoking8. Waterpipes and e-cigarettes are misconstrued as being safer than cigarettes10,26. However, most e-cigarettes contain highly addictive substances, mainly nicotine, although they deliver different levels of nicotine27. Therefore, e-cigarette smokers had higher nicotine dependence than traditional smokers, and it increased with cigarette smoking27. However, it is a controversial topic that requires more research. Although e-cigarettes main purpose of use may be to help with smoking cessation, many studies have linked them to smoking relapse in former smokers and even initiation in non-smokers7,8. In addition, the duration of usage of cigarette smoking (≤47 years and a median of 7 years) and waterpipe smoking (≤17 years and a median of 5 years) was greater than that of e-cigarette smoking (≤4 years and a median of 2 years), indicating that waterpipe and e-cigarette smoking are new emerging hazards in the West Bank. In agreement with other studies, most non-traditional tobacco smokers were single young adults and students. However, more investigation is required to fully comprehend the reasons behind e-cigarette smoking among this population, given the unique cultural and social context of Palestine. This can be made through exploring factors like peer pressure, social norms, and the advertising strategies used by e-cigarette companies in Palestine12,13,17. Moreover, researchers and policymakers can work toward developing more effective strategies to prevent and reduce e-cigarette usage among young adults and students in Palestine by gaining a more comprehensive understanding of these factors. In this study, the results show a significant association between energy drinks and waterpipe smoking. Moreover, the study found that 46.3% of male Palestinians consume energy drinks, which is consistent with previous studies. These results highlight the importance of understanding the factors that can influence both consumption of energy drinks and waterpipe smoking among young adults in Palestine, specifically males. Further research in this area could help develop targeted interventions that address the unique challenges15,17.
Most waterpipe smokers (58.1%) smoked up to one head per day. In addition, the majority (53.9%) of cigarette smokers were heavy smokers (>20 cigarettes per day). One head of unflavored tobacco equals 70 cigarettes, and one session inhales several times more smoke than traditional smoking28. Likewise, most e-cigarette users (52.5%) smoke >30 puffs per day, consuming 72–164 μg of nicotine per puff (equivalent to 13–30 cigarettes at 200 puffs)27. Waterpipes have been shown to have similar respiratory effects to cigarettes29. Therefore, these findings suggest that the more a person is exposed to these materials, the greater the health risks29. Recently, Palestinian adolescent refugees who smoked waterpipes had higher rates of metabolic syndrome, dyslipidemia, and central obesity30. E-cigarettes decrease airway resistance and conductivity and increase asthma and COPD risk31. They also caused anxiety, insomnia, and depression32.
In addition to extrapulmonary effects like immunological and neurodevelopmental33,34, there may be a relation between using e-cigarettes and having greater weight35. Many of these effects are dose-dependent36. Waterpipe smokers’ lack of physical activity is often shown during long smoking sessions in cafes or while eating meals as part of socio-cultural norms that cause metabolic effects and contribute to cardiovascular disease15. In this study, increased central obesity was associated with waterpipe smoking. Although the result of e-cigarette smoking being associated with central obesity was not statistically significant, it is on the boundary of statistical significance and hence should not be ignored. Therefore, these results indicate that waterpipe and e-cigarette smoking could have a similar effect on health. However, e-cigarette health effects on body mass index are poorly described and controversial. One study found that e-cigarette smoking increased abdominal obesity in Koreans37. However, further longitudinal studies were recommended37. On the other hand, another study linked e-cigarette use to a lower BMI38. Considering the different types of tobacco smoking, the long duration of smoking, and Palestinians’ heavy tobacco use, more studies are needed to determine the health effects of e-cigarette smoking. Moreover, to avoid the health consequences of non-traditional tobacco smoking, Palestinians should be encouraged to quit and adopt healthier lifestyles. This could include evidence-based education, prevention programs, and effective smoking cessation aids.
Limitations
This study has several limitations. One of the limitations of this study is the lack of previous research to compare the results to, which could potentially limit the generalizability of the findings and make it difficult to draw firm conclusions. Therefore, we recommend further research on these topics. In addition, the number of puffs inhaled from e-cigarettes was measured regardless of the liquid concentration, which would significantly affect nicotine levels. Moreover, the initiation age for tobacco smoking was not assessed. Finally, the tea and coffee intake durations were not assessed due to recall bias. Despite these limitations, besides the large sample size, this is the first study to investigate non-traditional smoking in the general population of Palestine.
CONCLUSIONS
This study showed a new challenge in treating Palestinian males’ emerging health conditions. This study found alarmingly high rates of traditional and non-traditional tobacco smoking among Palestinian men. Over two-thirds of the general tested population smoked cigarettes, and one-third smoked waterpipes. The study recommends working on more research on the health effects of non-traditional tobacco smoking, a new West Bank hazard. We also recommend helping smokers quit and educating students and the public about e-cigarettes and their health risks. These findings can raise awareness of the adverse events that may result from continued use of these hazards and spur change.
