E-cigarette Use Reaches One in Five Palestinian University Students
E-cigarette use has moved well beyond the margins of campus behavior in Palestine. In a cross-sectional survey of 1,792 university students from six universities in the West Bank, 19.7% reported using e-cigarettes, while 41.2% reported tobacco use overall. The pattern is clinically important because nicotine exposure in young adults rarely stays confined to one product. It often sits alongside waterpipe smoking, caffeine-heavy habits, peer influence, and other behavioral cues that normalize continued use.
The survey captured an early 2023 snapshot of student behavior using a self-administered questionnaire that covered sociodemographic characteristics, daily habits, exposure to smoking, and knowledge and attitudes toward e-cigarettes. The data were analyzed with descriptive statistics, χ2 testing, and multivariate regression. The result is a detailed picture of how nicotine use clusters in a university setting, where social contact and routine habits can shape both experimentation and persistence.
Knowledge was not keeping pace with product uptake. Students showed suboptimal understanding of e-cigarettes, including misconceptions about safety and health effects. In practical terms, that creates a setting where use can expand faster than risk perception. When a product is framed as cleaner or less harmful without a matching understanding of nicotine dependence, airway exposure, and cardiovascular effects, uptake becomes easier to rationalize and harder to reverse.
Misconceptions and Negative Attitudes Coexisted With Higher Use
The survey found that negative attitudes toward e-cigarettes were common, yet those attitudes did not translate into lower use. Students with negative attitudes were more likely to use e-cigarettes, with an adjusted odds ratio of 2.6 and a 95% confidence interval of 1.9 to 3.6. The finding may seem counterintuitive at first glance, but it fits a familiar public health pattern: awareness of harm does not always prevent use when social exposure, nicotine dependence, and habitual patterns are already established.
Behavior around nicotine rarely follows a simple knowledge-behavior line. Among university students, the decision to use an e-cigarette can be shaped by peer settings, routine stress relief, and easy access, even when attitudes are skeptical. The survey’s findings suggest that negative attitudes may reflect concern or ambivalence rather than protective behavior. In other words, students may dislike the product and still keep using it.
Social Exposure, Waterpipe Smoking, and Lifestyle Habits Mapped to Use
Several factors were independently associated with e-cigarette use. Gender was associated with use, with an adjusted odds ratio of 2.1 and a 95% confidence interval of 1.4 to 3.0. Waterpipe smoking showed a much stronger association, with an adjusted odds ratio of 4.5 and a 95% confidence interval of 3.2 to 6.3. Physical inactivity was also linked to use, with an adjusted odds ratio of 1.4, while high coffee consumption carried an adjusted odds ratio of 1.6. Spending time with friends, having a mother who smokes, and having a friend who uses e-cigarettes were each associated with higher odds of use as well.
The social gradient here is striking. Waterpipe smoking and e-cigarette use likely share a common behavioral environment: group use, normalization of nicotine, and ritualized consumption. Peer settings matter because nicotine products are rarely adopted in isolation. A student who spends more time with friends may face repeated cues, easier access, and stronger social modeling, all of which can reinforce experimentation and continuation.
Family exposure matters too. Having a mother who smokes was associated with e-cigarette use, with an adjusted odds ratio of 1.5 and a 95% confidence interval of 1.1 to 2.2. The same odds ratio appeared for having a friend who uses e-cigarettes, with a 95% confidence interval of 1.1 to 2.1. Home and peer environments can normalize nicotine long before a student makes an active decision to use a device. That combination of exposure and availability can lower the threshold for trying e-cigarettes and may also weaken the social friction that usually discourages use.
Why Campus Nicotine Patterns Matter Beyond the Device Itself
The biomedical concern is not limited to the e-cigarette as a standalone product. Youth and young adult nicotine use can reinforce dependence, encourage dual use with other tobacco products, and complicate later cessation. Among students who already smoke waterpipe or use tobacco, e-cigarettes may function as an additional nicotine source rather than a replacement. That makes the prevention target broader than one device type.
Physical inactivity and high coffee consumption, both linked to e-cigarette use in this cohort, also point to lifestyle clustering. Students with nicotine use may be embedded in routines that combine stimulant use, sedentary time, and socializing in settings where vaping is common. These are not trivial background details. They help explain why brief warnings about harm often fail to change behavior on their own.
Tobacco Control on Campus Needs More Than a Warning Label
This study points toward a prevention strategy that goes beyond generic health messaging. Educational initiatives are needed because misinformation about e-cigarette safety remains common. Social interventions are also necessary, since peer use and friend networks were strongly associated with vaping. Policy measures that address access and the broader nicotine environment on campus are equally important.
A comprehensive tobacco control approach for university students should not treat e-cigarettes as detached from other products. Waterpipe smoking, conventional tobacco use, and vaping appear to move through the same social channels in this population. The public health challenge is therefore not only to reduce curiosity about e-cigarettes, but also to interrupt the full network of nicotine normalization that supports use.
The study was cross-sectional, so it cannot determine direction of causality between attitudes, habits, and use. Even so, the associations are strong enough to justify immediate prevention planning in university settings. With nearly one in five students reporting e-cigarette use and misconceptions still common, the next step is not waiting for the pattern to mature. It is building campus-level interventions that reach students where nicotine behavior is forming and spreading.