Prevalence and associated factors of water pipe smoking among Iraqi secondary school students: a cross-sectional study

The prevalence of waterpipe tobacco smoking has surged globally, posing a significant threat to public health, particularly among adolescents and young adults. This study aims to assess the prevalence, knowledge, beliefs, and possible associated factors with waterpipe smoking among secondary school students. A cross-sectional study was conducted among 649 secondary school students in Al-Najaf Province between March 1, 2020, and August 31, 2021. Participants were recruited using a non-probability, convenience sampling approach through educational channels in both urban and rural areas, as well as from private and government schools. Data were collected using an online, anonymous, structured, self-administered modified Arabic version of the WHO Global Youth Tobacco Survey (GYTS) questionnaire. Data analysis was performed using SPSS version 26, employing descriptive and bivariate, size effect, and multiple logistic regression statistical analyses. The prevalence of waterpipe smoking was 29.4%. Among waterpipe smokers, 25.9% initiated smoking at ages 9–10, and 36.7% also smoked cigarettes. Male sex was independently associated with waterpipe smoking (AOR 7.83, 95% CI 3.74–16.41). Parental smoking remained a strong independent predictor, most notably maternal smoking (AOR 16.76, 95% CI 6.89–40.76) and smoking by both parents (AOR 11.38, 95% CI 1.88–68.79). Waterpipe smokers were more likely to perceive smoking as attractive for males (43.7% vs 4.2%) (p < 0.001), (Cramér’s V = 0.493). Perceived harmfulness differed markedly (p < 0.001; Cramér’s V = 0.645): only 25.5% of smokers reported that smoking is “certainly” harmful compared with 87.4% of non-smokers. This study found a high prevalence of waterpipe smoking among children and adolescents. Associated factors include male sex, parental smoking, particularly by mothers, and smoking of other family members.