This study identified significant predictors of tobacco smoking (including cigarettes and shisha) in the Gaza Strip. This study with a representative sample aimed to assess the burden of smoking among adults aged above 40 years in Gaza.
In the context of cigarette smoking, a greater likelihood of smoking was associated with being male. Historically, smoking has been more socially accepted among men than among women. Furthermore, findings from neuroimaging data indicate that smoking triggers reward pathways in men more than in women.17 Additionally, advertising agencies have traditionally targeted male consumers using role models such as actors and athletes. Given the near absence of smoking among women in the population of Gaza, we focused our analysis exclusively on men. Smoking is nearly nonexistent among women in Gaza, and if it does occur, it is not openly reported due to societal taboos. Women might also be more aware of the negative impact of smoking, especially its impact on pregnancy.18
In our study, smoking was also found to be less prevalent among older adults. This can be explained by the fact that older individuals might have quit smoking due to health conditions that make it inadvisable or due to its negative impact on their overall wellbeing. Another plausible explanation is that individuals aged 70 years and above are more likely to be healthy and are initially nonsmokers. 19
Our study also revealed an association between being physically active in the past year and reduced cigarette smoking. Individuals who lead a healthy lifestyle by exercising are more likely to be smoke-free. Relying on physical activity is an excellent stress relief mechanism that can be adopted rather than resorting to tobacco smoking.20 Recent studies have shown that physical activity is an effective mechanism used in many smoking cessation programs.21
Furthermore, our study revealed a negative correlation between intermediate education and cigarette smoking. Educated individuals are better equipped to understand the detrimental effects of smoking and may have a higher socioeconomic status, granting them improved access to healthcare services and the means to participate in smoking cessation programs. Conversely, individuals with intermediate education may face limitations in resources and healthcare access compared to their higher-educated counterparts, potentially resulting in lower smoking rates among this group.8,22
Regarding body mass index (BMI), individuals who were overweight or obese had a lower likelihood of being smokers. Smoking has the potential to curb appetite and increase metabolism, leading to smokers often having a reduced BMI. Conversely, individuals with a higher BMI are at increased risk of developing several noncommunicable diseases.23
Having health insurance was associated with a lower risk of smoking. Health insurance is a marker of higher socioeconomic status in Gaza. People with health insurance generally have better access to healthcare services. Furthermore, smokers are less likely to purchase insurance deals, which contradicts theoretical expectations given the serious complications that can arise from smoking.24
In our study, we found that working in the past 30 days, having cash assistance or being married were not associated with cigarette smoking.
Moreover, being elderly or receiving cash assistance was negatively associated with smoking.14,15
In relation to the study's secondary outcomes in men, these data are limited by the fact that they are self-reported and elicited at the same time as the smoking questionnaire. Therefore, they are looking for associations, and no causal implications can be drawn.
Cigarette smoking was found to be significantly associated with a history of CAD and CLD. Conversely, no association was found between smoking shisha rice and a history of these noncommunicable diseases. In fact, studies have shown that the number of cigarettes smoked is associated with the number of damaged vessels and the severity of CAD.24 Moreover, according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, approximately 50% of smokers will eventually develop COPD.25 In our study, no significant association was noted between cigarette smoking and the risk of developing stroke. Indeed, it was demonstrated in the literature that up to one-quarter of all strokes are directly attributed to cigarette smoking. No association was noted between shisha smoking and the risk of developing noncommunicable diseases such as CAD, CLD and stroke. This might be related to the small population size of people who smoke shisha, which may negatively impact the study’s power to detect a significant difference.
Limitations/Strengths
The data were collected three years prior to the beginning of the Gaza War on October 7, 2023. The insights derived from these data may remain pertinent for the population and could offer valuable understanding of the risk factors for noncommunicable diseases associated with smoking, particularly in a population currently contending with a healthcare system that has completely collapsed. Despite war-related destruction, preconflicting data remain a vital resource for informing public health strategies, shaping policies, and guiding long-term health planning and interventions during the reconstruction of Gaza's healthcare system.
The current study provides valuable insights into the predictors of cigarette and shisha smoking in the Gaza population. Although this is one of the largest reports on the prevalence of smoking in Gaza, there are several limitations to consider. First, the study's cross-sectional design prevents us from establishing temporality and determining whether subjects were exposed to smoking before or after contracting diseases.
Another limitation of the study is that all variables, including smoking and reporting NCDs, relied on self-reported data. This introduces the possibility of overestimation or underestimation in some cases, potentially affecting the accuracy of the findings. Additionally, due to the low prevalence of shisha rice, the statistical models employed may lack power or may not fit the data well.
Moreover, as this study was not primarily designed to investigate smoking as the main outcome, there may be additional predictors of smoking that were not included in the analysis, such as family history of smoking, peer pressure, advertising and media.
It is important to acknowledge these limitations, as they provide context for the findings and emphasize the need for further research to overcome these challenges and gain a more comprehensive understanding of smoking behavior in the Gaza population.
The current study on the predictors of cigarette and shisha smoking in the Gaza population is a significant contribution to the literature. This study not only provides important information on smoking patterns in the Gaza population but also sheds light on the risk of developing noncommunicable diseases such as cardiovascular diseases and chronic lung disease. Several key strengths of the study can be highlighted. First, the study boasts a reasonably large sample size, ensuring that the findings are based on a substantial number of participants. This approach enhances the statistical power and reliability of the results. A notable strength is the representative nature of the sample, which ensures that the prevalence rates of smoking and associated risk factors accurately reflect the population of interest. Another strength of the study lies in its ability to assess multiple outcomes and predictors. By examining the relationship between smoking and various diseases, this study provides a comprehensive understanding of the risks associated with smoking.