Prevalence, risk perception and motivations for waterpipe tobacco use among university students in Northern Nigeria: a mixed-methods study

Introduction Waterpipe tobacco (hookah or shisha) and other alternative nicotine delivery methods are increasingly used by young adults. Understanding their prevalence, risk perceptions, motivations and predictors is essential for developing effective public health responses, especially in university settings. We determined the prevalence, risk perception, motivations and predictors of shisha use among university students in Nigeria.Methods This is a cross-sectional mixed-methods study. We collected quantitative data via self-administered questionnaires (n=431) and identified predictors using multivariable logistic regression analysis. Qualitative insights were obtained from in-depth interviews with a purposive subsample of participants (n=20) and analysed thematically.Results Among 431 respondents, 83.1% (n=358) recognised that shisha contains harmful substances; however, 10.4% (n=45) believed water filtration removed toxins. Approximately 23.0% of respondents (n=99) perceived shisha as being less addictive than cigarettes. The prevalence of ever-use was 26.2% (n=113) and 13.7% (n=59) for current use. Shisha use was independently associated with cigarette smoking (adjusted OR (aOR)=10.42, 95% CI 6.43 to 16.35), male sex (aOR=3.76, 95% CI 1.43 to 6.89), perception of shisha as being less harmful (aOR=3.53, 95% CI 1.17 to 6.34), higher weekly allowances (≥₦20 000) (aOR=3.63, 95% CI 1.42 to 7.36), course major (agriculture/management, aOR=2.47, 95% CI 1.43 to 7.24) and state of origin (aOR=1.99, 95% CI 1.12 to 4.75). Qualitative themes identified peer influence, accessibility, stress relief, psychological factors, misinformation and societal acceptance as key drivers of use.Conclusions Shisha smoking is prevalent among university students in Nigeria and influenced by a combination of behavioural, socioeconomic and regional factors. Our findings could inform the development of tailored interventions that reflect these sociocultural and contextual realities and guide national youth tobacco control strategies in similar settings.