Background:
Alternative tobacco product (ATP) use is increasing in Lebanon. Dokha (or 'diziness') is an ATP smoked in a pipe called a midwakh. Research evidence suggests high nicotine content, with resultant physiologic effects. The objective of this study was to assess prevalence and correlates of midwakh tobacco use among 7^th-12^th grade students in Lebanon.

Methods:
The analyses is based on one question included in the 2016 Lebanon Global School-based Student Health Survey (GSHS) that assessed past 30-day (current) use of midwakh in a representative sample of 5708 7^th-12^th graders sampled from public and private schools. All analyses were weighted accounting for the multi-stage cluster sampling design.

Results:
Overall, 4.6% of students were current midwakh users, varying between 3.9%-5.4% across grade levels. A significantly higher percentage of males than females currently smoked midwakh (6.7% versus 2.7% respectively). Current use was higher in public versus private school students (6.3% vs. 3.6% respectively) but this difference was not statistically significant. Midwakh use was significantly associated with current smoking of cigarettes [OR: 16.61; 95%CI=12.21-22.58], as well as initiating cigarette smoking prior to 14 years of age among cigarette smokers [OR: 2.31; 95%CI=1.53-3.49]. Midwakh smoking was also statistically significantly related to ever smoking of waterpipe [OR: 9.89; 95%CI=6.78-14.45], current use of any tobacco products other than cigarettes [OR: 14.29; 95%CI=8.53-23.94], parental smoking [OR: 1.61; 95%CI=1.13-2.2], and with second-hand smoking [OR: 1.73; 95%CI=1.11-2.70].

Conclusions:
This study is one of the few that has provided prevalence rates and determinants of midwakh use outside of the Arabian Gulf, where it has been mostly confined. Although prevalence remains low, its consistency across grade levels is concerning. In addition, the pattern of associations is in line with evidence on other tobacco products. A trans-disciplinary research agenda for midwakh is urgently needed to understand use and effects, and contain its spread.