Dual Use of Tobacco and Khat in Eastern Ethiopia: A Qualitative Study

Abstract

Background:

Tobacco-khat co-use is common in Ethiopia, where khat is cultivated. However, information is limited regarding tobacco-khat co-use among adults in the study setting.

Aims:

(1) Explore behavioral patterns of tobacco-khat co-use, and (2) investigate the factors associated with tobacco-khat co-use in Haramaya district, and Maya City, Eastern Ethiopia.

Methods:

We conducted eight focus groups with adult males (n= 36, 4 FGs) and females who use tobacco (n = 18, 2 FGs), and community leaders (n =17, 2 FGs). Participants were purposively recruited. The interview guide addressed tobacco–khat co-use behaviors and related factors. The data were analyzed using thematic analysis.

Results:

The male participants had a mean age of 37.7 (SD ± 12.4), while the females had a mean age of 44.9 (SD ± 15.5) years. Males initiated tobacco and khat use at a younger average age compared to females. All participants acknowledged the widespread co-use of tobacco-khat in the region. Two key themes emerged: (1) Tobacco use is tied to khat consumption, reflecting distinct behavioral patterns of co-use. (2) Multiple drivers of co-use included deeply rooted social and cultural practices, progression from habitual use to dependence, and accessibility and affordability.

Conclusion:

Findings suggest that male participants begin tobacco and khat use at an earlier age, driven by socio-cultural norms and gendered expectations. This co-use is sustained by multiple reinforcing drivers: perceived synergistic stimulation between khat and tobacco, deeply rooted social and cultural practices, progression from habitual use to dependence, and accessibility and affordability, which perpetuate the behavior. Thus, effective cessation programs must address co-use and be adapted to sociocultural realities.

Introduction

Tobacco use is a major global health threat, causing more than 8 million deaths each year [1]. It significantly increases the risk of heart attack and stroke, with tobacco use attributed to 26% and 7% of ischemic heart disease deaths in men and women, respectively [2]. Smoking also weakens immune function, exacerbates diabetes outcomes, and contributes to infertility and low birth weight [3].

Khat (Catha edulis) refers to the young leaves and shoots of a shrub native to eastern Africa and the Arabian Peninsula [4]. It is consumed for its stimulant properties, primarily due to cathinone and cathine, which induce euphoria and alertness [5]. Studies have linked khat use to increased heart rate, insomnia, and psychological distress, and long-term risks for both physical and mental health [6–8].It has also been associated with oral carcinoma [9], low birth weight [10], premature rupture of membranes, congenital anomalies, perinatal mortality, maternal anemia, and psychosis in pregnant women [11], and cognitive deficits [12].

Prior research highlights the frequent co-use of khat and tobacco in regions where khat consumption is culturally entrenched [13]. A global review found disproportionately high tobacco use among people who use khat, with smoking prevalence ranging from 30–60% across regions [14]. A meta-analysis found that khat use was associated with cigarette smoking, highlighting the persistence of this public health issue [15]. Community surveys in Eastern Ethiopia (Harar and Dire Dawa) reported 40–50% of people who use khat also smoked during or after sessions[16]. Co-use of tobacco and khat has been linked to increased burden of chronic diseases, like cardiovascular conditions and certain cancers, and khat’s stimulant effects, intensified by nicotine, increase cardiovascular strain and the risk of hypertension and arrhythmias [17]. People who use tobacco and khat have reported increased anxiety, irritability, and sleep disturbances [18], mental health issues, and cognitive impairment [19–21], poor oral health, gastrointestinal issues, and reduced appetite, which may lead to nutritional deficits [22]. Dual use extends beyond health concerns, creating significant socioeconomic challenges [18]. Moreover, co-use intensifies the addiction potential, complicating tobacco cessation efforts [19, 23–25].

Studies have identified multiple factors associated with dual use of tobacco and khat. This pattern is more common among males, older adolescents, particularly those with limited awareness of health risks [26], lower educational attainment [27], and within contexts where khat use is socially normalized [6]. This pattern is also more common in urban residents, driven by peer and family influence, unemployment, and psychological distress, and in communal khat-use settings [18, 22], migrant communities, as well as in individuals experiencing social marginalization and mental health vulnerabilities [28].

Ethiopia ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in 2014, aiming to reduce tobacco use through taxation, advertising bans, education, smoke-free policies, and cessation support. However, these provisions did not address khat use [29]. Tobacco-khat co-use continues to be a challenge in Ethiopia, where access to healthcare and cessation support is often limited [30]. Understanding the intertwined drivers of co-use is critical for developing effective implementation strategies[31]. The sociocultural and psychological influences that perpetuate these behaviors remain poorly understood [32], particularly in khat cultivation regions [33]. Therefore, the primary objectives of this study were to (1) explore the behavioral patterns of tobacco-khat co-use, and (2) identify the key factors associated with tobacco-khat co-use among adults in both urban and rural settings in Eastern Ethiopia. The findings will inform targeted cessation programs and policies to reduce co-use and improve health outcomes.

Methods

Research team and reflexivity

The study followed the COREQ framework, a 32-item checklist covering research team and reflexivity, study design, and data analysis reporting. It ensures the transparent reporting of team roles, methodology, context, and findings [34]. The data collection team consisted of three researchers, two male and one female. One researcher held a Master’s in Public Health degree, while the two others held doctoral degrees in Nursing. The male researchers conducted interviews with male participants, while the female researcher conducted interviews with female participants. Matching the interviewer and participant genders helps respect cultural boundaries and reduce discomfort. Researchers described their role primarily as facilitators of dialogue, focusing on creating a respectful and open space for participants to share their experiences. The research team was well-versed in qualitative research methods and proficient in both English and Afaan Oromo (the local language). There were no interactions between the researchers and participants before the study. The intention was to avoid interaction between the researchers and participants before the study began, aiming to minimize bias and preserve the authenticity of the study. It also helped maintain a neutral environment, reduce social desirability effects, and unbiased data collection in line with qualitative research best practices.

Study setting

Haramaya district and Maya city are situated in the East Hararghe region of the Oromia state in Ethiopia, 500 km from the capital, Addis Ababa, and 18 km west of the city of Harar. The district comprises 34 rural kebeles (the smallest administrative unit) and three urban kebeles, with a total population of 310,000. Khat cultivation plays a dominant role in the local economy, serving as the primary source of income for many households [35].

Study design and population

A qualitative study using focus groups (FGs) was conducted among adult people who use tobacco and community leaders, comprising 71 participants. Inclusion criteria included male and female adults aged 18 years and older who smoked manufactured or traditionally prepared tobacco products, including shisha, or other forms of tobacco either daily or occasionally, within the past 30 days, had resided in the study area for at least six months, and were willing and able to provide informed consent.

Community leaders were individuals recognized by the residents of their village and institutions for their leadership roles. These included religious leaders, elders, traditional leaders, and local government officials. Participants had at least one year of active engagement in community leadership, resided in the study area for at least one year, and were willing and able to provide informed consent. Additionally, they were involved in health-related community mobilization activities relevant to the study. Recruitment used local networks of health officials (i.e., health extension workers) to enable participant selection. Accordingly, the study included six FGs with adult males (n=36, 4 FGs) and females (n=18, 2 FGs) who use tobacco (n=54), and two FGs with community leaders (n=17).

Data collection methods

Initially, interview guides were developed after reviewing previous studies [35, 36] and were drafted in English. These guides were first reviewed by native English speakers from the research team. They were subsequently translated into Afaan Oromo by bilingual team members to ensure both linguistic and cultural accuracy. These guides were piloted in the Sofi district of the Harari region, and then, a few questions related to khat use were modified and included at the end of the interview, given the sensitivity of the topic. All interviews were conducted in Afaan Oromo to ensure cultural appropriateness and facilitate open communication, allowing participants to express their experiences in their native language, thereby enhancing depth and authenticity. Separate FGs were held for males, females, and community leaders to ensure open discussion. Each interview lasted approximately 40-75 minutes, which were audio-recorded while note-taking on non-verbal cues. Data collection continued until no new information emerged, indicating data saturation. The point of saturation was reached by the fourth focus group among male participants, and by the second focus group among female participants and community leaders. Member checking involved sharing summaries of discussions with participants at the end of the session to ensure their views and experiences were accurately captured. In addition, follow-up questions were strategically used during discussions to probe ambiguous responses and ensure an accurate understanding of their intended meaning. Together, these approaches strengthened the trustworthiness and contextual richness of the data.

Data analysis

Thematic analysis was employed to identify key themes from the transcribed verbatim. Three members of the research team independently conducted transcription and translation to ensure accuracy and contextual fidelity. An inductive (data-driven) approach was employed to analyze the qualitative data, allowing themes to emerge directly from participants’ narratives without imposing pre-existing theoretical frameworks. Analysis was conducted following Braun and Clarke’s six-phase process [37]. Team members initially familiarized themselves with the data through a rigorous review of the transcripts and notes, and by listening to the recordings. Then, initial codes were independently generated by two of the team members who systematically coded the data across the full dataset. These codes were subsequently organized into potential themes. The themes were reviewed and refined to ensure they accurately reflected the data. After clear definitions and names were assigned to each theme, a coherent and concise narrative was developed and supported by direct quotes. Peer debriefing and bracketing were used to strengthen analytic rigor and reduce potential researcher bias, which involved regular discussions to reflect on the data collection process and emerging findings. Bracketing was applied to identify and set aside personal assumptions and preconceptions, allowing participant narratives to guide the analysis.

Ethics approval and consent to participate

Ethical approval was obtained from the Institutional Health Research Ethical Review Committee of the College of Health and Medical Sciences, Haramaya University, with Reference number IHRERC/234/2024. Informed consent was obtained from all participants before their involvement in the study. Participants were assured of the confidentiality and anonymity of their responses. The study adhered to ethical guidelines to ensure respect and protection for all involved participants. There were no formal incentives offered for them; however, they were provided with snacks and 1-liter bottles of water during the FG discussions.

Results

Demographics and tobacco-khat use patterns of participants

The mean age of male participants was 37.7(standard deviation [SD]± 12.4) years, and female participants was 44.9 (SD± 15.5) years. Smoking onset in males was 16.1 (SD, 4.4) years and 33.3 (SD± 14.6) years in females. Khat use started at 15.1 (SD± 3.1) years in males and 22.8 (SD± 7.2) years in females. Men smoked an average of 13.5 (SD± 8.2) cigarettes/day, over double that of women at 6.2 (SD± 5.3) cigarettes. Khat use duration was comparable between males at 20.6 (SD±12.3) years and females at 21.7 (SD±14.9) years (Table 1).

Table 1.

Demographics and tobacco-khat co-use patterns of participants (n=54).

Variables	Male (n=36) Mean (±SD)	Female (n=18) Mean (±SD)
Age, in years	37.7 (12.4)	44.9 (15.5)
Age of initiation of tobacco use	16.1 (4.4)	33.3 (14.6)
Age of khat initiation	15.1 (3.1)	22.8 (7.2)
Number of cigarettes used per day	13.5 (8.2)	6.2 (5.3)
Duration of tobacco use, in years	21.2 (13.5)	15.7 (15.1)
Duration of khat use, in years	20.6 (12.3)	21.7 (14.9)

Demographic profile of the community leaders

The majority of community leaders (n=15) were aged 27-60 years old. Village leaders (n=6) were central to local decision-making, counseling, education, and advocacy. Religious leaders (n=6) provided spiritual education and guidance. Additionally, Abba Geda (i.e., community council leader, n=4) represented traditional leadership, offering guidance on social, economic, health, and political matters within the Oromo community (Table 2).

Table 2:

Demographic profile of community leaders participating in focus groups (n=17).

Variable	Frequency	Percentage (%)
Age group, in years
27-60	15	88.2
60 +	2	11.8
Educational level
Unable to read and write	1	5.9
Can read and write	2	11.8
Grade 1-8	8	41.2
Grade 9 and above	5	35.3
Quran study only	1	5.9
Role in the community
Village representative	6	35.3
Religious leader	6	35.3
Abba Geda (Elder)	4	23.5
Youth association leader	1	5.9

Behavioral patterns and factors associated with tobacco-khat co-use

We identified two key themes related to tobacco-khat co-use behaviors. First, co-use was strongly embedded in prevailing social and cultural norms, reinforced by community practices. Secondly, perceived stimulant synergy, social and cultural reinforcement, emerging patterns of addiction and dependence, and accessibility and affordability were key factors associated with tobacco-khat co-use (Table 3).

Table 3:

Summary of key findings from focus group participants in Maya city and Haramaya district, Eastern Ethiopia, 2025 (n=71).

Main theme	Sub-theme	Descriptions
Behavioral pattern of tobacco-khat co-use	Deeply embedded practice	A habit that is firmly rooted within the community refers to a consistent practice, behavior, or tradition that has become an integral part of the community’s daily life and identity.
	Interplay between tobacco and khat	Refers to the complex, often synergistic relationship between khat and tobacco use.
	Emotional reinforcement	When substance use repeatedly provides emotional relief or reward, it reinforces patterns that promote initiation and sustain habitual use.
	Routine of tobacco-khat co-use	A habitual and structured pattern of tobacco and khat co-use, such as smoking after khat use, or in response to stress.
Factors associated with tobacco-khat co-use	Perceived stimulant synergy	A strong belief that co-using khat and tobacco intensifies psychoactive effects, boosting stamina, alertness, and focus more than using either substance alone.
	Social and cultural reinforcement	Substance use patterns, including khat and tobacco co-use, are shaped by personal motives, cultural norms, and social feedback like rituals, peer approval, and community expectations.
	Addiction and dependence	Compulsive substance use despite adverse consequences or harms that are driven by physical or psychological need.
	Accessibility and affordability	Tobacco and khat can be easily obtained through markets or communal sharing during khat sessions; khat is affordable, often due to its low cost or locally grown options.

Theme 1: Behavioral patterns of tobacco-khat co-use

The participants stated that tobacco and khat are frequently co-used, woven into daily routines and cultural traditions. This co-use is sustained by a complex interplay of cultural norms, social influences, and behavioral patterns. The phenomenon can be explored through three interrelated sub-themes: embedded practices, routinized use, and the interplay of khat and tobacco use with emotional reinforcement.

Deeply embedded practices

The participants explained that tobacco and khat are often consumed together in structured social settings, and khat use is viewed as the norm. The widespread social acceptance and availability of both substances normalize co-use, shaping everyday routines and interpersonal dynamics. Early and repeated exposure to tobacco during khat sessions further reinforces smoking habits and contributes to persistent smoking rates.

“Tobacco and khat go together. I mostly use khat, but I also smoke sometimes.” (P3, 22-year-old male farmer, using tobacco for 4 years).

Another participant stated that tobacco is an essential catalyst that activates khat’s effects. This reflects deeply held beliefs about substance interplay, reinforcing a pattern of habitual co-use.

“When you use khat and smoke a cigarette with it, you will have proper urination. Unless you use cigarettes in addition to using khat, your body motors will not work.” (P8, 35-year-old male, using tobacco and khat for 17 years)

Interplay in khat-tobacco co-use

Participants described how the timing and context of khat use frequently prompted tobacco smoking, revealing a pattern of co-use behavior. They reported that khat use sessions often create a psychological and social environment that encourages smoking, either during or immediately after the session.

“Many young people start smoking when they start khat use.” (P5, 40 years old, community representative).

The participants also reflected their experiential belief that the co-use of tobacco and khat enhances physical and mental readiness for work, illustrating that the interplay between tobacco and khat use, which is framed as a means for labor support.

“When we smoke and use khat, we feel energized to work.” (P1, 70-year-old woman, uses traditional tobacco for 40+ years).

“Khat and tobacco go together. The addiction of khat and tobacco is the same. We will not use khat if we don’t have tobacco. We will sleep if there is no tobacco besides khat.” (P6, 60-year-old male farmer, smoking for 45 years)

Emotional reinforcement

Participants felt that tobacco-khat co-use helps maintain emotional balance, which may counteract anxiety, boost confidence, and sustain relaxation during khat sessions. This perceived effect contributes to dependence on tobacco, not only for its physiological stimulation but also for its role in managing psychological states.

“When you use khat, your soul will need smoking. I started tobacco use at the age of forty.” (P8, 70-year-old woman, using manufactured and locally prepared tobacco products)

Tobacco-khat co-use patterns

Participants described how tobacco and khat use are interconnected with daily work routines, specifically during rest or break periods. Their use not only facilitates recovery but also provides psychological comfort, reinforcing habitual engagement through perceived relaxation. One participant emphasized that tobacco-khat co-use often occurs at specific times of the day, making it deeply embedded in everyday life.

“I will lie down to rest and use khat and smoke a cigarette from 12:00 p.m. to 2:00 p.m.” (P4, 35-year-old woman, using tobacco for two years)

Theme 2: Factors associated with tobacco-khat co-use

Participants described multiple interrelated factors driving tobacco-khat co-use. These included the perceived synergistic stimulation, whereby tobacco was seen to amplify khat’s psychoactive effects; strong social and cultural reinforcement, with communal use and smoking practices embedded in everyday life; dependence-related patterns, in which habitual use evolves into addiction; and the role of social events, and accessibility and affordability substances, which often serve as entry points or reinforcing factors for dual consumption. Together, these factors suggest that co-use is shaped by both physiological motivations and socially embedded practices.

Perceived stimulant synergy

Participants expressed that khat’s stimulant properties were insufficient on their own, with tobacco intensifying the desired psychoactive effects. This perceived synergy contributed to a habitual pattern of dual use, in which tobacco became embedded in the khat-use ritual, often from the very onset of initiation. Many participants perceived that without tobacco, the khat experience felt incomplete. As one participant explained,

“We are stimulated from use khat, we add a cigarette to increase our stimulation more.” (P1, 40-year-old male construction worker, using tobacco for 26 years)

Participants explained that tobacco use is closely tied to labor practices, with the combined stimulant effect of khat and tobacco perceived to enhance endurance and reduce fatigue in physically demanding jobs. This pattern suggests that dual substance use may serve as a functional adaptation to the demands of strenuous labor. One participant described the experience briefly:

“When we use tobacco and khat, we feel energized to work” (P1, 70-year-old woman, 40+ years using traditional tobacco).

Many individuals believed that co-use enhances energy, focus, and productivity, particularly in demanding work environments. This perception seems to foster habitual tobacco use. The participant highlighted this belief:

“I feel strong enough to work when I use cigarettes along with khat.” (P5, 50-year-old male farmer, smoking for 35 years)

Social and cultural reinforcement

The co-use of khat and tobacco is deeply embedded in social settings, particularly in communal gatherings and peer interactions. Within khat-use circles, smoking is frequently initiated, reinforcing patterns of dual use through social modeling and shared ritual. Participant recounted:

“I started tobacco when we used khat together. We used to share khat and water. We then started using tobacco together.” (P3, 30-year-old male farmer using tobacco for 5 years)

Another participant highlighted how social occasions normalized dual use.

“We used to use khat when we went to the home of our friends’ or fiancé’s home and used tobacco along with khat.” (P2, 50-year-old male farmer, using tobacco for 25 years)

Addiction and dependence

The simultaneous use of tobacco and khat appears to intensify patterns of addiction and dependence, creating a mutually reinforcing cycle. Participants expressed a strong psychological attachment to khat and tobacco, reporting that even when they recognized its negative effects on health, family life, and finances, they found it difficult to stop. This highlights how substance use becomes a coping mechanism, reinforcing dependence despite awareness of harm.

“We tried to stop it and failed so far… Today, when I am very eager to smoke because of my addiction.” (P5, 5-year-old farmer, used khat and tobacco for 35 years)

“I stopped for 2 days. I destroyed household utensils and materials. I beat my children. I started to smoke again.” (P7, 46-year-old farmer, used khat and tobacco for 28 years)

Accessibility and affordability

Participants indicated that the widespread availability and affordability of locally grown tobacco and khat in both rural and urban markets greatly influence co-use patterns. Their presence in roadside shops, khat-use gatherings, and informal markets promotes regular co-consumption. Participants from Awaday, Adele, and Finkile reported various forms of locally found tobacco, highlighting its accessibility.

“Some farmers may cultivate tobacco for personal use or local sale.” (P4, 35 years, smoking for 2 years).

“There is traditionally used tobacco like ‘Burii’, a sublingual form made from ash and plant roots, sniffed, and hand-rolled cigarettes prepared from locally grown tobacco.” (P2, 35 years old, using tobacco for 20 years).

In addition, participants reported that various tobacco brands, predominantly those not commonly produced in Ethiopia, are being imported through informal routes from Somalia and Djibouti. These contraband routes enable the circulation of foreign cigarette brands, often bypassing regulatory oversight and contributing to the widespread availability of potent tobacco products.

“Different tobacco brands imported through Somalia and Djibouti. People get them from contrabandists.” (P1, 70 years old, using traditional and modern tobacco products).

Discussion

This study explored the dual use of tobacco and khat and investigated the factors associated with tobacco-khat co-use in Haramaya District and Maya City, Eastern Ethiopia. The study found that both tobacco and khat use tend to be initiated earlier by males than by females. In addition, far from incidental, this dual use is reinforced by multiple drivers: the perceived synergistic stimulation of the substances, their embedding within entrenched social and cultural traditions, the progression from habitual use to dependence, and availability and affordability normalize and perpetuate the behavior.

The study showed that tobacco-khat co-use emerges as a patterned and interdependent practice in which tobacco consumption is deeply integrated into the khat use experience. However, such dual co-use of tobacco and khat intensifies cardiovascular, respiratory, and oral health risks [17, 22], creating a compounded burden compared to single-substance use. Moreover, it perpetuates and consolidates dual addictive behaviors, where one induces and sustains the use of the other, thereby complicating cessation strategies beyond single -substance intervention. This evidence calls for harmonized strategies that integrate khat into tobacco control and regulate access.

In this study, males were found to initiate tobacco and khat use earlier compared to females. This gender-based disparity in initiation likely reflects the interplay of socio-cultural norms, gendered expectations, and peer dynamics [13]. In many communities across Ethiopia, substance use among males is comparatively permissible [38]. These kinds of perceptions may facilitate earlier exposure and access to tobacco and khat, leading to patterns of early initiation and highlighting gender-specific vulnerabilities requiring targeted interventions.

The study also revealed that tobacco and khat are often used together, influenced by various factors. Khat sessions are usually followed by tobacco use, which is not merely due to pharmacological effects, but because the two behaviors are deeply intertwined within social and cultural practices [36, 39]. This conditioned association may occur, where one can trigger the other, reinforcing co-use. The coupling is common during gatherings and work routines, sustaining alertness, sociability, and endurance. Moreover, khat is cultivated as a profitable cash crop in the region, while tobacco is widely marketed and accessible, and these dynamics reinforce the co-use [18, 22]. To address this, National tobacco control frameworks should extend regulation to khat, limiting its availability together with tobacco, and address the economic and cultural drivers that sustain tobacco–khat co-use through taxation, awareness campaigns, and alternative livelihoods.

It was reported that tobacco-khat co-use was shaped by perceived stimulant synergy. Participants believe that combining these substances produces a synergetic stimulant effect. The reason for this perception could be due to khat containing cathinone, which increases alertness, euphoria, and energy. However, scientific evidence shows that long-term use can impair cognition and cause negative mood [40]. Nicotine in tobacco also enhances dopamine release, which intensifies khat’s stimulant effects. That could be the possible explanation for why people often report that tobacco-khat co-use prolongs the euphoric state and reduces fatigue [36, 41]. In substance use, starting one may lead to another, intended to enhance or counteract its effects [42].

In this study, social and cultural reinforcement play an essential role in sustaining the dual use of these substances. Evidence showed that khat use often co-occurs with tobacco use in social events and informal peer circles [35], and tobacco use during these sessions is perceived as enhancing the experience and maintaining group cohesion, indicating participation, and supporting the tempo of collaboration despite growing evidence indicating its adverse health effects[43, 44]. Moreover, its deep-rooted cultural acceptance of khat and tobacco may normalize and encourage habitual consumption patterns [14, 22].

The study revealed that addiction is central to khat-tobacco co-use, which was described as a deeply intertwined pattern of co-dependence, where tobacco becomes an essential component of the khat-use experience. This finding may be explained by difficulty in stopping use once initiated, even when the individual is aware of the adverse consequences [45]. Khat use is also deeply tied to daily routines and social gatherings. With repeated use, what begins as a cultural practice gradually evolves into dependence [36]. These perceived benefits reinforce continued use, contributing to dependence over time [46]. The co-use of khat and tobacco augments health risks and dual dependence, which further complicates tobacco cessation efforts.

The study presented that accessibility of tobacco and khat plays a decisive role in shaping co-use patterns. This finding is consistent with reports from the USA [47], South Africa [48], Abu Dhabi[48], and Ethiopia [40]. The proximity of both substances reduces logistical barriers, embedding them into daily routines and social interactions, which normalizes consumption and reinforces patterns of dual use. In parallel, research confirms that Khat is economically accessible and affordable, which intensifies the widespread use, embedding it into daily life and strengthening dual consumption patterns [13, 22]. Although Ethiopia implemented a tobacco tax reform in 2020, the overall tax share of the retail price remains below the WHO-recommended threshold of 70% [29]. Moreover, evidence from Ethiopia indicates that the specific excise component has not been adjusted for inflation, causing its real value to decline over time and keeping cigarettes relatively affordable [49]. Collectively, these findings imply that both availability and affordability are significantly associated with the dual use of tobacco and khat. Policy response might therefore focus on increasing taxation of tobacco and tobacco; regulating informal and unlicensed markets; subsidizing cessation supports (nicotine replacement, counseling, etc.) alongside alternative livelihood opportunities.

Conclusion

This study revealed the complex behavioral patterns and investigated the factors associated with tobacco-khat co-use in Haramaya district and Maya City, Eastern Ethiopia. Findings showed that early initiation among males is shaped by socio-cultural norms and gendered expectations, while ritualized co-use of khat and tobacco is reinforced through communal practices and perceived stimulant synergy, which may exacerbate dependence. The dual use is a socially entrenched behavior, maintained by conditioned associations, cultural acceptance, and economic incentives, despite known health risks.

To effectively address the entrenched practice of khat–tobacco co-use in the study setting, a multi-layered strategy is essential. This includes reshaping perceptions of stimulant synergy, fostering alternative communal activities to disrupt ritualized patterns of use, and developing integrated cessation programs tailored to dual-use behaviors. In addition, advocating for local regulations that restrict tobacco sales near khat hubs. These approaches should be contextually grounded, culturally sensitive, and supported by strong health system integration to effectively mitigate the dual burden of tobacco and khat use in Eastern Ethiopia.

What this paper adds.

What is already known about this topic?

• Tobacco use is disproportionately high among people who use khat.

• Men exhibit a markedly higher tendency than women to use khat and tobacco concurrently.

What does this study add?

• Behavioral and psychosocial patterns of people who use tobacco and khat are distinct from single-substance use.

• Contrary to common assumptions, dual use of khat and tobacco is common among females.

• The social and cultural interdependence of tobacco-khat co-use, with co-use deeply rooted in daily routines and community norms.

• Khat may act as a reverse gateway to use tobacco, complicating tobacco cessation.

• Tobacco and khat co-use are shaped by perceived stimulant synergy, entrenched cultural norms around communal use, progression from habit to dependence, and the reinforcing role of social gatherings.

How might this study affect research, practice, or policy?

This study fills a gap in the behavioral, psychosocial, and cultural dynamics of dual use of tobacco and khat. Implications can inform health professionals in creating culturally sensitive screening and cessation tools aligned with local norms. Policymakers may consider harmonized strategies that address both khat and tobacco, rather than treating them in isolation. The study opens avenues for longitudinal research to examine the progression from initiation to dependence in people who use both.

Availability of Data and Materials

Most of the data generated or analyzed during this study are included in this article. For the sake of protecting study participants’ privacy, the full datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.