Background <p>Tobacco smoking remains a major public health challenge in the Eastern Mediterranean Region (EMR), where progress toward global tobacco-reduction targets has been limited. In addition to cigarette smoking, waterpipe (shisha) tobacco use has become increasingly prevalent, particularly among young adults and women. In Syria, prolonged conflict has disrupted routine health surveillance, resulting in substantial gaps in contemporary population-level data on smoking prevalence and patterns.</p> Objectives <p>This study aimed to estimate the prevalence and patterns of cigarette and waterpipe smoking among adult blood donors at the Damascus University Blood Center between January and May 2024.</p> Methods <p>Sociodemographic characteristics and tobacco-use behaviors were collected using a structured questionnaire. Current smoking was defined as self-reported current use of cigarettes or waterpipe (daily or non-daily) at the time of donation, consistent with commonly used epidemiological definitions in tobacco surveillance studies.</p> <p>Smoking patterns were categorized as exclusive cigarette use, exclusive waterpipe use, or dual use. Multivariable logistic regression was used to identify independent sociodemographic predictors of current smoking.</p> Results <p>A total of 4,036 donors were included (89.8% men; median age 26 years, IQR 21–38). The overall prevalence of current tobacco smoking was 55.4%. Smoking prevalence varied across age groups and peaked in early to mid-adulthood. Cigarette smoking was the most common pattern overall (33.2%), followed by exclusive waterpipe smoking (14.1%) and dual use (7.9%). Marked sex differences were observed: smoking was more prevalent among men than women (58.4% vs. 28.8%), while waterpipe smoking constituted a larger share of tobacco use among women. In multivariable analyses, male sex (adjusted odds ratio [AOR] 2.62, 95% CI 2.03–3.39) and lower educational attainment were independent predictors of current smoking, whereas age ≥55 years was independently associated with lower odds. Income level showed no consistent gradient.</p> Conclusions <p>Tobacco smoking prevalence among Syrian adults attending a large urban blood-donation center was high relative to available regional estimates, with substantial contributions from waterpipe smoking and pronounced sociodemographic gradients. These findings highlight the urgent need for strengthened, product-specific, and equity-oriented tobacco-control strategies in Syria, particularly those addressing waterpipe use and socially disadvantaged groups.</p> <p>The results should be interpreted in light of the study’s cross-sectional design and the use of a donor-based sample, which may limit generalizability despite the quasi-voluntary nature of blood donation in this setting.</p>