Background <p>Dry eye symptoms are common and can negatively affect visual function and quality of life, particularly among young adults. Electronic cigarette use has increased markedly in this age group; however, evidence regarding its association with dry eye symptoms, especially in Middle Eastern populations, remains limited.</p> Methods <p>A cross-sectional study was conducted among undergraduate students enrolled at multiple Palestinian universities in the West Bank between January and May 2025. Data were collected using a structured self-administered questionnaire assessing sociodemographic characteristics, smoking status, and dry eye symptoms measured by the Ocular Surface Disease Index (OSDI). Smoking status was categorized as non-smoking, exclusive e-cigarette use, exclusive traditional cigarette smoking, or dual use of e-cigarettes and traditional cigarettes. Dry eye symptom severity was classified using established OSDI cutoffs. Crude and adjusted associations between smoking status and dry eye symptom severity were evaluated using ordinal logistic regression, adjusting for age, sex, and academic year.</p> Results <p>A total of 450 participants were included in the analysis, of whom 58.2% of participants had dry eye symptoms defined as an OSDI score &gt; 12 (mild, moderate, or severe categories). In adjusted analyses, Dual use of e-cigarettes and traditional cigarettes was significantly associated with higher odds of more severe dry eye symptoms compared with non-smoking (OR = 2.35; 95% CI 1.23–4.49; <i>p</i> = 0.010). Exclusive e-cigarette use was associated with higher odds of dry eye symptom severity (OR = 1.64; 95% CI 0.89–3.02; <i>p</i> = 0.113), although this association did not reach statistical significance. Traditional cigarette smoking demonstrated an inverse association with dry eye symptom severity in crude analysis (OR = 0.49; 95% CI 0.25–0.96; <i>p</i> = 0.038), which was no longer significant after adjustment (OR = 0.90; 95% CI 0.43–1.90; <i>p</i> = 0.789). The proportional odds assumption was not violated.</p> Conclusions <p>Dual use of e-cigarettes and traditional cigarettes is independently associated with increased severity of dry eye symptoms among Palestinian undergraduate students. These findings suggest that combined smoking behaviors may pose additional ocular health risks and highlight the need for targeted awareness and preventive strategies addressing smoking-related ocular surface symptoms among young adults.</p> Clinical trial number <p>Not applicable.</p>