Background: Evidence is conflicting as to the whether tobacco smoking prevalence is higher in refugee than non-refugee populations. The aim of this study was to compare the prevalence and frequency of tobacco smoking in Palestine refugee and non-refugee adolescent populations in the Middle East. Methods: We conducted a cross-sectional analysis of the Global Youth Tobacco Survey (GYTS) conducted in Jordan, Lebanon, Syria, and the West Bank among adolescent Palestine refugees and non-refugees. Age- and sexadjusted regression models assessed the association between refugee status and current (past-30 day) tobacco use prevalence and frequency. Results: Prevalence estimates for current tobacco smoking were similar between Palestine refugee and nonrefugee groups in Jordan (26.7 % vs. 24.0 %), Lebanon (39.4 % vs. 38.5 %), and the West Bank (39.5 % vs. 38.4 %). In Syria, Palestine refugees had nearly twice the odds of current tobacco smoking compared to non-refugees (23.2 % vs. 36.6 %, AOR 1.96, 95 % CI 1.46???2.62). Palestine refugees consumed more cigarettes per month than non-refugees in Lebanon (?? 0.57, 95 % CI 0.17???0.97) and Palestine refugees consumed more waterpipe tobacco per month than non-refugees in Syria (?? 0.40, 95 % CI 0.19???0.61) and the West Bank (?? 0.42, 95 % CI 0.21???0.64). Conclusions: Current tobacco smoking prevalence is in excess of 20 % in both adolescent Palestine refugee and non-refugee populations in Middle Eastern countries, however Palestine refugees may smoke tobacco more frequently than non-refugees. Comparison of simple prevalence estimates may therefore mask important differences in tobacco use patterns within population groups.