Heart failure in water pipe smokers: a review of evidence on ventricular dysfunction, oxidative stress, and inflammatory pathways

Water pipe smoking, commonly referred to as hookah or shisha, is a centuries-old practice that has gained global popularity in recent decades, particularly among young adults. This resurgence is fueled by its cultural appeal, social nature, and the perception of it being a safer alternative to cigarette smoking. However, mounting evidence suggests that waterpipe smoking has significant cardiovascular consequences, including the development of ventricular dysfunction, a precursor to heart failure. Heart failure (HF), a complex clinical syndrome characterized by the heart's inability to pump blood adequately, affects approximately 64 million people worldwide, with regional variations in prevalence and etiology. In high-income countries, the prevalence ranges from 1-2% of the adult population, increasing to over 10% in individuals above 70 years, while in low- and middle-income countries (LMICs), the prevalence is often underreported due to limited healthcare access. Emerging evidence links water pipe smoking to ventricular dysfunction through mechanisms such as oxidative stress, systemic inflammation, and direct myocardial toxicity. Comparative studies highlight that a single water pipe session delivers greater quantities of carbon monoxide and nicotine than a cigarette, intensifying cardiovascular strain. These substances induce myocardial hypoxia, lipid peroxidation, and cytokine-mediated inflammation, impairing ventricular function. Given the growing prevalence of water pipe smoking, especially among younger populations, this practice constitutes an underrecognized but significant public health risk. Addressing the cardiovascular implications of water pipe smoking requires targeted research and global efforts to enhance awareness, implement preventive strategies, and inform healthcare policies. Water pipe smoking, commonly known as shisha or hookah, is often perceived as a safer alternative to cigarettes. However, mounting evidence shows that it significantly harms the heart. This review highlights how water pipe smoking contributes to heart failure by damaging the heart's pumping ability, increasing oxidative stress, and triggering harmful inflammation. These effects, when prolonged, can lead to severe cardiovascular complications. Understanding these risks is crucial for public awareness and emphasizes the need for stricter regulations and preventive measures against waterpipe smoking.