All forms of smoking are bad for the heart. Studies suggest that waterpipe smoking, also referred to as shisha and hookah, may be associated with even greater toxin exposure because sessions are longer and involve more and larger "puffs," leading to smoke inhalation as much as 100 times more than from a cigarette.

"Smoking of all types is still, without any competition, the strongest risk factor for cardiovascular disease. It beats everything. There has been a lot of research over the past 2-3 years which makes us very clear that all tobacco use, including the waterpipe, smokeless tobacco and electronic cigarettes, is simply not good for your health," said ESC prevention spokesperson Professor Joep Perk.

Studies suggest that waterpipe smoking, also referred to as shisha and hookah, may be associated with even greater toxin exposure because sessions are longer and involve more and larger "puffs," leading to smoke inhalation as much as 100 times more than from a cigarette.

"Electronic cigarettes may be moderately effective in helping smokers quit but they need the same marketing restrictions as cigarettes to avoid uptake by young people and non-smokers," said Prof Perk.

The ESC advocates that electronic cigarettes should be regulated as a tobacco and medical product in the European Commission's Tobacco Products Directive. Scientific evidence shows that even cartridges labelled as containing "no nicotine" may contain nicotine and other toxic substances and that flavours such as vanilla or chocolate attract children.

Tobacco use among adolescents is increasing, and in some countries (e.g. Czech Republic, Latvia, Lithuania), tobacco use among youth is very similar to that among adults.

Prof Perk highlighted the importance of stopping teenagers from beginning to smoke. He said: "I would compare it with a fire in a hay barn. In the beginning it smokes a little but in the end the whole thing goes up in flames. If you start smoking in your teens you won't suffer immediately but you start a process of vascular damage5 that you will have to pay for later in life. It's the worst thing you can do to your health."

He added: "The job of parents as role models and educators has not been underlined strongly enough. Parents are responsible for their kids and can't give up on them when they become teenagers. A 12 year old who starts smoking also begins the process of atherosclerotic disease with inflammation in the vascular wall. Parents need to be very strict and not allow smoking because we know it is so damaging to health."

Prof Perk continued: "The tobacco industry knows how to infiltrate youth activities by promoting cigarettes during rave parties and discos. This is unacceptable and we need stricter controls. Legislative measures on packaging, no sale of tobacco products to under-18s and forbidding smoking in public places including school yards is essential."

The ESC is lobbying for the protection of young people in the Tobacco Products Directive through banning flavours, avoiding trademarks or promotions and instead introducing plain packaging, displaying health warnings on 75% of the back and front surfaces of packages, having age verification systems for retailers with large economic penalties for those who fail to comply, and requiring medicine authorisation for all non-tobacco nicotine containing products.

Passive smoking is also deadly. A non-smoker living with a smoking spouse has an estimated 30% higher risk of cardiovascular disease and exposure in the work place poses similar risks.

Prof Perk said: "There are so many studies now confirming that passive smoking carries a significant risk for cardiovascular disease. This includes secondary smoke from all sources including the waterpipe."

He concluded: "Smoking of all types is the number one villain in the battlefield of cardiovascular disease prevention. Smoking is two times more significant for heart attacks on a population level than nutritional habits, physical activity and other risk factors. Countries that want to get rid of heart attacks should get rid of smoking before even thinking about anything else."