Preeclampsia stands as one of the most common and significant complications during pregnancy, characterized by hypertension and proteinuria, often leading to adverse maternal and fetal outcomes [1]. Despite extensive research efforts, its etiology and risk factors remain multifactorial and not entirely understood [2].

Among the various factors explored, smoking has been a subject of interest due to its potential effects on vascular health and endothelial function, which are central to the pathophysiology of preeclampsia [3]. Traditionally, cigarette smoking has been associated with a myriad of adverse health outcomes, including cardiovascular diseases and various cancers [4]. Paradoxically, however, several epidemiological studies have suggested a potential protective effect of cigarette smoking against the development of preeclampsia. This phenomenon has sparked considerable debate and prompted further investigation into the underlying mechanisms and clinical implications [5], [6].

The proposed protective effect of cigarette smoking on preeclampsia has been attributed to various biological mechanisms, including alterations in placental development, vascular function, and immune response [7], [8]. Carbon monoxide, the primary psychoactive component in cigarettes, has been hypothesized to modulate these pathways through its vasoconstrictive and immunomodulatory effects [9]. Additionally, smoking-induced changes in maternal hemodynamics and oxidative stress have been proposed as potential contributors to the observed protective effect [10].

While the association between cigarette smoking and preeclampsia has been explored extensively, the association between WP (also known as hookah or shisha) smoking and preeclampsia remains relatively understudied. WP smoking, characterized by the inhalation of flavored tobacco smoke through a water-cooled pipe, has gained popularity worldwide, particularly among young adults and women of reproductive age [11]. Despite its increasing prevalence and potential health implications, limited research exists regarding its impact on pregnancy outcomes, including preeclampsia [12], [13].

Given the evolving landscape of tobacco use patterns and the emerging popularity of alternative smoking methods such as WP smoking, there is a critical need to investigate the potential associations between different forms of smoking and pregnancy-related complications, including preeclampsia. In light of the conflicting evidence regarding the effects of cigarette smoking and the paucity of data on WP smoking in the context of preeclampsia, our cohort study aims to address this gap by elucidating the independent and comparative effects of cigarette and WP smoking on the risk of developing preeclampsia among pregnant women. By examining these associations comprehensively, we seek to provide valuable insights into the potential public health implications and clinical management strategies related to tobacco use during pregnancy.