Health Risks of E-cigarettes, Smokeless Tobacco, and Waterpipes

Approved by the Cancer.Net Editorial Board, 09/2023

Tobacco use is responsible for more than 8 million deaths around the world each year. This includes many people who do not use tobacco but are exposed to its effects.

Cigarette smoking is the most common way to use tobacco worldwide. However, there are many other ways, and all of them are harmful. This information is about the use of tobacco and/or related chemicals such as nicotine in forms other than cigarettes.

Examples of these other forms include:

  • E-cigarettes or "vaping"

  • Smokeless tobacco

  • Waterpipes

These come in various forms, sizes, and flavors. Each contains chemicals and toxins that can cause cancer and other serious health problems. Learn more about these forms below.

E-cigarettes or "vaping"

Electronic cigarettes are also known as e-cigarettes, e-cigs, vape pens, and vapor cigarettes. They may look like regular cigarettes, pens, or USB flash drives. They can be battery operated or rechargeable.

E-cigarettes do not burn tobacco. Instead, they have cartridges filled with liquid. When heated, this liquid turns to steam that you inhale.

Inhaling steam instead of smoke might make vaping sound better than smoking cigarettes. However, the liquid contains harmful substances that have not been fully studied. These can include:

  • Chemical flavors

  • Nicotine

  • Tetrahydrocannabinol (THC), the ingredient that gives marijuana its main psychological effects

  • Cannabinoid (CBD) oils; CBD is another compound derived from marijuana

  • Other chemicals

The type of toxins, and how much there is, is different for different devices. But all e-cigarettes are harmful. They are regulated or banned in more than 100 countries. In 2019, the U.S. Food and Drug Administration (FDA) made them illegal to sell to people under 18 in the United States.

What are the health risks of e-cigarettes?

Research is still ongoing to understand the risks of using e-cigarettes. But studies have shown that long-term use of e-cigarettes is linked to problems with brain and heart health.

The chemicals in e-cigarettes have also been linked to many health problems, including cancer. These include:

  • Lung disease (see "Lung disease linked to e-cigarettes" below)

  • Acute lung injury

  • Chronic obstructive pulmonary disease (COPD)

  • Lung cancer

  • Asthma

  • Heart disease

The chemicals found in secondhand emissions from e-cigarettes are also linked with serious lung diseases. Learn more about what people with cancer and survivors should know about the health risks of using e-cigarettes.

Lung disease linked to e-cigarettes

In 2019, researchers identified a severe lung disease, called EVALI, that is linked to the use of e-cigarettes. An additive called Vitamin E acetate may be the cause, but e-cigarettes contain many other substances that can cause illness.

In the United States, the U.S. Centers for Disease Control and Prevention (CDC) and the FDA have recommended that people stop using e-cigarettes. If you do use them, the CDC recommends:

  • Do not change the cartridge or add anything to it

  • Do not buy e-cigarettes from street vendors

  • Pay close attention to your health

Lung disease symptoms include:

  • Coughing

  • Shortness of breath

  • Chest pain

  • Fatigue

  • Abdominal (belly) pain

Contact your doctor right away if you have these symptoms.

What if I use e-cigarettes to quit smoking?

There is some evidence e-cigarettes can help people trying to quit cigarette smoking, but using these products brings their own health risks that need more study. The FDA has not approved e-cigarettes as a way to quit smoking.

Instead, the FDA recommend other methods for quitting smoking. If you have used e-cigarettes to stop smoking, do not return to smoking cigarettes instead of using e-cigarettes. Turn to other ways, such as nicotine patches, gum, lozenges, and nasal spray. Learn more about ways to quit smoking and using tobacco, and talk with your health care team about next steps so you get the support you need to quit tobacco.

Smokeless tobacco

Smokeless tobacco products contain tobacco or tobacco blends. They have many names, and there are several types.

Chewing tobacco. This is tobacco in the following forms:

  • Loose leaves

  • Leaves pressed together, commonly called a plug

  • Leaves twisted together to resemble a rope, commonly called a twist

Chewing tobacco sits between the cheek and gum. You usually spit out the tobacco juices. Long-time users may swallow some.

Snuff. This is finely ground tobacco. It comes in dry or moist forms. It is sometimes packaged in ready-to-use pouches.

Dry snuff can be sniffed or swallow dry. Moist snuff is placed between the gum and lip or cheek. Then, it slowly absorbs.

Snus. This is moist tobacco powder in a pouch. The pouch is placed inside the cheek so the tobacco absorbs. The pouch is not swallowed. It must be thrown away after it is used.

Tobacco companies often market snus to people who smoke, because it is allowed in smoke-free areas. But it does not help you use less tobacco.

Dissolvable tobacco. This is powdered tobacco in a small, hard form like candy. It dissolves in the mouth.

What are the health risks of smokeless tobacco products?

Long-term smokeless tobacco use can cause disease, including cancer and heart disease.

Some smokeless tobacco products have 3 to 4 times more nicotine than cigarettes. The substances in smokeless tobacco raise your risk of mouth and throat cancer.

Chewing tobacco may cause white patches, called leukoplakia. They appear on the gums, tongue, or lining of the mouth. Most are not cancer, but some show early signs of cancer. Mouth cancer often happens nearby.

Smokeless tobacco products also cause tooth problems. They are a cause of gum disease and tooth decay.

Many people believe these products are less harmful than smoking and can help people stop smoking. But there is no scientific evidence for this. Many other methods and medications are approved to help you quit smoking.


Another popular alternative tobacco product is the waterpipe. Some people call them hookahs, and they have many other names. They have been used around the world for hundreds of years.

Modern-day waterpipes have 4 main parts:

  • A broad base to hold water

  • A pipe connecting the bowl to the base

  • A small bowl on top of the pipe. The bowl holds tobacco or another substance

  • A rubber hose attached to a mouthpiece. The smoke is pulled from the mouthpiece.

Vendors sell small packets of tobacco mixture in various flavors.

Waterpipes are often used by groups of people. This means many different people are sharing the mouthpiece.

Waterpipes may seem safer than smoking because water filters the smoke. But there is no proof this is less harmful than breathing smoke directly.

What are the potential health risks of waterpipes?

The risks of waterpipes include:

The same toxins as cigarettes but in higher quantities. Waterpipe smoke has high levels of many toxins found in cigarettes. These include carbon monoxide, heavy metals, and chemicals linked to cancer.

Cancers associated with the toxins and chemicals are:

  • Lung cancer

  • Stomach cancer

  • Bladder cancer

  • Esophageal cancer

Other conditions associated with the toxins and chemicals include:

  • Heart disease

  • Lung diseases like emphysema, which causes difficulty breathing

Waterpipe smoking sessions last up to 1 hour. This exposes you to higher toxin levels than cigarette smoking.

Potential to spread disease. Sharing a waterpipe raises your risk of getting a virus or other infection. Mouthpieces are often not cleaned properly or sanitized.

Nicotine addiction. Waterpipes and cigarettes contain similar levels of nicotine. Nicotine is highly addictive.

Questions to Ask Your Health Care Team

  • What are the health risks of using the form of tobacco or nicotine delivery that I use?

  • What do you recommend to help me quit?

  • How can I find ongoing support to help me with quitting?

  • What is my risk if I live with someone who uses tobacco or vapes?

  • How can I best help them quit?

Related Resources

Talking With Your Doctor About Your Tobacco Use

Is Vaping Safe? 1 in 5 Young Americans Think So.

Is CBD Safe for People With Cancer?

How Does Smoking Increase Your Health Risk: An Expert Q&A

More Information

Centers for Disease Control and Prevention: E-Cigarettes

Centers for Disease Control and Prevention: Smokeless Tobacco Fact Sheets

FDA: Tobacco Products What We Know About Electronic Cigarettes

World Health Organization: Waterpipe Tobacco Smoking

American Lung Association: E-cigarette or Vaping Use-Associated Lung Injury (EVALI)