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

Approved by the Cancer.Net Editorial Board, 07/2017

Cigarette smoking has slowly been declining in the United States. But many alternatives have been gaining popularity.

Alternative tobacco and nicotine delivery products are:

  • E-cigarettes

  • Smokeless tobacco

  • Waterpipes

These come in various forms, sizes, and flavors. They are often marketed as being relatively safe. However, alternative tobacco products contain potentially harmful chemicals and toxins. These may cause serious health problems, including cancer. Because of these risks, the US Food and Drug Administration (FDA) started regulating these products in 2016.

If you smoke or use these products, talk with your doctor. Find out about ways to quit.


Electronic cigarettes are also known as e-cigarettes or vapor cigarettes. They are battery-operated devices. Some e-cigarettes are made to look like traditional cigarettes. Other devices such as tank systems do not look like cigarettes. E-cigarettes do not burn tobacco. Instead, they have cartridges filled with nicotine and other chemicals. The liquid chemicals turn into a vapor or steam that a person inhales.

E-cigarettes may contain harmful substances. But the types or concentrations of chemicals a person is exposed to will vary by brand, type of device, and how it is used.

E-cigarettes have only been readily available in the United States since 2006. As a result, there’s limited research on their health risks.

It is important to note that the FDA has not approved e-cigarettes as a way to quit smoking. Doctors and the FDA recommend evidence-based methods for quitting smoking. Learn more about the options available to quit smoking.

Smokeless tobacco

Smokeless tobacco products contain tobacco or tobacco blends. They have many names. And they fall into several categories.

Chewing tobacco. This is tobacco in the following forms:

  • Loose leaves

  • Leaves pressed together, commonly called plug

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

Chewing tobacco sits between the cheek and gum. Usually the person spits out the tobacco juices. But long-time users may swallow some of the juices.

Snuff. This is finely ground tobacco. It comes in dry or moist forms. It is sometimes packaged in ready-to-use pouches. People usually sniff or swallow dry snuff. In contrast, people place moist snuff between the gum and lip or cheek. Then, it slowly absorbs.

Snus. This is a tobacco product that originated in Sweden. Typically, the moist tobacco powder is packaged in a pouch. People place it inside the cheek for absorption. The pouch isn’t made to be swallowed. It must be thrown away after use.

Tobacco companies often market snus to people who smoke cigarettes because it is allowed in smoke-free areas.

Public health advocates worry that snus undermines efforts to reduce tobacco use. Currently, laws ban smoking in certain public places. But the option to use snus may promote continued tobacco use.

Dissolvable tobacco. This is powdered tobacco that’s compressed. It resembles a small, hard candy that dissolves in the mouth.

Dangers of smokeless tobacco products

Prolonged use of smokeless tobacco products contributes to serious health issues such as, cancer and heart disease. Some smokeless tobacco products contain 3 to 4 times more nicotine than cigarettes. And these products contain substances that increase risk of oral and oropharyngeal cancer.

Chewing tobacco may cause white patches, called leukoplakia. They appear on the gums, tongue, or lining of the mouth. Most of these are noncancerous, but some show early signs of cancer. Oral cancer often occurs near patches of leukoplakia.

Smokeless tobacco products also cause dental problems and contribute to gum disease and tooth decay.

Many people claim that these products are less harmful than smoking and can help people stop smoking. But these alternatives are not evidence-based methods for quitting smoking and are not supported by the FDA.


Another popular alternative tobacco product is the waterpipe. Waterpipes are also called hookahs, among other names. People worldwide have smoked them for centuries. Particularly in the Middle East, Asia, and Africa.

Modern-day waterpipes are composed of 4 main parts:

  • A small bowl on top of the waterpipe. This holds a mixture of shredded tobacco and sweetener

  • A broad base to hold water

  • A pipe connecting the bowl to the base

  • A rubber hose attached to a mouthpiece through which smoke is pulled

Small packets of the tobacco mixture are sold in various flavors. People can smoke waterpipes alone. However, waterpipes are often used in social settings. Multiple people commonly share the same mouthpiece.

In the United States, waterpipes are especially popular among college students and young people. Unfounded assumptions about their relative safety fuel the trend. People think that water can “filter” tobacco smoke, making it less harmful. But there’s no proof of this.

Potential health risks associated with waterpipes:

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

Cancers associated with the toxins and chemicals:

  • Lung cancer

  • Stomach cancer

  • Bladder cancer

  • Esophageal cancer

Other conditions associated with the toxins and chemicals:

  • Heart disease

  • Respiratory diseases like emphysema, which causes difficulty breathing

Typically, waterpipe smoking sessions last up to 1 hour. This exposes people to higher toxin levels than cigarettes.

Potential to spread infectious disease. Sharing a waterpipe with other people increases the risk transferring diseases and viruses. Especially if the mouthpieces are not cleaned properly.

Nicotine addiction. The tobacco in waterpipes and cigarettes contains similar levels of nicotine. And nicotine is highly addictive.

Related Resources

Prevention and Healthy Living

Stopping Tobacco Use After a Cancer Diagnosis

More Information

Centers for Disease Control and Prevention: Smokeless Tobacco Fact Sheet

FDA: Tobacco Products

World Health Organization: Waterpipe Tobacco Smoking