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E-cigarettes, smokeless tobacco and shisha

Preparing chewing tobaccoA range of alternatives to smoking are become increasingly popular in the UK. Using tobacco in different ways, such as smokeless tobacco and shisha, is associated with much of the same harm as cigarettes. 

E-cigarettes on the other hand, do not contain deadly tobacco, but the long-term safety of these new products is uncertain.

E-cigarettes - the controversial smoking alternative

Although e-cigarettes may look like cigarettes, they do not contain tobacco. These new products, which have become increasingly popular in the UK over the last few years produce vapour from heating nicotine dissolved in propylene glycol or glycerine. Low levels of contaminating chemicals have been found in e-cigarettes but using e-cigarettes is almost certainly far safer than smoking cigarettes.

E-cigarettes may have the potential to help smokers escape their deadly addiction to tobacco. But more evidence is needed to prove this. And these new products are not regulated yet, so they can vary significantly in quality and any possible long-term risks are not known.

At the moment there is great debate about the wider impact of e-cigarettes. They could potentially prevent millions of tobacco related deaths by providing smokers with a less harmful alternative to cigarettes. Or they could be used along with cigarettes and sustain addiction or renormalize smoking.

Until more evidence is available, we recommend using NHS Stop Smoking Services which we know can increase your likelihood of quitting by more than three times.

E-cigarettes are discussed in more detail on our blog and in our policy briefing document:

Different types of tobacco

Tobacco can be used in many different forms – but all are linked to cancer. There is no safe way to use tobacco.

  • Cigars and pipes are known to increase the risk of cancers of the lung, mouth, food pipe (oesophagus), voice box (larynx), throat and stomach. Smoking these products is just as bad for you as smoking cigarettes.
  • Smoking bidis, the most common form of tobacco in South Asian communities, also causes the same types of cancer.
  • Smokeless tobacco includes a wide variety of products which can be used in different ways, chewed (‘dry chewing tobacco’), sucked (‘moist oral tobacco’) or inhaled (‘nasal snuff’). Scientists have shown that many forms of smokeless tobacco increase your risk of mouth, oesophageal (food pipe) and pancreatic cancers.

What’s in smokeless tobacco?

Most smokeless tobacco products in the UK are used by South Asian communities. In these communities, dry chewing tobacco is often used as part of a ‘betel quid’ or ‘paan’. These consist of a mixture of betel nut (or areca nut), slaked lime and various herbs and spices, wrapped in a betel leaf.

Betel nut itself can cause cancer, so chewing betel quids can cause mouth cancer even if no tobacco is added.

Most types of smokeless tobacco contains at least 28 different chemicals that can cause cancer. Smokeless tobacco users can be exposed to similar, if not higher, levels of cancer-causing tobacco-specific nitrosamines (TSNAs) and nicotine than cigarette smokers.So like cigarettes, smokeless tobacco is both dangerous and highly addictive.

What is snus?

Snus is a special type of smokeless tobacco that is used in Sweden. It is banned in most other countries in the EU. Snus is manufactured using a special process that considerably lowers the levels of TSNAs in the finished product. Because of this, snus may be less dangerous than other types of tobacco.

But it still contains these cancer-causing chemicals at a low level. Snus use has been linked to pancreatic cancer, but not mouth or lung cancer.

It is possible that snus could be used specifically to help hardcore smokers, who are unlikely to quit through other means, to stop smoking altogether. But so far the evidence is uncertain and the International Agency for Research on Cancer has concluded that smokeless tobacco should not be recommended for quitting smoking.


Many people think shisha is harmless but this is not the case – shisha also contains tobacco. Shisha, also called hookah or waterpipe, smokers inhale flavoured tobacco through a long pipe attached to a water bowl. Shisha smokers still inhale toxic cancer-causing chemicals and addictive nicotine.

Unlike cigarettes, shisha is burnt using charcoal so users can also be exposed to dangerously high levels of the poisonous gas carbon monoxide. Levels of carbon monoxide in the body from smoking shisha can be up to 17 times higher than from cigarettes and can cause carbon monoxide poisoning.

Looking at all the evidence together suggests that smoking shisha could double your risk of lung cancer. Some studies have also suggested a link between shisha and cancer of the oesophagus (food pipe) and stomach.

But most of the research that has been done so far has included only small numbers of users or has looked at specific types of smokers.

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Updated: 15 September 2014