Smokeless tobacco, cigars, pipes and hookah are not safe substitutes

People who want to leave cigarettes behind sometimes consider a switch to chewing tobacco, a cigar, a pipe or a hookah on the assumption that it must be gentler. The public health bodies that have looked at this say otherwise. The US National Cancer Institute (NCI) reports that at least 28 chemicals in smokeless tobacco have been found to cause cancer, and the World Health Organization (WHO) states that all forms of tobacco use are harmful and that there is no safe level of exposure. This page covers smokeless tobacco (chew, snuff and snus), cigars, pipes and hookah, what each source says about the risks, and where help with quitting is available. It is general information and not a substitute for advice from a clinician.

Smokeless tobacco: chew, snuff and snus

Smokeless tobacco is tobacco that is not burned. The NCI describes two main types: chewing tobacco, sold as loose leaves, plugs or twists, and snuff, which is finely cut or powdered tobacco. Moist snuff is also called snus, and nicotine is absorbed through the lining of the mouth. Names such as dip, chew and spit tobacco all fall under this heading.

The CDC states that smokeless tobacco causes cancer of the mouth, esophagus and pancreas, can cause white patches in the mouth called leukoplakia, and can cause gum disease, tooth decay and tooth loss. It also reports that use during pregnancy can raise the risk of early delivery and stillbirth, that smokeless tobacco can cause nicotine poisoning in children, and that it may increase the risk of death from heart disease and stroke. The most harmful chemicals, the CDC and NCI both say, are tobacco-specific nitrosamines, and the levels vary by product.

Nicotine dependence is part of the picture. The NCI says users of smokeless tobacco and users of cigarettes have comparable levels of nicotine in the blood, and that nicotine stays in the blood longer for smokeless users than for smokers. For background on why that makes stopping difficult, see how nicotine dependence works.

Does switching to smokeless tobacco help people quit smoking?

The NCI answers this directly: there is no scientific evidence that using smokeless tobacco can help a person quit smoking. It notes that an advisory committee to the US Surgeon General concluded as long ago as 1986 that smokeless tobacco is not a safe substitute for smoking cigarettes. An NIH-convened expert panel in 2006 added that the range of risks from smokeless products can vary widely because nicotine, carcinogen and toxin levels differ between products. In short, the products are not interchangeable, and none has been shown to be a route out of smoking.

Cigars and pipes

A cigar is a roll of tobacco wrapped in leaf tobacco or in a substance that contains tobacco. The CDC says cigar smoke contains the same toxic chemicals found in cigarette smoke, including chemicals that cause cancer, and that cigar smoking can cause lung cancer and increase the risk of cancers of the mouth and throat. It also says people who report they do not inhale cigar smoke are still exposed to nicotine and toxic chemicals. Large cigars typically contain 5 to 20 grams of tobacco, which the CDC compares to as much as a pack of cigarettes, and researchers estimate that regular cigar smoking is responsible for 9,000 premature deaths per year in the United States.

Pipe tobacco appears in WHO's list of tobacco products, alongside cigars, waterpipe tobacco and smokeless tobacco, and WHO's conclusion applies to the whole list: all forms of tobacco use are harmful. The sources read for this page contained no separate figures for pipes, so none are given here.

Hookah and waterpipe

A hookah is a water pipe used to smoke specially made tobacco. The CDC is blunt that hookah smoking is not a safe alternative to smoking cigarettes. Heating the tobacco with burning charcoal produces smoke that the CDC says is at least as toxic as cigarette smoke, and the water in the pipe does not filter it. The CDC cites research that an hour-long session involves inhaling about 90,000 ml of smoke, against about 500 to 600 ml for a single cigarette, and that one session can expose a person to nearly 9 times more carbon monoxide and 1.7 times more nicotine than a single cigarette.

"Herbal" shisha does not escape the problem. The CDC reports that studies of both tobacco-based and herbal shisha show the smoke contains carbon monoxide and other toxic agents. Electronic hookah products such as hookah pens are newer, and the CDC says limited information is available on their health risks.

What quit support exists

Because every one of these products delivers nicotine, the same principles apply as for cigarettes. WHO says counselling and medication can more than double a tobacco user's chance of quitting successfully. The CDC's cigar page names access to evidence-based quitting resources, including counselling and medication, as a way to help people quit, and its hookah page notes that free resources such as quitlines and websites can help. The NCI's fact sheet on withdrawal says its tips are relevant for people quitting any tobacco product, so the experience described on the withdrawal symptoms and timeline page applies here as well.

In the United States, the NCI notes that the toll-free number 1-800-QUIT-NOW routes callers to state-run quitlines, which provide free cessation assistance to all tobacco users, and that NCI also offers a quitline and an online chat service with smoking cessation counsellors who can talk about quitting smokeless tobacco. Our pages on counselling and quitlines and nicotine replacement therapy describe those support types in more detail, and quit methods compared sets them side by side.

A doctor, dentist or pharmacist can help with the choice of treatment, especially during pregnancy, with heart disease, with a mental health condition, or when other medicines are involved. White or gray patches inside the mouth, which the CDC says can lead to cancer, are worth showing to a dentist or doctor.

The short version

Smokeless tobacco, cigars, pipes and hookah all carry nicotine and cancer-causing chemicals, and the CDC, NCI and WHO do not describe any of them as a safe substitute for cigarettes. Help with quitting exists for all of them, mainly counselling and medication. A doctor, dentist or pharmacist can advise on the right route, particularly in pregnancy or alongside heart disease, mental health conditions or other medicines.