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[113] Considerable differences in exposure to metals have been identified from the e-cigarettes tested, particularly metals such as cadmium, lead, and nickel

Thus, prolonged or heavy use of hookah may induce risk of tumor development, especially in oral cavity and esophagus, which further argues against the notion that hookah has no/less harm if not inhaled kept in mouth. Indeed, incidence of benign lesions of the vocal cords was linked to the presence of cysts in 4.8% of hookah users, which was similar to cigarette smokers [134]

However, this research methodology can be compromised by participants giving more socially acceptable answers rather than truthful responses

Lung cancer risk and demographic characteristics of current 20-29 pack-year smokers: implications for screening

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