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British Journal of Cancer (2009) 100, 1016. doi:10.1038/sj.bjc.6604959 www.bjcancer.comPublished online 3 March 2009& 2009 Cancer Research UKSir,We thank Dr Chaouachi for his interest in our study.Dr Chaouachi suggests that the association of hookah andoesophageal cancer observed in our study (Nasrollahzadeh et al,2008) may be due to smoking opium, rather than tobacco, by ahookah. Whereas this is a very interesting hypothesis, it is unlikelyto explain the results associated with hookah use. The prevalenceof hookah use in the study area is low, and only 5% of the studypopulation have used hookah ever. Smoking opium by hookah isnot the custom of the local people in North East Iran. In addition,the high sensitivity (93%) of the study questionnaire for detectingopium use significantly decreases any misclassification of exposureto opium (Abnet et al, 2004). We think that the conclusion of ourstudy, that every type of tobacco smoking with or without usingopium is not a major contributor to oesophageal cancer risk in thestudy area of Golestan, remains valid.

Reply: Hookah, opium, and tobacco smoking in relation to ESCC