Difficulty in its early diagnosis, fast progression and high mortality makes esophageal carcinoma one of the most important fatal diseases in the world. Its unequal geographic distribution gives a hint to clinicians and epidemiologists an impression that this disease is definitely related to environmental factors. Deficiencies in essential vitamins and other substances in diet have been blamed for many years. Tobacco and alcohol were also found guilty for a long time. But a great majority of people in high-risk areas are Moslem and teetotalers. Therefore some other factors as nitrosamines, which were found to enhance the risk of esophageal carcinoma, should be also emphasized in the etiology of the disease. Nitrosamines are most likely acting as the promoters in the carcinogenesis of esophagus. It is difficult to explain the importance of alcohol in high-risk areas where most of the people are teetotalers.