Current issues of ACP Journal Club are published in Annals of Internal Medicine


Switching from cigarettes to pipes or cigars reduced smoking-related mortality

ACP J Club. 1998 Jan-Feb;128:18. doi:10.7326/ACPJC-1998-128-1-018

Source Citation

Wald NJ, Watt HC. Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases. BMJ. 1997 Jun 28; 314:1860-3.



To determine whether switching from smoking cigarettes to smoking pipes or cigars reduces risk for death from 3 smoking-related diseases.


Cohort study with a mean follow-up of 14.4 years.


British United Provident Association (BUPA) Medical Centre, London, UK.


21 520 professional men and businessmen who were 35 to 64 years of age when they were recruited from the BUPA Medical Centre between 1975 and 1982 at the time of a routine health examination.

Assessment of risk factors

Patients were categorized according to their smoking habits (lifelong nonsmoker, former cigarette smoker who had quit > 20 y before study entry, pipe or cigar smoker who had never smoked cigarettes [nonswitcher], pipe or cigar smoker who had switched from cigarettes > 20 y before study entry [switcher], and current cigarette smoker). Inhaling habits (none, slight, moderate, and deep) and tobacco consumption were also assessed.

Main outcome measures

Risk for death from lung cancer, ischemic heart disease, and chronic obstructive lung disease. All-cause mortality was also assessed.

Main results

Compared with lifelong nonsmokers, the relative risk (RR) for death from the 3 smoking-related diseases combined in current cigarette smokers was 3.13 (95% CI 2.55 to 3.84). The greatest risk for death was from chronic obstructive lung disease (RR 30, CI 4 to 220). The risk for death in switchers was less than that in current cigarette smokers (RR 1.68, CI 1.16 to 2.45). Switchers had a 46% lower risk for death from the 3 diseases than current cigarette smokers (RR 0.54, CI 0.38 to 0.77), a 68% higher risk than non-smokers (RR 1.68, CI 1.16 to 2.45), and a 51% higher risk than nonswitchers (RR 1.51, CI 0.96 to 2.38). For all-cause mortality, the rates were lowest in nonsmokers and were increasingly greater in former smokers (RR 1.11, CI 0.92 to 1.34), nonswitchers (RR 1.23, CI 0.99 to 1.75), switchers (RR 1.33, CI 1.03 to 1.73), and current cigarette smokers (RR 2.26, CI 1.97 to 2.58). Switchers consumed about the same amount of tobacco as nonswitchers but inhaled more.


Switching from cigarettes to pipes or cigars reduced the risk for death from 3 smoking-related diseases, but the risk was still greater than that in persons who had never smoked cigarettes or had never smoked at all.

Source of funding: BUPA Medical Research and Development Ltd.

For article reprint: Professor N.J. Wald, BUPA Epidemiological Research Group, Department of Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, St. Bartholomew's and the Royal London School of Medicine and Dentistry, London EC1M 6BQ, England, UK. FAX 44-171-982-6270.


Epidemiologic studies have shown a strong association between tobacco smoking and increased risk for death from ischemic heart disease, lung cancer, and chronic obstructive lung disease and for death from all causes. Since the landmark legal settlement in the United States, this association is now accepted by both the tobacco industry and health professionals. Clearly, the single most important decision that smokers can make to reduce their risk for morbidity and mortality is to stop smoking.

Some interventions, ranging from brief advice (1) to nicotine replacement therapies (2) and more intensive behavioral counseling interventions (3), have been shown in controlled trials to assist this process. The downside is that long-term cessation rates remain relatively low (about 10% to 25%).

Given this scenario, harm-reduction strategies—which might minimize the negative health consequences of cigarette smoking but do not involve complete cessation—intuitively seem worthwhile. Wald and Watt have shown that one such strategy could be the recommendation to switch from cigarettes to pipes and cigars. However, although harm-reduction strategies may reduce risk for the individual person, widespread adoption of these strategies may lead more smokers to opt for the "easier option." This might mean that a smaller proportion of smokers would achieve long-term cessation and could lead to an overall increase in tobacco-related morbidity and mortality.

Until reliable data are available about the public health consequences of a tobacco harm-reduction strategy, physicians should avoid recommending a switch to alternative forms of tobacco. When dealing with smokers, health professionals should make complete cessation the primary goal.

Chris Silagy, MBBS, PhD
The Flinders University of South AustraliaAdelaide, South Australia, Australia


1. Silagy C, Ketteridge S. The effectiveness of physician advice to aid smoking cessation. In: The Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration; Issue 3. Oxford: Update Software; 1997.

2. Silagy C, Mant D, Fowler G, Lancaster T. The effect of nicotine replacement therapy on smoking cessation. In: The Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration; Issue 3. Oxford: Update Software; 1997.

3. Baillie AJ, Mattick RP, Hall W, Webster P. Meta-analytic review of the efficacy of smoking cessation interventions. Drug and Alcohol Review. 1994;13:157-70.