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<jats:title>Introduction<\/jats:title>\n                    <jats:p>Smoked tobacco is a leading risk factor for cardiopulmonary disease. Pipe and cigar use remains common among US adults, yet its risks remain insufficiently understood.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We analysed data from five pooled cohorts with adults enrolled from 1971 to 2011 with follow-up through 2018. Pipe\/cigar use was defined by baseline self-report. Forced expiratory volume in 1\u2009s (FEV\n                      <jats:sub>1<\/jats:sub>\n                      ), forced vital capacity (FVC) and FEV\n                      <jats:sub>1<\/jats:sub>\n                      \/FVC ratio were measured by spirometry. All-cause mortality, coronary heart disease mortality and hospitalisation, respiratory-related mortality, and chronic obstructive pulmonary disease (COPD) mortality and hospitalisation were classified via adjudication or validated algorithms. Associations were estimated with linear mixed models and Fine-Gray subdistribution hazards models adjusted for sociodemographic and clinical factors.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 22\u2009823 participants (mean (SD) age 48.0 (15.7) years; 44.9% male sex; 70.5% white, 25.4% black, 2.4% Hispanic\/Latino), 2621 (11.5%) reported ever pipe\/cigar use, including 518 (2.3%) exclusive users without cigarette history. Compared with never tobacco users (n=9931), exclusive pipe\/cigar use was associated with faster decline in FEV\n                      <jats:sub>1<\/jats:sub>\n                      (3.36\u2009mL\/year; 95%\u2009CI 1.99 to 4.72), FVC (3.73\u2009mL\/year; 95%\u2009CI 2.05 to 5.42) and FEV\n                      <jats:sub>1<\/jats:sub>\n                      \/FVC (0.031 per year; 95%\u2009CI 0.008 to 0.054). Exclusive users had higher all-cause mortality (adjusted HR (aHR) 1.24; 95% CI 1.08 to 1.41), COPD hospitalisation\/mortality (aHR 2.02; 95%\u2009CI 1.41 to 2.90) and preserved ratio impaired spirometry (aHR 1.83; 95%\u2009CI 1.24 to 2.71).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Pipe and cigar use was associated with accelerated lung function decline and increased mortality and cardiopulmonary events, including among never cigarette users. These findings underscore the need for prevention and cessation efforts targeting non-cigarette tobacco.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/thorax-2025-224461","type":"journal-article","created":{"date-parts":[[2026,3,3]],"date-time":"2026-03-03T18:20:32Z","timestamp":1772562032000},"page":"686-693","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Pipe and cigar use, lung function decline and clinical outcomes: an analysis of the NHLBI Pooled Cohorts Study"],"prefix":"10.1136","volume":"81","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7607-3586","authenticated-orcid":false,"given":"William M","family":"Gardner","sequence":"first","affiliation":[{"name":"Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pallavi P","family":"Balte","sequence":"additional","affiliation":[{"name":"Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3249-926X","authenticated-orcid":false,"given":"Christina M","family":"Eckhardt","sequence":"additional","affiliation":[{"name":"Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jack E","family":"Morris","sequence":"additional","affiliation":[{"name":"Columbia University Mailman School of Public Health, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8418-4497","authenticated-orcid":false,"given":"Surya P","family":"Bhatt","sequence":"additional","affiliation":[{"name":"Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama At Birmingham, Birmingham, Alabama, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David J","family":"Couper","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neal D","family":"Freedman","sequence":"additional","affiliation":[{"name":"Tobacco Control Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David R","family":"Jacobs","sequence":"additional","affiliation":[{"name":"Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, 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