---
title: "Impact of cigar, cigarillo and pipe smoking on lung cancer risk and LDCT screening eligibility"
id: "british-journal-of-cancer-1-the-effect-of-cigar-cigarillo-and-pipe-smoking-on-lung-cancer-risk-and"
canonical_url: "https://medichelpline.com/clinical-feed/british-journal-of-cancer-1-the-effect-of-cigar-cigarillo-and-pipe-smoking-on-lung-cancer-risk-and"
content_type: "clinical_feed_article"
specialty: "Oncology"
source_name: "British Journal of Cancer"
source_url: "https://www.nature.com/articles/s41416-026-03578-9"
published_at: "2026-08-07T12:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Impact of cigar, cigarillo and pipe smoking on lung cancer risk and LDCT screening eligibility
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/british-journal-of-cancer-1-the-effect-of-cigar-cigarillo-and-pipe-smoking-on-lung-cancer-risk-and
- **Specialty:** [Oncology](https://medichelpline.com/clinical-feed/oncology.md)
- **Primary Source:** British Journal of Cancer
- **Source URL:** [Original Journal Publication](https://www.nature.com/articles/s41416-026-03578-9)
- **Published At:** 2026-08-07T12:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- The SUMMIT prospective cohort evaluated how use of **cigars**, **cigarillos**, and **pipes** affects lung cancer risk and eligibility for low-dose CT (**LDCT**) screening among people who also smoked cigarettes. - Eligibility for LDCT in some programmes (for example England) is determined using validated risk models (PLCOm2012 and **LLPv2**) and thresholds; many models historically quantify tobacco exposure using **cigarette** consumption only. - SUMMIT recruited people aged 55–77 with a smoking code in the past 20 years; baseline data included detailed questions about frequency, current/former status, start age and amount per week of cigars, cigarillos and pipes, in addition to cigarette habits. - Among ~13,000 participants who were current or former cigarette smokers, 511 (about 1 in 25) were regular users of cigars, pipe or cigarillos in addition to cigarettes. - The observed 5-year cumulative lung cancer incidence was higher in people currently smoking both cigarette and other tobacco products (8.85%) than in current cigarette-only smokers (5.74%). - When recalculating screening eligibility including other tobacco products among the 511 dual-product users, 0.6% moved from below to above the LLPv2 threshold, while 8.2% moved from below to above the PLCOm2012 threshold. - The study concludes that failing to account for non-cigarette tobacco use can misclassify some higher-risk individuals as ineligible for screening and that **all tobacco consumption** should be considered when assessing LDCT eligibility. - SUMMIT also served broader aims (LDCT screening delivery performance and validation of a multi-cancer blood test) and used standard eligibility criteria including USPSTF 2013 and PLCOm2012 thresholds; the trial is registered at ClinicalTrials.gov (NCT03934866). - The report references international context: lung cancer remains the most common cancer and leading cause of cancer death globally, and screening approaches differ by country; risk-based screening using validated models is used to improve efficiency. - The LLPv2 model used in the UK was revised from the original LLP to include multiple tobacco products; PLCOm2012 was developed from US PLCO trial data where non-cigarette product prevalence was low, explaining historical exclusion of these products from some models.
## Clinical Analysis & Structured Key Points
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[nature](https://www.nature.com/) 2. [british journal of cancer](https://www.nature.com/bjc) 3. [articles](https://www.nature.com/bjc/articles?type=article) 4. article The effect of cigar, cigarillo and pipe smoking on lung cancer risk and screening eligibility [ Download PDF ](https://www.nature.com/articles/s41416-026-03578-9.pdf) [ Download PDF ](https://www.nature.com/articles/s41416-026-03578-9.pdf) * Article * [Open access](https://www.springernature.com/gp/open-science/about/the-fundamentals-of-open-access-and-open-research) * Published: 07 August 2026 Clinical Study # The effect of cigar, cigarillo and pipe smoking on lung cancer risk and screening eligibility * [Simran Vaja](https://www.nature.com/articles/s41416-026-03578-9#auth-Simran-Vaja-Aff1)[1](https://www.nature.com/articles/s41416-026-03578-9#Aff1), * [Jennifer L. Dickson](https://www.nature.com/articles/s41416-026-03578-9#auth-Jennifer_L_-Dickson-Aff2-Aff3)[2](https://www.nature.com/articles/s41416-026-03578-9#Aff2),[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3), * [Carolyn Horst](https://www.nature.com/articles/s41416-026-03578-9#auth-Carolyn-Horst-Aff4)[4](https://www.nature.com/articles/s41416-026-03578-9#Aff4), * [Monica L. Mullin](https://www.nature.com/articles/s41416-026-03578-9#auth-Monica_L_-Mullin-Aff3-Aff5)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3),[5](https://www.nature.com/articles/s41416-026-03578-9#Aff5), * [Amyn Bhamani](https://www.nature.com/articles/s41416-026-03578-9#auth-Amyn-Bhamani-Aff3-Aff6)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3),[6](https://www.nature.com/articles/s41416-026-03578-9#Aff6), * [Andrew Creamer](https://www.nature.com/articles/s41416-026-03578-9#auth-Andrew-Creamer-Aff3)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3), * [Helen Hall](https://www.nature.com/articles/s41416-026-03578-9#auth-Helen-Hall-Aff7)[7](https://www.nature.com/articles/s41416-026-03578-9#Aff7), * [Chuen R. Khaw](https://www.nature.com/articles/s41416-026-03578-9#auth-Chuen_R_-Khaw-Aff3-Aff8)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3),[8](https://www.nature.com/articles/s41416-026-03578-9#Aff8), * [Ruth Prendecki](https://www.nature.com/articles/s41416-026-03578-9#auth-Ruth-Prendecki-Aff8)[8](https://www.nature.com/articles/s41416-026-03578-9#Aff8), * [Priyam Verghese](https://www.nature.com/articles/s41416-026-03578-9#auth-Priyam-Verghese-Aff3)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3), * [Sophie Tisi](https://www.nature.com/articles/s41416-026-03578-9#auth-Sophie-Tisi-Aff9)[9](https://www.nature.com/articles/s41416-026-03578-9#Aff9), * [John McCabe](https://www.nature.com/articles/s41416-026-03578-9#auth-John-McCabe-Aff3)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3), * [Esther Arthur-Darwka](https://www.nature.com/articles/s41416-026-03578-9#auth-Esther-Arthur_Darwka-Aff1)[1](https://www.nature.com/articles/s41416-026-03578-9#Aff1), * [Neal Navani](https://www.nature.com/articles/s41416-026-03578-9#auth-Neal-Navani-Aff3-Aff8) [ORCID: orcid.org/0000-0002-6412-7516](https://orcid.org/0000-0002-6412-7516)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3),[8](https://www.nature.com/articles/s41416-026-03578-9#Aff8), * [Anand Devaraj](https://www.nature.com/articles/s41416-026-03578-9#auth-Anand-Devaraj-Aff10-Aff11)[10](https://www.nature.com/articles/s41416-026-03578-9#Aff10),[11](https://www.nature.com/articles/s41416-026-03578-9#Aff11), * [Arjun Nair](https://www.nature.com/articles/s41416-026-03578-9#auth-Arjun-Nair-Aff3-Aff8)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3),[8](https://www.nature.com/articles/s41416-026-03578-9#Aff8), * [SUMMIT consortium](https://www.nature.com/articles/s41416-026-03578-9#group-1), * [Sam M. Janes](https://www.nature.com/articles/s41416-026-03578-9#auth-Sam_M_-Janes-Aff3-Aff8) [ORCID: orcid.org/0000-0002-6634-5939](https://orcid.org/0000-0002-6634-5939)[3](https://www.nature.com/articles/s41416-026-03578-9#Aff3),[8](https://www.nature.com/articles/s41416-026-03578-9#Aff8) & * … * [Allan Hackshaw](https://www.nature.com/articles/s41416-026-03578-9#auth-Allan-Hackshaw-Aff1) [ORCID: orcid.org/0000-0002-5570-5070](https://orcid.org/0000-0002-5570-5070)[1](https://www.nature.com/articles/s41416-026-03578-9#Aff1) Show authors [_British Journal of Cancer_](https://www.nature.com/bjc) (2026) [Cite this article](https://www.nature.com/articles/s41416-026-03578-9#citeas) [ Save article ](https://www.nature.com/articles/s41416-026-03578-9/save-research?_csrf=peb5HHLsQj7BCzrpF-oIwJAOYYhUG8nj) [ View saved research ](https://www.nature.com/saved-research) ## Abstract ### Background Smokers are eligible for lung cancer screening using low dose CT (LDCT) if they have a sufficiently high risk of lung cancer. In England, for example, people are eligible if their estimated risk using either of two validated models (PLCOm2012 and Liverpool Lung Project) exceeds a certain threshold. Risk is often estimated using only cigarette consumption (duration and number per day), yet many smokers also use other cancer-causing tobacco products. ### Methods SUMMIT is a prospective cohort study of a LDCT screening service. We evaluated the impact of cigars, pipes, and cigarillos on lung cancer risk. ### Results Among 13,000 participants who were current/former cigarette smokers, 511 (1 in 25) were also regular users of cigars, pipes, or cigarillos. The 5-year cumulative lung cancer incidence in people who currently smoked both types of tobacco products was 8.85%, versus 5.74% for cigarette only current smokers. Among these 511 participants, the percentage whose risk was below the screening eligibility threshold ignoring other tobacco products which then exceeded the threshold including these products was 0.6% using LLPv2, and 8.2% using PLCOm2012. ### Conclusions All tobacco consumption should be considered when determining screening eligibility to avoid missing those who can benefit from LDCT. ### Clinical trial registration Clinicaltrials.gov no: NCT03934866. ## Background Globally, lung cancer was the most common cancer type in 2022 (12.4% of all cancers), and the leading cause of cancer death (1.8 million deaths annually) [[1](https://www.nature.com/articles/s41416-026-03578-9#ref-CR1 "Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74:229–63.")]. Population screening for lung cancer using low dose CT (LDCT) is recommended in the US [[2](https://www.nature.com/articles/s41416-026-03578-9#ref-CR2 "US Preventive Services Task Force. Screening for Lung Cancer. US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325:962–70.")] and programmes are in place in other countries such as the UK that has rapidly increasing coverage with full roll out and completion of the prevalence screen planned for 2030 [[3](https://www.nature.com/articles/s41416-026-03578-9#ref-CR3 "O’Dowd EL, Lee RW, Akram AR, Bartlett EC, Bradley SH, Brain K, et al. Defining the road map to UK national lung cancer screening programme. Lancet Oncol. 2023;24:e207–18.")]. Unlike cancer screening for breast, cervical and bowel, that are based on age alone, LDCT screening is only cost-effective in higher risk people (i.e. smokers) because of the low incidence in never-smokers or former smokers who quit many years ago. The US Preventive Services Task Force (USPSTF 2013) recommends screening for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years [[2](https://www.nature.com/articles/s41416-026-03578-9#ref-CR2 "US Preventive Services Task Force. Screening for Lung Cancer. US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325:962–70.")]. However, ageing alone increases absolute lung cancer risk beyond 15 quit-years, so there is an argument that such people should not be exempt from screening [[4](https://www.nature.com/articles/s41416-026-03578-9#ref-CR4 "Landy R, Cheung LC, Young CD, Chaturvedi AK, Katki HA. Absolute lung cancer risk increases among individuals with >15 quit-years: Analyses to inform the update of the American Cancer Society lung cancer screening guidelines. Cancer. 2023;130:201–15.")]. Risk-based targeted cancer screening improves efficiency by increasing the number of people with the cancer of interest who are eligible while reducing the false-positive rate [[5](https://www.nature.com/articles/s41416-026-03578-9#ref-CR5 "Kerlikowske K, Bibbins-Domingo K. Toward Risk-Based Breast Cancer Screening. Ann Intern Med. 2021;174:710–1."), [6](https://www.nature.com/articles/s41416-026-03578-9#ref-CR6 "Autier P. Personalised and risk based cancer screening. BMJ. 2019;367:l5558.")]. Risk prediction models use demographic or behavioural characteristics or biomarkers. The most well-known model for lung cancer is the Prostate, Lung, Colorectal and Ovarian (PLCO)m2012 [[7](https://www.nature.com/articles/s41416-026-03578-9#ref-CR7 "Tammemägi MC, Katki HA, Hocking WG, Church TR, Caporaso N, Kvale PA, et al. Selection criteria for lung-cancer screening. N Engl J Med. 2013;368:728–36.")]. Other models have been developed for specific countries, for example in the UK: the Liverpool Lung Project (LLP), the UK Biobank Prospective Cohort Study (UK Biobank), and CanPredict (QResearch and Clinical Practice Research Datalink national primary care datasets) [[8](https://www.nature.com/articles/s41416-026-03578-9#ref-CR8 "Cassidy A, Myles JP, van Tongeren M, Page RD, Liloglou T, Duffy SW, et al. The LLP risk model: an individual risk prediction model for lung cancer. Br J Cancer. 2008;98:270–6."),[9](https://www.nature.com/articles/s41416-026-03578-9#ref-CR9 "Field JK, Vulkan D, Davies MPA, Duffy SW, Gabe R. Liverpool Lung Project lung cancer risk stratification model: calibration and prospective validation. Thorax. 2021;76:161–8."),[10](https://www.nature.com/articles/s41416-026-03578-9#ref-CR10 "Muller DC, Johansson M, Brennan P. Lung cancer risk prediction model incorporating lung function: development and validation in the UK biobank prospective cohort study. J Clin Oncol. 2017;35:861–9."),[11](https://www.nature.com/articles/s41416-026-03578-9#ref-CR11 "Liao W, Coupland CAC, Burchardt J, Baldwin DR, DART initiative, Gleeson FV, et al. Predicting the future risk of lung cancer: development, and internal and external validation of the CanPredict \(lung\) model in 19.67 million people and evaluation of model performance against seven other risk prediction models. Lancet Respir Med. 2023;11:685–97.")]. In the UK, the Lung Cancer Screening Programme uses both PLCOm2012 and the LLP version 2. Quantifying tobacco exposure is a crucial element of lung cancer risk: whether by the number of cigarettes smoked or pack-years (a combination of cigarette consumption and duration). Tobacco exposure can come from cigarettes, cigars, cigarillos, pipes and smokeless tobacco. However, researchers have often specifically only considered cigarette use when deriving and applying lung cancer risk models. This was because the prevalence of tobacco products other than cigarettes in the studies used to develop risk models was low, particularly in the US (PLCOm2012). Systematic reviews clearly show that people who smoke cigars and pipes, with or without concurrent cigarette use, have a significantly higher risk of lung cancer compared to never-smokers [[12](https://www.nature.com/articles/s41416-026-03578-9#ref-CR12 "Lee PN, Forey BA, Coombs KJ. Systematic review with meta-analysis of the epidemiological evidence in the 1900s relating smoking to lung cancer. BMC Cancer. 2012;12:385."), [13](https://www.nature.com/articles/s41416-026-03578-9#ref-CR13 "Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health. 2015;15:390.")]. Screening eligibility is sensitive to tobacco exposure, so it is important that risk is accurately estimated in populations that use multiple tobacco products. Otherwise, people who are heavy users of cigars or pipes, alongside cigarette use, could be misclassified as having insufficient risk and therefore be ineligible for LDCT. Cigars and pipes are used in the UK and several European countries. We used the SUMMIT study to examine the effect on lung cancer risk and LDCT eligibility. ## Methods SUMMIT is a large prospective cohort study designed to examine the performance of delivering an LDCT screening service to a high-risk population in London and to validate a multi-cancer early detection blood test ([ClinicalTrials.gov NCT03934866](https://thorax.bmj.com/lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03934866&atom=%2Fthoraxjnl%2F75%2F10%2F831.atom)) [[14](https://www.nature.com/articles/s41416-026-03578-9#ref-CR14 "Dickson JL, Hall H, Horst C, Tisi S, Verghese P, Mullin AM, et al. Telephone risk-based eligibility assessment for low-dose CT lung cancer screening. Thorax. 2022;77:1036–40."), [15](https://www.nature.com/articles/s41416-026-03578-9#ref-CR15 "Dickson JL, Hall H, Horst C, Tisi S, Verghese P, Mullin AM, et al. SUMMIT consortium. Uptake of invitations to a lung health check offering low-dose CT lung cancer screening among an ethnically and socioeconomically diverse population at risk of lung cancer in the UK \(SUMMIT\): a prospective, longitudinal cohort study. Lancet Public Health. 2023;8:e130–e140.")]. Individuals aged 55 to77 registered with participating GP surgeries and coded as being a smoker within the past 20 years were invited to attend a Lung Health Check at one of four LDCT scanning sites across North and East London. At this assessment, individuals were eligible for the study and LDCT if they met either the USPSTF 2013 criteria (i.e. at least 30 pack-year history and if a former smoker they had stopped within 15 years), or they had a PLCOm2012 risk estimate of ≥1.3%. For both criteria only cigarette consumption was considered [[16](https://www.nature.com/articles/s41416-026-03578-9#ref-CR16 "Tammemägi MC, Church TR, Hocking WG, Silvestri GA, Kvale PA, Riley TL, et al. Evaluation of the lung cancer risks at which to screen ever- and never-smokers: screening rules applied to the PLCO and NLST cohorts. PLoS Med. 2014;11:e1001764.")]. Eligible individuals were offered a same day LDCT, and they had two subsequent annual visits for a lung health check and one or two more annual LDCT scans, unless they required additional scans for nodule management. Individuals were asked at baseline about their cigar, cigarillo and pipe smoking habits. They were asked how often they smoked these products: occasionally (less than weekly) or regularly (at least once per week). For those who regularly smoked cigars, cigarillos, or pipes, they were asked whether they were current or former users, at what age they started smoking them, and the amount per week. This information was in addition to cigarette habits. The PLCOm2012 model was developed using smokers in the control arm of the PLCO trial in the US, which produces a predicted risk of lung cancer over the next 6 years. The LLPv2 risk model was developed in England and it produces a 5-year risk. It should be noted that although the original LLP risk model only included cigarettes it was later revised to include other smoking products in LLPv2 [[9](https://www.nature.com/articles/s41416-026-03578-9#ref-CR9 "Field JK, Vulkan D, Davies MPA, Duffy SW, Gabe R. Liverpool Lung Project lung cancer risk stratification model: calibration and prospective validation. Thorax. 2021;76:161–8.")]. This model incorporating multiple tobacco products was used to determine eligibility for the randomised UKLS screening trial of LDCT and meant for eligibility assessment in the UK screening programme. Hence some other groups have indeed allowed for multiple tobacco products when usi
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