Objectives To estimate the risk of dying from all causes and from specified smoking-related diseases in men who were exclusive daily pipe smokers at two consecutive examinations, and in men who switched from smoking cigarettes only to pipe only.

Design A prospective cohort study.

Setting Three counties in Norway.

Participants 16 932 men, aged 20–49, screened for cardiovascular disease risk factors in the mid-1970s, re-screened after 3–13 years, and followed throughout 2007.

Outcomes Absolute mortality and relative risks adjusted for confounding variables, of dying from all causes and ischaemic heart disease, stroke, cardiovascular disease, lung cancer and other smoking-related cancer.

Results Altogether, the men were observed for 403 327 years, and during the observation period, 4933 deaths occurred. With sustained never smokers as reference, the sustained smokers of a pipe only had adjusted relative risk (95% CI), of dying from any cause that was 1.99 (1.73 to 2.27). At comparable tobacco consumption, no significant difference in risk between pipe and cigarette smokers appeared. As to survival, no difference was found between sustained smokers of a pipe only and of cigarettes only. Men who switched from cigarettes only to pipe only had a risk which was not significantly different from the risk in sustained smokers of cigarettes only.

Conclusions Between pipe and cigarette smokers, no or only minor differences were found in mortality from any cause and the specified smoking-related diseases. Pipe smoking is not safer than cigarette smoking.