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The usual caveats about the inability to determine the actual causal contrast (smokers being assigned to use NRT, with complicated effects on actual product usage) apply

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Smoking is still the primary, causal risk factor leading to COPD, but environmental exposures, such as exposure to biomass fuel combustion, air pollution, and occupational exposures, and poor lung development (both pre- and post-natal) are increasingly recognized as important causes of COPD [3, 12]

The trend has escalated in recent months