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This may be because longer smoking duration is associated with several genetic changes19 produced by the accumulation of specific polycyclic aromatic hydrocarbons, aromatic amines and nitrosamines from tobacco smoke.20 Long periods of tobacco exposure can lead to alterations in the pulmonary microbiome and reduced microbial diversity that contribute to COPD progression.21,22 The results of this study show that the COPD risk increases with smoking intensity