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Smoking cigarettes reduces the pressure of the lower esophageal sphincter (LES), which acts as a protective barrier between the stomach and the esophagus

In these two latter countries, a pack of premium cigarettes such as the Marlboro brand can cost between US$1 and US$1.99, [31] rendering cigarettes more accessible and encouraging more consumption

Furthermore, lower COPD prevalence with exclusive cigar use may be explained by the reduced smoke inhalation and lower frequency of smoking in exclusive users of traditional cigars [39], the predominant cigar type used by the study population [40]

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Given the pragmatic nature of the study and the heterogeneity of the participants, the results from this study will be externally valid and will be applicable to a wide variety of healthcare settings