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Chronic exposure to this smoke causes metaplastic alterations to the respiratory mucosa with an increase in the number and size of goblet cells and consequent increase in upper airway secretion.17,18 Cohen et al.13 and Kreindler et al.19 also showed in vitro that exposure to cigarette smoke inhibits chloride transport in epithelial cells, causing physiological alterations similar to those found in patients with cystic fibrosis

In addition, oxidative stress also disrupts cellular renewal, which leads to an accumulation of dead cells on the skin, causing a dull complexion