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In this same study, the authors showed that this greater colonization is due to a greater resistance of Gram-negative bacteria to cigarette smoke when compared to Grampositive.37 Chronic exposure to cigarette smoke is also capable of increasing the adhesion of these bacteria to epithelial cells, possibly for altering the characteristics of the mucosal surface potentializing the binding of pathogenic bacteria.38,39 This greater bacteria-epithelium interaction causes an increase in inflammatory reaction on the upper airways by mechanisms that do not depend on toxins.40 Still, Tamashiro et al., in 2009, showed that the exposure to high concentrations of cigarette smoke stimulates the in vitro formation of pathogenic bacterial biofilms obtained from patients with CR.41 FINAL REMARKS Although there is data strengthening a link between smoking and CS, these studies point out that there must be an important individual susceptibility to cigarette smoke response insofar as the development of CS is concerned

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Many people use them with hand-rolled cigarettes, roll-your-own tobacco, or herbal smoking blends