Although smoking is not a major risk factor for GERD, it can exacerbate the symptoms of the disease. Conversely, smoking cessation coupled with medication can improve GERD symptoms. Smoking decreases the pressure of the lower esophageal sphincter, making people vulnerable to GERD when they are stressed and fatigued. Cigarette smoking also increases the number of reflux episodes associated with deep inhalation and coughing. Smoking decreases salivary secretion, which prolongs the time it takes for the esophagus to clear acid. In addition, nicotine affects acid clearance and tension of the lower esophageal sphincter. All of these effects combined suggest that smoking may be a moderate risk factor for GERD and that smoking can exacerbate GERD symptoms. Smoking cessation would benefit patients with a highly sensitive lower esophageal sphincter because it would increase lower esophageal sphincter pressure above 10 mm Hg, which is the threshold for stress-induced reflux. In addition, smoking cessation also benefits patients with prolonged esophageal clearance of acid and patients with hyposalivation because it reverses these abnormalities.