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Measurements included reported number of cigarettes smoked per day (CPD), body fluid cotinine and expired air CO concentrations.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Twenty\u2010nine studies were included in the review. Meta\u2010analysis of nine showed that, compared with when solely smoking, fewer cigarettes were smoked daily when NRT was used (mean difference during concurrent smoking and NRT use, \u22122.06 CPD [95% CI = \u22123.06 to \u22121.07, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001]). Meta\u2010analysis of seven studies revealed a non\u2010significant reduction in exhaled CO during concurrent smoking and NRT use (mean difference, \u22120.58\u2009ppm [95% CI = \u22122.18 to 1.03, <jats:italic>P<\/jats:italic>\u2009=\u20090.48]), but in the three studies that tested NRT used in the lead\u2010up to quitting (i.e. as preloading), a similar reduction in exhaled CO was statistically significant (mean difference, \u22122.54\u2009ppm CO [95% CI = \u22124.14 to \u22120.95, <jats:italic>P<\/jats:italic>\u2009=\u20090.002]). Eleven studies reported cotinine concentrations, but meta\u2010analysis was not possible because of data reporting heterogeneity; of these, seven reported lower cotinine concentrations with concurrent NRT use and smoking, four reported no differences, and none reported higher concentrations.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>People who smoke and also use nicotine replacement therapy report smoking less heavily than people who solely smoke. When nicotine replacement therapy is used in the lead\u2010up to quitting (preloading), this reported smoking reduction has been biochemically confirmed. There is no evidence that concurrent smoking and nicotine replacement therapy use result in greater nicotine exposure than solely smoking.<\/jats:p><\/jats:sec>","DOI":"10.1111\/add.16279","type":"journal-article","created":{"date-parts":[[2023,7,3]],"date-time":"2023-07-03T04:10:58Z","timestamp":1688357458000},"page":"2076-2092","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Systematic review and meta\u2010analysis investigating nicotine, cotinine and carbon monoxide exposures in people who both smoke and use nicotine replacement therapy"],"prefix":"10.1111","volume":"118","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7297-7169","authenticated-orcid":false,"given":"Anna","family":"Podlasek","sequence":"first","affiliation":[{"name":"Centre for Academic Primary Care University of Nottingham  Nottingham Nottinghamshire UK"},{"name":"Tayside Innovation and MedTech Ecosystem (TIME) University of Dundee  Dundee Scotland UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ravinder","family":"Claire","sequence":"additional","affiliation":[{"name":"National Institute for Health and Care Excellence  London London City UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7453-9138","authenticated-orcid":false,"given":"Katarzyna A.","family":"Campbell","sequence":"additional","affiliation":[{"name":"Centre for Academic Primary Care University of Nottingham  Nottingham Nottinghamshire UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8577-216X","authenticated-orcid":false,"given":"Sophie","family":"Orton","sequence":"additional","affiliation":[{"name":"Centre for Academic Primary Care University of Nottingham  Nottingham Nottinghamshire UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ross","family":"Thomson","sequence":"additional","affiliation":[{"name":"Centre for Academic Primary Care University of Nottingham  Nottingham Nottinghamshire UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7303-4805","authenticated-orcid":false,"given":"Tim","family":"Coleman","sequence":"additional","affiliation":[{"name":"Centre for Academic Primary Care University of Nottingham  Nottingham Nottinghamshire UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2023,7,2]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1089\/ped.2021.0018"},{"key":"e_1_2_11_3_1","unstructured":"Tobacco.https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/tobacco. 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