Conceptual framework of the interaction between environmental exposure including smoking, alpha-1 antitrypsin (AAT) level and/or AAT genotype, other genetic factors and chronic obstructive pulmonary disease (COPD) risk. Conceptual framework of the interaction between environmental exposure including smoking, alpha-1 antitrypsin (AAT) level and/or AAT genotype, other genetic factors and chronic obstructive pulmonary disease (COPD) risk. Note that there are no studies that show that genotype is more important than blood concentration of AAT for COPD risk assessment. Haitham S. Al Ashry, and Charlie Strange Eur Respir Rev 2017;26:170068 ©2017 by European Respiratory Society