bulletin Cannabis and asthma Smoking cannabis bulletin series 24 January 2015

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Bartholomew Eric Fleming
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1 bulletin Cannabis and asthma This bulletin is about the link between asthma and smoking cannabis. As with tobacco smoke, cannabis smoke contains harmful levels of carcinogenic compounds including benzopyrene, benzanthracene, phenols, vinyl chlorides, nitrosamines and reactive oxygen species. Smoking cannabis More than a third (35.4%) of Australians have smoked cannabis and more than 1 in 10 have smoked it in the past year. Those currently aged years are more likely to have smoked cannabis than tobacco. People with asthma are not less likely to report smoking cannabis or tobacco than those who do not have asthma This is a concern, as smoking cannabis can cause more asthma symptoms and more frequent asthma attacks. 2, Among young people with asthma, those who have reported ever smoking cannabis before the age of 13 years are approximately twice as likely to have had an asthma attack in the past year. 2 As with tobacco smoke, cannabis smoke (as a product of combustion from a pipe, joint or bong) contains harmful chemicals which can damage the lungs, and stop them from working properly For some people, this damage is increased due to a prolonged and deeper inhalation when smoking cannabis compared with tobacco. This style of smoking can lead to a three-fold increase in the amount of tar and nearly five-fold increase in the carbon monoxide that is taken into the lung. 21 People who smoke cannabis often have more coughing and wheezing, and produce more sputum, compared to non-smokers This becomes more likely and more severe as the exposure to cannabis smoking increases. 17 In addition, cannabis smokers develop a similar type of inflammation in the airways as tobacco smokers This may reduce the effectiveness of asthma preventer medications and may lead to higher doses being required to achieve good asthma control. Importantly, these negative effects on the respiratory system are made even worse when smoking 24, 33, 34 cannabis and tobacco together. Surprisingly, cannabis was once advertised as a treatment for asthma before the development of modern medicine. 35 This may have been because of a reduction in constriction of the airways (bronchospasm) and an initial opening of the airway immediately following use. 16, These effects of cannabis smoking are thought to be modest and smoking cannabis is likely to be less effective than using bronchodilators such as salbutamol or terbutaline (Ventolin, Asmol, Bricanyl). 44 The negative effects on respiratory health from cannabis smoking are more pronounced in the medium and long term. 1

2 Smoking cannabis in the medium to long term has two main negative effects on the airways: 1. Increases and damages the mucus lining in the airways 22, 24, more mucus-producing cells and glands grow in the airway walls the mucus which is produced may be damaged and immune cells which respond to the 31, ingestion of toxic agents may be less effective 2. Damages the airways causes inflammation in the airways some research has shown that chemicals in cannabis smoke can result in a narrowing of the 41, 50 airway following long-term, regular use Some people with asthma believe that by not smoking cannabis, but rather vaporising the plant, they will avoid the harmful effects from cannabis smoke. While this method is likely to reduce some of the negative impact on respiratory health, it is not without harm as toxic levels of the potent and long-lasting neurotoxin ammonia are produced from heating cannabis in this way. 51 Moreover, there is no long-term research on the impact of using a vaporiser and other alternative means of using the drug. 33 Unfortunately there is also very little research on the impact of cannabis smoke when inhaled passively. Given cannabis smoke can contain even higher levels of carcinogens than tobacco smoke the same precautions should be taken to reduce passive exposure to children and pets 18. Extra precaution should also be taken around individuals with asthma and other respiratory and cardiovascular diseases. Finally, there is mixed evidence that cannabis smoking is associated with an increased risk of suffering a collapsed lung (pneumothorax). 44, 52 As there have been several cases of lung collapse that may be due to unusual inhalation techniques, this possibility is of concern Other health issues References Smoking cannabis is associated with many other health issues including an increased risk of developing cardiovascular disease as well as mental health concerns such as addiction, psychosis and schizophrenia. 61 As asthma is also associated with mental health concerns such as depression 62, the interaction of these comorbidities deserves exploration. 1. Australian Institute of Health and Welfare National Drug Strategy Household Survey Report. Canberra: Department of Health and Ageing: Drug statistics series No. 25. Category No. PHE 145; Jones SE, Merkle S, Wheeler L, Mannino DM, Crossett L. Tobacco and Other Drug Use among High School Students with Asthma. Journal of Adolescent Health //;39(2): Tercyak KP. Brief Report: Social Risk Factors Predict Cigarette Smoking Progression Among Adolescents with Asthma. Journal of Pediatric Psychology April 1, 2006;31(3): Bender BG. Depression symptoms and substance abuse in adolescents with asthma. Annals of Allergy, Asthma & Immunology //;99(4): Hublet A, De Bacquer D, Boyce W, Godeau E, Schmid H, Vereecken C, et al. Smoking in young people with asthma. Journal of Public Health December 1, 2007;29(4): Rhee H, Hollen PJ, Sutherland M, Rakes G. A Pilot Study of Decision-Making Quality and Risk Behaviors in Rural Adolescents with Asthma. Pediatric Asthma, Allergy & Immunology. 2007;20(2): Otten R, Engels RC, van den Eijnden RJ. Parental smoking and smoking behavior in asthmatic and nonasthmatic adolescents. The Journal of asthma: official journal of the Association for the Care of Asthma Jun;42(5): PubMed PMID: Epub 2005/07/23. eng. 2

3 8. Brook U, Shiloh S. Attitudes of asthmatic and nonasthmatic adolescents toward cigarettes and smoking. Clinical pediatrics Nov;32(11): PubMed PMID: Epub 1993/11/01. eng. 9. Forero R, Bauman A, Young L, Larkin P. Asthma prevalence and management in Australian adolescents: results from three community surveys. The Journal of adolescent health: official publication of the Society for Adolescent Medicine Dec;13(8): PubMed PMID: Epub 1992/12/01. eng. 10. Wakefield M, Ruffin R, Campbell D, Roberts L, Wilson D. Smoking-related beliefs and behaviour among adults with asthma in a representative population sample. Australian and New Zealand journal of medicine Feb;25(1):12-7. PubMed PMID: Epub 1995/02/01. eng. 11. Guo S-E, Ratner PA, Johnson JL, Okoli CTC, Hossain S. Correlates of smoking among adolescents with asthma. Journal of Clinical Nursing. 2010;19(5-6): Lester MR. Depression Symptoms and Substance Abuse in Adolescents With Asthma. Pediatrics November 1, 2008;122(Supplement 4):S214-S Parker J, Kim K, Silverman* R, McLaurin K, Tu X, Molfino N. Characteristics and 12-week outcomes for marijuana smokers in subjects with asthma treated in the emergency department for an asthma exacerbation. CHEST Journal. 2012;142(4_MeetingAbstracts):733A-A. 14. Gaeta TJ, Hammock R, Spevack TA, Brown H, Rhoden K. Association between substance abuse and acute exacerbation of bronchial asthma. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Dec;3(12): PubMed PMID: Epub 1996/12/01. eng. 15. Chopra GS. Studies on psycho-clinical aspects of long-term marihuana use in 124 cases. Substance Use & Misuse. 1973;8(6): Tetrault JM, Crothers K, Moore BA, Mehra R, Concato J, Fiellin DA. Effects of marijuana smoking on pulmonary function and respiratory complications: a systematic review. Archives of internal medicine Feb 12;167(3): Taylor DR, Fergusson DM, Milne BJ, Horwood LJ, Moffitt TE, Sears MR, et al. A longitudinal study of the effects of tobacco and cannabis exposure on lung function in young adults. Addiction (Abingdon, England) Aug;97(8): Moir D, Rickert WS, Levasseur G, Larose Y, Maertens R, White P, et al. A comparison of mainstream and sidestream marijuana and tobacco cigarette smoke produced under two machine smoking conditions. Chemical research in toxicology Feb;21(2): Novotný M, Merli F, Wiesler D, Fencl M, Saeed T. Fractionation and capillary gas chromatographic mass spectrometric characterization of the neutral components in marijuana and tobacco smoke condensates. Journal of Chromatography A /2/;238(1): Hoffmann D, Brunneman DK, Gori GB, Wynder EL. On the carcinogenicity of marijuana smoke. Recent Advances in Phytochemistry. 1975;9: Wu TC, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. New England Journal of Medicine 1988;318: Aldington S, Williams M, Nowitz M, Weatherall M, Pritchard A, McNaughton A, et al. Effects of cannabis on pulmonary structure, function and symptoms. Thorax Dec;62(12): Sherrill DL, Krzyzanowski M, Bloom JW, Lebowitz MD. Respiratory effects of non-tobacco cigarettes: a longitudinal study in general population. International journal of epidemiology Mar;20(1): Moore BA, Augustson EM, Moser RP, Budney AJ. Respiratory effects of marijuana and tobacco use in a U.S. sample. Journal of general internal medicine Jan;20(1):33-7. Pubmed Central PMCID: PMC Reid PT, McKenzie J, Copeland L, Elton R, Macleod J, Robertson JR. P263 Cannabis use, respiratory symptoms and lung function, in a North Edinburgh primary care population. Thorax December 1, 2011;66(Suppl 4):A174-A Tashkin DP, Coulson AH, Clark VA, Simmons M, Bourque LB, Duann S, et al. Respiratory symptoms and lung function in habitual heavy smokers of marijuana alone, smokers of marijuana and tobacco, smokers of tobacco alone, and nonsmokers. The American review of respiratory disease Jan;135(1): Bloom JW, Kaltenborn WT, Paoletti P, Camilli A, Lebowitz MD. Respiratory effects of non-tobacco cigarettes. British medical journal (Clinical research ed) Dec 12;295(6612): Taylor DR, Poulton R, Moffitt TE, Ramankutty P, Sears MR. The respiratory effects of cannabis dependence in young adults. Addiction (Abingdon, England) Nov;95(11): Gong H, Jr., Fligiel S, Tashkin DP, Barbers RG. Tracheobronchial changes in habitual, heavy smokers of marijuana with and without tobacco. The American review of respiratory disease Jul;136(1): PubMed PMID: Epub 1987/07/01. eng. 3

4 30. Fligiel SE, Venkat H, Gong H, Jr., Tashkin DP. Bronchial pathology in chronic marijuana smokers: a light and electron microscopic study. Journal of psychoactive drugs Jan-Mar;20(1): PubMed PMID: Epub 1988/01/01. eng. 31. Fligiel SEG, Roth MD, Kleerup EC, Barsky SH, Simmons MS, Tashkin DP. Tracheobronchial histopathology in habitual smokers of cocaine, marijuana, and/or tobacco. CHEST Journal. 1997;112(2): Roth MD, Arora A, Barsky SH, Kleerup EC, Simmons M, Tashkin DP. Airway inflammation in young marijuana and tobacco smokers. Am J Respir Crit Care Med Mar;157(3 Pt 1): PubMed PMID: Epub 1998/03/28. eng. 33. Taylor DR, Hall W. Respiratory health effects of cannabis: position statement of the Thoracic Society of Australia and New Zealand. Internal medicine journal Jul;33(7): PubMed PMID: Epub 2003/06/26. eng. 34. Sherman MP, Campbell LA, Gong H, Jr., Roth MD, Tashkin DP. Antimicrobial and respiratory burst characteristics of pulmonary alveolar macrophages recovered from smokers of marijuana alone, smokers of tobacco alone, smokers of marijuana and tobacco, and nonsmokers. The American review of respiratory disease Dec;144(6): Grinspoon L. Marijuana. Scientific American. 1969;221: Vachon L, FitzGerald MX, Solliday NH, Gould IA, Gaensler EA. Single-Dose Effect of Marihuana Smoke. New England Journal of Medicine. 1973;288(19): Tashkin DP, Shapiro BJ, Frank IM. Acute Pulmonary Physiologic Effects of Smoked Marijuana and Oral Δ9- Tetrahydrocannabinol in Healthy Young Men. New England Journal of Medicine. 1973;289(7): Laviolette M, Belanger J. Role of prostaglandins in marihuana-induced bronchodilation. Respiration; international review of thoracic diseases. 1986;49(1): Tashkin DP, Reiss S, Shapiro BJ, Calvarese B, Olsen JL, Lodge JW. Bronchial effects of aerosolized delta 9-tetrahydrocannabinol in healthy and asthmatic subjects. The American review of respiratory disease Jan;115(1): Vachon L, Sulkowski A, Rich E. Marihuana effects on learning, attention and time estimation. Psychopharmacologia. 1974;39(1): Hartley JP, Nogrady SG, Seaton A. Bronchodilator effect of delta1-tetrahydrocannabinol. British journal of clinical pharmacology Jun;5(6): Tashkin DP, Gliederer F, Rose J, Change P, Hui KK, Yu JL, et al. Effects of varying marijuana smoking profile on deposition of tar and absorption of CO and delta-9-thc. Pharmacology, biochemistry, and behavior Nov;40(3): Tashkin DP, Shapiro BJ, Frank IM. Acute effects of smoked marijuana and oral delta9-tetrahydrocannabinol on specific airway conductance in asthmatic subjects. The American review of respiratory disease Apr;109(4): Tashkin DP. Effects of marijuana smoking on the lung. Annals of the American Thoracic Society Jun;10(3): Beshay M, Kaiser H, Niedhart D, Reymond MA, Schmid RA. Emphysema and secondary pneumothorax in young adults smoking cannabis. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery Dec;32(6): Barsky SH, Roth MD, Kleerup EC, Simmons M, Tashkin DP. Histopathologic and molecular alterations in bronchial epithelium in habitual smokers of marijuana, cocaine, and/or tobacco. Journal of the National Cancer Institute Aug 19;90(16): Sarafian TA, Magallanes JA, Shau H, Tashkin D, Roth MD. Oxidative stress produced by marijuana smoke. An adverse effect enhanced by cannabinoids. American journal of respiratory cell and molecular biology Jun;20(6): Barbers RG, Gong H, Jr., Tashkin DP, Oishi J, Wallace JM. Differential examination of bronchoalveolar lavage cells in tobacco cigarette and marijuana smokers. The American review of respiratory disease Jun;135(6): Beals TF, Fligiel SEG, Stuth S, Tashkin DP. Morphological alterations of alveolar macrophages from marijuana smokers. The American review of respiratory disease. 1989;139 (part 2):A Tashkin DP, Shapiro BJ, Lee YE, Harper CE. Subacute effects of heavy marihuana smoking on pulmonary function in healthy men. The New England journal of medicine Jan 15;294(3):

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DOES SMOKING MARIJUANA INCREASE THE RISK OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE?

DOES SMOKING MARIJUANA INCREASE THE RISK OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Pubdate: Tue, 14 Apr 2009 Source: Canadian Medical Association Journal (Canada) Copyright: 2009 Canadian Medical Association