Cannabis Smoking in 2015: A Concern for Lung Health?

doi:10.1378/chest.15-0447

CHEST

Volume 148, Issue 3, September 2015, Pages 596-606

https://doi.org/10.1378/chest.15-0447 Get rights and content

Recent legislative successes allowing expanded access to recreational and medicinal cannabis have been associated with its increased use by the public, despite continued debates regarding its safety within the medical and scientific communities. Despite legislative changes, cannabis is most commonly used by smoking, although alternatives to inhalation have also emerged. Moreover, the composition of commercially available cannabis has dramatically changed in recent years. Therefore, developing sound scientific information regarding its impact on lung health is imperative, particularly because published data conducted prior to widespread legalization are conflicting and inconclusive. In this commentary, we delineate major observations of epidemiologic investigations examining cannabis use and the potential associated development of airways disease and lung cancer to highlight gaps in pulmonary knowledge. Additionally, we review major histopathologic alterations related to smoked cannabis and define specific areas in animal models and human clinical translational investigations that could benefit from additional development. Given that cannabis has an ongoing classification as a schedule I medication, federal funding to support investigations of modern cannabis use in terms of medicinal efficacy and safety profile on lung health have been elusive. It is clear, however, that the effects of inhaled cannabis on lung health remain uncertain and given increasing use patterns, are worthy of further investigation.

Section snippets

Biology of the Cannabis Plant

To understand the potential clinical impact of inhaled cannabis use on lung health, it is important to appreciate the plant's complexity and mechanisms of action.⁵ Cannabis contains 483 unique compounds, including 66 cannabinoids. Ten subclasses of cannabinoids have been characterized, including Δ-9-tetrahydrocannabinols (THCs) and seven subclasses of cannabidiols (CBDs).⁶ THCs are the primary psychoactive substances, with pharmacologic properties including euphoria and analgesia. In contrast,

Epidemiologic Investigations Related to Cannabis and Lung Health

The focus of epidemiologic data published in the past 15 years has primarily been on understanding the relationship between cannabis use and airways diseases9, 10, 11, 12, 13, 14, 15 (Table 1). Smoking cannabis has been associated with an increase in total lung capacity and FVC,^9,^10,¹³ potentially resulting from deep-breathing maneuvers of users.^9,¹⁰ In the setting of heavy, prolonged cannabis use (typically > 20 joint-years),^9,^11,^13,¹⁵ a dose-response association between development of airflow

Needs in Future Research

Excellent reviews have been published describing the respiratory tract effects of cannabis, including its influence on inflammation and immunity that may contribute to the development of airways disease or lung cancer.^7,²⁸ Notable effects of smoked cannabis on airways include enhanced mucous secretion, airway hyperemia, basal and goblet cell hyperplasia, and squamous metaplasia.29, 30, 31 Additionally, impaired alveolar macrophage phagocytosis and increased apoptosis have been consistently

Conclusions

Increasing prevalence of cannabis consumption in the United States and continued predominant use through an inhaled route suggest an immediate and far-reaching impact on lung health. As the composition of and methods to use cannabis expand, additional research capitalizing on new technologies in cell lines and animal models along with careful consideration addressing deficiencies in prior human clinical investigations will be necessary to establish the effects of cannabis on lung health.

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHESTthat no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: The authors acknowledge Alicia McNally, BA, for assistance with the manuscript.

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Cited by (33)

Effects of cannabis smoking on the respiratory system: A state-of-the-art review
2024, Respiratory Medicine
The diminished perception of the health risks associated with the consumption of cannabis (marijuana) lead to a progressive increase in its inhalational use in many countries. Cannabis can be smoked through the use of joints, spliffs and blunts, and it can be vaporised with the use of hookah or e-cigarettes. Delta-9 tetrahydrocannabinol (THC) is the main psychoactive component of cannabis smoke but contains numerous other substances. While the recreational use of cannabis smoking has been legalised in several countries, its health consequences have been underestimated and undervalued. The purpose of this review is to critically review the impact of cannabis smoke on the respiratory system.
Cannabis smoke irritates the bronchial tree and is strongly associated with symptoms of chronic bronchitis, with histological signs of airway inflammation and remodelling. Altered fungicidal and antibacterial activity of alveolar macrophages, with greater susceptibility to respiratory infections, is also reported. The association with invasive pulmonary aspergillosis in immunocompromised subjects is particularly concerning. Although cannabis has been shown to produce a rapid bronchodilator effect, its chronic use is associated with poor control of asthma by numerous studies. Cannabis smoking also represents a risk factor for the development of bullous lung disease, spontaneous pneumothorax and hypersensitivity pneumonitis. On the other hand, no association with the development of chronic obstructive pulmonary disease was found. Finally, a growing number of studies report an independent association of cannabis smoking with the development of lung cancer.
In conclusion, unequivocal evidence established that cannabis smoking is harmful to the respiratory system. Cannabis smoking has a wide range of negative effects on respiratory symptoms in both healthy subjects and patients with chronic lung disease. Given that the most common and cheapest way of assumption of cannabis is by smoking, healthcare providers should be prepared to provide counselling on cannabis smoking cessation and inform the public and decision-makers.
Associations for subgroups of E-cigarette, cigarette, and cannabis use with asthma in a population sample of California adolescents
2023, Addictive Behaviors
Knowledge about the respiratory health consequences of adolescents’ use of tobacco products with cannabis remains limited. We studied whether e-cigarettes, combustible cigarettes, and cannabis were independently associated with asthma in a population-based sample of 150,634 public high school students (10th and 12th graders), drawn in a two-stage design to be representative of the state of California in 2019–2020. Measures were obtained for use of e–cigarettes, combustible cigarettes, and cannabis; motives for use (three substances); method of use (for cannabis); ever being diagnosed with asthma; and having an asthma attack in past 12 months. Cross-classification indicated Nonuse for 64% of the sample; 15% Dual E–cigarette/Cannabis Use; 10% Exclusive Cannabis Use; 5% Exclusive E-cigarette Use; and 5% Triple Use. Multinomial logistic regression with a three-level criterion variable, controlling for age, sex, parental education, race/ethnicity, and three types of household use showed that compared with Nonuse, odds of Lifetime Asthma (vs. Never Had) was elevated for Triple Use (AOR = 1.14, CI 1.06–1.24), Dual E-cigarette/Cannabis Use (1.17, 1.12–1.23), Exclusive Cannabis Use (1.17, 1.11–1.23), and Exclusive E-cigarette Use (1.10, 1.02–1.18). Similar results were noted for Recent Asthma. Among persons who had used cannabis, 88% of the Triple group and 74% of the Dual E-cigarette/Cannabis group reported both smoking and vaping cannabis.
Thus, co-occurrence of e-cigarette and cannabis use was a common pattern among adolescents in this study, and subgroups of cannabis and e-cigarette use showed similar associations with asthma. Preventive approaches should highlight the health implications of exclusive or combined e–cigarette and cannabis use.
Inhaled Marijuana and the Lung
2022, Journal of Allergy and Clinical Immunology: In Practice
Although vaping has recently increased as a mode of inhaling marijuana and has been associated with numerous and sometimes fatal cases of acute severe lung injury, smoking remains the most common method of inhaling marijuana and has been studied more extensively. Smoking marijuana has been shown to produce modest but significant short-term bronchodilation both in healthy subjects and in those with asthma. Long-term effects of habitual marijuana smoking include the following: (1) symptoms of chronic bronchitis (increased cough, sputum production, and wheezing); (2) modest effects on lung function in cross-sectional studies (no significant decrease in FEV₁ but mild reductions in FEV₁/forced vital capacity ratio, an increase in forced vital capacity and other lung volumes, reductions in specific airway conductance, and variable effects of maximal midexpiratory flow rates and diffusing capacity); and (3) variable effects on age-related decline in FEV₁ in longitudinal studies. Most cohort and case-control studies have failed to show that marijuana smoking is a significant risk factor for lung cancer despite the presence of procarcinogenic components in marijuana smoke, although further study is warranted. The question whether marijuana smoking is associated with asthma is unclear and requires further investigation. Although delta-9 tetrahydrocannabinol, the principal psychoactive component of marijuana, has immunomodulatory properties that hypothetically could increase the risk of pneumonia, the few available studies in marijuana smokers have failed to find an increased risk of pneumonia in immunocompetent users, although effects in immunosuppressed individuals have been variable.
Wonder or evil?: Multifaceted health hazards and health benefits of Cannabis sativa and its phytochemicals
2021, Saudi Journal of Biological Sciences
Cannabis sativa, widely known as ‘Marijuana’ poses a dilemma for being a blend of both good and bad medicinal effects. The historical use of Cannabis for both medicinal and recreational purposes suggests it to be a friendly plant. However, whether the misuse of Cannabis and the cannabinoids derived from it can hamper normal body physiology is a focus of ongoing research. On the one hand, there is enough evidence to suggest that misuse of marijuana can cause deleterious effects on various organs like the lungs, immune system, cardiovascular system, etc. and also influence fertility and cause teratogenic effects. However, on the other hand, marijuana has been found to offer a magical cure for anorexia, chronic pain, muscle spasticity, nausea, and disturbed sleep. Indeed, most recently, the United Nations has given its verdict in favour of Cannabis declaring it as a non-dangerous narcotic. This review provides insights into the various health effects of Cannabis and its specialized metabolites and indicates how wise steps can be taken to promote good use and prevent misuse of the metabolites derived from this plant.
Therapeutic Application of Cannabis in Medicine and Its Relevance to Thoracic Surgery
2021, Annals of Thoracic Surgery
Citation Excerpt :
Cannabis products exert their effects through a variety of consumption methods, including smoking, vaporizing through electronic nicotine delivery systems, ingestion (“edibles”), patches, and sprays (Figure 3).7 CBD primarily causes anxiolysis, whereas cannabinoids cause euphoria and analgesia.7 Cannabinoids come in many varieties, however, δ-9-tetrahydrocannabinol (THC) is the ingredient that elicits a euphoric effect, and therefore, manufacturers have modulated its potency by means of cultivation, breeding, and genetic manipulation.8
Cannabis is the most commonly used illicit substance in the United States. As cannabis use rises in popularity and its legalization continues to expand, the scientific community must address the controversy between beneficial and adverse effects of cannabis consumption.
We performed a comprehensive literature review to study the medicinal and pathologic effects of cannabis use, with emphasis on its association with cancer pathophysiology and thoracic surgery.
We found evidence that cannabis products often contain carcinogenic materials and that their use is associated with the development of certain head and neck cancers, but not lung cancer. Indeed, several in vitro and in vivo studies have demonstrated that cannabis may have a therapeutic role in cancer given the antiproliferative effects of its active compounds such as δ-9-tetrahydrocannabinol. Cannabis-derived products have also been shown to be effective treatments for chronic pain, neuropathy, spasticity, and as antiemetics.
We acknowledge that additional studies are required to elucidate the long-term effects of cannabis products and that many potential biases and limitations exist in the literature due to self-reporting and limited survey studies. Appropriate stewardship over cannabis use among our patient population will likely determine its full implications in both oncologic and perioperative outcomes.
Alcohol and cannabis use alter pulmonary innate immunity
2019, Alcohol
Citation Excerpt :
Very little is known about how cannabis use alone, and in conjunction with alcohol, affects pulmonary innate immunity and airway inflammation. Published reports indicate that cannabis smokers have more respiratory symptoms such as cough, shortness of breath, sputum production, and wheeze (Biehl & Burnham, 2015; Bloom, Kaltenborn, Paoletti, Camilli, & Lebowitz, 1987; Ribeiro & Ind, 2016). These symptoms are often associated with increased airway inflammation.
Cannabis use is increasing due to recent legislative changes. In addition, cannabis is often used in conjunction with alcohol. The airway epithelium is the first line of defense against infectious microbes. Toll-like receptors (TLR) recognize airborne microbes and initiate the inflammatory cytokine response. The mechanism by which cannabis use in conjunction with alcohol affects pulmonary innate immunity mediated by TLRs is unknown.
Samples and data from an existing cohort of individuals with alcohol use disorders (AUDs), along with samples from additional participants with cannabis use alone and with AUD were utilized. Subjects were categorized into the following groups: no alcohol use disorder (AUD) or cannabis use (control) (n = 46), AUD only (n = 29), cannabis use-only (n = 39), and AUD and cannabis use (n = 29). The participants underwent bronchoscopy with bronchoalveolar lavage (BAL) and airway epithelial brushings. We measured IL-6, IL-8, TNF⍺, and IL-10 levels in BAL fluid, and performed real-time PCR for TLR1–9 on the airway epithelial brushings.
We found significant increases in TLR2 with AUD alone, cannabis use alone, and cannabis use with AUD, compared to control. TLR5 was increased in cannabis users compared to control, TLR6 was increased in cannabis users and cannabis users with AUD compared to control, TLR7 was increased in cannabis users compared to control, and TLR9 was increased in cannabis users compared to control. In terms of cytokine production, IL-6 was increased in cannabis users compared to control. IL-8 and IL-10 were increased in AUD only.
AUD and cannabis use have complex effects on pulmonary innate immunity that promote airway inflammation.

View all citing articles on Scopus

FUNDING/SUPPORT: Funding support was provided through National Institutes of Health [Grant T32HL007085 to Dr Biehl].

originally published Online First May 21, 2015.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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CHEST

CommentaryAhead of the CurveCannabis Smoking in 2015: A Concern for Lung Health?

Section snippets

Biology of the Cannabis Plant

Epidemiologic Investigations Related to Cannabis and Lung Health

Needs in Future Research

Conclusions

Acknowledgments

Drug Alcohol Depend

Life Sci

J Neuroimmunol

Ann Epidemiol

Drug Alcohol Depend

Forensic Sci Int

J Pharm Biomed Anal

Chest

Forensic Sci Int

Drug Alcohol Depend

J Pharmacol Toxicol Methods

J Biol Chem

Toxicology

J Neuroimmunol

Before the grand opening: measuring Washington State's marijuana market in the last year before legalized commercial sales. RAND Corporation website

Market size and demand for marijuana in Colorado. Marijuana Policy Group, Colorado Department of Revenue. State of Colorado website

Effects of marijuana smoking on the lung

Ann Am Thorac Soc

Chemistry and analysis of phytocannabinoids and other Cannabis constituents

The endocannabinoid system: a new target for the regulation of energy balance and metabolism

Crit Pathw Cardiol

Effects of cannabis on pulmonary structure, function and symptoms.

Thorax

Effects of cannabis on lung function: a population-based cohort study

Eur Respir J

The effects of marijuana exposure on expiratory airflow. A study of adults who participated in the U.S. National Health and Nutrition Examination Study

Ann Am Thorac Soc

Respiratory effects of marijuana and tobacco use in a US sample

J Gen Intern Med

Association between marijuana exposure and pulmonary function over 20 years

JAMA

Commentary
Ahead of the Curve
Cannabis Smoking in 2015: A Concern for Lung Health?