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Smokers of cannabis the challenge…s. Dr Louise Restrick Respiratory Physician, Whittington Health and NHS Islington NHS London Respiratory Team Co-Lead. BLF cannabis report 2002. Cannabis smoking r espiratory experience in London. Tobacco and cannabis smoking common

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Smokers of cannabis the challenge s

Smokers of cannabis

the challenge…s

Dr Louise Restrick

Respiratory Physician, Whittington Health and NHS Islington

NHS London Respiratory Team Co-Lead


Smokers of cannabis the challenge s

BLF cannabis report 2002


Smokers of cannabis the challenge s

Cannabis smokingrespiratory experience

in London

  • Tobacco and cannabis smoking common

  • Younger people with severe COPD

  • Bullous emphysema on CT scans

  • Young people with pneumothorax


Smokers of cannabis the challenge s

Cannabis smokingInner London experience

50 year old man

20 pack year smoker

Cannabis for 30 years


Smokers of cannabis the challenge s

Cannabis smoking and respiratory health

  • Is it common?

  • Does it matter for respiratory health?

  • How do we help cannabis smokers stop smoking?


Smokers of cannabis the challenge s

UK Prevalence of Cannabis Smoking

  • 8% of 11-15 year olds smoke cannabis

  • Smoking, Drinking and Drug Use Among Young People in England in 2010, NHS Information Centre for Health and Social Care

  • Social Survey of 7,296 secondary school pupils aged 11-15 in 246 shcools

  • 1 in 5 young adults say they have recently used drugs, mostly cannabis Healthy Lives, Healthy People White Paper 2010

  • HOSB. Drug Misuse Declared. 2009/2010 British Crime Survey, England & Wales

  • 1 in 3 tobacco smokers in an inner London hospital population also smoke cannabis*

    • all groups in society

    • have to ask not volunteered

*Restrick et al ERJ 2011; 776S


Smokers of cannabis the challenge s

Cannabis smoking and respiratory health

  • Symptoms

  • COPD

  • Pneumothorax &pneumomediastinum

  • Bullous emphysema

  • Lung cancer


Smokers of cannabis the challenge s

Challenges of studying cannabis smoking & respiratory health

  • Variations in smoking method and content

  • Resin - Scotland

  • Marijuana/‘grass’ - America, London?

  • Without tobacco – New Zealand

  • Water pipe - Australasia

  • Skunk - ‘sensemilla’

  • Lack of data

  • Not volunteered

  • Health professionals uncomfortable asking


Smokers of cannabis the challenge s

Comparisons of cannabis and tobacco smoking

1 joint cf 1 cigarette same weight

3 x carbon monoxide levels

5 x tar deposition

No filter, shorter butt length, higher temperature

Deeper inspiration, breath-hold, Valsalva at maximum breath-hold

0.4 g cannabis cf 1g tobacco per cigarette

Joint-year - ‘one joint/day for 1 year’


Smokers of cannabis the challenge s

Cannabis & respiratory symptoms in Scotland

N= 238

Age (range) years

N= 142

38 (20-63)

N= 96

37 (22-58)

  • Resin - 77% (grass 16%; both 7%)

  • Mixed with tobacco - 93%

Reid et al, ERJ 2011; 778S


Smokers of cannabis the challenge s

Cannabis & respiratory symptoms in Scotland

Reid et al, ERJ 2011; 778S


Smokers of cannabis the challenge s

Cannabis and COPD

  • US studies

  • California – no effect on airway obstruction

  • Arizona – airway obstruction

  • New Zealand* Adlington et al Thorax 2007;62:1058-1063

  • Dose response with FEV1/FVC ratio & hyperinflation

  • 1 joint equivalent to 2.5-5 cigarettes

  • Additive to tobacco

  • Canada Tan et al CMAJ 2009:180;814-20

  • Increased risk of COPD after 50 ‘joints’ with tobacco

  • Synergistic with tobacco


Smokers of cannabis the challenge s

Cannabis and COPD

  • Random sample

  • 878 people >40 years in Vancouver

  • 43% men, mean (SD) age 56 (12) years

  • Only 12/878 (1.4%) refused to complete questionnaire!

  • Prevalence history of

  • marijuana use 46%

  • tobacco use 53%

  • Current smoking (past 12 months)

  • marijuana 14%

  • tobacco 14%

  • COPD Prevalence 19% GOLD 1-4, 8% GOLD 2-4

Tan et al, Vancouver BOLD Research Group CMAJ 2009;180:814-20


Smokers of cannabis the challenge s

Cannabis and COPD

Tan et al, Vancouver BOLD Research Group CMAJ 2009;180:814-20


Smokers of cannabis the challenge s

Cannabis and pneumothorax

Emphysema & secondary pneumothorax in young adults smoking cannabis

17 patients: pneumothoraces with bullous emphysema

Mean (range) age 27 (19-43) years; 16 M; Switzerland

All smoked marijuana; 8.8 years; tobacco 11.8 years

Asymptomatic

CT: multiple bullae or bullous emphysema at apices

Histology (VATS): emphysema, inflammation & heavily pigmented macrophages

‘1 joint/day equivalent to 1 pack cigarettes/day’

Beshay et al, European Journal of Cardiothoracic Surgery 2007:32;834-838


Smokers of cannabis the challenge s

Cannabis and lung cancer

  • Tunisia, Morocco & Algeria*

  • OR 2.4 for history of cannabis use

  • New Zealand** Case-control study

  • 79 cases lung cancer in <55 years

  • Lung cancer risk increased:

  • 8% for each joint-year cannabis smoking

  • 7% for each pack-year cigarette smoking

  • 5.7 Relative risk if >10.5 joint-years cannabis

  • ‘5% of lung cancer in those aged <55 years may be attributable to cannabis smoking.’

*Berthiller et al J Thoracic Oncology 2008

**Aldington et al ERJ 2008:31;280-286


Smokers of cannabis the challenge s

Cannabis and respiratory health

Increasing evidence smoking cannabis causes respiratory symptoms, apical bullae & emphysema, COPD, pneumothoraces and lung cancer.

So what now…


Smokers of cannabis the challenge s

Cannabis & lung health challenges

  • Raising awareness of respiratory risks

    • Cannabis smokers

    • Health professionals NB Mental health

  • Silos

    • DH responsible for tobacco

    • Home Office (National Treatment Agency) responsible for drugs

    • ‘NTA is not interested in tobacco & drug action teams

    • do not have tobacco strategies’.

  • Evidence gaps in cannabis cessation strategies


Smokers of cannabis the challenge s

Cannabis and Respiratory Health

‘Anti-smoking campaigns should include a reduction in marijuana use amongst their goals, aiming especially at those who regularly use both marijuana and tobacco.’

Tan et al, CMAJ 2009

Coming in 2012…

‘A smoking gun II’

What else should and can we do as respiratory clinicians/BTS Quit Smoking Champions?


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