than tobacco smoking alone, and the effect of both typesof smoking was additive.
In 1997, Tashkin and colleagues
reported that therate of decline in respiratory function over 8 years amongmarijuana smokers did not differ from that in non-smokers. This finding contrasted with that of a follow-upof the Tucson cohort,
in which there was a greater rateof decline in respiratory function among marijuana-onlysmokers than in tobacco-only smokers and additiveeffects of tobacco and marijuana smoking. Both studiesshowed that long-term cannabis smoking increasedbronchitic symptoms.In view of the adverse effects of tobacco smoking, thesimilarity between tobacco and cannabis smoke, and theevidence that cannabis smoking produceshistopathological changes that precede lung cancer,
long-term cannabis smoking may also increase the risksof respiratory cancer.
There have been reports of cancers in the aerodigestive tract in young adults with ahistory of heavy cannabis use.
These reportsareworrying since such cancers are rare amongadultsunder the age of 60, even those who smoketobacco and drink alcohol.
Case-control studies of therole of cannabis smoking in these cancers are urgentlyneeded.
Chronic administration of high doses of THC to animalslowers testosterone secretion, impairs sperm production,motility, and viability, and disrupts the ovulatory cycle.
Whether cannabis smoking has these effects in humanbeings is uncertain because the published evidence issmall and inconsistent.
Cannabis administration during pregnancy reducesbirthweight in animals.
The results of humanepidemiological studies have been more equivocal.
Thestigma of using illicit drugs during pregnancy discourageshonest reporting,
and when associations are found, theyare difficult to interpret because cannabis users are morelikely than non-users to smoke tobacco, drink alcohol,and use other illicit drugs during pregnancy, and theydiffer in social class, education, and nutrition.
Severalstudies have suggested that cannabis smoking inpregnancy may reduce birthweight.
In the bestcontrolled of these studies, this relation has persistedafter statistical control for potential confoundingvariables,
but other studies
have not shown any suchassociation. The effect of cannabis on birthweight in thestudies that have found an association has been smallcompared with that of tobacco smoking.
That cannabis use during pregnancy increases the riskof birth defects is unlikely. Early case reports have notbeen supported by large well-controlled epidemiologicalstudies. For example, the study by Zuckerman et al
included a large sample of women with a substantialprevalence of cannabis use that was verified by urineanalysis, and there was no increase in birth defects.There is suggestive evidence that infants exposed inutero to cannabis have behavioural and developmentaleffects during the first few months after birth.
Betweenthe ages of 4 and 9 years, children who were exposed inutero have shown deficits in sustained attention,memory, and higher cognitive functioning.
The clinicalsignificance of these effects remains unclear since theyare small compared with the effects of maternal tobaccouse.
Three studies have shown an increased risk of non-lymphoblastic leukaemia,
in children whose mothers reported usingcannabis during their pregnancies. None of these was aplanned study of the association; cannabis use was one of many potential confounders included in statisticalanalyses of the relation between the exposure of interestand childhood cancer. Their replication is a priority.
Behavioural effects in adolescence
There is a cross-sectional association between heavycannabis use in adolescence and the risk of leaving high-school education and of experiencing job instability inyoung adulthood.
However, the strength of thisassociation is reduced in longitudinal studies whenstatistical adjustments are made for the fact that,compared with their peers, heavy cannabis users havepoor high-school performance before using cannabis.
There is some evidence that heavy use has adverseeffects on family formation, mental health, andinvolvement in drug-related crime.
In each case, thestrong associations in cross-sectional studies are moremodest in longitudinal studies after statistical control forassociations between cannabis use and other pre-existingcharacteristics that independently predict these adverseoutcomes.
A consistent finding in the USA has been the regularsequence of initiation into drug use in which cannabisuse has typically preceded involvement with “harder”illicit drugs such as stimulants and opioids.
Theinterpretation of this sequence remains controversial.
SEMINAR THELANCET • Vol 352 • November 14, 1998
Summary of adverse effects of cannabis
Anxiety and panic, especially in naïve users.
Impaired attention, memory, and psychomotor performance whileintoxicated.
Possibly an increased risk of accident if a person drives a motorvehicle while intoxicated with cannabis, especially if cannabis isused with alcohol.
Increased risk of psychotic symptoms among those who arevulnerable because of personal or family history of psychosis.
Chronic effects (uncertain but most probable)
Chronic bronchitis and histopathological changes that may beprecursors to the developmentof malignant disease.
A cannabis dependence syndrome characterised by an inability toabstain from or to control cannabis use.
Subtle impairments of attention and memory that persist whilethe user remains chronically intoxicated, and that may or maynot be reversible after prolonged abstinence.
Possible adverse effects (to be confirmed)
Increased risk of cancers of the oral cavity, pharynx, andoesophagus; leukaemia among offspring exposed in utero.
Impaired educational attainment in adolescents andunderachievement in adults in occupations requiring high-levelcognitive skills.
Groups at higher risk of experiencing these adverse effects
Adolescents with a history of poor school performance, whoinitiate cannabis use in the early teens, are at increased risk of using other illicit drugs and of becoming dependent on cannabis.
Women who continue to smoke cannabis during pregnancy mayincrease their risk of having a low-birthweight baby.
People with asthma, bronchitis, emphysema, schizophrenia, andalcohol and other drug dependence, whose illnesses may beexacerbated by cannabis use.