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and to release proinflammatory cytokines, suggests that marijuana might be an immunosuppressant with clinically significant effects on host defense. Therefore, the risks of smoking marijuana should be seriously weighed before recommending its use in any patient with preexisting immune deficits-including AIDS patients, cancer patients, and those receiving immunosuppressive therapies (for example, transplant or cancer patients).

Bronchial and Pulmonary Damage

Animal Studies.

A number of animal studies have revealed respiratory tract changes and diseases associated with marijuana smoking, but others have not. Extensive damage to the smaller airways, which are the major site of chronic obstructive pulmonary disease (COPD),* and acute and chronic pneumonia have been observed in various species exposed to different doses of marijuana smoke.41,42,128 In contrast, rats exposed to increasing doses of marijuana smoke for one year did not show any signs of COPD, whereas rats exposed to tobacco smoke did.67

Chronic Bronchitis and Respiratory Illness.

Results of human studies suggest that there is a greater chance of respiratory illness in people who smoke marijuana. In a survey of outpatient medical visits at a large health maintenance organization (HMO), marijuana users were more likely to seek help for respiratory illnesses than people who smoked neither marijuana or tobacco.120 However, the incidence of seeking help for respiratory illnesses was not higher in those who smoked marijuana for 10 years or more than in those who smoked for less than 10 years. One explanation for this is that people who experience respiratory symptoms are more likely to quit smoking and that people who continue to smoke constitute a set of survivors who do not develop or are indifferent to such symptoms. One limitation of this study is that no data were available on the use of cocaine, which when used with marijuana could contribute to the observed differences. Another limitation is that the survey relied on self-reporting; tobacco, alcohol, and marijuana use might have been underreported (S. Sidney, IOM workshop).

When marijuana smokers were compared with nonsmokers and tobacco smokers in a group of 446 volunteers, 15-20% of the marijuana smokers reported symptoms of chronic bronchitis, including chronic

*COPD is a slow progressive obstruction of the airways, loss of their elasticity, and loss of lung volume, characterized by chronic shortness of breath, chronic bronchitis, and reduced oxygenation of blood.

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