Cannabis and cancer

By Mary Brett

There are several problems associated with the investigation of possible links between cannabis use and any carcinogenic effects it may have on human cells.

There are now some 140,000 or so scientific research papers on tobacco, while those on cannabis still amount only to about a tenth of that number. It is a relatively young science and, like tobacco, its side effects are usually not apparent for decades.

Cannabis smoking has only been widespread in Western society since the early 1970s and there would presumably be a 20 to 30 year latency period between the initiation of smoking and the development of cancer as is the case with tobacco.

Cannabis smokers often mix tobacco with their cannabis so they run all the well-documented risks of developing cancer associated with tobacco smoke. Relatively few of them smoke cannabis alone so any consequences and therefore causes are almost impossible to separate out. Marijuana smokers are more likely to under report their smoking, if they report it at all.

Large samples are required for case-control studies to take place. It is very difficult to get reliable information about an illegal substance from a large number of people. Questions about cannabis smoking are rarely asked of lung cancer patients.

On the other hand the similarities between tobacco and cannabis are many, the main difference being the presence of nicotine in tobacco and the 60 or so cannabinoids in cannabis (Hoffman et al 1975, Tashkin et al 1997, BMA 1997). So similar side effects may be expected.

Although the number of cannabis “cigarettes” consumed in a day would generally be much fewer than the daily total of tobacco cigarettes, the technique is different. Cannabis smoke is usually inhaled more deeply, held in the lungs for longer and smoked right down to the butt to get full money value. Cannabis cigarettes generally lack filters. (Wu et al 1988). More tar is inhaled from the cannabis butt than from its tip (Tashkin et al 1999).

Cannabis smoke contains 4 to 5 times as much tar as tobacco smoke so the amount of tar deposited in the lungs daily in a cannabis smoker is comparable to that of a tobacco smoker with a 20 a day habit (Benson et al, 1995).

Also the tar from cannabis contains 50% more of some of the carcinogens found in tobacco, notably benzpyrene, a potent carcinogen and a key factor in the promotion of lung cancer (Hoffman et al 1997, Tashkin et al 1997, Novotny et al 1976, Leuchtenberger et al 1983).

For lung cells to become cancerous, a particular combination of cell-growth regulating genes (oncogenes) must become activated or undergo mutation (suppressor genes of tumours).

Marijuana smoke has been reported to produce chromosome aberrations in bacteria as demonstrated by the Ames test (Busch et al 1979 and Wehner et al 1980).

Biopsies of bronchial mucosa have yielded interesting results. Abnormal proliferation of cells (goblet and reserve), transformation of normal ciliated cells to squamous metaplasia (skin-like cells), accumulation of inflammatory cells and abnormal cell nuclei have all been observed (Gong et al 1987, Fliegel et al 1997, Barsky et al 1998). A much higher proportion of these abnormalities was seen in marijuana smokers compared to non-smokers, the number was similar to that of tobacco smokers. Smokers of both tobacco and marijuana exhibited the highest number of all, suggesting the two have an additive effect. Precursors of the development of lung cancer in tobacco smokers include squamous metaplasia and abnormal nuclei (Auerbachet al 1961). Confirmation of these observations also came in 1980 from FS Tennant when he examined US servicemen who were heavy hashish smokers. The mutagenic properties of cannabis smoke were previously recorded in papers in the seventies (Magus and Harris 1971 and Hoffman et al 1975). Human lung explants, exposed to marijuana smoke resulted in DNA and chromosomal alterations (Van Hoozen et al 1997).

Oncogenes and tumour suppressive genes, when mutated, produce proteins which cause cells to multiply rapidly and uncontrollably, resulting in tumours. Two of these proteins were found to be markedly increased in cannabis smokers compared to tobacco or non-smokers, the effects of tobacco and cannabis being additive (Roth et al 1998). The mutagenic effects of marijuana smoke have also been observed by Chiesara and Rizzi 1983, Gilmore et al 1971, Herha and Obe 1974 and Stenchever et al 1974.

Benzpyrene can cause alteration of a gene, P53, one of the commonest tumour suppressor genes if acted on by a chemical particle, CYP1A1. THC has been shown to increase production of this particle so making possible the development of respiratory cancer. P53 is thought to play a part in 75% of lung cancers and it is expressed in 11% of cannabis and tobacco smokers (Dinissenko et al 1996, Marques-Magallanes et al 1997).

The immune system has a role to play in the development of cancer. Alveolar macrophages protect the lungs from infection, they also kill tumour cells. Marijuana and tobacco smokers produce two or three times as many of these cells as non-smokers. The effects of smoking both being additive (Barbers et al 1987). The macrophages in both tobacco and marijuana smokers were larger and had more inclusions, probably due to the ingestion of smoke particles (Beals et al 1989). A more recent paper by Baldwin et al in 1997 found significant impairment of the macrophage cells of both tobacco and marijuana smokers. These cells have been shown to have cannabis receptors (Bouaboula et al 1993). Anti-tumour immunity depends on antigen-presenting dendritic cells being able to stimulate the proliferation of T lymphocytes that identify and destroy tumour cells. In in-vitro studies in which dendritic cells and T lymphocytes were incubated with or without THC, the THC suppressed the T cell proliferation in a dose-dependent manner (Roth et al 1997). Two earlier papers on this subject were written in 1975, Peterson et al and Nahas et al. DNA alterations have been seen in the lymphocytes of pregnant marijuana smokers and their newborns. This study is particularly important as tobacco smokers were excluded (Ammenheuser et al 1998). Cannabis smoking also depressed pro-inflammatory cytokine production. Cytokines regulate macrophage function so this may account for the impairment of their ability to kill tumour cells (Baldwin et al 1997).

Experiments on animals have yielded confirmatory evidence for many of the previous observations. In 1979 Rosenkranz and Fleischman found changes in the bronchial epithelia of rats after they had inhaled marijuana smoke for several months. These changes were consistent with precancerous alterations in cells. In the same year Fried and Charlebois administered cannabis smoke to rats during pregnancy and discovered impaired development in the F2 generation, so not only was damage caused to the first but also the second generation. In 1997 Zhu and others treated mice for 2 weeks with THC prior to the implantation of Lewis lung cancer cells. Larger faster-growing tumours resulted suggesting that the THC impairs the development of anti-tumour immunity in vivo. Dubinett et al in 2000 also found that mice injected with THC had reduced capability to fight the growth of tumours.

Painting tar from marijuana smoke on the skins of mice produced lesions correlated with malignancies (Cottrell 1973).

There are a significant number of reports of human cancers which may be linked to the smoking of marijuana. FM Taylor in 1988 examined adults with upper respiratory tract cancer over a period of 4 years. Of 6 men and 4 women, average age 33.5 years, nine had carcinomas of the lungs tongue or larynx, five were heavy cannabis smokers, two smoked it regularly, one had possibly used other drugs and two were non cannabis smokers. It was complicated by the fact that six were heavy alcohol users and six were smokers of tobacco. He concluded that regular marijuana use was a potent factor especially in the presence of other risk factors. He conceded that alcohol and tobacco may have played a part, but pointed out that the peak incidence for cancers due to tobacco or alcohol is in the seventh decade of life. All of these victims were much younger.

In 1989 Caplan and Brigham reported two cases of tongue cancer. One was a man of 37 the other a man of 52. Both were heavy cannabis users, neither smoked tobacco or drank alcohol. Endicott and Skipper in 1991 conducted a 2-centre USA retrospective study. Twenty-six patients of age 41 or less were diagnosed with throat or head tumours. The normal average age for tumours of this type is 57. All 26 were current or former marijuana smokers.

PJ Donald in 1993 examined patients with cancer of the head and throat over a 20-year period. He found 22 patients of age 40 or under on diagnosis, with squamous cell cancer. Their average age was 26. Nineteen of them were cannabis smokers, 16 being heavy users. In 13 the tumour was in the tongue or elsewhere in the oral cavity. Only half of them smoked tobacco.

110 private patients with lung cancer were studied. Nineteen (17%) of them were under 45. Thirteen of these had smoked marijuana of whom 12 reported current tobacco use. No tobacco-only smoking patients under 45 were noted (Sridhar et al 1994).

An epidemiological study to examine a possible association between cancer and marijuana was published in 1997 by Sidney and colleagues. 65,000 health plan members aged between 15 and 49 in 1979 to 1985 were followed for the development of new cancers till 1993. 182 tobacco-related cancers were detected, of which 97 were in the lungs. The study revealed no risk factors for cancers for lifetime or current use of marijuana.

The major limitation in this exercise is that those who were heavy or long-term users of cannabis were not followed up for long enough to detect cancers. Another criticism is that there may not have been sufficient of these long-term or heavy users to make the study effective. It must be remembered that most marijuana users quit before the level of exposure is sufficient to initiate the development of cancer and cannabis smoking has only been widespread in the USA since the 70s.

Zhang et al in 1999 studied 173 patients with carcinoma of the head and neck and compared them with 176 cancer-free controls. Age, sex, race, education, alcohol consumption and exposure to cigarette smoke either actively or passively, were all controlled for. Marijuana smoking increased the risk of squamous cell carcinoma of the head or neck, and a further increased risk was suggested with rising doses. Among people who smoked once a day the risk factor was 2.1 times compared with non-smokers, with those using it more than once a day the risk factor rose to 4.9. With patients who smoked cannabis and tobacco the risk was 36 times that for non-smokers.

The most prominent name and authority on cannabis and diseases of the respiratory system is that of Dr Donald Tashkin. He has researched the topic since the early seventies.

In 1993 he listed the factors suggesting that cannabis smoking may be associated with an increased risk of respiratory tract cancers.

1. Cannabis smoke has 50% more of certain carcinogens than tobacco smoke, especially the highly carcinogenic benz-pyrene.

2. Four times as much tar is produced by a cannabis cigarette than a tobacco one.

3. Experiments on animals have shown that cannabis smoke or tar from it is carcinogenic.

4. Heavy cannabis consumers have significantly higher numbers of cellular changes consistent with the preliminary stages of cancer.

5. There have been several reports of young cannabis-using people exhibiting the development of cancer. Tumours have appeared 10 to 30 years earlier than those who smoked tobacco alone.

In a review paper in 2002 he added that examination of the mucous membranes in long-term smokers suggests that THC weakens the immune defences against tumour cells.

In November 2002 the British Lung Foundation produced a paper “A Smoking Gun? The Impact of Cannabis Smoking on Respiratory Health”. One of their recommendations was: “ The British Lung Foundation recommends a public health education campaign aimed at young people to ensure that they are fully aware of the increased risk of pulmonary infections and respiratory cancers associated with cannabis smoking”.

In September 2003 The Thoracic Society of Australia and New Zealand produced a position paper in The Internal Medicine Journal on the respiratory health effects of cannabis (Taylor and Hall). They also called for a campaign. “Public Health Education should dispel the myth that cannabis smoking is relatively safe by highlighting that the adverse respiratory effects of smoking cannabis are similar to those of smoking tobacco…that the respiratory hazards of smoking cannabis are significant…almost all studies indicate that the effects of cannabis and tobacco smoking are additive and independent”.

In June 2005 Roth and Tashkin of UCLA, the two leading authors of many papers linking cannabis and cancer for over 10 years, described an epidemiological study at the meeting of the International Cannabinoid Research Society in Tampa, Florida. This paper has yet to appear on the ICRS website. Tashkin reported that they had failed to substantiate the link. Needless to say the press immediately issued banner headlines like “Marijuana is safer than tobacco”. However it has emerged that the study lacked statistical power. Tashkin and Roth explained that they had very few patients smoking more than 6 joints a day, a very mild level of consumption. Had they had more moderate and heavy smokers, their outcomes would almost certainly have been different. The study was originally designed to have 3 controls for each cancer case, in reality the ratio was around 0.7. Statistics are powerful but not powerful enough to account for gross flaws in sampling errors and study design.

In 1981 the WHO report on cannabis use said, “It is instructive to make comparisons with the study of effects of other drugs, such as tobacco or alcohol. With these drugs, “risk factors” have been freely identified, although full causality has not yet been established. Nevertheless such risk factors deserve and receive serious attention with respect to the latter drugs. It is puzzling that the same reasoning is often not applied to cannabis”… “To provide rigid proof of causality in such investigations is logically and theoretically impossible, and to demand it is unreasonable”.

Mary Brett, biologist and former head of health education, Dr Challoner’s Grammar School (boys) Chesham Road, Amersham, Bucks. HP6 5HA, UK 17th July 2005 References are available for this paper – please send a s.a.e. to NDPA

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