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Research

Health effects of exposure to second- and third-hand marijuana smoke: a systematic review

Hannah Holitzki, Laura E. Dowsett, Eldon Spackman, Tom Noseworthy and Fiona Clement
November 30, 2017 5 (4) E814-E822; DOI: https://doi.org/10.9778/cmajo.20170112
Hannah Holitzki
Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta.
BHSc
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Laura E. Dowsett
Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta.
MSc
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Eldon Spackman
Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta.
PhD
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Tom Noseworthy
Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta.
MDMPH
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Fiona Clement
Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta.
PhD
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    Flow chart of identified records.

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    Urine levels of tetrahydrocannabinol (THC) and metabolites and subjective effects in participants passively exposed to marijuana smoke in an unventilated environment, 4-8 hours after exposure, by THC content.

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    Table 1: Characteristics of included studies
    Author/countryInterventionParticipant selectionNo. of participantsParticipant characteristicsReported outcomesQuality*
    Cone et al.,22 2015, United StatesIntervention: nonsmokers were exposed to marijuana smoke from participants smoking marijuana in controlled environment laboratory over 3 sessions; potency and ventilation of environment were changed between each session
    Multiple trials: 1) 5.3% THC in unventilated environment, 2) 11.3% THC in unventilated environment, 3) 11.3% THC in ventilated environment
    Participant selection: recruited through newspaper advertisements, flyers posted on university campus and around community, and word of mouth
    Inclusion criteria for smokers: self-reported use of cannabis at least 2 times per week during previous 90 d, negative results of testing for other illicit substances
    Inclusion criteria for nonsmokers: healthy participants who self-reported lifetime cannabis use but had not used cannabis or any other illicit drug in previous 6 mo
    6 smokersNRTHC level in oral fluid and whole blood, self-report of drug effects (Drug Effects Questionnaire visual analogue scale)22
    6 nonsmokersNR
    Cone et al.,23 2015, United StatesIntervention: nonsmokers were exposed to marijuana smoke from participants smoking marijuana in controlled environment laboratory over 3 sessions; potency and ventilation of environment were changed between each session
    Multiple trials: 1) 5.3% THC in unventilated environment, 2) 11.3% THC in unventilated environment, 3) 11.3% THC in ventilated environment
    Participant selection: recruited through newspaper advertisements, flyers posted on university campus and around community, and word of mouth
    Inclusion criteria for smokers: self-reported use of cannabis at least 2 times per week during previous 90 d, negative results of testing for other illicit substances
    Inclusion criteria for nonsmokers: healthy participants who self-reported lifetime cannabis use but had not used cannabis or any other illicit drug in previous 6 mo
    8 smokers3 women, 5 men, average age 29 (SD 6) yr, average BMI 25.6Total cannabis use (weight), THC level in urine22
    18 nonsmokers9 women, 9 men, average age 28 (SD 7) yr, average BMI 24.7
    Cone et al.,19 1987, United StatesIntervention: nonsmokers were exposed to marijuana cigarette smoke (2.8% THC) under double-blind conditions
    Multiple trials: 3 trials, 1 with 4 cigarettes and 2 with 16 cigarettes
    Participant selection: NR
    Inclusion criteria for nonsmokers: healthy, drug-free men with history of marijuana use who had 14 consecutive d of cannabinoid-free urine tests; 2 cannabis-naive men (members of research team)
    7 nonsmokersAll men, average age 36 yr, average weight 74.7 kgRoom air THC concentrations, THC level in urine20
    Cone et al.,25 1986, United StatesIntervention: nonsmokers were exposed to marijuana cigarette smoke (2.8% THC) under double-blind conditions
    Multiple trials: 3 trials, 1 with 4 cigarettes and 2 with 16 cigarettes
    Participant selection: NR
    Inclusion criteria for nonsmokers: healthy, drug-free men with history of marijuana use who had 14 consecutive d of cannabinoid-free urine tests; 2 cannabis-naive men
    7 nonsmokersAll men, average age 36 yr, average weight 74.7 kgTHC level in urine (EMIT 20 ng/mL and 100 ng/mL) and whole blood, heart rate, blood pressure, subscales of Addiction Research Center Inventory (single-dose questionnaire, visual analogue scale)22
    Cone et al.,26 1986, United StatesIntervention: nonsmokers were exposed to marijuana cigarette smoke (2.8% THC) under double-blind conditions
    Multiple trials: 3 trials, 1 with 4 cigarettes and 2 with 16 cigarettes
    Participant selection: NR
    Inclusion criteria for nonsmokers: healthy, drug-free men with history of marijuana use who had 14 consecutive d of cannabinoid-free urine tests; 2 cannabis-naive men
    7 nonsmokersAll men, average age 36 yr, average weight 74.7 kgTHC level in urine (EMIT 20 ng/mL and 100 ng/mL) and whole blood, subscales of Addiction Research Center Inventory (single-dose questionnaire, visual analogue scale, circular lights task, digit-symbol substitution task)19
    Herrmann et al.,24 2015, United StatesIntervention: nonsmokers were exposed to marijuana smoke from participants smoking marijuana in controlled environment laboratory over 3 sessions; unlimited marijuana was provided to smokers
    Multiple trials: 1) 11.3% THC in unventilated environment, 2) 11.3% THC in ventilated environment (11 air exchanges per hour)
    Participant selection: recruited from Baltimore through media advertising and word of mouth
    Inclusion criteria for smokers: age 18-45 yr, used cannabis at least 2 times per week during previous 90 d, urine sample positive for THC and negative for other drugs, negative breath alcohol reading at screening and on day of session, BMI 19-34, not pregnant or nursing
    Inclusion criteria for nonsmokers: age 18-45 yr, cannabis use at least once but not during previous 6 mo, urine sample negative for all drugs, negative breath alcohol reading at screening and on day of session, BMI 19-34, not pregnant or nursing
    7 smokers4 men, 3 women, average age 29.4 (SD 5.8) yr, average BMI 25.6Total weight of cannabis smoked, THC level in blood and urine, heart rate, blood pressure, subscales of Drug Effects Questionnaire (divided attention task, digit-symbol substitution task, paced auditory serial addition task)22
    12 nonsmokers3 men, 3 women, average age 28.7 yr, average BMI 25.3
    Law et al.,27 1984, United KingdomIntervention: nonsmokers were exposed to marijuana smoke (9.8% THC) in a small, unventilated room
    Multiple trials: No
    Timeline of exposure: after smokers had consumed their cannabis cigarette (which took 10-34 min), nonsmoking participants remained in room for 3 h
    Participant selection: NR
    Inclusion criteria for smokers: NR
    Inclusion criteria for nonsmokers: NR
    6 smokersNREnvironmental exposure (gas chromatography), THC level in urine and whole blood (radioimmunoassay)13
    4 nonsmokersNR
    Moore et al.,28 2011, United StatesIntervention: passive 3-h exposure to marijuana in Dutch "coffee shop"
    Multiple trials: 2 trials in 2 different coffee shops, with varying numbers of active smokers (varying THC percentage)
    Participant selection: volunteers; selection strategy NR
    Inclusion criteria for smokers: any active smoker in coffee shop during exposure timeline
    Inclusion criteria for nonsmokers: healthy participants who did not smoke marijuana
    16 smokers in trial 1, 6 smokers in trial 2NRAir cannabinoid content (Quantisal collection device), THC level in oral fluid (Quantisal collection device)19
    10 nonsmokers5 men, average age 22.8 yr, average weight 84 kg, average height 1.9 m, average BMI 233; 5 women, average age 23.8 yr, average weight 62.4 kg, average height 1.71 m, average BMI 21.2
    Mørland et al.,33 1985, NorwayIntervention: participants were exposed to marijuana and hashish smoke in small, unventilated car
    Multiple trials: 1) hashish (1.5% THC), 2) marijuana (1.5% THC)
    Participant selection: volunteers; selection strategy NR
    Inclusion criteria for smokers: NR
    Inclusion criteria for nonsmokers: healthy cannabis-naive participants
    5 smokersNRBlood cannabinoid levels (radioimmunoassay), THC level in urine (EMIT)16
    10 nonsmokers7 men, 3 women "of normal weight in relation to their height, age, and sex"
    Mulé et al.,29 1988, United StatesIntervention: in first part of experiment, smokers were asked to smoke cannabis as they usually did and were observed; in second part, nonsmokers were exposed to smoke of 4 cannabis cigarettes (27 mg THC) in unventilated room
    Multiple trials: no
    Participant selection: NR
    Inclusion criteria for smokers: occasional (1 cigarette/wk) or moderate (1-3 cigarettes/wk) smoking
    Inclusion criteria for nonsmokers: NR
    8 smokersAll male, age 21-27 yr, height 5'9"-6'1" (1.75-1.85 m), weight 154-175 lbs (69.8-79.4 kg)THC level in urine (EMIT)18
    3 nonsmokersNR
    Niedbala et al.,20 2005, United StatesIntervention: participants were placed in severe second-hand smoke conditions in unventilated van for 1 h
    Multiple trials: 2 trials, each with 4 smokers and 4 passive inhalers; 5.4% THC in trial 1, 10.4% THC in trial 2
    Participant selection: volunteers; recruitment strategy NR
    Inclusion criteria for smokers: healthy white men who reported infrequent past cannabis use
    Inclusion criteria for nonsmokers: healthy white men who tested as cannabis-free before study based on oral fluid and urine tests and self-reported data
    8 smokers18-24 yr for both groupsTHC level in oral fluid (Intercept collector pads) and urine16
    8 nonsmokers34-50 yr in first group, 25-50 yr in second group
    Niedbala et al.,21 2004, United StatesIntervention: smokers consumed 1 cannabis cigarette each (approximate THC level 1.75%) in presence of nonsmokers in sealed room
    Multiple trials: no
    Participant selection: volunteers; recruitment strategy NR
    Inclusion criteria for smokers: healthy white men who reported infrequent prior use of cannabis
    Inclusion criteria for nonsmokers: healthy white men who tested as cannabis-free before start of study
    5 smokersAge 21-25 yrAir cannabinoid content, THC level in oral fluid and urine15
    4 nonsmokersAge 37-49 yr
    Perez-Reyes et al.,30 1983, United StatesIntervention: smokers consumed cannabis cigarettes in presence of nonsmokers in a room (trials 1 and 3) and a car (trial 2); biological samples were then taken and compared between the 2 groups
    Multiple trials: 1) 2 cigarettes (2.5% and 2.8% THC), 2) 2 cigarettes (2.8% THC), 3) 4 cigarettes (2.8% THC)
    Participant selection: NR
    Inclusion criteria for smokers: experienced marijuana users
    Inclusion criteria for nonsmokers: marijuana-naive participants
    6 smokers3 men, 3 women, "healthy and of normal weight and height in relation to their age and sex"THC presence in air, THC level in urine (EMIT) and blood16
    6 nonsmokers3 men, 3 women, "healthy and of normal weight and height in relation to their age and sex"
    Röhrich et al.,31 2010, GermanyIntervention: nonsmokers were exposed to marijuana smoke in Dutch coffee shop with ventilation (THC percentage NR)
    Multiple trials: no
    Participant selection: NR
    Inclusion criteria for smokers: active smoker in coffee shop at time of experiment
    Inclusion criteria for nonsmokers: no history of cannabis use, no contact with cannabis in month preceding experiment
    8-25 smokers at a timeNRTHC level in blood and urine (gas chromatography-mass spectrometry)15
    8 nonsmokers4 men, 4 women
    Zeidenberg et al.,32 1977, United StatesIntervention: heavy marijuana smokers consumed cannabis (THC level NR) in presence of placebo smoker in locked ward
    Multiple trials: no
    Participant selection: NR
    Inclusion criteria for smokers: NR
    Inclusion criteria for nonsmoker: NR
    5 smokersNRTHC level in urine, subjective reporting, physical examination14
    1 nonsmokerNR

    Note: BMI = body mass index, EMIT = enzyme multiplied immunoassay technique, NR = not reported, SD = standard deviation, THC = tetrahydrocannabinol.

    *Assessed with the use of the Downs and Black checklist,17 which rates papers on 5 constructs: 1) reporting, 2) external validity, 3) internal validity - bias, 4) internal validity - confounding and 5) power. A total score of 24-28 points = excellent, 19-23 points = good, 14-18 points = fair, less than 14 points = poor.18

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    Health effects of exposure to second- and third-hand marijuana smoke: a systematic review
    Hannah Holitzki, Laura E. Dowsett, Eldon Spackman, Tom Noseworthy, Fiona Clement
    Nov 2017, 5 (4) E814-E822; DOI: 10.9778/cmajo.20170112

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    Health effects of exposure to second- and third-hand marijuana smoke: a systematic review
    Hannah Holitzki, Laura E. Dowsett, Eldon Spackman, Tom Noseworthy, Fiona Clement
    Nov 2017, 5 (4) E814-E822; DOI: 10.9778/cmajo.20170112
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