Open access peer-reviewed chapter

Evidence of Health Effects Associated with Marijuana Use: A Comprehensive Public Health Review

Written By

Richard Holdman

Submitted: 17 June 2022 Reviewed: 04 July 2022 Published: 04 August 2022

DOI: 10.5772/intechopen.106250

From the Edited Volume

Cannabinoids - Recent Perspectives and Applications in Human Health

Edited by Steven P. James

Chapter metrics overview

120 Chapter Downloads

View Full Metrics


Starting in 2014, Colorado Department of Public Health was designated to monitor the emerging science and medical information relevant to the health effects associated with marijuana use. After years of conducting an ongoing systematic review of scientific literature, we have established 139 evidence statements within 11 health topics. Our mission is to translate the science into meaningful public health statements and recommendations to inform and educate the general public, healthcare providers, and everyone in-between on the health effects associated with marijuana use. This chapter summarizes evidence from all of our health topics; ranging from respiratory effects of marijuana to cognitive and academic effects of marijuana use on adolescents and young adults.


  • tetrahydrocannabinol
  • marijuana use
  • health effects
  • public health
  • systematic review

1. Introduction

In 2014 recreational, adult-use of cannabis (interchangeably referred to as marijuana) was established in the state of Colorado. At this time the Colorado Department of Public Health and Environment (CDPHE) was given statutory responsibility in Colorado Revised Statute (C.R.S.) 25-1.5-110, to; “monitor changes … in the emerging science and medical information relevant to the health effects associated with marijuana use.” and “appoint a panel of health care professionals with expertise in, but not limited to, neuroscience, epidemiology, toxicology, cannabis physiology, and cannabis quality control to further direct policy.” Based on this charge, CDPHE appointed a 14-member committee titled the Retail Marijuana Public Health Advisory Committee (RMPHAC) to review scientific literature on the health effects of marijuana.

Under the same statute mentioned previously, the RMPHAC is directed to “…establish criteria for studies to be reviewed, reviewing studies and other data, and making recommendations, as appropriate, for policies intended to protect consumers of marijuana or marijuana products and the general public.” To implement this charge, the RMPHAC meets four or five times a year to review the scientific literature currently available on health effects of marijuana use, evaluate findings without bias, openly discuss the science and apply expert opinion, come to consensus on the science, translate the science into public health messages, make policy-related recommendations, recommend surveillance activities, and identify and address gaps in the science important to public health. All this information is compiled and detailed in a report every two years for the Colorado State Board of Health, the Colorado Department of Revenue, and the Colorado General Assembly, titled “Monitoring Health Concerns Related to Marijuana in Colorado” [1].

Since 2014, and prior to this publication, the RMPHAC has come together on a quarterly basis, held discussions concerning hundreds of articles, and developed over one hundred evidence statements within eleven health topics. As more scientific evidence regarding cannabis health effects are published, this committee continues to build upon existing evidence statements or will construct new statements when appropriate. This chapter will detail the review methods used by the RMPHAC to develop evidence statements about the health effects associated with marijuana use, describe the findings from all eleven health topics, and report the public health statements, recommendations, and research gaps used to inform public health policy in the State of Colorado.


2. Systematic review development and process

The first step in the process of investigating the health effects from marijuana use was to develop and implement an unbiased, transparent, and complete process for evaluating scientific literature and data on marijuana use and health outcomes. To ensure this, the RMPHAC and CDPHE technical staff developed a twelve step review process guided by the established preferred reporting items for systematic reviews and meta-analyses (PRISMA) framework [2]. These twelve steps are followed for each review and are as follows:

  1. Conduct a broad search of current peer-reviewed publications quarterly. Relevant articles cited in reviews or other primary studies are also included.

  2. Review relevant full-text articles identified in the search.

  3. Rate the findings: each finding in the articles is rated as a high-, medium-, or low-quality finding based on strengths and limitations of the methods. Evaluation of the strengths and limitations was based on criteria in the grading of recommendations assessment, development and evaluation (GRADE) system, a well-accepted method for evaluating the quality of scientific evidence [3].

  4. Group related findings: each finding is categorized based on population, exposure, and outcome (health effect), to answer specific questions.

  5. Weigh the evidence: draft evidence statements that summarize the quantity and quality of evidence answering a specific question.

  6. Translate the evidence: draft public health statement that translate the evidence statement into language at an 11th grade reading level.

  7. Synthesize the evidence: draft public health recommendations (e.g., for education or monitoring) based on important information identified through the review process.

  8. Identify research gaps: draft statements to articulate the research gaps identified during the review process.

  9. Present to committee: findings, evidence statements, public health statements, public health recommendations, and research gaps are publicly presented to the RMPHAC for review and revision during open public meetings.

  10. Public comment: during the open public meetings, interested stakeholders and members of the public are invited to provide comments relevant to the topics presented.

  11. Reach consensus: committee members come to consensus on findings, evidence statement, public health statement, public health recommendations, and research gaps.

  12. Adopt summary statements: committee votes to officially accept findings, evidence statements, public health statements, public health recommendations, and research gaps.

All review methods were approved by the RMPHAC, including the terms used to conduct the ongoing broad search of peer-reviewed publications for relevant literature. Medline is the priority research database used to obtain articles for review. Embase, the biomedical database, and gray literature were secondarily reviewed when references in included articles were not included in Medline searches. Studies of marijuana use in humans were the primary focus of the review, with animal studies included for only specific topics with limited human research. All identified peer-reviewed literature on a given topic was reviewed, regardless of positive or negative findings or quality of the methods utilized. For the ongoing broad Medline search, medical subject heading (MeSH) terms were used and is as follows; “Cannabis”[Mesh] OR Marijuana “Smoking”[Mesh] OR “Marijuana Abuse”[Mesh] OR cannabis OR marijuana OR marihuana OR hash oil OR hashish. In 2014, when this review was established, specific searches were conducted using the appropriate MeSH terms for each topic area.

Once relevant literature is obtained, each finding is rated high, medium, or low quality based on the strengths and limitations of the methods which is determined by criteria in the GRADE system. The GRADE system is a well-established method for systematic literature review and has been used by the Cochrane Collaboration, British Medical Journal, American College of Physicians, World Health Organization, and many others [3]. Findings rated high quality are defined as “We are very confident that the true effect lies close to that of the estimate of the effect outlined in the study.” These are well-designed and well-controlled studies with few limitations. Due to the fact that most studies included in our review are observational epidemiology studies, receiving a high quality rating does not necessarily imply causation. It simply implies that an observed association persists between an exposure and effect in an appropriately-sized study population after adjusting for appropriate confounders. Medium quality findings are defined as “we are moderately confident in the effect estimate outlined in the study. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.” For observational epidemiology studies this implies the finding of an observed association may be limited by a small study population or insufficient adjustment for important confounders. Low quality findings are defined as “our confidence in the effect estimate outlined in the study is limited. The true effect may be substantially different from the estimate of the effect.” For observational epidemiology studies this implies the finding of an observed association with an interpretation that is significantly restricted by study limitations.

Findings from relevant literature are usually grouped based on outcome or the health effect in question. However, in some situations findings are further subdivided based on factors such as: age range of the exposed population, special subject circumstances such as pregnancy or breastfeeding, level or method of marijuana use, time period since last use of marijuana, amount of marijuana used, and THC concentration. Standardized definitions of level of marijuana use (daily, weekly, etc.) and age groups (child, adolescent, young adult, etc.) were established to help facilitate grouping of findings. Once findings are grouped appropriately, the evidence is drafted into evidence statements that summarize the quality and quantity of scientific evidence supporting an association between marijuana use and a health outcome.


3. Systematic review findings

In order to make our review findings easily interpretable we used a standardized rating system to classify evidence statements. These statements are also constructed to accurately portray the quality and quantity of all findings used to support the particular health outcome. Evidence statements all use standardized language from one of the following six classifications:

  • Substantial evidence—indicates robust scientific findings that support an association between marijuana use and the outcome.

  • Moderate evidence—indicates scientific findings that support an association, but these findings have some limitations.

  • Limited evidence—indicates modest scientific findings that support an association, but these findings have significant limitations.

  • Mixed evidence—indicates both supporting and opposing scientific findings for an association, with neither direction dominating.

  • Insufficient evidence—indicates the outcome has not been sufficiently studied to conclude whether or not there is an association between marijuana use and the outcome.

  • Body of research failing to show an association—indicates the topic has been researched without evidence of an association; is further classified as a limited, moderate, or substantial body of research.

In the following sections evidence statements will be discussed according to health topic and statements with enough findings to receive a substantial or moderate rating are displayed in tables. All statements, regardless of evidence level, are drafted by CDPHE technical staff, revised based on committee review and feedback from technical advisors and public stakeholders. Statements in their final form are approved by a vote of the committee.

3.1 Marijuana use among adolescents and young adults

The RMPHAC has reviewed the relationships between adolescent and young adult marijuana use on various areas of concern; including cognitive abilities, academic performance, mental health, and future substance use, displayed in Table 1. Specifically regarding cognitive and academic abilities, weekly marijuana use by adolescents is associated with deficits for at least twenty-eight days after last use. Weekly use among adolescents is also associated with failure to graduate from high school or complete a college degree. Information on how marijuana use affects short-term and long-term IQ is currently insufficient and limited, respectively. As with many of our statements that reflect long-term marijuana use, the paucity of long-term studies is a research gap that will hopefully improve due to the changing legal landscape of cannabis throughout the United States.

Substantial evidenceModerate evidence
Benefits of quittingTreatment for cannabis use disorder can reduce use and dependence [4, 5, 6, 7, 8, 9, 10]Quitting or decreasing marijuana use lowers the risk of adverse mental health outcomes [11, 12, 13, 14]
Cognitive and academic effectsWeekly, or more frequent, use is associated with a lower rate of graduating high school [15, 16, 17, 18, 19, 20, 21, 22, 23]Weekly, or more frequent, use is associated with a lower rate of attaining a college degree (among those who start a degree program) [19, 24, 25, 26, 27, 28, 29]
Weekly, or more frequent, use is associated with ongoing cognitive and academic impairment for at least 28 days after last use [30, 31, 32, 33, 34, 35]
Mental healthDaily or near daily use is associated with future psychotic disorders like schizophrenia [36, 37, 38, 39, 40, 41, 42, 43]Marijuana use is associated with suicidal thoughts or attempting suicide [22, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63]
Use is associated with future psychotic symptoms (likelihood increases with more frequent use) [14, 40, 42, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80]
Substance use, abuse, and addictionThose who use marijuana can develop cannabis use disorder (addiction) [81, 82, 83, 84, 85, 86, 87]Marijuana use is associated with future use and use disorder for alcohol [15, 20, 88, 89, 90, 91, 92]
Marijuana use is associated with future use and use disorder for marijuana, tobacco and other drugs [13, 15, 20, 22, 25, 28, 79, 84, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105]
High THC (%) concentrationUsing marijuana with higher THC concentration (>10% THC) is associated with continued use [38, 106, 107, 108]
Use of marijuana with higher THC concentration (>10% THC) is associated with future mental health symptoms and disorders [38, 78, 107]

Table 1.

Marijuana use among adolescents and young adults.

Adolescents and young adults who use marijuana are more likely to experience psychotic symptoms in adulthood (such as hallucinations, paranoia, and delusional beliefs), future psychotic disorders (such as schizophrenia), and suicidal thoughts or attempting suicide, when compared to adolescents and young adults who do not use marijuana. Additionally, those using marijuana with higher tetrahydrocannabinol (THC) concentration (>10% THC) are more likely than non-users to continue using and to develop future mental health symptoms and disorders. How marijuana use during adolescence affects symptoms or a diagnosis of anxiety in adulthood currently stands at a mixed evidence level, with fourteen articles contributing to this rating. Only one of which received a high quality rating and also reported mixed findings relevant to this evidence statement on anxiety [64]. Results from their main analysis did show an association with adolescent cannabis use and adulthood anxiety, however, results from a monozygotic-only co-twin control analysis reported no association [64].

Evidence shows that adolescents who use marijuana can develop cannabis use disorder, along with marijuana use being associated with developing use disorder for tobacco, alcohol, and other drugs. On a more positive note, evidence shows that adolescents who receive treatment for cannabis use disorder can decrease their use and dependence. Additionally, those who quit using marijuana have lower risks of adverse cognitive and mental health outcomes than those who continue to use.

3.2 Marijuana use and cancer

To assess how marijuana use may or may not be associated with cancer, the RMPHAC reviewed health effects of the chemicals released in marijuana smoke and vapor and evaluated how different rates of marijuana use relate to cancer. Strong evidence shows marijuana smoke contains many of the same cancer-causing chemicals found in tobacco smoke [109]. There is also substantial evidence that daily or near-daily marijuana smoking is associated with pre-malignant lesions in the airway. However, there is conflicting research for whether or not marijuana smoking is associated with lung cancer. As shown by the moderate evidence statement in Table 2, the body of research reviewed has failed to show an association between smoking less than the equivalent of one joint per day for 10 years and lung cancer.

Substantial evidenceModerate evidence
Cancer and precancerous lesionsDaily or near daily use is associated with pre-cancerous lesions in airway [110, 111, 112]Smoking less than the equivalent of one joint per day for 10 years is not associated with lung cancer [113, 114, 115, 116, 117, 118]
Chemicals in MJ smoke or vaporMarijuana smoke contains many of the same cancer causing chemicals as tobacco smoke [109, 119, 120, 121, 122]
Genitourinary CancerUse among adult males is associated with increased risk of nonseminoma testicular cancer [123, 124, 125, 126, 127]

Table 2.

Marijuana use and cancer.

Apart from the respiratory system, most of our statements are not in Table 2 due to the limited evidence available concerning cancers of the bladder, prostate, head and neck. These limited statements all suggest these forms of cancer might not have any association with marijuana use. However, there is evidence that marijuana use among adult males may be associated with nonseminoma testicular cancer. High quality research on non-respiratory tract cancers related to marijuana use remains a research gap identified by the RMPHAC.

3.3 Marijuana use and cardiovascular effects

Related to cardiovascular health effects, how marijuana use associates with myocardial infarction, stroke, and death from cardiovascular causes were reviewed. Evidence shows that marijuana use or consumption in those under the age of fifty-five years are at an increased risk of ischemic stoke, as shown in Table 3. However, currently there is only limited scientific evidence to support our statements on myocardial infarction and death related to a cardiovascular event.

Substantial evidenceModerate evidence
Marijuana users/consumers younger than 55 years of age are at an increased risk of stroke [128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145]

Table 3.

Marijuana use and cardiovascular effects.

3.4 Marijuana dose and drug interactions

An important metric to understand is how THC blood levels compare from various marijuana methods of use and the numerous concentrations of THC in available products on the retail marijuana market. For example, there is substantial evidence that smoking more than 10 mg THC (or 10–20% of a 1 g marijuana joint) produces a blood THC level near or above 5 ng/mL within 10 min. As we see the THC concentration of marijuana products increase, we can expect this association to remain strong. One important finding in Table 4 is that it can take up to four hours after consuming an edible marijuana product to reach the peak THC blood concentration and feel the full effects. Another method of use, vaporized THC, shows moderate evidence of producing a similar blood THC level to smoking the same amount.

Substantial evidenceModerate evidence
THC blood levels resulting from different exposuresIt takes up to four hours after ingesting marijuana (edible products) to reach peak blood THC levels [146, 147, 148, 149, 150, 151]Ingesting (edible products) more than 15 mg THC may produce a blood THC level above 5 ng/mL [148, 152, 153, 154]
Smoking more than 10 mg THC produces a blood THC level near or above 5 ng/mL within 10 min [152, 155, 156, 157, 158, 159]Inhaling vaporized THC produces a blood THC level similar to smoking the same dose [149, 159, 160]
Secondhand exposureTypical secondhand marijuana smoke exposure is unlikely to cause a positive drug screen by urine or blood [161, 162, 163, 164, 165, 166, 167, 168, 169]

Table 4.

Marijuana dose and drug interactions.

Within this topic the RMPHAC reviewed effects of secondhand marijuana smoke, drug-drug interactions involving marijuana, and relationships between marijuana and opioid use. There is credible evidence of clinically important drug-drug interactions between marijuana and multiple medications, including some anti-seizure medications and a common blood-thinner, warfarin. Data about potential interactions are lacking for many drugs at this time and are likely to evolve substantially in the coming years. Other than our statement about secondhand marijuana smoke exposure being unlikely to cause a positive drug screen, our statements in this topic area are all based on limited evidence. Health effects resulting from secondhand marijuana smoke exposure is an area lacking in research. There is also conflicting evidence for whether or not marijuana use is associated with a decrease in opioid use among chronic pain patients or individuals with a history of problem drug use.

3.5 Marijuana use and driving

As with any psychoactive substance it is imperative to know how marijuana affects a person’s ability to drive and the crash risks associated with use. To fully comprehend how marijuana causes driving impairment we must also understand the pharmacokinetics of THC in the human body to know how long these affects will persist after last use. Table 5 displays all driving related statements that have evidence to provide a substantial or moderate rated statement. Current research shows substantial evidence that recent marijuana use by a driver increases the risk of a motor vehicle crash. In addition, using alcohol and marijuana together increases impairment and the risk of a motor vehicle crash more than using either substance alone.

Substantial evidenceModerate evidence
Combined marijuana and alcohol useCombined use of marijuana and alcohol increases crash risk more than either substance alone [170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181]
Impairment and crash riskRecent marijuana use/consumption by a driver increases the risk of a motor vehicle crash [170, 171, 172, 174, 182, 183, 184, 185, 186, 187, 188]Higher THC blood level increases the risk of a motor vehicle crash [173, 178, 180, 189]
Smoking more than 10 mg THC can lead to driving impairment [147, 155, 157, 177, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200]Blood THC levels of impaired drivers are higher now than they were in the past [201]
Orally ingesting more than 10 mg THC can lead driving impairment [146, 147, 153, 155]
Increased risk of driving impairment at blood THC as low as 2–5 ng/mL [155, 185, 190, 202, 203, 204, 205, 206]
Time to wait before drivingWaiting at least 6 after smoking less than 18 mg allows driving impairment to resolve or nearly resolve [155, 190, 207]Waiting at least 6 h after smoking about 35 mg allows driving impairment to resolve or nearly resolve [157, 192, 196]
Waiting at least 8 h after orally ingesting less than 18 mg allows driving impairment to resolve or nearly resolve [147, 153, 155, 208]

Table 5.

Marijuana use and driving.

The RMPHAC also set out to determine how various patterns of marijuana use affect driving. People that consume marijuana less-than-weekly are likely to experience impaired driving after using marijuana containing ten milligrams or more of THC. This statement holds true for smoking or consuming edible marijuana products. Research on driving impairment for those that consume more frequently than weekly is currently lacking in scientific literature. Due to this our evidence statement on crash risk for different levels of use (less-than-weekly compared to more frequent use) has received an insufficient rating at this time.

Articles measuring THC blood levels were also assessed to evaluate for any correlation to driving impairment, crash risk, and to develop statements informing consumers the amount of time to wait prior to driving. There is substantial evidence, including a randomized clinical trial [202], which has displayed meaningful driving impairment with a whole blood THC of 2–5 ng/mL. Additionally, moderate evidence points to a positive relationship between THC blood level and motor vehicle crash risk. In order for marijuana consumers to allow impairment to resolve, less-than-weekly consumers should wait at least six hours after smoking or eight hours after eating or drinking marijuana products. When consuming larger amounts of THC or for people that consume more frequently, evidence is currently insufficient to determine the safe amount of time for impairment to wear off. Evidence is also showing that blood THC levels of marijuana-impaired drivers are higher now than in the past, likely resulting from the increasing THC concentration of available marijuana products.

3.6 Marijuana use and gastrointestinal or reproductive effects

The RMPHAC reviewed how marijuana use may affect gastrointestinal disease, particularly cyclic vomiting, and infertility or abnormal reproductive function. Displayed in Table 6, evidence shows that long-time, daily or near daily marijuana use is associated with cyclic vomiting, also called cannabinoid hyperemesis syndrome (CHS). A majority of evidence supporting this statement is from case reports or case series of identified CHS patients, however, many review articles detail diagnostic criteria, treatment options, and the physiology behind marijuana use and CHS presentation [220]. Regarding reproductive function, there is limited research showing marijuana use is associated with male infertility or abnormal function, however, the research is conflicting for women.

Substantial evidenceModerate evidence
Cyclic vomitingCyclic vomiting can occur with long-time, daily or near daily marijuana use/consumption (cannabinoid hyperemesis syndrome) [209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219]

Table 6.

Marijuana use and gastrointestinal and reproductive effects.

3.7 Marijuana use and injury

The RMPHAC reviewed workplace, recreational and other non-driving injuries, burns from hash-oil extraction or failed electronic smoking devices, and physical dating violence. Evidence shows mixed results for marijuana use affecting the risk of workplace injury, recreational injury, and other types of non-driving-related injury. There have been many reports of severe burns resulting from home-extraction of butane hash oil leading to explosions, and cases of electronic smoking devices exploding, leading to trauma and burns.

Concerning dating violence, Table 7 shows our only statement reaching moderate or substantial levels of evidence is that young adult women who use marijuana are unlikely to perpetrate physical dating violence against their dating partners. Otherwise, evidence does show that young adults who use marijuana are unlikely to commit or be victims of physical dating violence, however evidence is limited at this time. Evidence for adolescent boys that use marijuana has mixed findings for physical dating violence perpetration and limited evidence for victimization, with evidence for adolescent girls being the opposite (Table 7).

Substantial evidenceModerate evidence
Physical dating violenceYoung adult women who use marijuana are unlikely to perpetrate physical dating violence [221, 222, 223, 224, 225, 226]

Table 7.

Marijuana use and injury.

3.8 Marijuana use and neurological, cognitive, and mental health effects

Similar to statements in our adolescent and young adult section, it is imperative to understand how marijuana could impact neurological, cognitive, and mental health in adult marijuana consumers. This section also explores how marijuana consumption relates to marijuana abuse and addiction among adult consumers. While our review on cognitive effects includes decision making, executive function, memory impairment, and lasting cognitive effects, strong evidence has been found only for memory impairment, as shown in Table 8. We have found substantial evidence that daily or near daily adult marijuana consumers are more likely than non-users to have memory impairments for at least seven days after last use. Evidence is mixed for whether or not these memory impairments or other cognitive effects last for at least twenty-eight days after last use, among the same population of adult consumers.

Substantial evidenceModerate evidence
Cognitive effectsDaily or near daily use is associated with impaired memory for at least 7 days [30, 227, 228, 229, 230, 231, 232, 233, 234, 235]
Mental health effectsUse is associated with acute psychotic symptoms during intoxication, which are worse with higher doses [236, 237, 238, 239, 240, 241, 242, 243]
Daily or near daily use is associated with future psychotic disorders like schizophrenia [38, 42, 107, 244, 245, 246]Use of marijuana with THC concentration > 10% is associated with future psychotic disorders like schizophrenia [38, 107, 247]
Substance use, abuse and addictionThose who use marijuana can develop cannabis use disorder (addiction) [82, 85, 86, 93, 248, 249, 250, 251, 252]
Treatment for cannabis use disorder can reduce use and dependence [4, 6, 8, 9, 253, 254, 255, 256, 257]
Those using daily or near daily can experience withdrawal symptoms when abstaining [11, 258, 259, 260, 261, 262, 263, 264, 265, 266, 267, 268, 269, 270]

Table 8.

Marijuana use and neurological, cognitive, mental health effects.

As with all psychoactive substances, mental health effects in adult marijuana consumers must be examined. An important acute effect of THC with substantial evidence is psychotic symptoms, such as hallucinations, paranoia, and delusional beliefs during intoxication, and these symptoms are worse with higher doses. Additionally, daily or near daily marijuana use is associated with developing a psychotic disorder such as schizophrenia. As detailed in our report focusing on the increasing concentration of THC in products available, there is increased public health concern as these products may lead to higher potential for adverse health effects in consumers [1]. This concern is substantiated by available research enabling us to provide a moderate rated statement showing association between higher concentration THC products and future psychotic disorders in adult marijuana consumers.

Finally, evidence shows marijuana consumers can experience withdrawal symptoms when abstaining and become addicted to marijuana or develop cannabis use disorder. However, as with adolescents, treatment for cannabis use disorder can reduce use and dependence in adult consumers. Many associations within this section lack high quality evidence or research currently exhibits mixed findings, such as marijuana use being associated with anxiety, depression, or bipolar disorder (Table 8).

3.9 Marijuana use during pregnancy and/or breastfeeding

Table 9 details our evidence concerning marijuana use during pregnancy and breastfeeding. Biological evidence shows THC passes through the placenta to the fetus and is present in the breast milk of women who use marijuana. Scientific evidence shows the fetus absorbs and metabolizes THC passed through the placenta and THC metabolites are found in the meconium or first stool passed by the newborn after birth. Additionally, infants who drink breast milk containing THC absorb and metabolize the THC. These statements show how important it is to understand how marijuana use during pregnancy and/or breastfeeding can affect the offspring or impact delivery of the offspring.

Substantial evidenceModerate evidence
Effects on exposed offspringPrenatal marijuana exposure is associated with reduced cognitive function, academic ability, and IQ scores in childhood [271, 272, 273, 274, 275, 276, 277, 278, 279, 280]
Prenatal marijuana exposure is associated with attention problems in childhood [273, 281, 282, 283, 284, 285]
Birth defectsPrenatal marijuana use is not associated with birth defects [286, 287, 288, 289, 290, 291, 292]
Preterm delivery or abnormal birth weightMaternal use during pregnancy is associated with infants being born small for gestational age (birth weight less than 10th percentile for gestational age) [286, 287, 289, 292, 293, 294, 295, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305]
Biological evidence concerning marijuana use during pregnancy and breastfeeding
THC is passed through the placenta of women who use marijuana, the fetus absorbs and metabolizes the THC, and THC metabolites are found in the meconium [306, 307, 308, 309, 310].
THC is present in the breast milk of women who use marijuana. Infants who drink breast milk containing THC absorb and metabolize the THC [311, 312, 313, 314, 315, 316].

Table 9.

Marijuana use during pregnancy and/or breastfeeding.

Specifically regarding exposed offspring, the RMPHAC reviews potential effects starting at birth and later in childhood or adolescence. Marijuana use during pregnancy has shown to not be associated with birth defects in general, but limited evidence of an association with an increased risk of heart defects, stillbirth, and decreased growth in offspring. Stronger evidence was found for effects that are seen in offspring years after birth if a child’s mother used marijuana while pregnant. These include impaired cognitive function and academic ability, lower IQ scores, and attention problems in childhood.

3.10 Marijuana use and respiratory effects

While consumers have a variety of marijuana products to choose from, smoking marijuana flower remains the most common method of use and thus respiratory effects must be evaluated [317]. The RMPHAC reviews respiratory diseases such as chronic obstructive pulmonary disorder (COPD), chronic bronchitis and asthma, respiratory infections, lung function relative to smoked marijuana. The committee has also reviewed potential health effects of vaporized marijuana as those products have emerged on the legal market. Displayed in Table 10, strong evidence shows an association between daily or near-daily marijuana use and chronic bronchitis, including chronic cough, sputum production, and wheezing. Weaker evidence shows daily or near-daily marijuana use may be associated with bullous lung disease leading to pneumothorax in individuals younger than forty years of age. Additionally, limited evidence does show frequent smokers who switch from marijuana smoking to marijuana vaporizing may have fewer respiratory symptoms and improved pulmonary function. Finally, a notable effect of acute marijuana smoking is a short-term improvement in lung airflow, though evidence contributing to this statement is dated (Table 10).

Substantial evidenceModerate evidence
Smoked marijuanaUse is associated with chronic bronchitis with cough, wheezing and mucus [318, 319, 320, 321, 322, 323, 324, 325, 326, 327]
Acute use is associated with short-term lung airflow improvement [328, 329, 330]

Table 10.

Marijuana use and respiratory effects.

3.11 Unintentional marijuana exposure in children

As marijuana becomes more accessible to the public, we must consider unintentional exposures in homes with children and how packaging can affect these. Strong evidence was found, shown in Table 11, that more unintentional exposures of children occur in states with increased legal access to marijuana, and exposures can lead to significant clinical effects requiring medical attention and even hospitalization. However, evidence does show that child-resistant packaging reduces unintentional pediatric marijuana poisonings (Table 11).

Substantial evidenceModerate evidence
Legal marijuana access increases unintentional marijuana exposures in children [331, 332, 333, 334, 335, 336, 337, 338, 339, 340, 341]Child-resistant packaging reduces unintentional pediatric poisonings [342, 343, 344]

Table 11.

Unintentional marijuana exposure in children.


4. Public health statements and recommendations

Once evidence statements have been drafted and approved by the RMPHAC, the next step (number 6 from our systematic review process) is to translate the evidence into public health statements. These are designed to accurately reflect the evidence statements using language the public can understand. The committee also wanted to ensure these statements conveyed the volume and quality of research related to the outcome and allowed the statement to stand on its own without context. Similar to our evidence statements, these use standardized language to represent the strength of relationship and use the phrase “associated with” to represent epidemiologic associations that do not imply causation. As of the date of this book’s publication CDPHE has seventy-four public health statements corresponding to all our evidence statements rated moderate or substantial.

In a similar manner, public health statements are subsequently drafted into public health recommendations. These are synthesized in order to inform the development of evidence-based prevention and education campaigns performed by CDPHE. Furthermore, recommendations are separated by data quality issues, surveillance, and education. Our recommendations share common themes to those put forth by the National Academies of Sciences, Engineering, and Medicine’s review of health effects associated with cannabis and cannabinoids [345].

Data quality issues are defined as recommendations to improve current data collection deficiencies at the clinical or governmental level that prevent full analysis of public health outcomes related to marijuana use. It is especially important to improve data quality by systematically collecting information on the frequency, amount, THC content, and method of marijuana use in both public health surveillance and medical care settings. Clinicians should routinely screen for marijuana use during hospitalizations, especially among pregnant or adolescent patients.

Public health surveillance recommendations are based on improving capacity to detect an acute public health danger (e.g., real time emergency department surveillance to detect poisonings from contaminated product); the ability to characterize chronic public health dangers to support policy and other intervention decisions; or the ability to generate epidemiologic data to contribute to planning and evaluating population level interventions. Questions regarding marijuana use should be continued on population-based surveys such as the Behavioral Risk Factor Surveillance System, the Healthy Kids Colorado Survey, and Pregnancy Risk Assessment Monitoring System. Additionally, methods should be expanded to collect more detailed information, such as quantity and methods of use, THC content of products used, and adverse effects experienced.

Education recommendations are included to ensure evidence-based information on potential health effects of marijuana use is provided to the appropriate target audiences. Public education is especially important related to the effects of use during pregnancy, adolescent use, driving after use, increasing THC concentration of products, and unsafe storage around children. Education for health care providers should also be emphasized on the need for marijuana use screening, the known health effects of use, and encouraging more open dialog between providers and patients.


5. Research gaps

In addition to public health recommendations, important research gaps related to the population-based health effects of marijuana use were identified during the literature review process. These research gaps are based on common limitations of existing research or issues important to public education or policymaking. Research gaps particularly important to public health and safety include the need for: (1) research on the effects of marijuana use on pregnant women and their offspring, including while breastfeeding; (2) research on marijuana and marijuana products that contain THC concentrations consistent with products currently available in legalized markets; (3) research on health effects among individuals who have used marijuana frequently for a long period of time; (4) research on driving impairment among people who use marijuana more than weekly and may have developed tolerance; (5) research to better characterize the pharmacokinetics/pharmacodynamics, potential drug interactions, health effects, and impairment related to non-smoking methods of marijuana use such as edible products and vaporizing; and (6) research to better describe the risk of adverse health effects due to contamination of the marijuana product by fungi, mold, solvents, additives, heavy metals, and pesticides.

Other research gaps identify areas that need improvement in new research moving forward. Such as studies using better and more standardized indicators of marijuana use, including frequency, THC content, and route of exposure, including populations that use marijuana daily or near daily, and stratifying groups by age and gender. Finally one step to provide strong evidence would be research data on a community based cohort to study both beneficial and adverse health effects of marijuana consumption. Identifying these research gaps provides researchers and funding sources with an important framework to prioritize areas of research related to marijuana use and public health.


6. Conclusion

Since 2014, when CDPHE was designated to monitor the emerging science and medical information relevant to the health effects associated with marijuana use, the RMPHAC and CDPHE technical staff have conducted an ongoing systematic review of scientific literature to establish over one hundred evidence statements with eleven health topics. Our mission is to translate the science into meaningful public health statements and recommendations to inform and educate the general public, healthcare providers, and everyone in-between on the health effects associated with marijuana use.

First, the committee established a strict process to ensure a thorough and unbiased review, set up quarterly meetings to enable open discussions on a continuous basis, and come to consensus on the science and how to present this information to the public. After establishing our process, evidence from scientific research is constantly reviewed and added when appropriate to form a comprehensive review of marijuana health effects across eleven health topic. Strong evidence statements from all health topics were displayed in tables and key findings were detailed in subsections to provide an overview of effects associated with marijuana use across many different populations and health topics. Additional details were described on how these evidence statements are used to inform public health policy in the State of Colorado through public health recommendations and research gaps.



Elyse Contreras, DeLayna Goulding, Daniel I. Vigil, Katelyn E. Hall, Michael Van Dyke, Shireen Banerji, Russell Bowler, Ashley Brooks-Russell, Christopher Domen, Heather Krug, David J Kroll, Sharon Langendoerfer, Andrew Monte, Kenneth Novoa, Judith Shlay, Elizabeth Stuyt, George Sam Wang, Bernadette Albanese, Lisa Barker, Laura Borgelt, Alvin C. Bronstein, Todd Carlson, Rowena Crow, Teresa Foo, Ken Gershman, Tista Ghosh, Heath Harmon, Rebecca Helfand, Renee M. Johnson, Bruce Mendelson, Madeline Morris, Kristina T. Phillips, Allison Rosenthal, Kim Siegal, Scott Simpson, Christian Thurstone.


Conflict of interest

“The authors declare no conflict of interest.”


  1. 1. Monitoring Health Concerns Related to Maijuana; Reports and Summaries. Colorado Department of Public Health and Environment. Colorado Department of Public Health and Environment. 2022. Available from:
  2. 2. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Journal of Clinical Epidemiology. 2009;62(10):1006-1012
  3. 3. GRADE guidelines—best practices using the GRADE framework.: GRADE working group; 2014. Available from:
  4. 4. Dennis M, Godley SH, Diamond G, Tims FM, Babor T, Donaldson J, et al. The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment. 2004;27(3):197-213
  5. 5. Hendriks V, van der Schee E, Blanken P. Treatment of adolescents with a cannabis use disorder: Main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands. Drug and Alcohol Dependence. 2011;119(1-2):64-71
  6. 6. Olmos A, Tirado-Munoz J, Farre M, Torrens M. The efficacy of computerized interventions to reduce cannabis use: A systematic review and meta-analysis. Addictive Behaviors. 2018;79:52-60
  7. 7. Rigter H, Henderson CE, Pelc I, Tossmann P, Phan O, Hendriks V, et al. Multidimensional family therapy lowers the rate of cannabis dependence in adolescents: A randomised controlled trial in Western European outpatient settings. Drug and Alcohol Dependence. 2013;130(1-3):85-93
  8. 8. Stanger C, Budney AJ, Kamon JL, Thostensen J. A randomized trial of contingency management for adolescent marijuana abuse and dependence. Drug and Alcohol Dependence. 2009;105(3):240-247
  9. 9. Stanger C, Ryan SR, Scherer EA, Norton GE, Budney AJ. Clinic- and home-based contingency management plus parent training for adolescent cannabis use disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 2015;54(6):445-53 e2
  10. 10. Stanger C, Scherer EA, Babbin SF, Ryan SR, Budney AJ. Abstinence based incentives plus parent training for adolescent alcohol and other substance misuse. Psychology of Addictive Behaviors. 2017;31(4):385-392
  11. 11. Jacobus J, Squeglia LM, Escobar S, McKenna BM, Hernandez MM, Bagot KS, et al. Changes in marijuana use symptoms and emotional functioning over 28-days of monitored abstinence in adolescent marijuana users. Psychopharmacology. 2017;234(23-24):3431-3442
  12. 12. Pahl K, Brook JS, Koppel J. Trajectories of marijuana use and psychological adjustment among urban African American and Puerto Rican women. Psychological Medicine. 2011;41(8):1775-1783
  13. 13. Swift W, Coffey C, Carlin JB, Degenhardt L, Patton GC. Adolescent cannabis users at 24 years: Trajectories to regular weekly use and dependence in young adulthood. Addiction. 2008;103(8):1361-1370
  14. 14. van Gastel WA, Vreeker A, Schubart CD, MacCabe JH, Kahn RS, Boks MP. Change in cannabis use in the general population: A longitudinal study on the impact on psychotic experiences. Schizophrenia Research. 2014;157(1-3):266-270
  15. 15. Brook JS, Balka EB, Whiteman M. The risks for late adolescence of early adolescent marijuana use. American Journal of Public Health. 1999;89(10):1549-1554
  16. 16. Ehrenreich H, Nahapetyan L, Orpinas P, Song X. Marijuana use from middle to high school: Co-occurring problem behaviors, teacher-rated academic skills and sixth-grade predictors. Journal of Youth and Adolescence. 2015;44(10):1929-1940
  17. 17. Fergusson DM, Horwood LJ, Beautrais AL. Cannabis and educational achievement. Addiction. 2003;98(12):1681-1692
  18. 18. Green KM, Doherty EE, Ensminger ME. Long-term consequences of adolescent cannabis use: Examining intermediary processes. The American Journal of Drug and Alcohol Abuse. 2017;43(5):567-575
  19. 19. Horwood LJ, Fergusson DM, Hayatbakhsh MR, Najman JM, Coffey C, Patton GC, et al. Cannabis use and educational achievement: Findings from three Australasian cohort studies. Drug and Alcohol Dependence. 2010;110(3):247-253
  20. 20. Lynne-Landsman SD, Bradshaw CP, Ialongo NS. Testing a developmental cascade model of adolescent substance use trajectories and young adult adjustment. Development and Psychopathology. 2010;22(4):933-948
  21. 21. Melchior M, Bolze C, Fombonne E, Surkan PJ, Pryor L, Jauffret-Roustide M. Early cannabis initiation and educational attainment: Is the association causal? Data from the French TEMPO study. International Journal of Epidemiology. 2017;46(5):1641-1650
  22. 22. Silins E, Horwood LJ, Patton GC, Fergusson DM, Olsson CA, Hutchinson DM, et al. Young adult sequelae of adolescent cannabis use: An integrative analysis. Lancet Psychiatry. 2014;1(4):286-293
  23. 23. Stiby AI, Hickman M, Munafo MR, Heron J, Yip VL, Macleod J. Adolescent cannabis and tobacco use and educational outcomes at age 16: Birth cohort study. Addiction. 2015;110(4):658-668
  24. 24. Baggio S, Iglesias K, Deline S, Studer J, Henchoz Y, Mohler-Kuo M, et al. Not in education, employment, or training status among young Swiss men. Longitudinal associations with mental health and substance use. The Journal of Adolescent Health. 2015;56(2):238-243
  25. 25. Fergusson DM, Horwood LJ. Does cannabis use encourage other forms of illicit drug use? Addiction. 2000;95(4):505-520
  26. 26. Fergusson DM, Boden JM. Cannabis use and later life outcomes. Addiction. 2008;103(6):969-976; discussion 77-8
  27. 27. Patrick ME, Schulenberg JE, O'Malley PM. High school substance use as a predictor of college attendance, completion, and dropout: A national multi-cohort longitudinal study. Youth Society. 2016;48(3):425-447
  28. 28. Schaefer JD, Hamdi NR, Malone SM, Vrieze S, Wilson S, McGue M, et al. Associations between adolescent cannabis use and young-adult functioning in three longitudinal twin studies. Proceedings of the National Academy of Sciences of the United States of America. 2021;118(14):e2013180118
  29. 29. Wilhite ER, Ashenhurst JR, Marino EN, Fromme K. Freshman year alcohol and marijuana use prospectively predict time to college graduation and subsequent adult roles and independence. Journal of American College Health. 2017;65(6):413-422
  30. 30. Bolla KI, Brown K, Eldreth D, Tate K, Cadet JL. Dose-related neurocognitive effects of marijuana use. Neurology. 2002;59(9):1337-1343
  31. 31. Hooper SR, Woolley D, De Bellis MD. Intellectual, neurocognitive, and academic achievement in abstinent adolescents with cannabis use disorder. Psychopharmacology. 2014;231(8):1467-1477
  32. 32. Medina KL, Hanson KL, Schweinsburg AD, Cohen-Zion M, Nagel BJ, Tapert SF. Neuropsychological functioning in adolescent marijuana users: Subtle deficits detectable after a month of abstinence. Journal of the International Neuropsychological Society. 2007;13(5):807-820
  33. 33. Pope HG Jr, Gruber AJ, Hudson JI, Cohane G, Huestis MA, Yurgelun-Todd D. Early-onset cannabis use and cognitive deficits: What is the nature of the association? Drug and Alcohol Dependence. 2003;69(3):303-310
  34. 34. Scott JC, Slomiak ST, Jones JD, Rosen AFG, Moore TM, Gur RC. Association of cannabis with cognitive functioning in adolescents and young adults: A systematic review and meta-analysis. JAMA Psychiatry. 2018;75(6):585-595
  35. 35. Selamoglu A, Langley C, Crean R, Savulich G, Cormack F, Sahakian BJ, et al. Neuropsychological performance in young adults with cannabis use disorder. Journal of Psychopharmacology. 2021;35(11):1349-1355
  36. 36. Arranz S, Monferrer N, Jose Algora M, Cabezas A, Sole M, Vilella E, et al. The relationship between the level of exposure to stress factors and cannabis in recent onset psychosis. Schizophrenia Research. 2018;201:352-359
  37. 37. Bechtold J, Simpson T, White HR, Pardini D. Chronic adolescent marijuana use as a risk factor for physical and mental health problems in young adult men. Psychology of Addictive Behaviors. 2015;29(3):552-563
  38. 38. Di Forti M, Marconi A, Carra E, Fraietta S, Trotta A, Bonomo M, et al. Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: A case-control study. Lancet Psychiatry. 2015;2(3):233-238
  39. 39. Godin SL, Shehata S. Adolescent cannabis use and later development of schizophrenia: An updated systematic review of longitudinal studies. Journal of Clinical Psychology. 2022;78(7):1331-1340
  40. 40. Marconi A, Di Forti M, Lewis CM, Murray RM, Vassos E. Meta-analysis of the association between the level of cannabis use and risk of psychosis. Schizophrenia Bulletin. 2016;42(5):1262-1269
  41. 41. Mustonen A, Niemela S, Nordstrom T, Murray GK, Maki P, Jaaskelainen E, et al. Adolescent cannabis use, baseline prodromal symptoms and the risk of psychosis. The British Journal of Psychiatry. 2018;212(4):227-233
  42. 42. van Os J, Bak M, Hanssen M, Bijl RV, de Graaf R, Verdoux H. Cannabis use and psychosis: A longitudinal population-based study. American Journal of Epidemiology. 2002;156(4):319-327
  43. 43. Zammit S, Allebeck P, Andreasson S, Lundberg I, Lewis G. Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: Historical cohort study. BMJ. 2002;325(7374):1199
  44. 44. Agrawal A, Tillman R, Grucza RA, Nelson EC, McCutcheon VV, Few L, et al. Reciprocal relationships between substance use and disorders and suicidal ideation and suicide attempts in the Collaborative Study of the Genetics of Alcoholism. Journal of Affective Disorders. 2017;213:96-104
  45. 45. Alexander D, Niemelä S, Scott JG, Salom C, Emily H, Miettunen J, et al. Does cannabis use in adolescence predict self-harm or suicide? Results from a Finnish Birth-Cohort Study. Acta Psychiatrica Scandinavica. 2021;145(3):234-243
  46. 46. Borges G, Bagge CL, Orozco R. A literature review and meta-analyses of cannabis use and suicidality. Journal of Affective Disorders. 2016;195:63-74
  47. 47. Borges G, Benjet C, Orozco R, Medina-Mora ME, Menendez D. Alcohol, cannabis and other drugs and subsequent suicide ideation and attempt among young Mexicans. Journal of Psychiatric Research. 2017;91:74-82
  48. 48. Buckner JD, Lemke AW, Walukevich KA. Cannabis use and suicidal ideation: Test of the utility of the interpersonal-psychological theory of suicide. Psychiatry Research. 2017;253:256-259
  49. 49. Sellers CM, Diaz-Valdes Iriarte A, Wyman Battalen A, O'Brien KHM. Alcohol and marijuana use as daily predictors of suicide ideation and attempts among adolescents prior to psychiatric hospitalization. Psychiatry Research. 2019;273:672-677
  50. 50. Consoli A, Peyre H, Speranza M, Hassler C, Falissard B, Touchette E, et al. Suicidal behaviors in depressed adolescents: Role of perceived relationships in the family. Child and Adolescent Psychiatry and Mental Health. 2013;7(1):8
  51. 51. Gobbi G, Atkin T, Zytynski T, Wang S, Askari S, Boruff J, et al. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: A systematic review and meta-analysis. JAMA Psychiatry. 2019;76(4):426-434
  52. 52. Gukasyan N, Strain EC. Relationship between cannabis use frequency and major depressive disorder in adolescents: Findings from the National Survey on Drug Use and Health 2012-2017. Drug and Alcohol Dependence. 2020;208:107867
  53. 53. Guo L, Wang W, Du X, Guo Y, Li W, Zhao M, et al. Associations of substance use behaviors with suicidal ideation and suicide attempts among US and Chinese adolescents. Frontiers in Psychiatry. 2020;11:611579
  54. 54. Han B, Compton WM, Einstein EB, Volkow ND. Associations of suicidality trends with cannabis use as a function of sex and depression status. JAMA Network Open. 2021;4(6):e2113025
  55. 55. Hengartner MP, Angst J, Ajdacic-Gross V, Rossler W. Cannabis use during adolescence and the occurrence of depression, suicidality and anxiety disorder across adulthood: Findings from a longitudinal cohort study over 30 years. Journal of Affective Disorders. 2020;272:98-103
  56. 56. Kokkevi A, Richardson C, Olszewski D, Matias J, Monshouwer K, Bjarnason T. Multiple substance use and self-reported suicide attempts by adolescents in 16 European countries. European Child & Adolescent Psychiatry. 2012;21(8):443-450
  57. 57. Labuhn M, LaBore K, Ahmed T, Ahmed R. Trends and instigators among young adolescent suicide in the United States. Public Health. 2021;199:51-56
  58. 58. Pereira-Morales AJ, Adan A, Camargo A, Forero DA. Substance use and suicide risk in a sample of young Colombian adults: An exploration of psychosocial factors. The American Journal on Addictions. 2017;26(4):388-394
  59. 59. Rasic D, Weerasinghe S, Asbridge M, Langille DB. Longitudinal associations of cannabis and illicit drug use with depression, suicidal ideation and suicidal attempts among Nova Scotia high school students. Drug and Alcohol Dependence. 2013;129(1-2):49-53
  60. 60. Sampasa-Kanyinga H, Dupuis LC, Ray R. Prevalence and correlates of suicidal ideation and attempts among children and adolescents. International Journal of Adolescent Medicine and Health. 2017;29(2):/j/ijamh.2017.29.issue-2/ijamh-2015-0053/ijamh-2015-0053.xml
  61. 61. Spears M, Montgomery AA, Gunnell D, Araya R. Factors associated with the development of self-harm amongst a socio-economically deprived cohort of adolescents in Santiago, Chile. Social Psychiatry and Psychiatric Epidemiology. 2014;49(4):629-637
  62. 62. Weeks M, Colman I. Predictors of suicidal behaviors in canadian adolescents with no recent history of depression. Archives of Suicide Research. 2017;21(2):354-364
  63. 63. Zhang X, Wu LT. Suicidal ideation and substance use among adolescents and young adults: A bidirectional relation? Drug and Alcohol Dependence. 2014;142:63-73
  64. 64. Schaefer JD, Jang SK, Vrieze S, Iacono WG, McGue M, Wilson S. Adolescent cannabis use and adult psychoticism: A longitudinal co-twin control analysis using data from two cohorts. Journal of Abnormal Psychology. 2021;130(7):691-701
  65. 65. Albertella L, Le Pelley ME, Copeland J. Cannabis use in early adolescence is associated with higher negative schizotypy in females. European Psychiatry. 2017;45:235-241
  66. 66. Albertella L, Le Pelley ME, Yucel M, Copeland J. Age moderates the association between frequent cannabis use and negative schizotypy over time. Addictive Behaviors. 2018;87:183-189
  67. 67. Arseneault L, Cannon M, Witton J, Murray RM. Causal association between cannabis and psychosis: Examination of the evidence. The British Journal of Psychiatry. 2004;184:110-117
  68. 68. Bourque J, Afzali MH, O'Leary-Barrett M, Conrod P. Cannabis use and psychotic-like experiences trajectories during early adolescence: The coevolution and potential mediators. Journal of Child Psychology and Psychiatry. 2017;58(12):1360-1369
  69. 69. Carlyle M, Constable T, Walter ZC, Wilson J, Newland G, Hides L. Cannabis-induced dysphoria/paranoia mediates the link between childhood trauma and psychotic-like experiences in young cannabis users. Schizophrenia Research. 2021;238:178-184
  70. 70. Fergusson DM, Horwood LJ, Ridder EM. Tests of causal linkages between cannabis use and psychotic symptoms. Addiction. 2005;100(3):354-366
  71. 71. Henquet C, Krabbendam L, Spauwen J, Kaplan C, Lieb R, Wittchen HU, et al. Prospective cohort study of cannabis use, predisposition for psychosis, and psychotic symptoms in young people. BMJ. 2005;330(7481):11
  72. 72. Jones HJ, Gage SH, Heron J, Hickman M, Lewis G, Munafo MR, et al. Association of combined patterns of tobacco and cannabis use in adolescence with psychotic experiences. JAMA Psychiatry. 2018;75(3):240-246
  73. 73. Kiburi SK, Molebatsi K, Ntlantsana V, Lynskey MT. Cannabis use in adolescence and risk of psychosis: Are there factors that moderate this relationship? A systematic review and meta-analysis. Substance Abuse. 2021:42(4)527-542
  74. 74. Kuepper R, van Os J, Lieb R, Wittchen HU, Hofler M, Henquet C. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study. BMJ. 2011;342:d738
  75. 75. Leadbeater BJ, Ames ME, Linden-Carmichael AN. Age-varying effects of cannabis use frequency and disorder on symptoms of psychosis, depression and anxiety in adolescents and adults. Addiction. 2019;114(2):278-293
  76. 76. McGrath J, Welham J, Scott J, Varghese D, Degenhardt L, Hayatbakhsh MR, et al. Association between cannabis use and psychosis-related outcomes using sibling pair analysis in a cohort of young adults. Archives of General Psychiatry. 2010;67(5):440-447
  77. 77. Pardo M, Matali JL, Sivoli J, Regina VB, Butjosa A, Dolz M, et al. Early onset psychosis and cannabis use: Prevalence, clinical presentation and influence of daily use. Asian Journal of Psychiatry. 2021;62:102714
  78. 78. Quattrone D, Ferraro L, Tripoli G, La Cascia C, Quigley H, Quattrone A, et al. Daily use of high-potency cannabis is associated with more positive symptoms in first-episode psychosis patients: The EU-GEI case-control study. Psychological Medicine. 2020:51(8)1-9
  79. 79. Shanahan L, Steinhoff A, Bechtiger L, Copeland WE, Ribeaud D, Eisner M, et al. Frequent teenage cannabis use: Prevalence across adolescence and associations with young adult psychopathology and functional well-being in an urban cohort. Drug and Alcohol Dependence. 2021;228:109063
  80. 80. Wainberg M, Jacobs GR, di Forti M, Tripathy SJ. Cannabis, schizophrenia genetic risk, and psychotic experiences: A cross-sectional study of 109,308 participants from the UK Biobank. Translational Psychiatry. 2021;11(1):211
  81. 81. Forman-Hoffman VL, Glasheen C, Batts KR. Marijuana use, recent marijuana initiation, and progression to marijuana use disorder among young male and female adolescents aged 12-14 living in US Households. Substance Abuse. 2017;11:1178221817711159
  82. 82. Hasin DS, Saha TD, Kerridge BT, Goldstein RB, Chou SP, Zhang H, et al. Prevalence of marijuana use disorders in the United States between 2001-2002 and 2012-2013. JAMA Psychiatry. 2015;72(12):1235-1242
  83. 83. Marel C, Sunderland M, Mills KL, Slade T, Teesson M, Chapman C. Conditional probabilities of substance use disorders and associated risk factors: Progression from first use to use disorder on alcohol, cannabis, stimulants, sedatives and opioids. Drug and Alcohol Dependence. 2019;194:136-142
  84. 84. Millar SR, Mongan D, Smyth BP, Perry IJ, Galvin B. Relationships between age at first substance use and persistence of cannabis use and cannabis use disorder. BMC Public Health. 2021;21(1):997
  85. 85. Richter L, Pugh BS, Ball SA. Assessing the risk of marijuana use disorder among adolescents and adults who use marijuana. The American Journal of Drug and Alcohol Abuse. 2017;43(3):247-260
  86. 86. Schuermeyer J, Salomonsen-Sautel S, Price RK, Balan S, Thurstone C, Min SJ, et al. Temporal trends in marijuana attitudes, availability and use in Colorado compared to non-medical marijuana states: 2003-11. Drug and Alcohol Dependence. 2014;140:145-155
  87. 87. Simpson KA, Cho J, Barrington-Trimis JL. The association of type of cannabis product used and frequency of use with problematic cannabis use in a sample of young adult cannabis users. Drug and Alcohol Dependence. 2021;226:108865
  88. 88. Guttmannova K, Kosterman R, White HR, Bailey JA, Lee JO, Epstein M, et al. The association between regular marijuana use and adult mental health outcomes. Drug and Alcohol Dependence. 2017;179:109-116
  89. 89. Otten R, Mun CJ, Dishion TJ. The social exigencies of the gateway progression to the use of illicit drugs from adolescence into adulthood. Addictive Behaviors. 2017;73:144-150
  90. 90. Silins E, Swift W, Slade T, Toson B, Rodgers B, Hutchinson DM. A prospective study of the substance use and mental health outcomes of young adult former and current cannabis users. Drug and Alcohol Review. 2017;36(5):618-625
  91. 91. Swift W, Coffey C, Degenhardt L, Carlin JB, Romaniuk H, Patton GC. Cannabis and progression to other substance use in young adults: Findings from a 13-year prospective population-based study. Journal of Epidemiology and Community Health. 2012;66(7):e26
  92. 92. Taylor M, Collin SM, Munafo MR, MacLeod J, Hickman M, Heron J. Patterns of cannabis use during adolescence and their association with harmful substance use behaviour: Findings from a UK birth cohort. Journal of Epidemiology and Community Health. 2017;71(8):764-770
  93. 93. Feingold D, Livne O, Rehm J, Lev-Ran S. Probability and correlates of transition from cannabis use to DSM-5 cannabis use disorder: Results from a large-scale nationally representative study. Drug and Alcohol Review. 2020;39(2):142-151
  94. 94. Lanza HI, Bello MS, Cho J, Barrington-Trimis JL, McConnell R, Braymiller JL, et al. Tobacco and cannabis poly-substance and poly-product use trajectories across adolescence and young adulthood. Preventive Medicine. 2021;148:106545
  95. 95. Copeland WE, Hill SN, Shanahan L. Adult psychiatric, substance, and functional outcomes of different definitions of early cannabis use. Journal of the American Academy of Child and Adolescent Psychiatry. 2021;61(4):533-543
  96. 96. Fergusson DM, Boden JM, Horwood LJ. Cannabis use and other illicit drug use: Testing the cannabis gateway hypothesis. Addiction. 2006;101(4):556-569
  97. 97. Fiellin LE, Tetrault JM, Becker WC, Fiellin DA, Hoff RA. Previous use of alcohol, cigarettes, and marijuana and subsequent abuse of prescription opioids in young adults. The Journal of Adolescent Health. 2013;52(2):158-163
  98. 98. Moss HB, Chen CM, Yi HY. Early adolescent patterns of alcohol, cigarettes, and marijuana polysubstance use and young adult substance use outcomes in a nationally representative sample. Drug and Alcohol Dependence. 2014;136:51-62
  99. 99. Nakawaki B, Crano WD. Predicting adolescents' persistence, non-persistence, and recent onset of nonmedical use of opioids and stimulants. Addictive Behaviors. 2012;37(6):716-721
  100. 100. Schepis TS, Krishnan-Sarin S. Characterizing adolescent prescription misusers: A population-based study. Journal of the American Academy of Child and Adolescent Psychiatry. 2008;47(7):745-754
  101. 101. Zaman T, Malowney M, Knight J, Boyd JW. Co-occurrence of substance-related and other mental health disorders among adolescent cannabis users. Journal of Addiction Medicine. 2015;9(4):317-321
  102. 102. Berg CJ, Haardörfer R, Lanier A, Childs D, Foster B, Getachew B, et al. Tobacco use trajectories in young adults: Analyses of predictors across systems levels. Nicotine & Tobacco Research. 2020;22(11):2075-2084
  103. 103. Cornacchione Ross J, Sutfin EL, Suerken C, Walker S, Wolfson M, Reboussin BA. Longitudinal associations between marijuana and cigar use in young adults. Drug and Alcohol Dependence. 2020;211:107964
  104. 104. Mayer ME, Kong G, Barrington-Trimis JL, McConnell R, Leventhal AM, Krishnan-Sarin S. Blunt and non-blunt cannabis use and risk of subsequent combustible tobacco product use among adolescents. Nicotine & Tobacco Research. 2020;22(8):1409-1413
  105. 105. Rubinstein ML, Rait MA, Prochaska JJ. Frequent marijuana use is associated with greater nicotine addiction in adolescent smokers. Drug and Alcohol Dependence. 2014;141:159-162
  106. 106. Barrington-Trimis JL, Cho J, Ewusi-Boisvert E, Hasin D, Unger JB, Miech RA, et al. Risk of persistence and progression of use of 5 cannabis products after experimentation among adolescents. JAMA Network Open. 2020;3(1):e1919792
  107. 107. Di Forti M, Quattrone D, Freeman TP, Tripoli G, Gayer-Anderson C, Quigley H, et al. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): A multicentre case-control study. Lancet Psychiatry. 2019;6(5):427-436
  108. 108. Hines LA, Freeman TP, Gage SH, Zammit S, Hickman M, Cannon M, et al. Association of high-potency cannabis use with mental health and substance use in adolescence. JAMA Psychiatry. 2020;77(10):1044-1051
  109. 109. Moir D, Rickert WS, Levasseur G, Larose Y, Maertens R, White P, et al. A comparison of mainstream and sidestream marijuana and tobacco cigarette smoke produced under two machine smoking conditions. Chemical Research in Toxicology. 2008;21(2):494-502
  110. 110. Barsky SH, Roth MD, Kleerup EC, Simmons M, Tashkin DP. Histopathologic and molecular alterations in bronchial epithelium in habitual smokers of marijuana, cocaine, and/or tobacco. Journal of the National Cancer Institute. 1998;90(16):1198-1205
  111. 111. Fligiel SE, Roth MD, Kleerup EC, Barsky SH, Simmons MS, Tashkin DP. Tracheobronchial histopathology in habitual smokers of cocaine, marijuana, and/or tobacco. Chest. 1997;112(2):319-326
  112. 112. Gong H Jr, Fligiel S, Tashkin DP, Barbers RG. Tracheobronchial changes in habitual, heavy smokers of marijuana with and without tobacco. The American review of respiratory disease. 1987;136(1):142-149
  113. 113. Aldington S, Harwood M, Cox B, Weatherall M, Beckert L, Hansell A, et al. Cannabis use and risk of lung cancer: A case-control study. The European Respiratory Journal. 2008;31(2):280-286
  114. 114. Callaghan RC, Allecbeck P, Sidorchuk A. Marijuana use and risk of lung cancer: A 40-year cohort study. Cancer Causes & Control. 2013;24:1811-1820
  115. 115. Han B, Gfroerer JC, Colliver JD. Associations between duration of illicit drug use and health conditions: Results from the 2005-2007 national surveys on drug use and health. Annals of Epidemiology. 2010;20(4):289-297
  116. 116. Hashibe M, Morgenstern H, Cui Y, Tashkin DP, Zhang ZF, Cozen W, et al. Marijuana use and the risk of lung and upper aerodigestive tract cancers: Results of a population-based case-control study. Cancer Epidemiology, Biomarkers & Prevention. 2006;15(10):1829-1834
  117. 117. Sidney S Jr, CPQ , Friedman GD, Tekawa IS. Marijuana use and cancer incidence (California, United States). Cancer Causes & Control. 1997;8(5):722-728
  118. 118. Zhang LR, Morgenstern H, Greenland S, Chang SC, Lazarus P, Teare MD, et al. Cannabis smoking and lung cancer risk: Pooled analysis in the International Lung Cancer Consortium. International Journal of Cancer. 2014;136(4):894-903
  119. 119. Gieringer D. Waterpipe study. Multidisciplinary Assocation for Psycheldelic Studies (MAPS). 1996;6(3).
  120. 120. Gieringer D, St. Laurent J, Goodrich S. Cannabis vaporizer combines efficient delivery of THC with effective suppression of pyrolytic compounds. Journal of Cannabis Therapeutics. 2004;4(1):7-27
  121. 121. Lee ML, Novotny M, Bartle KD. Gas chromatography/mass spectrometric and nuclear magnetic resonance spectrometric studies of carcinogenic polynuclear aromatic hydrocarbons in tobacco and marijuana smoke condensates. Analytical Chemistry. 1976;48(2):405-416
  122. 122. Sparacino CM, Hyldburg PA, Hughes TJ. Chemical and biological analysis of marijuana smoke condensate. NIDA Res Monogr. 1990;99:121-140.
  123. 123. Callaghan RC, Allebeck P, Akre O, McGlynn KA, Sidorchuk A. Cannabis use and incidence of testicular cancer: A 42-year follow-up of Swedish men between 1970 and 2011. Cancer Epidemiology, Biomarkers & Prevention. 2017;26(11):1644-1652
  124. 124. Daling JR, Doody DR, Sun X, Trabert BL, Weiss NS, Chen C, et al. Association of marijuana use and the incidence of testicular germ cell tumors. Cancer. 2009;115(6):1215-1223
  125. 125. Gurney J, Shaw C, Stanley J, Signal V, Sarfati D. Cannabis exposure and risk of testicular cancer: A systematic review and meta-analysis. BMC Cancer. 2015;15:897
  126. 126. Lacson JCA, Carroll JD, Tuazon E, Castelao EJ, Bernstein L, Cortessis VK. Population-based case-control study of recreational drug use and testis cancer risk confirms an association between marijuana use and nonseminoma risk. Cancer. 2012;118(21):5374-5383
  127. 127. Trabert B, Sigurdson AJ, Sweeney AM, Strom SS, McGlynn KA. Marijuana use and testicular germ cell tumors. Cancer. 2011;117(4):848-853
  128. 128. Barber PA, Pridmore HM, Krishnamurthy V, Roberts S, Spriggs DA, Carter KN, et al. Cannabis, ischemic stroke, and transient ischemic attack: A case-control study. Stroke. 2013;44(8):2327-2329
  129. 129. Desai R, Singh S, Patel K, Goyal H, Shah M, Mansuri Z, et al. Stroke in young cannabis users (18-49 years): National trends in hospitalizations and outcomes. International Journal of Stroke. 2020;15(5):535-539
  130. 130. Dutta T, Ryan KA, Thompson O, Lopez H, Fecteau N, Sparks MJ, et al. Marijuana use and the risk of early ischemic stroke: The stroke prevention in young adults study. Stroke. 2021;52(10):3184-3190
  131. 131. Falkstedt D, Wolff V, Allebeck P, Hemmingsson T, Danielsson AK. Cannabis, tobacco, alcohol use, and the risk of early stroke: A population-based Cohort Study of 45 000 Swedish men. Stroke. 2017;48(2):265-270
  132. 132. Geller T, Loftis L, Brink DS. Cerebellar infarction in adolescent males associated with acute marijuana use. Pediatrics. 2004;113(4):e365-e370
  133. 133. Hackam DG. Cannabis and stroke: Systematic appraisal of case reports. Stroke. 2015;46(3):852-856
  134. 134. Hemachandra D, McKetin R, Cherbuin N, Anstey KJ. Heavy cannabis users at elevated risk of stroke: Evidence from a general population survey. Australian and New Zealand Journal of Public Health. 2016;40(3):226-230
  135. 135. Kalla A, Krishnamoorthy PM, Gopalakrishnan A, Figueredo VM. Cannabis use predicts risks of heart failure and cerebrovascular accidents: Results from the National Inpatient Sample. Journal of Cardiovascular Medicine (Hagerstown, Md.). 2018;19(9):480-484
  136. 136. Reis JP, Auer R, Bancks MP, Goff DC Jr, Lewis CE, Pletcher MJ, et al. Cumulative lifetime marijuana use and incident cardiovascular disease in middle age: The coronary artery risk development in young adults (CARDIA) study. American Journal of Public Health. 2017;107(4):601-606
  137. 137. Rumalla K, Reddy AY, Mittal MK. Recreational marijuana use and acute ischemic stroke: A population-based analysis of hospitalized patients in the United States. Journal of the Neurological Sciences. 2016;364:191-196
  138. 138. Shah S, Patel S, Paulraj S, Chaudhuri D. Association of marijuana use and cardiovascular disease: A behavioral risk factor surveillance system data analysis of 133,706 US adults. The American Journal of Medicine. 2020;134(5):614-620
  139. 139. Thanvi BR, Treadwell SD. Cannabis and stroke: Is there a link? Postgraduate Medical Journal. 2009;85(1000):80-83
  140. 140. Vin-Raviv N, Akinyemiju T, Meng Q , Sakhuja S, Hayward R. Marijuana use and inpatient outcomes among hospitalized patients: Analysis of the nationwide inpatient sample database. Cancer Medicine. 2017;6(1):320-329
  141. 141. Westover AN, McBride S, Haley RW. Stroke in young adults who abuse amphetamines or cocaine: A population-based study of hospitalized patients. Archives of General Psychiatry. 2007;64(4):495-502
  142. 142. Wolff V, Armspach J-P, Lauer V, Rouyer O, Bataillard M, Marescaux C, et al. Cannabis-related stroke: Myth or reality? Stroke; A Journal of Cerebral Circulation. 2013;44(2):558-563
  143. 143. Yang PK, Odom EC, Patel R, Loustalot F, Coleman King S. Nonmedical marijuana use and cardiovascular events: A systematic review. Public Health Reports. 2021;137(1):62-71. DOI: 10.1177/0033354920988285
  144. 144. Parekh T, Pemmasani S, Desai R. Marijuana use among young adults (18-44 years of age) and risk of stroke: A behavioral risk factor surveillance system survey analysis. Stroke. 2020;51(1):308-310
  145. 145. van Winkel R, Genetic R. Outcome of Psychosis I. Family-based analysis of genetic variation underlying psychosis-inducing effects of cannabis: Sibling analysis and proband follow-up. Archives of General Psychiatry. 2011;68(2):148-157
  146. 146. Bosker WM, Kuypers KP, Theunissen EL, Surinx A, Blankespoor RJ, Skopp G, et al. Medicinal Delta(9) -tetrahydrocannabinol (dronabinol) impairs on-the-road driving performance of occasional and heavy cannabis users but is not detected in Standard Field Sobriety Tests. Addiction. 2012;107(10):1837-1844
  147. 147. Curran HV, Brignell C, Fletcher S, Middleton P, Henry J. Cognitive and subjective dose-response effects of acute oral Delta 9-tetrahydrocannabinol (THC) in infrequent cannabis users. Psychopharmacology. 2002;164(1):61-70
  148. 148. Lile JA, Kelly TH, Charnigo RJ, Stinchcomb AL, Hays LR. Pharmacokinetic and pharmacodynamic profile of supratherapeutic oral doses of Delta(9) -THC in cannabis users. Journal of Clinical Pharmacology. 2013;53(7):680-690
  149. 149. Newmeyer MN, Swortwood MJ, Barnes AJ, Abulseoud OA, Scheidweiler KB, Huestis MA. Free and glucuronide whole blood cannabinoids' pharmacokinetics after controlled smoked, vaporized, and oral cannabis administration in frequent and occasional cannabis users: Identification of recent cannabis intake. Clinical Chemistry. 2016;62(12):1579-1592
  150. 150. Newmeyer MN, Swortwood MJ, Andersson M, Abulseoud OA, Scheidweiler KB, Huestis MA. Cannabis edibles: Blood and oral fluid cannabinoid pharmacokinetics and evaluation of oral fluid screening devices for predicting delta(9)-tetrahydrocannabinol in blood and oral fluid following cannabis brownie administration. Clinical Chemistry. 2017;63(3):647-662
  151. 151. Vandrey R, Herrmann ES, Mitchell JM, Bigelow GE, Flegel R, LoDico C, et al. Pharmacokinetic profile of oral cannabis in humans: Blood and oral fluid disposition and relation to pharmacodynamic outcomes. Journal of Analytical Toxicology. 2017;41(2):83-99
  152. 152. Bidwell LC, Karoly HC, Torres MO, Master A, Bryan AD, Hutchison KE. A naturalistic study of orally administered vs. inhaled legal market cannabis: Cannabinoids exposure, intoxication, and impairment. Psychopharmacology. 2021;239(2):385-397
  153. 153. Menetrey A, Augsburger M, Favrat B, Pin MA, Rothuizen LE, Appenzeller M, et al. Assessment of driving capability through the use of clinical and psychomotor tests in relation to blood cannabinoids levels following oral administration of 20 mg dronabinol or of a cannabis decoction made with 20 or 60 mg Delta9-THC. Journal of Analytical Toxicology. 2005;29(5):327-338
  154. 154. Schlienz NJ, Spindle TR, Cone EJ, Herrmann ES, Bigelow GE, Mitchell JM, et al. Pharmacodynamic dose effects of oral cannabis ingestion in healthy adults who infrequently use cannabis. Drug and Alcohol Dependence. 2020;211:107969
  155. 155. Berghaus G, Sticht G, Grellner W. Meta-analysis of Empirical Studies Concerning the Effects of Medicines and Illegal Drugs Including Pharmacokinetics on Safe Driving. Center for Traffic Sciences at the University of Wurzburg; Federal Highway Research Institute. 2011
  156. 156. Huestis MA, Henningfield JE, Cone EJ. Blood cannabinoids. I. Absorption of THC and formation of 11-OH-THC and THCCOOH during and after smoking marijuana. Journal of Analytical Toxicology. 1992;16(5):276-282
  157. 157. Ramaekers JG, Moeller MR, van Ruitenbeek P, Theunissen EL, Schneider E, Kauert G. Cognition and motor control as a function of Delta9-THC concentration in serum and oral fluid: Limits of impairment. Drug and Alcohol Dependence. 2006;85(2):114-122
  158. 158. Reeve VC, Grant JD, Robertson W, Gillespie HK, Hollister LE. Plasma concentrations of delta-9-tetrahydrocannabinol and impaired motor function. Drug and Alcohol Dependence. 1983;11(2):167-175
  159. 159. Spindle TR, Cone EJ, Schlienz NJ, Mitchell JM, Bigelow GE, Flegel R, et al. Acute pharmacokinetic profile of smoked and vaporized cannabis in human blood and oral fluid. Journal of Analytical Toxicology. 2019;43(4):233-258
  160. 160. Abrams DI, Vizoso HP, Shade SB, Jay C, Kelly ME, Benowitz NL. Vaporization as a smokeless cannabis delivery system: A pilot study. Clinical Pharmacology and Therapeutics. 2007;82(5):572-578
  161. 161. Cone EJ, Bigelow GE, Herrmann ES, Mitchell JM, LoDico C, Flegel R, et al. Nonsmoker exposure to secondhand cannabis smoke. III. Oral fluid and blood drug concentrations and corresponding subjective effects. Journal of Analytical Toxicology. 2015;39(7):497-509
  162. 162. Herrmann ES, Cone EJ, Mitchell JM, Bigelow GE, LoDico C, Flegel R, et al. Non-smoker exposure to secondhand cannabis smoke II: Effect of room ventilation on the physiological, subjective, and behavioral/cognitive effects. Drug and Alcohol Dependence. 2015;151:194-202
  163. 163. Law B, Mason PA, Moffat AC, King LJ, Marks V. Passive inhalation of cannabis smoke. The Journal of Pharmacy and Pharmacology. 1984;36(9):578-581
  164. 164. Mason AP, Perez-Reyes M, McBay AJ, Foltz RL. Cannabinoids in plasma after passive inhalation of marijuana smoke. Journal of the American Medical Association. 1983;249(4):475-476
  165. 165. Mule SJ, Lomax P, Gross SJ. Active and realistic passive marijuana exposure tested by three immunoassays and GC/MS in urine. Journal of Analytical Toxicology. 1988;12(3):113-116
  166. 166. Niedbala RS, Kardos KW, Fritch DF, Kunsman KP, Blum KA, Newland GA, et al. Passive cannabis smoke exposure and oral fluid testing. II. Two studies of extreme cannabis smoke exposure in a motor vehicle. Journal of Analytical Toxicology. 2005;29(7):607-615
  167. 167. Niedbala S, Kardos K, Salamone S, Fritch D, Bronsgeest M, Cone EJ. Passive cannabis smoke exposure and oral fluid testing. Journal of Analytical Toxicology. 2004;28(7):546-552
  168. 168. Perez-Reyes M, di Guiseppi S, Davis KH. Passive inhalation of marijuana smoke and urinary excretion cannabinoids. Journal of the American Medical Association. 1983;249(4):475
  169. 169. Rohrich J, Schimmel I, Zorntlein S, Becker J, Drobnik S, Kaufmann T, et al. Concentrations of delta9-tetrahydrocannabinol and 11-nor-9-carboxytetrahydrocannabinol in blood and urine after passive exposure to Cannabis smoke in a coffee shop. Journal of Analytical Toxicology. 2010;34(4):196-203
  170. 170. Chihuri S, Li G. Direct and indirect effects of marijuana use on the risk of fatal 2-vehicle crash initiation. Injury Epidemiology. 2020;7(1):49
  171. 171. Chihuri S, Li G, Chen Q. Interaction of marijuana and alcohol on fatal motor vehicle crash risk: A case-control study. Injury Epidemiology. 2017;4(1):8
  172. 172. Li G, Chihuri S, Brady JE. Role of alcohol and marijuana use in the initiation of fatal two-vehicle crashes. Annals of Epidemiology. 2017;27(5):342-7.e1
  173. 173. Drummer OH, Gerostamoulos J, Batziris H, Chu M, Caplehorn J, Robertson MD, et al. The involvement of drugs in drivers of motor vehicles killed in Australian road traffic crashes. Accident Analysis & Prevention. 2004;36(2):239-248
  174. 174. Drummer OH, Gerostamoulos D, Di Rago M, Woodford NW, Morris C, Frederiksen T, et al. Odds of culpability associated with use of impairing drugs in injured drivers in Victoria, Australia. Accident Analysis & Prevention. 2020;135:105389
  175. 175. Dubois S, Mullen N, Weaver B, Bedard M. The combined effects of alcohol and cannabis on driving: Impact on crash risk. Forensic Science International. 2015;248:94-100
  176. 176. Fierro I, González-Luque JC, Álvarez FJ. The relationship between observed signs of impairment and THC concentration in oral fluid. Drug and Alcohol Dependence. 2014;144:231-238
  177. 177. Hartman RL, Brown TL, Milavetz G, Spurgin A, Pierce RS, Gorelick DA, et al. Cannabis effects on driving lateral control with and without alcohol. Drug and Alcohol Dependence. 2015;154:25-37
  178. 178. Laumon B, Gadegbeku B, Martin JL, Biecheler MB, Group SAM. Cannabis intoxication and fatal road crashes in France: Population based case-control study. BMJ. 2005;331(7529):1371
  179. 179. Mura P, Kintz P, Ludes B, Gaulier JM, Marquet P, Martin-Dupont S, et al. Comparison of the prevalence of alcohol, cannabis and other drugs between 900 injured drivers and 900 control subjects: Results of a French collaborative study. Forensic Science International. 2003;133(1-2):79-85
  180. 180. Poulsen H, Moar R, Pirie R. The culpability of drivers killed in New Zealand road crashes and their use of alcohol and other drugs. Accident; Analysis and Prevention. 2014;67:119-128
  181. 181. Sewell RA, Poling J, Sofuoglu M. The effect of cannabis compared with alcohol on driving. The American Journal on Addictions. 2009;18(3):185-193
  182. 182. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: Systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536
  183. 183. Del Balzo G, Gottardo R, Mengozzi S, Dorizzi RM, Bortolotti F, Appolonova S, et al. "Positive" urine testing for Cannabis is associated with increased risk of traffic crashes. Journal of Pharmaceutical and Biomedical Analysis. 2018;151:71-74
  184. 184. Gjerde H, Strand MC, Morland J. Driving under the influence of non-alcohol drugs—An update part I: Epidemiological studies. Forensic Science Review. 2015;27(2):89-113
  185. 185. Hartman RL, Huestis MA. Cannabis effects on driving skills. Clinical Chemistry. 2013;59(3):478-492
  186. 186. Lowenstein SR, Koziol-McLain J. Drugs and traffic crash responsibility: A study of injured motorists in Colorado. The Journal of Trauma: Injury, Infection, and Critical Care. 2001;50(2):313-320
  187. 187. Preuss UW, Huestis MA, Schneider M, Hermann D, Lutz B, Hasan A, et al. Cannabis use and car crashes: A review. Frontiers in Psychiatry. 2021;12:643315
  188. 188. Rogeberg O, Elvik R. The effects of cannabis intoxication on motor vehicle collision revisited and revised. Addiction. 2016;111(8):1348-1359
  189. 189. Kuypers KP, Legrand SA, Ramaekers JG, Verstraete AG. A case-control study estimating accident risk for alcohol, medicines and illegal drugs. PLoS One. 2012;7(8):e43496
  190. 190. Berghaus G, Scheer N, Schmidt P. Effects of cannabis on psychomotor skills and driving performance—a metaanalysis of experimental studies. 1995. Available from:
  191. 191. Hart CL, van Gorp W, Haney M, Foltin RW, Fischman MW. Effects of acute smoked marijuana on complex cognitive performance. Neuropsychopharmacology. 2001;25(5):757-765
  192. 192. Hunault CC, Mensinga TT, Bocker KB, Schipper CM, Kruidenier M, Leenders ME, et al. Cognitive and psychomotor effects in males after smoking a combination of tobacco and cannabis containing up to 69 mg delta-9-tetrahydrocannabinol (THC). Psychopharmacology. 2009;204(1):85-94
  193. 193. Kelly TH, Foltin RW, Emurian CS, Fischman MW. Performance-based testing for drugs of abuse: Dose and time profiles of marijuana, amphetamine, alcohol, and diazepam. Journal of Analytical Toxicology. 1993;17(5):264-272
  194. 194. Lenne MG, Dietze PM, Triggs TJ, Walmsley S, Murphy B, Redman JR. The effects of cannabis and alcohol on simulated arterial driving: Influences of driving experience and task demand. Accident; Analysis and Prevention. 2010;42(3):859-866
  195. 195. Micallef J, Dupouey J, Jouve E, Truillet R, Lacarelle B, Taillard J, et al. Cannabis smoking impairs driving performance on the simulator and real driving: A randomized, double-blind, placebo-controlled, crossover trial. Fundamental & Clinical Pharmacology. 2018;32(5):558-570
  196. 196. Ramaekers JG, Kauert G, Theunissen EL, Toennes SW, Moeller MR. Neurocognitive performance during acute THC intoxication in heavy and occasional cannabis users. Journal of Psychopharmacology. 2009;23(3):266-277
  197. 197. Ramaekers JG, Kauert G, van Ruitenbeek P, Theunissen EL, Schneider E, Moeller MR. High-potency marijuana impairs executive function and inhibitory motor control. Neuropsychopharmacology. 2006;31(10):2296-2303
  198. 198. Ronen A, Chassidim HS, Gershon P, Parmet Y, Rabinovich A, Bar-Hamburger R, et al. The effect of alcohol, THC and their combination on perceived effects, willingness to drive and performance of driving and non-driving tasks. Accident; Analysis and Prevention. 2010;42(6):1855-1865
  199. 199. Schwope DM, Bosker WM, Ramaekers JG, Gorelick DA, Huestis MA. Psychomotor performance, subjective and physiological effects and whole blood Delta(9)-tetrahydrocannabinol concentrations in heavy, chronic cannabis smokers following acute smoked cannabis. Journal of Analytical Toxicology. 2012;36(6):405-412
  200. 200. Weinstein A, Brickner O, Lerman H, Greemland M, Bloch M, Lester H, et al. A study investigating the acute dose-response effects of 13 mg and 17 mg Delta 9- tetrahydrocannabinol on cognitive-motor skills, subjective and autonomic measures in regular users of marijuana. Journal of Psychopharmacology. 2008;22(4):441-451
  201. 201. Vindenes V, Strand DH, Kristoffersen L, Boix F, Morland J. Has the intake of THC by cannabis users changed over the last decade? Evidence of increased exposure by analysis of blood THC concentrations in impaired drivers. Forensic Science International. 2013;226(1-3):197-201
  202. 202. Arkell TR, Vinckenbosch F, Kevin RC, Theunissen EL, McGregor IS, Ramaekers JG. Effect of cannabidiol and Δ9-tetrahydrocannabinol on driving performance: A randomized clinical trial. Journal of the American Medical Association. 2020;324(21):2177-2186
  203. 203. Brooks-Russell A, Brown T, Friedman K, Wrobel J, Schwarz J, Dooley G, et al. Simulated driving performance among daily and occasional cannabis users. Accident; Analysis and Prevention. 2021;160:106326
  204. 204. Grotenhermen F, Leson G, Berghaus G, Drummer OH, Kruger HP, Longo M, et al. Developing limits for driving under cannabis. Addiction. 2007;102(12):1910-1917
  205. 205. Brubacher JR, Chan H, Erdelyi S, Macdonald S, Asbridge M, Mann RE, et al. Cannabis use as a risk factor for causing motor vehicle crashes: a prospective study. Addiction. 2019;114(9):1616-1626
  206. 206. Ortiz-Peregrina S, Ortiz C, Castro-Torres JJ, Jiménez JR, Anera RG. Effects of smoking cannabis on visual function and driving performance. A driving-simulator based study. International Journal of Environmental Research and Public Health. 2020;17(23):9033
  207. 207. Tank A, Tietz T, Daldrup T, Schwender H, Hellen F, Ritz-Timme S, et al. On the impact of cannabis consumption on traffic safety: A driving simulator study with habitual cannabis consumers. International Journal of Legal Medicine. 2019;133(5):1411-1420
  208. 208. Huestis MA. Human cannabinoid pharmacokinetics. Chemistry & Biodiversity. 2007;4(8):1770-1804
  209. 209. Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: Cyclical hyperemesis in association with chronic cannabis abuse. Gut. 2004;53(11):1566-1570
  210. 210. Contreras Narvaez C, Mola Gilbert M, Batlle de Santiago E, Bigas Farreres J, Gine Serven E, Canete CJ. Cannabinoid hyperemesis syndrome. A report of six new cases and a summary of previous reports. Adicciones. 2016;28(2):90-98
  211. 211. Kim HS, Anderson JD, Saghafi O, Heard KJ, Monte AA. Cyclic vomiting presentations following marijuana liberalization in Colorado. Academic Emergency Medicine. 2015;22(6):694-699
  212. 212. Lonsdale H, Kimsey KM, Brown JM, Dey A, Peck J, Son S, et al. Pediatric cannabinoid hyperemesis: A single institution 10-year case series. The Journal of Adolescent Health. 2021;68(2):255-261
  213. 213. Monte AA, Shelton SK, Mills E, Saben J, Hopkinson A, Sonn B, et al. Acute illness associated with cannabis use, by route of exposure: An observational study. Annals of Internal Medicine. 2019;170(8):531-537
  214. 214. Rotella JA, Ferretti OG, Raisi E, Seet HR, Sarkar S. Cannabinoid hyperemesis syndrome: A 6-year audit of adult presentations to an urban district hospital. Emergency Medicine Australasia. 2022;34(4):578-583
  215. 215. Simonetto DA, Oxentenko AS, Herman ML, Szostek JH. Cannabinoid hyperemesis: A case series of 98 patients. Mayo Clinic Proceedings. 2012;87(2):114-119
  216. 216. Soriano-Co M, Batke M, Cappell MS. The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: A report of eight cases in the United States. Digestive Diseases and Sciences. 2010;55(11):3113-3119
  217. 217. von Both I, Santos B. Death of a young woman with cyclic vomiting: A case report. Forensic Science, Medicine, and Pathology. 2021;17(4):715-722
  218. 218. Wallace EA, Andrews SE, Garmany CL, Jelley MJ. Cannabinoid hyperemesis syndrome: Literature review and proposed diagnosis and treatment algorithm. Southern Medical Journal. 2011;104(9):659-664
  219. 219. Donnino MW, Cocchi MN, Miller J, Fisher J. Cannabinoid hyperemesis: A case series. The Journal of Emergency Medicine. 2011;40(4):e63-e66
  220. 220. Venkatesan T, Levinthal DJ, Li BUK, Tarbell SE, Adams KA, Issenman RM, et al. Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome. Neurogastroenterology & Motility. 2019;31(Suppl 2):e13606
  221. 221. Epstein-Ngo QM, Cunningham RM, Whiteside LK, Chermack ST, Booth BM, Zimmerman MA, et al. A daily calendar analysis of substance use and dating violence among high risk urban youth. Drug and Alcohol Dependence. 2013;130(1-3):194-200
  222. 222. Nabors EL. Drug use and intimate partner violence among college students: An in-depth exploration. Journal of Interpersonal Violence. 2010;25(6):1043-1063
  223. 223. Rothman EF, Johnson RM, Azrael D, Hall DM, Weinberg J. Perpetration of physical assault against dating partners, peers, and siblings among a locally representative sample of high school students in Boston, Massachusetts. Archives of Pediatrics & Adolescent Medicine. 2010;164(12):1118-1124
  224. 224. Shorey RC, Stuart GL, Moore TM, McNulty JK. The temporal relationship between alcohol, marijuana, angry affect, and dating violence perpetration: A daily diary study with female college students. Psychology of Addictive Behaviors. 2014;28(2):516-523
  225. 225. Testa M, Hoffman JH, Leonard KE. Female intimate partner violence perpetration: Stability and predictors of mutual and nonmutual aggression across the first year of college. Aggressive Behavior. 2011;37(4):362-373
  226. 226. Testa M, Derrick JL, Wang W, Leonard KE, Kubiak A, Brown WC, et al. Does marijuana contribute to intimate partner aggression? Temporal effects in a community sample of marijuana-using couples. Journal of Studies on Alcohol and Drugs. 2018;79(3):432-440
  227. 227. Auer R, Vittinghoff E, Yaffe K, Kunzi A, Kertesz SG, Levine DA, et al. Association between lifetime marijuana use and cognitive function in middle age: The coronary artery risk development in young adults (CARDIA) study. JAMA Internal Medicine. 2016;176(3):352-361
  228. 228. Pope HG Jr, Gruber AJ, Hudson JI, Huestis MA, Yurgelun-Todd D. Neuropsychological performance in long-term cannabis users. Archives of General Psychiatry. 2001;58(10):909-915
  229. 229. Rodgers J, Buchanan T, Scholey AB, Heffernan TM, Ling J, Parrott A. Differential effects of Ecstasy and cannabis on self-reports of memory ability: A web-based study. Human Psychopharmacology. 2001;16(8):619-625
  230. 230. Roebke PV, Vadhan NP, Brooks DJ, Levin FR. Verbal learning in marijuana users seeking treatment: A comparison between depressed and non-depressed samples. The American Journal of Drug and Alcohol Abuse. 2014;40(4):274-279
  231. 231. Sanchez-Torres AM, Basterra V, Rosa A, Fananas L, Zarzuela A, Ibanez B, et al. Lifetime cannabis use and cognition in patients with schizophrenia spectrum disorders and their unaffected siblings. European Archives of Psychiatry and Clinical Neuroscience. 2013;263(8):643-653
  232. 232. Schoeler T, Kambeitz J, Behlke I, Murray R, Bhattacharyya S. The effects of cannabis on memory function in users with and without a psychotic disorder: Findings from a combined meta-analysis. Psychological Medicine. 2016;46(1):177-188
  233. 233. Solowij N. Cognitive functioning of long-term heavy cannabis users seeking treatment. Journal of the American Medical Association. 2002;287(9):1123
  234. 234. Tamm L, Epstein JN, Lisdahl KM, Molina B, Tapert S, Hinshaw SP, et al. Impact of ADHD and cannabis use on executive functioning in young adults. Drug and Alcohol Dependence. 2013;133(2):607-614
  235. 235. Thames AD, Arbid N, Sayegh P. Cannabis use and neurocognitive functioning in a non-clinical sample of users. Addictive Behaviors. 2014;39(5):994-999
  236. 236. Curran HV, Hindocha C, Morgan CJA, Shaban N, Das RK, Freeman TP. Which biological and self-report measures of cannabis use predict cannabis dependency and acute psychotic-like effects? Psychological Medicine. 2019;49(9):1574-1580
  237. 237. D'Souza DC, Perry E, MacDougall L, Ammerman Y, Cooper T, Wu YT, et al. The psychotomimetic effects of intravenous delta-9-tetrahydrocannabinol in healthy individuals: Implications for psychosis. Neuropsychopharmacology. 2004;29(8):1558-1572
  238. 238. Englund A, Atakan Z, Kralj A, Tunstall N, Murray R, Morrison P. The effect of five day dosing with THCV on THC-induced cognitive, psychological and physiological effects in healthy male human volunteers: A placebo-controlled, double-blind, crossover pilot trial. Journal of Psychopharmacology. 2016;30(2):140-151
  239. 239. Mason O, Morgan CJ, Dhiman SK, Patel A, Parti N, Patel A, et al. Acute cannabis use causes increased psychotomimetic experiences in individuals prone to psychosis. Psychological Medicine. 2009;39(6):951-956
  240. 240. Morrison PD, Zois V, McKeown DA, Lee TD, Holt DW, Powell JF, et al. The acute effects of synthetic intravenous Delta9-tetrahydrocannabinol on psychosis, mood and cognitive functioning. Psychological Medicine. 2009;39(10):1607-1616
  241. 241. Nestoros JN, Vakonaki E, Tzatzarakis MN, Alegakis A, Skondras MD, Tsatsakis AM. Long lasting effects of chronic heavy cannabis abuse. The American Journal on Addictions. 2017;26(4):335-342
  242. 242. Morrison PD, Stone JM. Synthetic delta-9-tetrahydrocannabinol elicits schizophrenia-like negative symptoms which are distinct from sedation. Human Psychopharmacology. 2011;26(1):77-80
  243. 243. Morgan CJ, Rothwell E, Atkinson H, Mason O, Curran HV. Hyper-priming in cannabis users: A naturalistic study of the effects of cannabis on semantic memory function. Psychiatry Research. 2010;176(2-3):213-218
  244. 244. Giordano GN, Ohlsson H, Sundquist K, Sundquist J, Kendler KS. The association between cannabis abuse and subsequent schizophrenia: A Swedish national co-relative control study. Psychological Medicine. 2015;45(2):407-414
  245. 245. Hjorthøj C, Posselt CM, Nordentoft M. Development over time of the population-attributable risk fraction for cannabis use disorder in schizophrenia in Denmark. JAMA Psychiatry. 2021;78(9):1013-1019
  246. 246. Nielsen SM, Toftdahl NG, Nordentoft M, Hjorthoj C. Association between alcohol, cannabis, and other illicit substance abuse and risk of developing schizophrenia: A nationwide population based register study. Psychological Medicine. 2017;47(9):1668-1677
  247. 247. Sideli L, Fisher HL, Murray RM, Sallis H, Russo M, Stilo SA, et al. Interaction between cannabis consumption and childhood abuse in psychotic disorders: Preliminary findings on the role of different patterns of cannabis use. Early Intervention in Psychiatry. 2018;12(2):135-142
  248. 248. Blanco C, Hasin DS, Wall MM, Florez-Salamanca L, Hoertel N, Wang S, et al. Cannabis use and risk of psychiatric disorders: prospective evidence from a US national longitudinal study. JAMA Psychiatry. 2016;73(4):388-395
  249. 249. Buu A, Hu YH, Pampati S, Arterberry BJ, Lin HC. Predictive validity of cannabis consumption measures: Results from a national longitudinal study. Addictive Behaviors. 2017;73:36-40
  250. 250. Callaghan RC, Sanches M, Kish SJ. Quantity and frequency of cannabis use in relation to cannabis-use disorder and cannabis-related problems. Drug and Alcohol Dependence. 2020;217:108271
  251. 251. Leung J, Chan GCK, Hides L, Hall WD. What is the prevalence and risk of cannabis use disorders among people who use cannabis? A systematic review and meta-analysis. Addictive Behaviors. 2020;109:106479
  252. 252. Lopez-Quintero C, Perez de los Cobos J, Hasin DS, Okuda M, Wang S, Grant BF, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug and Alcohol Dependence. 2011;115(1-2):120-130
  253. 253. Buckner JD, Zvolensky MJ, Ecker AH, Schmidt NB, Lewis EM, Paulus DJ, et al. Integrated cognitive behavioral therapy for comorbid cannabis use and anxiety disorders: A pilot randomized controlled trial. Behaviour Research and Therapy. 2019;115:38-45
  254. 254. Budney AJ, Higgins ST, Radonovich KJ, Novy PL. Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology. 2000;68(6):1051-1061
  255. 255. Budney AJ, Stanger C, Tilford JM, Scherer EB, Brown PC, Li Z, et al. Computer-assisted behavioral therapy and contingency management for cannabis use disorder. Psychology of Addictive Behaviors. 2015;29(3):501-511
  256. 256. Copeland J, Swift W, Roffman R, Stephens R. A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder. Journal of Substance Abuse Treatment. 2001;21(2):55-64; discussion 5-6
  257. 257. Rooke S, Copeland J, Norberg M, Hine D, McCambridge J. Effectiveness of a self-guided web-based cannabis treatment program: Randomized controlled trial. Journal of Medical Internet Research. 2013;15(2):e26
  258. 258. Budney AJ, Moore BA, Vandrey RG, Hughes JR. The time course and significance of cannabis withdrawal. Journal of Abnormal Psychology. 2003;112(3):393-402
  259. 259. Budney AJ, Novy PL, Hughes JR. Marijuana withdrawal among adults seeking treatment for marijuana dependence. Addiction. 1999;94(9):1311-1322
  260. 260. Budney AJ, Radonovich KJ, Higgins ST, Wong CJ. Adults seeking treatment for marijuana dependence: A comparison with cocaine-dependent treatment seekers. Experimental and Clinical Psychopharmacology. 1998;6(4):419-426
  261. 261. Budney AJ, Vandrey RG, Hughes JR, Moore BA, Bahrenburg B. Oral delta-9-tetrahydrocannabinol suppresses cannabis withdrawal symptoms. Drug and Alcohol Dependence. 2007;86(1):22-29
  262. 262. Budney AJ, Vandrey RG, Hughes JR, Thostenson JD, Bursac Z. Comparison of cannabis and tobacco withdrawal: Severity and contribution to relapse. Journal of Substance Abuse Treatment. 2008;35(4):362-368
  263. 263. Cousijn J, van Duijvenvoorde ACK. Cognitive and mental health predictors of withdrawal severity during an active attempt to cut down cannabis use. Frontiers in Psychiatry. 2018;9:301
  264. 264. Greene MC, Kelly JF. The prevalence of cannabis withdrawal and its influence on adolescents' treatment response and outcomes: a 12-month prospective investigation. Journal of Addiction Medicine. 2014;8(5):359-367
  265. 265. Hasin DS, Keyes KM, Alderson D, Wang S, Aharonovich E, Grant BF. Cannabis withdrawal in the United States: Results from NESARC. The Journal of Clinical Psychiatry. 2008;69(9):1354-1363
  266. 266. Herrmann ES, Weerts EM, Vandrey R. Sex differences in cannabis withdrawal symptoms among treatment-seeking cannabis users. Experimental and Clinical Psychopharmacology. 2015;23(6):415-421
  267. 267. Livne O, Shmulewitz D, Lev-Ran S, Hasin DS. DSM-5 cannabis withdrawal syndrome: Demographic and clinical correlates in U.S. adults. Drug and Alcohol Dependence. 2019;195:170-177
  268. 268. Vandrey R, Budney AJ, Kamon JL, Stanger C. Cannabis withdrawal in adolescent treatment seekers. Drug and Alcohol Dependence. 2005;78(2):205-210
  269. 269. Vandrey RG, Budney AJ, Hughes JR, Liguori A. A within-subject comparison of withdrawal symptoms during abstinence from cannabis, tobacco, and both substances. Drug and Alcohol Dependence. 2008;92(1-3):48-54
  270. 270. Vandrey RG, Budney AJ, Moore BA, Hughes JR. A cross-study comparison of cannabis and tobacco withdrawal. The American Journal on Addictions. 2005;14(1):54-63
  271. 271. Betts KS, Kisely S, Alati R. Prenatal cannabis use disorders and offspring primary and secondary educational outcomes. Addiction. 2022;117(2):425-432
  272. 272. Fried PA, Watkinson B, Siegel LS. Reading and language in 9- to 12-year olds prenatally exposed to cigarettes and marijuana. Neurotoxicology and Teratology. 1997;19(3):171-183
  273. 273. Goldschmidt L, Richardson GA, Cornelius MD, Day NL. Prenatal marijuana and alcohol exposure and academic achievement at age 10. Neurotoxicology and Teratology. 2004;26(4):521-532
  274. 274. Goldschmidt L, Richardson GA, Willford JA, Severtson SG, Day NL. School achievement in 14-year-old youths prenatally exposed to marijuana. Neurotoxicology and Teratology. 2012;34(1):161-167
  275. 275. Smith AM, Fried PA, Hogan MJ, Cameron I. Effects of prenatal marijuana on response inhibition: An fMRI study of young adults. Neurotoxicology and Teratology. 2004;26(4):533-542
  276. 276. Amoretti S, Verdolini N, Varo C, Mezquida G, Sánchez-Torres AM, Vieta E, et al. Is the effect of cognitive reserve in longitudinal outcomes in first-episode psychoses dependent on the use of cannabis? Journal of Affective Disorders. 2022;302:83-93
  277. 277. Torres CA, Medina-Kirchner C, O'Malley KY, Hart CL. Totality of the evidence suggests prenatal cannabis exposure does not lead to cognitive impairments: A systematic and critical review. Frontiers in Psychology. 2020;11:816
  278. 278. Willford JA, Chandler LS, Goldschmidt L, Day NL. Effects of prenatal tobacco, alcohol and marijuana exposure on processing speed, visual-motor coordination, and interhemispheric transfer. Neurotoxicology and Teratology. 2010;32(6):580-588
  279. 279. Day NL, Richardson GA, Goldschmidt L, Robles N, Taylor PM, Stoffer DS, et al. Effect of prenatal marijuana exposure on the cognitive development of offspring at age three. Neurotoxicology and Teratology. 1994;16(2):169-175
  280. 280. Goldschmidt L, Richardson GA, Willford J, Day NL. Prenatal marijuana exposure and intelligence test performance at age 6. Journal of the American Academy of Child and Adolescent Psychiatry. 2008;47(3):254-263
  281. 281. Eiden RD, Zhao J, Casey M, Shisler S, Schuetze P, Colder CR. Pre- and postnatal tobacco and cannabis exposure and child behavior problems: Bidirectional associations, joint effects, and sex differences. Drug and Alcohol Dependence. 2018;185:82-92
  282. 282. El Marroun H, Tiemeier H, Steegers EA, Jaddoe VW, Hofman A, Verhulst FC, et al. Intrauterine cannabis exposure affects fetal growth trajectories: The Generation R Study. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(12):1173-1181
  283. 283. Fried PA, Smith AM. A literature review of the consequences of prenatal marihuana exposure. An emerging theme of a deficiency in aspects of executive function. Neurotoxicology and Teratology. 2001;23(1):1-11
  284. 284. Noland JS, Singer LT, Short EJ, Minnes S, Arendt RE, Kirchner HL, et al. Prenatal drug exposure and selective attention in preschoolers. Neurotoxicology and Teratology. 2005;27(3):429-438
  285. 285. Paul SE, Hatoum AS, Fine JD, Johnson EC, Hansen I, Karcher NR, et al. Associations between prenatal cannabis exposure and childhood outcomes: Results from the ABCD Study. JAMA Psychiatry. 2021;78(1):64-76
  286. 286. Bandoli G, Jelliffe-Pawlowski L, Schumacher B, Baer RJ, Felder JN, Fuchs JD, et al. Cannabis-related diagnosis in pregnancy and adverse maternal and infant outcomes. Drug and Alcohol Dependence. 2021;225:108757
  287. 287. Day N, Sambamoorthi U, Taylor P, Richardson G, Robles N, Jhon Y, et al. Prenatal marijuana use and neonatal outcome. Neurotoxicology and Teratology. 1991;13(3):329-334
  288. 288. Forrester MB, Merz RD. Risk of selected birth defects with prenatal illicit drug use, Hawaii, 1986-2002. Journal of Toxicology and Environmental Health. Part A. 2007;70(1):7-18
  289. 289. Kharbanda EO, Vazquez-Benitez G, Kunin-Batson A, Nordin JD, Olsen A, Romitti PA. Birth and early developmental screening outcomes associated with cannabis exposure during pregnancy. Journal of Perinatology. 2020;40(3):473-480
  290. 290. Linn S, Schoenbaum SC, Monson RR, Rosner R, Stubblefield PC, Ryan KJ. The association of marijuana use with outcome of pregnancy. American Journal of Public Health. 1983;73(10):1161-1164
  291. 291. Petrangelo A, Czuzoj-Shulman N, Balayla J, Abenhaim HA. Cannabis abuse or dependence during pregnancy: A population-based cohort study on 12 million births. Journal of Obstetrics and Gynaecology Canada. 2019;41(5):623-630
  292. 292. Warshak CR, Regan J, Moore B, Magner K, Kritzer S, Van Hook J. Association between marijuana use and adverse obstetrical and neonatal outcomes. Journal of Perinatology. 2015;35(12):991-995
  293. 293. Brown SJ, Mensah FK, Ah Kit J, Stuart-Butler D, Glover K, Leane C, et al. Use of cannabis during pregnancy and birth outcomes in an Aboriginal birth cohort: A cross-sectional, population-based study. BMJ Open. 2016;6(2):e010286
  294. 294. Chabarria KC, Racusin DA, Antony KM, Kahr M, Suter MA, Mastrobattista JM, et al. Marijuana use and its effects in pregnancy. American Journal of Obstetrics and Gynecology. 2016;215(4):506.e1-506.e7
  295. 295. Corsi DJ, Walsh L, Weiss D, Hsu H, El-Chaar D, Hawken S, et al. Association between self-reported prenatal cannabis use and maternal, perinatal, and neonatal outcomes. Journal of the American Medical Association. 2019;322(2):145-152
  296. 296. Crume TL, Juhl AL, Brooks-Russell A, Hall KE, Wymore E, Borgelt LM. Cannabis use during the perinatal period in a state with legalized recreational and medical marijuana: The association between maternal characteristics, breastfeeding patterns, and neonatal outcomes. The Journal of Pediatrics. 2018;197:90-96
  297. 297. Hayatbakhsh MR, Flenady VJ, Gibbons KS, Kingsbury AM, Hurrion E, Mamun AA, et al. Birth outcomes associated with cannabis use before and during pregnancy. Pediatric Research. 2012;71(2):215-219
  298. 298. Koto P, Allen VM, Fahey J, Kuhle S. Maternal cannabis use during pregnancy and maternal and neonatal outcomes: A retrospective cohort study. BJOG: An International Journal of Obstetrics and Gynaecology. 2022; DOI: 10.1111/1471-0528.17114. Online ahead of print
  299. 299. Leemaqz SY, Dekker GA, McCowan LM, Kenny LC, Myers JE, Simpson NA, et al. Maternal marijuana use has independent effects on risk for spontaneous preterm birth but not other common late pregnancy complications. Reproductive Toxicology. 2016;62:77-86
  300. 300. Luke S, Hutcheon J, Kendall T. Cannabis use in pregnancy in British Columbia and selected birth outcomes. Journal of Obstetrics and Gynaecology Canada. 2019;41(9):1311-1317
  301. 301. Marchand G, Masoud AT, Govindan M, Ware K, King A, Ruther S, et al. Birth outcomes of neonates exposed to marijuana in utero: A systematic review and meta-analysis. JAMA Network Open. 2022;5(1):e2145653
  302. 302. Nguyen VH, Harley KG. Prenatal cannabis use and infant birth outcomes in the pregnancy risk assessment monitoring system. The Journal of Pediatrics. 2021;240:87-93
  303. 303. Sasso EB, Bolshakova M, Bogumil D, Johnson B, Komatsu E, Sternberg J, et al. Marijuana use and perinatal outcomes in obstetric patients at a safety net hospital. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2021;266:36-41
  304. 304. Shi Y, Zhu B, Liang D. The associations between prenatal cannabis use disorder and neonatal outcomes. Addiction. 2021;116(11):3069-3079
  305. 305. Straub HL, Mou J, Drennan KJ, Pflugeisen BM. Maternal marijuana exposure and birth weight: An observational study surrounding recreational marijuana legalization. American Journal of Perinatology. 2021;38(1):65-75
  306. 306. ElSohly MA, Feng S. delta 9-THC metabolites in meconium: Identification of 11-OH-delta 9-THC, 8 beta,11-diOH-delta 9-THC, and 11-nor-delta 9-THC-9-COOH as major metabolites of delta 9-THC. Journal of Analytical Toxicology. 1998;22(4):329-335
  307. 307. ElSohly MA, Stanford DF, Murphy TP, Lester BM, Wright LL, Smeriglio VL, et al. Immunoassay and GC-MS procedures for the analysis of drugs of abuse in meconium. Journal of Analytical Toxicology. 1999;23(6):436-445
  308. 308. Joya X, Pujadas M, Falcon M, Civit E, Garcia-Algar O, Vall O, et al. Gas chromatography-mass spectrometry assay for the simultaneous quantification of drugs of abuse in human placenta at 12th week of gestation. Forensic Science International. 2010;196(1-3):38-42
  309. 309. Kim J, de Castro A, Lendoiro E, Cruz-Landeira A, Lopez-Rivadulla M, Concheiro M. Detection of in utero cannabis exposure by umbilical cord analysis. Drug Testing and Analysis. 2018;10(4):636-643
  310. 310. Marchei E, Pellegrini M, Pacifici R, Palmi I, Lozano J, Garcia-Algar O, et al. Quantification of Delta9-tetrahydrocannabinol and its major metabolites in meconium by gas chromatographic-mass spectrometric assay: Assay validation and preliminary results of the "meconium project". Therapeutic Drug Monitoring. 2006;28(5):700-706
  311. 311. Perez-Reyes M, Lipton MA, Timmons MC, Wall ME, Brine DR, Davis KH. Pharmacology of orally administered 9-tetrahydrocannabinol. Clinical Pharmacology and Therapeutics. 1973;14(1):48-55
  312. 312. Baker T, Datta P, Rewers-Felkins K, Thompson H, Kallem RR, Hale TW. Transfer of inhaled cannabis into human breast milk. Obstetrics and Gynecology. 2018;131(5):783-788
  313. 313. Moss MJ, Bushlin I, Kazmierczak S, Koop D, Hendrickson RG, Zuckerman KE, et al. Cannabis use and measurement of cannabinoids in plasma and breast milk of breastfeeding mothers. Pediatric Research. 2021;90(4):861-868
  314. 314. Perez-Reyes M, Wall ME. Presence of delta9-tetrahydrocannabinol in human milk. The New England Journal of Medicine. 1982;307(13):819-820
  315. 315. Sempio C, Wymore E, Palmer C, Bunik M, Henthorn TK, Christians U, et al. Detection of cannabinoids by LC-MS-MS and ELISA in breast milk. Journal of Analytical Toxicology. 2021;45(7):686-692
  316. 316. Wymore EM, Palmer C, Wang GS, Metz TD, Bourne DWA, Sempio C, et al. Persistence of Δ-9-tetrahydrocannabinol in human breast milk. JAMA Pediatrics. 2021;175(6):632-634
  317. 317. Behavioral Risk Factor Surveillance System (BRFSS) data. Colorado Department of Public Health and Environment. Available from:
  318. 318. Aldington S, Williams M, Nowitz M, Weatherall M, Pritchard A, McNaughton A, et al. Effects of cannabis on pulmonary structure, function and symptoms. Thorax. 2007;62(12):1058-1063
  319. 319. Bloom JW, Kaltenborn WT, Paoletti P, Camilli A, Lebowitz MD. Respiratory effects of non-tobacco cigarettes. British Medical Journal. 1987;295(6612):1516-1518
  320. 320. Kempker JA, Honig EG, Martin GS. The effects of marijuana exposure on expiratory airflow. A study of adults who participated in the U.S. National Health and Nutrition Examination Study. Annals of the American Thoracic Society. 2015;12(2):135-141
  321. 321. Macleod J, Robertson R, Copeland L, McKenzie J, Elton R, Reid P. Cannabis, tobacco smoking, and lung function: A cross-sectional observational study in a general practice population. The British Journal of General Practice. 2015;65(631):e89-e95
  322. 322. Moore BA, Augustson EM, Moser RP, Budney AJ. Respiratory effects of marijuana and tobacco use in a U.S. sample. Journal of General Internal Medicine. 2005;20(1):33-37
  323. 323. Morris MA, Jacobson SR, Kinney GL, Tashkin DP, Woodruff PG, Hoffman EA, et al. Marijuana use associations with pulmonary symptoms and function in tobacco smokers enrolled in the subpopulations and intermediate outcome measures in COPD study (SPIROMICS). Chronic Obstructive Pulmonary Disease. 2018;5(1):46-56
  324. 324. Roth MD, Arora A, Barsky SH, Kleerup EC, Simmons M, Tashkin DP. Airway inflammation in young marijuana and tobacco smokers. American Journal of Respiratory and Critical Care Medicine. 1998;157(3 Pt 1):928-937
  325. 325. Sherrill DL, Krzyzanowski M, Bloom JW, Lebowitz MD. Respiratory effects of non-tobacco cigarettes: A longitudinal study in general population. International Journal of Epidemiology. 1991;20(1):132-137
  326. 326. Tashkin DP, Coulson AH, Clark VA, Simmons M, Bourque LB, Duann S, et al. Respiratory symptoms and lung function in habitual heavy smokers of marijuana alone, smokers of marijuana and tobacco, smokers of tobacco alone, and nonsmokers. The American Review of Respiratory Disease. 1987;135(1):209-216
  327. 327. Taylor DR, Poulton R, Moffitt TE, Ramankutty P, Sears MR. The respiratory effects of cannabis dependence in young adults. Addiction. 2000;95(11):1669-1677
  328. 328. Tashkin DP, Shapiro BJ, Frank IM. Acute pulmonary physiologic effects of smoked marijuana and oral 9 -tetrahydrocannabinol in healthy young men. The New England Journal of Medicine. 1973;289(7):336-341
  329. 329. Tashkin DP, Shapiro BJ, Frank IM. Acute effects of smoked marijuana and oral delta9-tetrahydrocannabinol on specific airway conductance in asthmatic subjects. The American Review of Respiratory Disease. 1974;109(4):420-428
  330. 330. Tashkin DP, Shapiro BJ, Lee YE, Harper CE. Effects of smoked marijuana in experimentally induced asthma. The American Review of Respiratory Disease. 1975;112(3):377-386
  331. 331. Dean D, Passalacqua KD, Oh SM, Aaron C, Van Harn MG, King A. Pediatric cannabis single-substance exposures reported to the michigan poison center from 2008-2019 after medical marijuana legalization. The Journal of Emergency Medicine. 2021;60(6):701-708
  332. 332. Myran DT, Cantor N, Finkelstein Y, Pugliese M, Guttmann A, Jesseman R, et al. Unintentional pediatric cannabis exposures after legalization of recreational cannabis in canada. JAMA Network Open. 2022;5(1):e2142521
  333. 333. Onders B, Casavant MJ, Spiller HA, Chounthirath T, Smith GA. Marijuana exposure among children younger than six years in the United States. Clinical Pediatrics (Phila). 2016;55(5):428-436
  334. 334. Shi Y, Liang D. The association between recreational cannabis commercialization and cannabis exposures reported to the US National Poison Data System. Addiction. 2020;115(10):1890-1899
  335. 335. Thomas AA, Dickerson-Young T, Mazor S. Unintentional pediatric marijuana exposures at a tertiary care children's hospital in Washington State: A retrospective review. Pediatric Emergency Care. 2021;37(10):e594-e5e8
  336. 336. Wang GS, Banerji S, Contreras AE, Hall KE. Marijuana exposures in Colorado, reported to regional poison centre, 2000-2018. Injury Prevention. 2020;26(2):184-186
  337. 337. Wang GS, Le Lait MC, Deakyne SJ, Bronstein AC, Bajaj L, Roosevelt G. Unintentional pediatric exposures to marijuana in Colorado, 2009-2015. JAMA Pediatrics. 2016;170(9):e160971
  338. 338. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Pediatrics. 2013;167(7):630-633
  339. 339. Wang GS, Roosevelt G, Le Lait MC, Martinez EM, Bucher-Bartelson B, Bronstein AC, et al. Association of unintentional pediatric exposures with decriminalization of marijuana in the United States. Annals of Emergency Medicine. 2014;63(6):684-689
  340. 340. Whitehill JM, Dilley JA, Brooks-Russell A, Terpak L, Graves JM. Edible cannabis exposures among children: 2017-2019. Pediatrics. 2021;147(4):e2020019893
  341. 341. Whitehill JM, Harrington C, Lang CJ, Chary M, Bhutta WA, Burns MM. Incidence of pediatric cannabis exposure among children and teenagers aged 0 to 19 years before and after medical marijuana legalization in Massachusetts. JAMA Network Open. 2019;2(8):e199456
  342. 342. Breault HJ. Five years with 5 million child-resistant containers. Clinical Toxicology. 1974;7(1):91-95
  343. 343. Clarke A, Walton WW. Effect of safety packaging on aspirin ingestion by children. Pediatrics. 1979;63(5):687-693
  344. 344. Rodgers GB. The effectiveness of child-resistant packaging for aspirin. Archives of Pediatrics & Adolescent Medicine. 2002;156(9):929-933
  345. 345. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Collection: Reports Funded by National Institutes of Health; 2017

Written By

Richard Holdman

Submitted: 17 June 2022 Reviewed: 04 July 2022 Published: 04 August 2022