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Poly-use of nicotine products and cannabis: a deadly combination

Presented By
Prof. Charlotta Pisinger, University of Copenhagen & Danish Heart Foundation, Denmark
ERS 2020

The ever-increasing variety of nicotine-containing products that flooded the market in recent years are definitely no “harm reduction products” as propagated by the tobacco industry. On the contrary, the use of e-cigarettes and conventional cigarettes, often together with cannabis, leads to a toxic cocktail that could be responsible for permanent lung damage and premature death [1,2]. 

Prof. Charlotta Pisinger (University of Copenhagen & Danish Heart Foundation, Denmark) pointed out that the new generation products, including e-cigarettes, smokeless tobacco, snuff, snus, and oral nicotine products or nicotine pouches are all non-combustible but highly addictive due to their nicotine content [1]. With these products, the tobacco industry attempted to rehabilitate its reputation by claiming they are “harm reduction products.” The tobacco industry had to adapt to marketing restrictions and health warnings for conventional tobacco products. “With these novel products, they could mostly bypass means of tobacco legislation such as a tobacco ban,” said Prof Pisinger. In addition, the taxes on these products are considerably lower than regular cigarettes, which means a higher profit for the companies. The large growth in consumers of new-generation products is driven primarily by young never-smokers.

Another evident trend is the fast-growing number of consumers that are using more than 1 device. “This increase in poly-use is a dream scenario for the tobacco industry,” Prof. Pisinger stated. This increasing poly-use is reported in adolescents across the world. A large Canadian cohort study with approximately 40,000 high-school students showed a steep increase between 2013/2014 and 2017/2018 in poly-users (i.e. smoking, vaping, cannabis, and alcohol), especially in young men.

Several trials have addressed the dual use of e-cigarettes and regular cigarettes. Cross-sectional, population-based studies showed that the prevalence of respiratory symptoms was highest among the current smokers who also used e-cigarettes [3]. Dual use was also associated with worse breathing. Longitudinal cohort studies have documented that toxicant exposure is greatest in dual users. In addition, according to a Korean study, dual users had a nearly 3-fold elevated relative risk to develop a metabolic syndrome compared with never-smokers [4]. They also had higher urinary cotinine levels and a greater nicotine dependence than cigarette-only smokers. “Studies have shown that poly-tobacco users were almost certain to have used marijuana too,” Prof. Pisinger added [1]. “Taken together, we have very good reason to worry about this novel poly-use,” concluded Prof. Pisinger.

Dramatic increase in cannabis use

Today, cannabis is the most widely used drug globally with an estimated 188 million people using it in 2017. Studies examining the relationship between cannabis use and airways diseases have been inconclusive [2]. “One reason is the concurrent tobacco use, making it difficult to assess a cannabis-only effect,” stated Prof. Ellen L Burnham (University of Colorado School of Medicine in Denver, USA). Vaping cannabis is becoming increasingly common.

E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) is the most severe consequence of vaping and characterised by the following patterns of acute lung injury: diffuse alveolar damage, organising pneumonia, and acute fibrinous pneumonitis. “Vitamin E acetate may be to blame for EVALI” explained Prof. Burnham. When inhaled, vitamin E acetate disrupts lung surfactant. As of 18 February 2020, 2,807 EVALI cases and 68 deaths were reported in the USA. “Healthcare providers cannot recommend or condone inhaled cannabis use for medical indications at the current time,” Prof. Burnham concluded.


    1. Pisinger C. Now it is not only about cigarettes: dual, triple, multiuse of nicotine and cannabis products. What to expect (focus on lung health). Abstract 13, ERS International Virtual Congress 2020, 7-9 Sept.
    2. Burnham E. What we know and what we do not know about cannabis health effects: a concern for lung health? Abstract 15, ERS International Virtual Congress 2020, 7-9 Sept.
    3. Hedmann L, et al. JAMA Netw Open 2018:1:e180789.
    4. Kim CY, et al. Sci Rep 2020;10(1):5612.


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