Environmental exposures are the leading causes of respiratory disease worldwide. Exposures to tobacco smoke and household air pollution consistently rank among the top risk factors not only for respiratory disease burden but also for the global burden of disease (Lim et al., 2012). Less is known, however, about the attributable effects of cannabis use on respiratory disease despite shared similarities with that of cigarette use and the fact that cannabis is the most commonly used inhaled drug in the United States after tobacco, with an estimated 22.2 million people ages 12 years and older reporting current use (CBHSQ, 2015). Moreover, it is estimated that more than 40 percent of current users smoke cannabis on a daily or near daily basis (Douglas et al., 2015). Given the known relationships between tobacco smoking and multiple respiratory conditions, one could hypothesize that long-term cannabis smoking leads to similar deleterious effects on respiratory health, and some investigators argue that cannabis smoking may be even more harmful than that of tobacco smoking. Indeed, data collected from 15 volunteers suggest that smoking one cannabis joint can lead to four times the exposure to carbon monoxide and three to five times more tar deposition than smoking a single cigarette (Wu et al., 1988). This may be, in part, because cannabis smokers generally inhale more deeply and hold their breath for longer than do cigarette smokers (Wu et al., 1988) and because cannabis cigarettes do not commonly have filters as tobacco cigarettes often do. On the other hand, cannabis cigarettes are not as densely packed as tobacco cigarettes (Aldington et al., 2008), and cannabis users usually smoke fewer cannabis cigarettes per day than tobacco users smoke tobacco cigarettes per day. (Ease Pain) Cbd Oil Bronchitis Cbd Oil Bronchitis, Gummies For Sleep Tru Infusion Cbd Gummy. Rachael Ray Gummies Cbd, King Leaf Gummies? Cbd Oil Oral Drops, Cbd Gummies Atlantic Ave. If there
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington (DC): National Academies Press (US); 2017 Jan 12.
The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research.
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda.
7 Respiratory Disease
It is unclear whether cannabis use is associated with chronic obstructive pulmonary disorder, asthma, or worsened lung function.
Environmental exposures are the leading causes of respiratory disease worldwide. Exposures to tobacco smoke and household air pollution consistently rank among the top risk factors not only for respiratory disease burden but also for the global burden of disease (Lim et al., 2012). Less is known, however, about the attributable effects of cannabis use on respiratory disease despite shared similarities with that of cigarette use and the fact that cannabis is the most commonly used inhaled drug in the United States after tobacco, with an estimated 22.2 million people ages 12 years and older reporting current use (CBHSQ, 2015). Moreover, it is estimated that more than 40 percent of current users smoke cannabis on a daily or near daily basis (Douglas et al., 2015). Given the known relationships between tobacco smoking and multiple respiratory conditions, one could hypothesize that long-term cannabis smoking leads to similar deleterious effects on respiratory health, and some investigators argue that cannabis smoking may be even more harmful than that of tobacco smoking. Indeed, data collected from 15 volunteers suggest that smoking one cannabis joint can lead to four times the exposure to carbon monoxide and three to five times more tar deposition than smoking a single cigarette (Wu et al., 1988). This may be, in part, because cannabis smokers generally inhale more deeply and hold their breath for longer than do cigarette smokers (Wu et al., 1988) and because cannabis cigarettes do not commonly have filters as tobacco cigarettes often do. On the other hand, cannabis cigarettes are not as densely packed as tobacco cigarettes (Aldington et al., 2008), and cannabis users usually smoke fewer cannabis cigarettes per day than tobacco users smoke tobacco cigarettes per day.
The committee responsible for the 1999 Institute of Medicine (IOM) report Marijuana and Medicine: Assessing the Science Base (IOM, 1999, p. 6) concluded that cannabis smoking was an important risk factor in the development of respiratory disease and recommended that “studies to define the individual health risks of smoking marijuana should be conducted, particularly among populations in which marijuana use is prevalent.” The literature search conducted by the current committee did not identify any fair- or good-quality systematic reviews for cannabis use and respiratory disease published since 2011 (the cutoff established by the current committee); however, the committee identified—and elected to include—a systematic review by Tetrault et al. (2007) that provides a detailed synthesis of the available literature through 2005. A review by Tashkin (2013) and a position statement by Douglas et al. (2015), which summarized current evidence of the link between cannabis smoking and respiratory disease, were also considered by the committee. Fourteen primary articles published since 1999 that were not included in the systematic review from Tetrault et al. (2007) provided additional evidence on the association between smoking cannabis and respiratory diseases (Aldington et al., 2007; Bechtold et al., 2015; Hancox et al., 2010, 2015; Kempker et al., 2015; Macleod et al., 2015; Papatheodorou et al., 2016; Pletcher et al., 2012; Tan et al., 2009; Tashkin et al., 2012; Van Dam and Earleywine, 2010; Walden and Earleywine, 2008; Weekes et al., 2011; Yadavilli et al., 2014).
Pulmonary function refers to lung size and function. Common measures of pulmonary function include forced expiratory volumes, lung volumes, airways resistance and conductance, and the diffusion capacity of the lung for carbon monoxide (DLCO). Spirometry values include the measurements of forced expiratory volumes, including forced expiratory volume at 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC. The latter is a measure of airflow obstruction and, when combined with bronchodilator therapy, is used in the diagnosis of chronic obstructive pulmonary disorder (COPD).
Is There an Association Between Cannabis Use and Pulmonary Function?
Tetrault et al. (2007) systematically reviewed the evidence found in 34 publications, of which 12 reported on the effects of airway response and 14 reported on the effects of pulmonary function. The authors found that short-term exposure to cannabis smoking resulted in bronchodilation. Specifically, acute cannabis smoking was consistently associated with improvements in specific airway conductance, peak flow measurements, and FEV1, as well as reversed bronchospasm from challenges by either methacholine or exercise. Any short-term benefits, however, were offset by the effects of long-term cannabis smoking. Specifically, regular cannabis smoking was associated with a lower specific airway conductance on average by 16 percent and also with a lower FEV1. There was also a dose–response effect between average daily quantity of cannabis and a lower specific airway conductance. However, the clinical significance of the association between regular cannabis smoking and a lower specific airways conductance is not known. Other studies that examined the association between long-term cannabis smoke exposure and pulmonary function have inconsistently found lower or no change in FEV1, FVC, FEV1/FVC, DLCO, and airway hyperresponsiveness (Tetrault et al., 2007).
Aldington et al. (2007) examined the cross-sectional relationship between long-term cannabis smoking and pulmonary function in a convenience sample of 339 participants in the Wellington Research Study. The inclusion criteria for cannabis and tobacco smokers were a lifetime exposure of at least 5 joint-years of cannabis (defined as smoking 1 joint per day for 1 year) or at least 1 pack-year of tobacco, respectively. Cannabis smoking was based on self-report. The researchers did not find an association between long-term cannabis smoking and pulmonary function variables. However, when cannabis smoking was analyzed in terms of joint-years, Aldington et al. (2007) found a significantly lower FEV1/FVC, lower specific airways conductance, and a higher total lung capacity per joint-year smoked in cannabis smokers compared to nonsmokers. Based on their analyses, the authors estimated that the negative association between each cannabis joint and a lower FEV1/FVC was similar to that of 2.5 to 5 tobacco cigarettes. The committee identified a couple of problems with the analyses and the presentation of the results in the paper by Aldington et al. (2007). First, the authors reported main effects only from their analysis of covariance. A more conservative analysis would have considered the examination of interaction effects between cannabis smoke (or joint-years) and tobacco smoke (or pack-years) in a regression model to better dissect the contribution of cannabis smoke (or joint-years) versus tobacco smoke (or pack-years). Second, the authors incorrectly labeled the association with continuous measures of pulmonary function with cannabis smoke (or joint-years) as odds ratios (ORs) in tables 3 and 4; however, their methods correctly state that a multivariable analysis of covariance methods was used for continuous data.
Papatheodorou et al. (2016) analyzed cross-sectional data from 10,327 adults who participated in the National Health and Nutrition Examination Survey (NHANES) between 2007 and 2012. Cannabis smoking was based on self-report, but the researchers could not quantify joint-years. Cannabis smokers were categorized as never smokers (n = 4,794), past cannabis smokers (n = 4,084), cannabis smokers in the past 5–30 days (n = 555), and cannabis smokers in the past 0–4 days (n = 891). Current cannabis smokers were heavier tobacco smokers than were past and never smokers of cannabis, as measured by mean pack-years. In multivariable analyses, the investigators found that current smokers had a smaller FEV1/FVC than never smokers (−0.01 and −0.02, respectively), and they observed moderate to large increases in FEV1 (49 mL and 89 mL, respectively) and FVC (159 mL and 204 mL, respectively) when comparing current smokers to never smokers. There was also an important decrease in exhaled nitric oxide among current smokers when compared to never smokers (−7 percent versus −14 percent), but it is unclear if this effect was confounded by the high prevalence of tobacco smoking in current cannabis users or if it represented a true decrease in exhaled nitric oxide due to cannabis smoking. The study by Papatheodorou et al. (2016) has some shortcomings. First, the researchers’ analyses were based on cross-sectional data. Second, cannabis use was obtained by self-report and there may have been a bias of underreporting. Finally, there was a lack of data on the method of smoke inhalation and the frequency of cannabis smoking, thus not allowing for an analysis of the relationship between the frequency of cannabis use and pulmonary function.
Pletcher et al. (2012) analyzed longitudinal data from 5,115 adults in the Coronary Artery Risk Development in Young Adults (CARDIA) study and concluded that occasional and low cumulative cannabis smoking was not associated with adverse effects on pulmonary function. The investigators noted that there was a trend toward decreases in FEV1 over 20 years only in the heaviest cannabis smokers (≥20 joint-years). Similar to the findings of Papatheodorou et al. (2016), CARDIA investigators found a higher-than-expected FVC among all categories of cannabis smoking intensity. Despite the large sample size, the study by Pletcher et al. (2012) had a small number of heavy cannabis smokers. Other limitations include the risk of bias due to the self-reporting of cannabis use, a lack of data on the method of cannabis smoke inhalation, and bias due to unmeasured confounders as cannabis smoking was not the main objective of this study.
The study by Hancox et al. (2010) analyzed data of a cohort of 1,037 adult participants in Dunedin, New Zealand, followed longitudinally since childhood and asked about cannabis and tobacco use at ages 18, 21, 26, and 32 years. Cumulative exposure to cannabis was quantified as joint-years since age 17 years. Spirometry was conducted at 32 years. Cumulative cannabis use was associated with higher FVC, total lung capacity, and functional residual capacity and residual volume, but not with lower FEV1 or FEV1/FVC.
A small feasibility study by Van Dam and Earleywine (2010) found that the use of a cannabis vaporizer instead of smoking cannabis in 12 adult participants who did not develop a respiratory illness was associated with improvements in forced expiratory volumes at approximately 1 month after the introduction of the vaporizer; however, this study did not have a control group.
Discussion of Findings
Overall, acute cannabis smoking was associated with bronchodilation, but many of the authors agreed that any benefits may be offset when cannabis is smoked regularly. The current findings are inconclusive on a variety of pulmonary function measurements, and the findings may be affected by the quality of the studies, a failure to adjust for important confounders, including tobacco and other inhaled drugs, and other occupational and environmental exposures. The committee’s findings are consistent with those reported in another recent review (Tashkin, 2013) and a position statement (Douglas et al., 2015).
The majority of studies, including those evaluated in the systematic review, relied on self-report for cannabis smoking. Many studies failed to control for tobacco smoking and occupational and other environmental exposures; did not control for the dose or duration of cannabis smoking; and did not use joint-years and instead based heavy cannabis smoking on having exceeded a specific threshold of joints. Even among studies that used joint-years, it is unclear how generalizable their findings are, given the potential high variability in lung-toxic content from joint to joint. Prior studies have inconsistently documented decreases or no change in FEV1, FEV1/FVC, DLCO, and airway hyperresponsiveness. Moreover, neither the mechanism nor the clinical significance of the association between cannabis smoking and pulmonary function deficits is known beyond the possible impact of a high FVC in lowering the FEV1/FVC ratio. While elevated lung volumes could be indicators of lung pathology, an elevated FVC by itself has not been associated with any lung pathology.
7-1(a) There is moderate evidence of a statistical association between cannabis smoking and improved airway dynamics with acute use, but not with chronic use.
7-1(b) There is moderate evidence of a statistical association between cannabis smoking and higher forced vital capacity (FVC).
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
COPD is a clinical syndrome that consists of lower airway inflammation and damage that impairs airflow. Ranked as the fourth-leading cause of death worldwide by the World Health Organization, COPD has been estimated to cause more than 3 million deaths worldwide annually and has an estimated global prevalence of 10 percent in adults (Buist et al., 2007; Diaz-Guzman and Mannino, 2014). COPD is diagnosed with spirometry and is defined by a post-bronchodilator forced expiratory volume at 1 second divided by forced vital capacity (FEV1/FVC) 1/FVC below the 5th percentile of a reference population (lower limit of normal). The committee responsible for Marijuana and Medicine: Assessing the Science Base (IOM, 1999) suspected, but did not conclude, that chronic cannabis smoking causes COPD.
Is There an Association Between Cannabis Use and COPD?
There is no discussion about the association between cannabis and COPD in the systematic review by Tetrault et al. (2007). In the position statement of the American Thoracic Society (Douglas et al., 2015), workshop members concluded that there was minimal impairment in occasional cannabis smokers when controlling for tobacco use. In contrast, there was a trend toward higher prevalence in heavier users based on studies of lung function decline (Pletcher et al., 2012; Tashkin et al., 1987); however, workshop members determined that this association was incompletely quantified.
The study by Aldington et al. (2007) examined high-resolution computed tomography scans among the subgroups of participants with cannabis smoking only, cannabis and tobacco smoking, tobacco smoking only, and never smokers. They found inconsistent results: a decreased mean lung density, which is suggestive of emphysematous changes (mean percent of area below −950 Hounsfield units in three slices at 2.4 percent [95% confidence interval (CI) = 1.0%–3.8%] for cannabis smokers, but −0.6 percent [−2.0%–0.8%] for tobacco smokers when compared to nonsmokers), but almost no evidence of macroscopic emphysema (1.3% versus 16.5% versus 18.5% versus 0% in cannabis-only smokers versus cannabis and tobacco smokers versus tobacco-only smokers versus non-smokers, respectively).
Tan et al. (2009) analyzed cross-sectional data collected in 878 adults ages 40 years and older from Vancouver, Canada, who participated in the Burden of Obstructive Lung Disease study on COPD prevalence. Current smoking of either tobacco or cannabis was defined as any smoking within the past year. Participants who had smoked at least 50 marijuana cigarettes but had no history of tobacco smoking were not at significantly greater risk of having COPD or more respiratory symptoms. There was inconsistent evidence for whether synergy from combined cannabis and tobacco smoking might affect the odds of having COPD or worse respiratory symptoms.
Specifically, the mean estimates for the tobacco and cannabis smoking versus tobacco-only smoking groups do not appear to be different, and the 95% CI for the tobacco and cannabis smoking group appears to overlap significantly with the tobacco-only smoking groups when evaluating either COPD or respiratory symptoms as the outcome.
Yadavilli et al. (2014) examined data from 709 participants over a 33-month period for hospital readmissions of COPD in illicit drug users and tobacco smokers. These investigators found that cannabis users had similar readmission rates to ex-tobacco or current tobacco users (mean readmissions at 0.22 versus 0.26) and much lower readmission rates than other illicit drug users (mean readmissions at 1.0). The unit for mean readmissions was not specified in either the tables or methods of this paper. The limitations of the study by Yadavilli et al. (2014) include a lack of spirometry data on all patients to confirm diagnosis of COPD, the self-report of tobacco use, the risk for potential underreporting of illicit drug use, and the lack of outpatient visit frequency.
Kempker et al. (2015) analyzed data from the 2007–2010 NHANES cohorts, similar to the work done by Papatheodorou et al. (2016). Kempker et al. (2015), however, also examined the information on cumulative lifetime use of cannabis available in the 2009–2010 NHANES cohort. Main findings were that 59 percent reported using cannabis at least once during their lifetime, and 12 percent reported use during the last month. When evaluating cumulative lifetime cannabis use, those with >20 joint-years had a two times higher odds (OR, 2.1; 95% CI = 1.1–3.9) of having a pre-bronchodilator FEV1/FVC 1, which would spuriously reduce the ratio FEV1/FVC. Beyond the limitations noted above for the paper by Papatheodorou et al. (2016), who also used NHANES data, the authors were limited to use pre-bronchodilator spirometry instead of using post-bronchodilator spirometry as commonly done in COPD studies.
Discussion of Findings
It is unclear whether regular cannabis use is associated with the risk of developing COPD or exacerbating COPD. Current studies may be confounded by tobacco smoking and the use of other inhaled drugs as well as by occupational and environmental exposures, and these studies have failed to quantify the effect of daily or near daily cannabis smoking on COPD risk and exacerbation. There is no evidence of physiological or imaging changes consistent with emphysema. The committee’s findings are consistent with those of a recent position statement from the American Thoracic Society Marijuana Workgroup which concluded that there was minimal impairment in light and occasional cannabis smokers when controlled for tobacco use and that the effects in heavy cannabis smokers remain poorly quantified (Douglas et al., 2015). The review by Tashkin (2013) concluded that the lack of evidence between cannabis use and longitudinal lung function decline (Pletcher et al., 2012) argues against the idea that smoking cannabis by itself is a risk factor for the development of COPD. This is further supported by the findings of Kempker et al. (2015), who concluded that smoking cannabis was not associated with lower FEV1 after adjusting for tobacco smoking. However, smoking cannabis was associated with a higher FVC, which may have led to a spuriously lower FEV1/FVC. Therefore, their analyses also do not support an association between heavy cannabis use (>20 lifetime joint-years) and obstruction on spirometry. The position statement by Douglas et al. (2015) concluded that the lack of solid epidemiologic association suggests that regular cannabis smoking may be a less significant risk factor for the development of COPD than tobacco smoking.
Cross-sectional studies are inadequate to establish temporality, and cohort studies of regular or daily cannabis users are a better design to help establish COPD risk over time. Better studies are needed to clearly separate the effects of cannabis smoking from those of tobacco smoking on COPD risk and COPD exacerbations, and better evidence is needed for heavy cannabis users.
7-2(a) There is limited evidence of a statistical association between occasional cannabis smoking and an increased risk of developing chronic obstructive pulmonary disease (COPD) when controlled for tobacco use.
7-2(b) There is insufficient evidence to support or refute a statistical association between cannabis smoking and hospital admissions for COPD.
RESPIRATORY SYMPTOMS, INCLUDING CHRONIC BRONCHITIS
Respiratory symptoms include cough, phlegm, and wheeze. Chronic bronchitis is defined as chronic phlegm production or productive cough for 3 consecutive months per year for at least 2 consecutive years (Medical Research Council, 1965). Chronic bronchitis is a clinical diagnosis and does not require confirmation by spirometry or evidence of airflow obstruction. The committee responsible for Marijuana and Medicine: Assessing the Science Base (IOM, 1999) concluded that acute and chronic bronchitis may occur as a result of chronic cannabis use.
Is There an Association Between Cannabis Use and Respiratory Symptoms, Including Chronic Bronchitis?
The systematic review by Tetrault et al. (2007) summarized information from 14 studies that assessed the association between long-term cannabis smoking and respiratory symptoms. Nine of these studies were cross-sectional, 3 were case series, 1 was a case-control study, and 1 was a longitudinal cohort study. Data were relatively consistent in both cross-sectional and cohort studies in indicating that long-term cannabis smoking worsens respiratory symptoms, including cough (ORs, 1.7–2.0), increased sputum production (ORs, 1.5–1.9), and wheeze (ORs, 2.0–3.0). Other studies have reported effects on more episodes of acute bronchitis and pharyngitis, dyspnea, hoarse voice, worse cystic fibrosis symptoms, and chest tightness.
Aldington et al. (2007) reported higher prevalence of wheeze (27 percent versus 11 percent), cough (29 percent versus 5 percent), chest tightness (49 percent versus 35 percent), and chronic bronchitis symptoms (19 percent versus 3 percent) among cannabis smokers than among nonsmokers. There were no clear additive effects observed in the combined cannabis and tobacco smoking groups on respiratory symptoms.
Hancox et al. (2015) conducted a study in a cohort of 1,037 adults (52 percent male) in the Dunedin Multidisciplinary Health and Development Study. Cannabis and tobacco smoking histories were obtained at the ages of 18, 21, 26, 32, and 38 years. At each assessment, participants were asked how many times they had used cannabis in the previous year. Frequent cannabis users were defined as those who reported using marijuana ≥52 times over the previous year. Quitters were defined as a frequent cannabis user at the previous assessment but less than frequent at the current assessment. Because it was possible to quit frequent cannabis use more than once during the follow-up from 18 to 38 years of age, only the first recorded episode of quitting was used in analyses. In this study, the investigators found that frequent cannabis use was associated with morning cough (OR = 1.97, p <0.001), sputum production (OR = 2.31, p <0.001), and wheeze (OR = 1.55, p <0.001), but not dyspnea (p = 0.09) (see Figure 7-1). Quitters (open triangles) also had fewer respiratory symptoms than those who did not quit (solid squares).
Prevalence of symptoms before and after quitting regular cannabis use (open triangles) and among those who used cannabis for two consecutive phases (solid squares). Vertical bars show 95% confidence level. SOURCE: Hancox et al., 2015.
Limitations of the study by Hancox et al. (2015) include its reliance on self-reported data of cannabis use without objective confirmation, the classification of nonusers as those with
Walden and Earleywine (2008) conducted a cross-sectional Internet survey of 5,987 adults worldwide who used cannabis at least once per month. They quantified frequency, amount, and degree of usual and maximal intoxication, and they also asked about respiratory symptoms using a composite score produced from the answers to six standard questions about cough, morning phlegm, dyspnea, chest wheezing other than during colds, and nighttime awakenings because of chest tightness. They found that the frequency of use, the amount used (in quarter bags per month), and the degree of usual intoxication were all positively associated with more respiratory symptoms. Limitations for this study include its recruitment of participants from organizations that advocate drug policy reform, its reliance on self-reported data of cannabis or tobacco use without objective confirmation, and the lack of data about cannabis use for medical versus recreational purposes.
Tashkin et al. (2012) followed 299 participants from a longitudinal cohort study for at least two visits over 9.8 years and examined the relationship between symptoms for chronic bronchitis and cannabis use. They found that current cannabis users were more likely to have cough (OR = 1.7), sputum (OR = 2.1), increased bronchitis episodes (OR = 2.3), and wheeze (OR = 3.4) when compared to never users. They also found that current cannabis users were more likely to have cough (OR = 3.3), sputum (OR = 4.2), or wheeze (OR = 2.1) than former users. Similar to the studies by Hancox et al. (2015) and Walden and Earleywine (2008), these findings demonstrated the benefit of cannabis smoking cessation in resolving preexisting symptoms of chronic bronchitis. The limitations of this study include its reliance on self-reported data of cannabis or tobacco use without objective confirmation and high rates of loss to follow-up or variable follow-up periods.
A small feasibility study by Van Dam and Earleywine (2010) of 12 adult participants who did not develop a respiratory illness during the trial found that the use of a cannabis vaporizer instead of smoking cannabis was correlated with the resolution of cannabis-related respiratory symptoms at approximately 1 month after the introduction of the vaporizer; however, this study did not have a control group.
Discussion of Findings
Regular cannabis use was associated with airway injury, worsening respiratory symptoms, and more frequent chronic bronchitis episodes. There were no clear additive effects on respiratory symptoms observed from smoking both cannabis and tobacco. Cannabis smoking cessation was temporally associated with the resolution of chronic bronchitis symptoms, and a small feasibility study suggests that use of a vaporizer instead of smoking cannabis may lead to the resolution of respiratory symptoms. The committee’s findings are consistent with those reported in a recent review (Tashkin, 2013) and position statement (Douglas et al., 2015).
The majority of studies relied on self-report for cannabis smoking. Many studies failed to control for tobacco, occupational, and other environmental exposures; did not control for the dose or duration of the cannabis smoke exposure; and did not use joint-years and instead based heavy cannabis exposure on exceeding a specific threshold of cigarettes. Even among studies that used joint-years, it is unclear how generalizable the findings are, given the potential high variability in tetrahydrocannabinol (THC) content from joint to joint and from year to year.
7-3(a) There is substantial evidence of a statistical association between long-term cannabis smoking and worse respiratory symptoms and more frequent chronic bronchitis episodes.
7-3(b) There is moderate evidence of a statistical association between cessation of cannabis smoking and improvements in respiratory symptoms.
Asthma is a clinical syndrome that is associated with airways inflammation, airflow limitation, bronchial hyperresponsiveness, and symptoms of episodic wheeze and cough. It is predominantly an allergic disease. Worldwide, asthma is thought to affect 300 million people, and it is responsible for more disability-adjusted life-years lost than diabetes mellitus. Asthma was not specifically addressed in Marijuana and Medicine: Assessing the Science Base (IOM, 1999).
Is There an Association Between Cannabis Use and Asthma?
The systematic review by Tetrault et al. (2007) referred to only one study that described the association between cannabis use and asthma exacerbations. Upon retrieving this study, the committee found that this was a letter to the editor which reported findings of a case-control study of 100 participants ages 18–55 years, with and without asthma, admitted to the emergency department. In this study, the authors found no association between THC and asthma (Gaeta et al., 1996).
Bechtold et al. (2015) reported on a follow-up of a cohort of boys who participated in the Pittsburgh Youth Study. A total of 506 boys were followed longitudinally: 257 scored at or above the 70th percentile of a multi-informant conduct problem score, and 249 scored below the 70th percentile. This study found no link between cannabis use and self-reported asthma symptoms. The limitations of this study include a lack of generalizability to the general population, given the selection criteria for conduct problems, a lack of inclusion of women in their study, and the fact that health outcomes were based on self-report and biased to those who had sought care for health problems.
Weekes et al. (2011) studied a cohort of 110 black urban adolescents with asthma. In this study, the investigators found that 16 percent of the adolescents smoked cannabis, but there was no association between cannabis use and asthma concern or asthma severity or asthma symptoms. The limitations of this study include the reliance on the self-report of cannabis use, which the study authors speculated may be underreported in black adolescents when compared to whites, and a lack of data on asthma medication adherence.
Discussion of Findings
The committee did not find evidence for an association between cannabis use and either asthma risk or asthma exacerbations, and current studies failed to control for other important confounders, including adherence to asthma medications.
The evidence linking cannabis use with asthma risk or exacerbation is limited by the scope and sample size of available studies and by the use of more standardized approaches to measure asthma prevalence or exacerbations of asthma. Few studies have examined the link between cannabis and asthma, and no clear evidence exists of a link between asthma or asthma exacerbation and cannabis use. However, asthma symptoms such as wheeze appear to be common among cannabis users.
CONCLUSION 7-4 There is no or insufficient evidence to support or refute a statistical association between cannabis smoking and asthma development or asthma exacerbation.
The effects of cannabis smoke on respiratory health remain poorly quantified. Further research is needed to better elucidate the influence of exposure levels to cannabis smoke on respiratory outcomes, the chronicity of cannabis smoking, the effects of an underlying predisposition to respiratory disease, and possible interaction effects with tobacco smoke to promote airway inflammation, worsen respiratory symptoms, accelerate lung function decline, or increase exacerbation of COPD and asthma. Previous studies have not been able to adequately separate cannabis smoke effects from tobacco smoke effects, and this has meant that some important questions remain unanswered. It is unknown whether or not:
Long-term cannabis smoking, above and beyond that of tobacco smoking, leads to a more rapid decline in lung function and to the development of chronic bronchitis or COPD.
To address the research gaps relevant to respiratory disease, the committee suggests the following:
Design better observational studies with both self-reported and quantitative measures of cannabis smoking and systematic approaches to measure the duration and dose to determine if long-term exposure to cannabis smoke, above and beyond exposure to tobacco smoke, leads to the development of chronic bronchitis or COPD or to a higher rate of COPD exacerbation.
Design longitudinal studies to determine if long-term cannabis smoking is associated with the development of allergic disease and risk of asthma.
Conduct clinical trials of alternative inhaled delivery methods versus cannabis smoking to determine if they reduce respiratory symptoms.
This chapter summarizes all of the respiratory disease literature that has been published since 1999 and deemed to be good or fair by the committee. Overall, the risks of respiratory complications of cannabis smoking appear to be relatively small and to be far lower than those of tobacco smoking. While heavy cannabis users may be at a higher risk for developing chronic bronchitis and COPD or at an increased risk of exacerbating COPD and asthma, current studies do not provide sufficient evidence for a link. Limitations of reviewed studies are that it is difficult to separate the effects of cannabis smoking from those of tobacco smoking from current available data; that exposures have generally been measured by self-report of cannabis smoking; and that there is a lack of cohort studies of regular or daily cannabis users, of adequate controls for environmental factors, and of generalizability of findings. The committee has formed a number of research conclusions related to these health endpoints (see Box 7-1); however, it is important that each of these conclusions be interpreted within the context of the limitations discussed in the Discussion of Findings sections.
Summary of Chapter Conclusions .
Aldington S, Williams M, Nowitz M, Weatherall M, Pritchard A, McNaughton A, Robinson G, Beasley R. Effects of cannabis on pulmonary structure, function and symptoms. Thorax. 2007; 62 :1058–1063. [PMC free article : PMC2094297 ] [PubMed : 17666437 ]
Aldington S, Harwood M, Cox B, Weatherall M, Beckert L, Hansell A, Pritchard A, Robinson G, Beasley R., Cannabis and Respiratory Disease Research Group. Cannabis use and cancer of the head and neck: Case-control study. Otolaryngology and Head and Neck Surgery. 2008; 138 (3):374–380. [PMC free article : PMC2277494 ] [PubMed : 18312888 ]
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 and Addictive Behaviors. 2015; 29 :552–563. [PMC free article : PMC4586320 ] [PubMed : 26237286 ]
Buist AS, McBurnie MA, Vollmer WM, Gillespie S, Burney P, Mannino DM, Menezes AMB, Sullivan SD, Lee TA, Weiss KB, Jensen RL, Marks GB, Gulsvik A, Nizankowska-Mogilnicka E. International variation in the prevalence of COPD (The BOLD study): A population-based prevalence study. Lancet. 2007; 370 :741–750. [PubMed : 17765523 ]
CBHSQ (Center for Behavioral Health Statistics and Quality). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. 2015. (NSDUH Series H-50). HHS Publication No. SMA 15-4927.
Diaz-Guzman E, Mannino DM. Epidemiology and prevalence of chronic obstructive pulmonary disease. Clinics in Chest Medicine. 2014; 35 (1):7–16. [PubMed : 24507833 ]
Douglas IS, Albertson TE, Folan P, Hanania NA, Tashkin DP, Upson DJ, Leone FT. Implications of marijuana decriminalization on the practice of pulmonary, critical care, and sleep medicine. A report of the American Thoracic Society Marijuana Workgroup. Annals of the American Thoracic Society. 2015; 12 :1700–1710. [PubMed : 26540421 ]
Gaeta TJ, Hammock R, Spevack TA, Brown H, Rhoden K. Association between substance abuse and acute exacerbation of bronchial asthma. Academic Emergency Medicine. 1996; 3 (12):1170–1172. [PubMed : 8959174 ]
Hancox RJ, Poulton R, Ely M, Welch D, Taylor DR, McLachlan CR, Greene JM, Moffitt TE, Caspi A, Sears MR. Effects of cannabis on lung function: a population-based cohort study. The European Respiratory Journal. 2010; 35 (1):42–47. [PMC free article : PMC3805041 ] [PubMed : 19679602 ]
Hancox RJ, Shin HH, Gray AR, Poulton R, Sears MR. Effects of quitting cannabis on respiratory symptoms. European Respiratory Journal. 2015; 46 :80–87. [PMC free article : PMC4780250 ] [PubMed : 25837035 ]
IOM (Institute of Medicine). Marijuana and medicine: Assessing the science base. Washington, DC: National Academy Press; 1999. [PubMed : 25101425 ]
Kempker JA, Honig EG, Martin G. The effects of marijuana exposure on respiratory health in U.S. adults. Annals of the American Thoracic Society. 2015; 12 :135–141. [PMC free article : PMC5466201 ] [PubMed : 25521349 ]
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380 :2224–2260. [PMC free article : PMC4156511 ] [PubMed : 23245609 ]
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. British Journal of General Practice. 2015; 65 :e89–e95. [PMC free article : PMC4325450 ] [PubMed : 25624312 ]
Medical Research Council. Definition and classification of chronic bronchitis for clinical and epidemiological purposes. A report to the Medical Research Council by their Committee on the Aetiology of Chronic Bronchitis. Lancet. 1965; 1 :775–779. [PubMed : 4165081 ]
Papatheodorou SI, Buettner H, Rice MB, Mittleman MA. Recent marijuana use and associations with exhaled nitric oxide and pulmonary function in adults in the United States. Chest. 2016; 149 :1428–1435. [PMC free article : PMC4944764 ] [PubMed : 26836917 ]
Pletcher MJ, Vittinghoff E, Kalhan R, Richman J, Safford M, Sidney S, Lin F, Kertesz S. Association between marijuana exposure and pulmonary function over 20 years. JAMA. 2012; 307 :173–181. [PMC free article : PMC3840897 ] [PubMed : 22235088 ]
Tan WC, Lo C, Jong A, Xing L, Fitzgerald MJ, Vollmer WM, Buist SA, Sin DD. Vancouver Burden of Obstructive Lung Disease (BOLD) Research Group. Marijuana and chronic obstructive lung disease: A population-based study. Canadian Medical Association Journal. 2009; 180 :814–820. [PMC free article : PMC2665947 ] [PubMed : 19364790 ]
Tashkin DP. Effects of marijuana smoking on the lung. Annals of the American Thoracic Society. 2013; 10 :239–247. [PubMed : 23802821 ]
Tashkin DP, Coulson AH, Clark VA, Simmons M, Bourque LB, Duann S, Spivey GH, Gong H. Respiratory symptoms and lung function in habitual heavy smokers of marijuana alone, smokers of marijuana and tobacco, smokers of tobacco alone, and nonsmokers. American Review of Respiratory Disease. 1987; 135 :209–216. [PubMed : 3492159 ]
Tashkin DP, Simmons MS, Tseng CH. Impact of changes in regular use of marijuana and/or tobacco on chronic bronchitis. COPD. 2012; 9 :367–374. [PubMed : 22497563 ]
Tetrault JM, Crothers K, Moore BA, Mehra R, Concato J, Fiellin DA. Effects of marijuana smoking on pulmonary function and respiratory complications: A systematic review. Archives of Internal Medicine. 2007; 167 :221–228. [PMC free article : PMC2720277 ] [PubMed : 17296876 ]
Van Dam NT, Earleywine M. Pulmonary function in cannabis users: Support for a clinical trial of the vaporizer. International Journal of Drug Policy. 2010; 21 :511–513. [PubMed : 20451365 ]
Walden N, Earleywine M. How high: Quantity as a predictor of cannabis-related problems. Harm Reduction Journal. 2008; 5 :20. [PMC free article : PMC2438353 ] [PubMed : 18510745 ]
Weekes JC, Cotton S, McGrady ME. Predictors of substance use among black urban adolescents with asthma: A longitudinal assessment. Journal of the National Medical Association. 2011; 103 :392–398. [PubMed : 21809788 ]
Wu TC, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. New England Journal of Medicine. 1988; 318 :347–351. [PubMed : 3340105 ]
Yadavilli R, Collins A, Ding WY, Garner N, Williams J, Burhan H. Hospital readmissions with exacerbation of obstructive pulmonary disease in illicit drug smokers. Lung. 2014; 192 :669–673. [PubMed : 25097097 ]
(Ease Pain) Cbd Oil Bronchitis
Cbd Oil Bronchitis, Gummies For Sleep Tru Infusion Cbd Gummy. Rachael Ray Gummies Cbd, King Leaf Gummies? Cbd Oil Oral Drops, Cbd Gummies Atlantic Ave.
If there are no new weapons and no famous generals to lead the team, then our southern gummy sharks candy near me expedition may even fail this time.
His face frowned, obviously nothing came of it, but after glancing at Wanwan, something suddenly came to mind.
In order to find out the news, he took the people and horses directly to the tribe. Now we cbd store near me have only fought one country, cbd oil bronchitis and now the wealth is rolling in, and in exchange for a battle, the treasury is nearly five years old.
But even so, the current Daqin Empire is not something we can shake, so God Hou is right, this time buy cbd gummies ireland we can only be better with it, and can t go to kill.
Although the position of His Highness the Crown Prince is now unshakable, the so-called high-impact things should not be done, and the first emperor should not be uncomfortable.
His Royal Highness guessed right, cbd oils many ministers came to the court, but I rejected them one by one, saying mall gummies candies that His Highness is resting now and will not meet, but let those ministers keep all the gifts! Mei said, Dressing aside, The two of them were shocked by cbd oil bronchitis this incident, They didn t expect that the clans cbd oil bronchitis in these places have already been rampant to such places, and now they dare to send people to find Xianyang here.
What? Everyone showed an cbd oil in nebulizer incredible expression, Mei cbd oil in las vegas Sanniang even scolded: You bastard can kill if you want, why do you need to destroy people s innocence here.
And it is still ranked first in the sky, The most important thing is that this old cbd oil bronchitis guy has also entered the late stage of the great master, and except for him who is about to enter online shop benefits of cbd the great master, the rest of cbd oil bronchitis the people are only in the late stage of the master.
My Si Yue Tang has always been dominated by brothers Tian Hu, It s better, and hand over this king s cbd oil bronchitis personal letter to the prime minister, and tell him that the conditions gummies products are cbd products open to him, as long as this king can do it, this king will definitely do it.
Hu Hai is also very anxious, He still thinks about the future ambition district edibles gummies tropical punch cbd to indoor grown cbd gummies dominate the industry.
Small, I don t know if the distinguished guests in the carriage can come out to see them.
Asda immediately regained her former shrewdness and hurriedly walked towards the door, King Right Xian also showed an incredible look on his face, organics cbd oil and finally cbd oil bronchitis went to hell 8 gummies with incomprehensible doubts.
But now the first emperor, King Ying, has obtained the immortality elixir, and the cbd oil bronchitis Yin-Yang family has repeatedly synthetic cbd products cbd gummies deceived King Ying, and even pure cbd gummies review contributed poisonous elixir, all of which are intolerable to cbd oil bronchitis the empire.
How To Make Pot Gummys?
For Situ Wanli, he will convention on biological diversity cbd oil definitely not accept it, of, Thinking of this, Situ Wanli asked Tian Hu, I wonder what Chi Youtang s opinion is.
At this time, our promise to everyone, if If something really happened, it s because we are not good at learning, and we won t blame everyone. But as the situation in the DPRK and China became clear, they cbd oil bronchitis didn t have that thought either.
Father, if you believe in medicinal pills, then Erchen also has two medicinal blue label full spectrum cbd gummies cbd oil pills here, but each person can only take one.
For example, in this cbd oil bronchitis final high quality delicious gummies battle, our original intention was to kill all these people.
Wang Jian immediately sent an order to the lieutenant: I will take a small part of my personal guards and a small part of the penetrating troops to take the lead, After all, Fusu was the eldest son of cbd oil cbd oil bronchitis bronchitis the empire, If he was left out here, he might not be able to explain it to the empire.
After finishing cbd oil walmart speaking, Covering the Sun handed over a token of Luo Net.
They are in high positions and don t gummies nutritious know how to benefit the people.
For them, they just want to make a little more money, there is no way does work benefits of cbd gummies they are giving too much, King Ying doesn cbd oil cbd oil bronchitis bronchitis t know everything about what Zhao Gao did, but most of them must be known.
And the Zhu family didn sleep gummies t want to best prices gor cbd gummies say anything more, they just preached lightly.
Tian Mi appeared out of nowhere, and smiled when she saw Han Xin.
I hope there will not be a day when cbd oil bronchitis online buy pure natural cbd oil Gu will kill you, You said Wuji. Desert, It used to be a nightmare cbd oil bronchitis for the people of the Central Plains, but it was a paradise for the Huns.
But soon this idea was crushed by Dianqing, hemp balm cbd oil Dianqing didn t give them any more opportunities.
Changsun Wuji felt even more guilty, and nodded anyway, It s just that the eldest grandson Wuji still said: I d better send someone to inform the second son! At least don t let people spend so much time, as for other things, you can do cbd oil bronchitis it yourself, but I think Go see this prince again.
Gu does not know his future, but Gu knows theirs, if you say, as long as you maintain a heart of awe, if you want to come to plus cbd c02 gummies review Guigu in your vein, it will be passed down well, There are nearly 50,000 civilians delicious gummies living here, Most of them are civilians, and only a few are royal families, but the answer cbd oil bronchitis to the defeat of the war is self-evident.
These coupon code for cbd gummies things are all fiddled with by the Hall of Longevity, I think you will be able to see it after you go back this time.
Whats The Difference Between Hemp And Cbd Oil?
stingy! When I heard full spectrum cbd oil what King Ying said, I couldn t help but glance at it.
On the other side, a team of 100 people crawled up the tower, He shouted to the people behind him: The people of the Yin and cbd oil bronchitis Yang family will go up to the tower for me.
Finally decided to best cbd gummies with thc for anxiety let go of Gao Yao, It can be considered cbd oil wilmington nc to satisfy the appetite.
Genie was also confused, and was about to say something when he heard: If I remember correctly, the empire never seems to have treated you badly, but you have a negative grace, what do you think you have the right to sit? by my side.
With a smile, without any fear, he walked into the Xianyang Palace with his head held high, Could cbd oil bronchitis it be cbd oil bronchitis that it was an organization within Daqin? The sound of the horse s hooves still woke up the group.
Please forgive me, His Royal Highness, I also cbd gummies san gummies francisco ask His Royal Highness to spare his life.
Your death is coming, put down your weapons quickly, the general can save you from dying.
You remember, the soldiers of Daqin will not cbd oil bronchitis take half a step back. The world can also be regarded as one of the best! Hearing this, I didn t expect that the originally cbd oil bronchitis proud Gongzuoqiu actually became very humble at this moment.
For Fusu s performance, he naturally expected best cbd oil sweden it, Without cbd gummy bear manufacturer answering, he turned his attention to daily cbd gummies Aji.
King Ying stood up at this time and asked, How is Xianyang City now.
King Han frowned when he heard this, Maybe others don t feel much about the net, but King Han, who is also the number one village in the world, is more aware of the horror of the net, After cbd drinks speaking, he left, It s just that cbd oil bronchitis Rochelle behind him showed an imperceptible smile.
Although Song Que didn t cbd oil bronchitis believe it, he still read royal cbd gummies the contents, but Song Que still buy hemp oil online doubted the authenticity of some of the things.
The Meng family is also loyal to the American Empire, but if it wasn t for the two of them, who could have found their location so accurately.
Hearing Song Yuzhi here, if she can pure cbd oil t hear what it means, then she is cbd oil bronchitis Pain really stupid, These things themselves should be handled by him, but cbd oil bronchitis now he is pushing them back to himself.
To tell the truth about Ying Zheng s order, everyone felt confused for a while, and didn t know what was going on, but everyone saw that Ying Zheng s cbd gummies in west bend wi face was really ugly, so they didn t ask any more questions.
Best Thc Cbd Gummies
Now Zhao Gao still has one thing to do, and this may be the only thing he needs to do.
Now the other party is not only rich, but also does cbd oil get you high yahoo has rights, The most important thing is that he has this right, Little girl, cbd oil bronchitis I just cannabis gummies killed everyone in my holy gate, and now I want to leave.
At this cbd gummies gummies time, Cbd Oil Bronchitis the big hammer on the side also knew that what he did just now seemed out of place in this army camp full of hormone secretion.
I cbd oil bronchitis online buy pure natural cbd oil didn t say anything, because once Ying Zheng decided, it was very difficult to change.
He also smiled, yes, one person in this family speaks more clearly than one person, is it because he is afraid that he will not understand, It looks like you want to keep cbd oil bronchitis both sides down! cbd oil bronchitis Zhu ignores it very clearly.
Dianqing stood up and turned cbd gummies tallmadge ohio away: I see, I ll go down and instruct, handle the affairs on your side properly.
If it wasn t cbd oil bronchitis for the strong guard of martial arts, and if Xu Fu really let Xu Fu slip away, then it would be really difficult for Aji to go back.
After Tian Hu and Situ Wanli heard it, they also began to think constantly in their hearts, Seeing that the opponent was defeated, he also laughed, Haha, you little brats, still want to be right cbd oil bronchitis with the miscellaneous family? You are not enough.
Xiao He strode towards the hall, and soon cbd oil review coupon came to the middle of the hall, and the eunuch on the side saw Xiao He s arrival, and immediately said: Please greet the envoy.
They have also been very aware of the horror of this man for a while.
They have also been very aware of the horror of this man for a while. As cbd oil bronchitis for Yu Wenhua and Fuzhong, there are also two people who are talking freely.
At this time, the originally suppressed best royal cbd gummy bears feelings were also released.
After all, Diwei is still unpredictable! When Zhang Han heard Cbd Oil Bronchitis this, he also understood a lot of painstaking efforts.
Wang Li smiled contemptuously, and immediately kicked Mei Sanniang out. As a general, Aji can cbd oil bronchitis sit on the side according to reason, but Aji just stood aside and acted as a guard.
Behind him, Da Qin Ruishi did chill gummies cbd 100x not speak, but raised the long spear in his hand, and then slammed it on the ground heavily.
Best Cbd Gummies For Stress And Anxiety
Seal the centurion, sons, kill! Under the encouragement of Tuo Yehai, the soldiers who were originally desperate now also took up their weapons and went in the direction of Wei Zhuang.
After Pei Ju said this, he glanced at Yu Wenwenji cbd gummies with a deep meaning, and the latter was also very sincere, Two million taels of gold and nearly eight million taels of cbd oil bronchitis silver! These are really good officials of my Daqin.
Li Si looked at Meng organic cbd oil colorado Yi and asked, How does Meng Xiang view this matter.
Miss Biao, you are finally back, Master, different types of cbd oil they are worried about you.
Seeing that the other party Cbd Oil Bronchitis didn t mean to ask about the treasure, Louis also decisively sold the previous two. Cui Ri and Wei Zhuang listened and muttered to themselves, cbd oil bronchitis but they were also puzzled.
We have participated strongest edible cbd gummies so many times before and did not get rid of it.
You seem to have injured cbd pain cream colorado the Prime Minister s bodyguard just now, but do you know what will happen to the car Cbd Oil Bronchitis that attacked the Prime gummies Minister.
The old man stood up and asked: His Royal Highness, please give us a chance to the Mo family, my Mo family is willing to biogold cbd gummies cost serve wyld strawberry cbd gummies the empire, There was already a trace of anger cbd oil bronchitis in Fu Nian s eyes, Have I already said that Confucian people should not cbd oil bronchitis have anything to do with anyone? Do you really want the entire Confucian school to go to hell with you.
At benefits of cbd gummies long term the same time, Meng Yi was also very surprised after receiving the news, and he and Aji were also discussing the next plan in the room.
Gai Nie turned around and looked at Wei Zhuang: Xiao Zhuang, you.
Thinking of this, I don t plan to play hide-and-seek anymore. He wanted to shout, but his mouth was covered, Seeing that he was about to leave, the old cbd oil bronchitis man quickly shouted: I don t know this distinguished guest, can you stay.
Although the doctor on the other side cbd oil bronchitis suffered a family accommodation adelaide cbd gummies lot, many soldiers and horses came to them.
These people can t even reach the most basic level, We are now The wind has already been released, and presumably the other weaker countries will still take the initiative to surrender.
This time, I will go to verma farms cbd gummies Songhai and bring Wang Jian s armor-piercing soldiers. But what Situ Wanli said cbd oil bronchitis now makes everyone feel a different feeling once again.
The buyer stood up and said: Now we list of spiked cbd gummies can burn the forage first, but we can t kill such a huge flock in such a short period of time! What can you do.
Cbd Gummies For Migraines
Others may not know it, but Tian Yan liquid cannabis is still very clear that this matter must have been done by Cbd Oil Bronchitis a lazarus cbd oil coupon snare, otherwise it would be impossible for someone to infiltrate the farmhouse so easily.
Iger sighed, It s my cbd oil bronchitis father s fault, I really shouldn t believe your big brother. When cbd oil bronchitis Li Xin and others saw it, they couldn t help but feel confused.
Although a few people were puzzled, they still knew that cbd oil capsules 20 mg the person who came was not an outsider.
Just don t think so, Zhiri, although Gu really likes someone like you gummies who resolutely executes orders, but to be honest, Gu really doesn t like you being such a person.
Every big city has it overnight, and it is impossible to cbd oil bronchitis do it with the ability of the Li cbd gummies for pain clan, and if the Li clan must have already started against us, the old fox of Li Yuan will not let us go, That is to make the other party pay a hundred times or even a thousand times the price, and let cbd oil bronchitis the other original daily cbd gummies party know how the word regret is written.
The consumption of the Daqin Empire in recent years is indeed not small, but if the first emperor of c4 healthlabs gummies the largest empire, if he really wanted to kill the Da Sui Dynasty just because of a message, it would still be very dangerous for the current Da Sui Dynasty.
Xiao He took the initiative to knelt down in front of him: Xiao He would like to thank His Highness the cbd oil bronchitis Crown Prince for his recommendation.
So the best cbd oil bronchitis way cbd gummies products is to complete the current task, Didn t the Crown Prince also say that the future here is over the counter edible gummies called the golden road, Ridiculous promises betray the entire empire, Xuan cbd oil bronchitis Jian s sword pointed at Genie like this.
Touman kicked the food in front of him and asked: cbd edibles the origianal gummy bears Do you know what you are cbd oil bronchitis talking about? Your entire 2,000-strong vanguard cavalry unit is actually surrounded by dozens of martial arts people? You are several times more than The strength of the enemy, but now they are still asking us for help, it is a shame for our clan.
But they know more about responsibility, something I have never seen in the other six countries.
Even Yu Wenhua gummies and these people are willing to spend cbd gummies supplements a lot of money to support these people, just let them take action at the right time, I think they are still very familiar gold cbd gummies cbd gummies supplements with that cbd oil bronchitis place, isn t your cbd store it Mr Zhang Liang.
Moreover, there are many masters who have already been under the command of His nsf certified cbd gummies Royal Highness the Crown Prince.
Although Asda fled here, he still shouted when he looked at Gao Fu: If he is a superior person, the iron horse will shatter the red dust.
At cbd oil bronchitis this time, I have to admire the vision again, otherwise at this time, there will be an East Factory in cbd gummies the unlucky one, Don cbd oil bronchitis t let a pack of dogs stand in our way! We still have things to do.
I didn t expect that the people buy green lobster cbd gummies here would be so considerate and prepared everything for us.
Levothyroxine And Cbd Gummies
Several cvs pharmacy cbd oil for sleep people are looking at Gui Hai Yi Dao like this, and their inner thoughts are very complicated now, one side is their adoptive father, and the other side is their former partner.
His Royal Highness, my father invites you to visit cbd store near me the mansion for a chat, and also asks His Highness to admire your face. After Wang Yan cbd oil bronchitis cbd oil bronchitis came out, he also saw Wang Jian and Cao Anyang.
Effectively reducing finest nutrition melatonin gummies the deaths of soldiers, this old man thank you sale cbd gummies on their behalf.
Tell the king, we encountered the enemy s blocking here, presumably our actions have been known, please send people to attack directly.
The reason why Wang Yan dared to do this was not only because he was the son delicious gummies of the county governor, cbd oil bronchitis but also because cbd oil bronchitis there were nearly 50,000 troops stationed in the city, You seem to be afraid cbd oil bronchitis of me? asked shamelessly, Changsun Wugou rolled his eyes.
Thinking of this, I couldn t help shaking my head, autism and cbd oil and I really answered that sentence, keeping warm and thinking of lust.
King Ying also laughed, How could you betray someone who has never been loyal to anyone, Gai Nie, Gai Nie, you are still like this.
The world is entrenched in all-pervasive ways, We can t fight him, Jianghu? Zhangsun Wugou asked hesitantly, Yes, because this is cbd oil bronchitis the royal cbd Jianghu, in this world, we have no other way.
Your cbd oil Majesty, this memorial pure sale benefits of cbd gummies isolate cbd gummies says that there will be a decisive battle tonight, but it doesn t seem to mention how to use it.
Li Xin heard the thc gummy words: What should we how long does cbd gummies last do now? We came with military orders.
Changsun Wugou nodded, but what he said next made Changsun Wuji and Gao Shilian feel tight, You mean, this vision was caused by? There was no emotion between the words, and cbd oil bronchitis suddenly King Ying opened his eyes and asked again, I found out what caused the vision.
For cbd chill gummies the First Emperor, he felt that his prestige had been seriously affected.
Song Hai said goodbye, I haven t seen the emperor for some time.
At this time, Concubine Xiao also hurriedly said: Please rest assured, Your Majesty, the concubine will be very tight-lipped, Gai Nie can betray the person in power for the sake of an assassin who he has seen several cbd oil bronchitis times, while the other brother who always protects him arrogantly has made many mistakes.