Marijuana Use & Asthma: Risks and Considerations for Users (Recording)
Published: January 6, 2025 Revised: February 3rd, 2025
This webinar was recorded on January 30, 2025
As cannabis use becomes legal in more states, many people are seeking it out for medical and recreational use. According to the Allergy & Asthma Network Pain, Exercise and Cannabis Experience survey, many people with asthma are smoking or vaping cannabis which can be harmful to their lungs and airways. We also learned that doctors and patients need to be better educated about marijuana use and its potential health benefits and risks. In this webinar, you’ll gain a comprehensive understanding of how marijuana use can affect those living with asthma.
Speaker:
• Anil Nanda, MD, PA
Dr. Nanda is an experienced board-certified physician who takes great pride in his work, helping his patients, and giving back to his community. He is a member of the clinical faculty at the Division of Allergy and Immunology at UT-Southwestern Medical Center in Dallas, TX, where he teaches and mentors physicians training to be allergists. He completed his allergy specialist training at the famed National Jewish Health Center in Denver, Colorado, which is consistently rated as one of the top-ranked respiratory hospitals in the country, as featured annually in U.S. News and World Report.
Dr. Nanda believes that spending time and listening to patients is extremely important. All patients are treated as individuals with personalized treatment plans. He strives to answer patient questions personally and discusses all testing results personally with patients.
For the exceptional treatment and care of allergies and asthma, visit the accomplished professionals at Asthma and Allergy Center.
Dr. Nanda is the President of the Texas Allergy, Asthma, and Immunology Society and President of the Denton County Medical Society.
This Advances webinar is in partnership with the American College of Allergy, Asthma & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for Advances webinars.
All attendees will be offered a certificate of attendance. No other continuing education credit is provided.
Sponsored by the American College of Allergy, Asthma and Immunology

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
De De: for today. I’m the chief research officer at the allergy network. We are in for a great treat today with Dr. Anil Nanda. Have a few housekeeping items. First of all, participants will be on mute for the webinar. We will record today’s webinar and posted on our website within a few days. You can find the recording on our website. Scroll to the bottom of the page to find our recorded webinars and any upcoming ones. This webinar will be one hour, and that includes time for questions. We will take those questions at the end of the webinar, you can put your questions in the Q&A at any time. It is a box at the bottom of the screen and we have someone monitoring the chat if you have any questions or need any help. We will get to his many questions as we can before we conclude today. The webinar is in partnership with the American College of allergy, asthma, and immunology. It offers CME’s and attendance credits. You can create a free college account and obtain CME or attendance credits from the member portal. All participants will be offered a certificate of attendance. A few days after this webinar, you will receive an email with information and a link to download. We will also try to add the link to the certificate in the chat while the program is taking place today. Let’s get started. Today’s topic is marijuana use and asthma, risks and considerations for users. As cannabis use becomes legal in more states and people are seeking it out for medical uses, according to the allergy and asthma networks, in the cannabis experience survey, many people with asthma are smoking or vaping cannabis, which can be harmful to their lungs and airways. We also learned that doctors and patients need to be better educated about marijuana use and its potential health benefits and risks. In this webinar, you will gain a competence of understanding of how marijuana use can affect those who have asthma. It is a pleasure to introduce our speaker, Dr. Anil Nanda, and experienced board certified physician. He is a member of the clinical faculty in the division of allergy and immunology at the University of Texas Southwestern Medical Center in Dallas, Texas. He completed his allergy specialist at the famed national Jewish Health Center in Denver, Colorado, it is consistently rated as one of the top-ranked respiratory hospitals in the country. Dr. Nanda believes spending time listening to his patients is extremely important. All are treated as individuals. He is the past president of the Texas allergy, asthma, and immunology society, and of the Denton medical society. Thank you for being here. I will turn it over to you.
Dr. Nanda: I appreciate so much, De De and everybody — I really appreciate the asthma and allergy network. And colleagues and patients that are joining us, including physicians — thank you so much. I am actually on the job right now. I am in my office in a patient exam room, because there are patients in the office right now. I am holed up in an exam room. It is great. I see patients. The topic is really excellent. As De De was saying, it is really timely, right? A patient this morning mentioned it right here at this office in this exam room. For my disclosures, really there are no relevant financial relationships to expose. Learning objectives — I want to explain the respiratory effects of cannabis smoking and its indications for asthma management, adapt asthma management plans to include cannabis-related risk assessments and questionnaires, integrate strategies to counsel patients about the risks associated with cannabis use related to asthma management. Not only that. I also want to talk about cannabis allergy, you know? Being an allergist, people have allergic reactions to cannabis and other potential issues with cannabis that I think as health care professionals we should all talk to our patients about and learn about. You get some bonus coverage here. Really excited about this topic.
To cannabis, otherwise known as marijuana — it is approximately 192 million people. It is probably underestimated. About 4% of the global population use cannabis the TiVo. It is used both medically and recreationally. It is estimated that consumption is increasing, especially in adults over 50 years of age. People are living longer and longer. But it is used by all ages, basically. Including teenagers. Just be aware of that. Right? It is the third most attentively psychoactive substance used worldwide after alcohol and tobacco.
In the United States, legal issues — it was legal in the U.S. prior to 1937. There was the 1937 marijuana tax act that prohibited marijuana. It goes back a long way. It was classified as a schedule one substance in 1970, and still is federally. It was legalized in California and 1996. It has been legalized in Colorado and Washington and other states as well. That is a bit of a timeline.
Cannabis plants, the can of ACA family — the Canna baceae family, cannabis the TV is there, and cannabis Indica is there and growing in front — cannabis Sativa is there, and cannabis Indica is growing in popularity. The stores they have both said TiVo — sativa and Indica. There are others, but these are the most common. THC — Delta nine tetrahydrocannabinol — I will say it THC for ease from now on. That is the psychoactive effect of marijuana. It causes euphoria, relaxation. Also delusions and psychosis. It is fast acting. The THC chemical is fast acting. It reaches the brain in about 30 seconds. Peak concentrations in the blood in about four to 10 minutes. The psychotropic effects can last up to three hours. It is fast acting and can last for a while. Be aware of that. 50% — it is 15% in proportion to cannabis. It is a class one controlled substance in the U.S. 10 of us containing less than 0.3% THC is a non-psychoactive component. The legal cannabis with the non-psychoactive effects is less than 0.3% THC. That is important. That 0.3 percent is kind of the borderline. Above that, more psychoactive effects. Beyond that, it does not have much addicting effect. Marijuana — the cannabis plant and its derivatives are considered marijuana if it’s THC concentration is more than 0.3 percent. If the concentration is less than 0.3%, the plant is considered hemp. You may have heard of hemp oil or hemp products. It is less than 0.3% THC, or is supposed to be. Can Abdel — Cannabidiol, CBD, is a derivative of marijuana that is less than three — 0.3% THC. CBD is a non-psychoactive product. It is found in oils and other products. This is the one you see a lot, sold online, at retail stores across the country, and in many parts of the world. It is from hemp. It is less than 0.3 percent THC, just to emphasize that. Some FDA approved uses of marijuana — this is not an exhaustive list. There is a schedule three drug that treats nausea and vomiting caused by chemotherapy, and it is used for weight loss in patients infected with HIV or AIDS. Nabilone is eight send attic — is a synthetic cannabinoid. It is a schedule to drug used for treating chemotherapy-induced nausea and vomiting and is widely used for chronic pain management. These are less than 0.3% THC. D Epidiolex is an oral solution for treating epilepsy. These are some products you can actually find in pharmacies, and regulated pharmacies. These are FDA approved. You can find them in regular pharmacies across the United States.
Uses of CBD oil — it has been used to reduce seizures, anxiety, nerd — no genitive disorders, pain relief. It is used for acne and cancer treatment. These are some examples. There is evidence that it does help patients with these ailments and conditions.
Some side effects, right? There is no such thing as perfection. Even everything over-the-counter has positives — benefits and side effects and risks. Be aware of that. This is something we should tell our patients and patients should know. Members of the asthma and allergy network should know that it can cause depression, hallucinations, low blood pressure, and there are some withdrawal symptoms such as irritability and insomnia. Just be aware of the side effects. Just because it is over the counter and you can get it at your local store, or a retail store around the corner, does not mean it is — that it is totally safe. Mention this to our patients.
Consumption of cannabis is different. It can be eaten. It can be injected. Inhalation — we will talk about that, especially with the risk and implications for asthma. There is smoking or vaping. That is very popular now, vaping products, including cannabis. Including for our younger population. It is a big issue.
This is just an example, you know? It is not black and white. How it is used, inhaled, the different products out there — different things patients talk to us about. This is a nice guide. A joint is cannabis that is rolled in a paper and smoked. Blunt is a term for emptied cigars in which the tobacco is replaced with cannabis. A spliff is a mix of cannabis and tobacco rolled in paper. A bonk is smoke — a bong is smoke drawn through water. A vaporizer is heated to a burning temperature and smoked. A hookah, we have seen these at restaurants and nightclubs and things. They are very popular. Cannabis is mixed with flavored tobacco over charcoal and smoke is drawn through the water. I do similar to a bonk a little bit. There are others too, so these are examples of how marijuana and cannabis is smoke. When a patient says they use or smoke marijuana, ask them how they use it. If they use it with a hookah, they are getting tobacco exposure as well, which has a lot of risks. It is important.
So, smoking cannabis — it is usually smoked with larger and more prolonged inhalations than tobacco, so be aware of that. It is usually smoked without a filter. You get about four times the particulates compared to tobacco. There is usually no nicotine in cannabis. But it is not safe. Marijuana or cannabis — it does share with tobacco — it has carbon monoxide. Hydrogen cyanide. It has acetyl aldehyde, formaldehyde, phenols — it takes me back to chemistry classes, talking about this. But what is the issue with these compounds, these chemicals? They are known to cause cancer. Marijuana is — it is not the healthiest thing to do. It has agents that cause cancer. There have not been any studies I am aware of showing smoking cannabis only leads to cancer as tobacco, but the risk is there, and I would tell a patient that. There are cancer-causing chemicals in cannabis, especially when you smoke it. You also get three times more of the tar in the respiratory tract, it has been shown, compared to tobacco, if you smoke marijuana. It is not a totally benign thing to do, as it is marketed, especially for patients with respiratory conditions, including asthma. So, some pathology on cannabis smoking, I know there are some physicians and health care professionals listening to this. And for patients, I think it is good to know. There are higher rates of bronchial wall thickening, mucus impaction, compared to tobacco smokers. There is some basement membrane thickening, goblet cell hyperplasia, swarm of cell metaplasia, which is a precursor to cancer. Basic membrane thickening — we see that with asthma patients. There is some pathology, and some pro-inflammatory cytokine, pro-inflammatory proteins. It is associated with a lot of inflammation.
Clinical effects — how do patients feel? We talk about that pathology. There are higher rates of coughing, wheezing, sputum, horse sent — hoarseness. The rates are comparable with tobacco smokers. Cessation of cannabis, stopping cannabis smoking, reduces respiratory symptoms. Be aware of that. That is a good thing to counsel our patients.
Lung function — there is a little short term bronchodilator affect, meaning it opens up a little bit. It is just a short term. Be aware of that. People look at that and go it is helpful for your lungs, or it is marketed as good for your lungs, and that is not true. There are effects to it. Or detrimental effects. There can be increased resistance, which is not a good thing in the airway. Hyperinflation is something we CNN for Xena — we see in emphysema. That is an issue. There is no evidence cannabis smoking leads to COPD. There are not — there is not much data out there. It was an illegal substance for so many things. As I just discussed, there is a lot of detrimental effects under a microscope in the pathology of the lung, on the respiratory symptoms.
Marijuana smoking with asthma — cannabis smoking or marijuana smoking — I will use those interchangeably. It is a risk factor for increased use of and filling of asthma medications. Observational studies have shown an increased prevalence of asthma among marijuana smokers. And it is a precipitating factor for asthma control — for poor asthma. That is something studies have shown and this is something we need to discuss with asthma patients. I know a lot of questions are coming in. We will have time to answer that. Absolutely. And I appreciate everyone interacting. No question is off the table. So I look forward to that discussion. Other conditions — this is the asthma and allergy network, but there are other lung conditions, right? There is bolus lung disease, primary spontaneous pneumothorax, which is basically lung collapse. Marijuana is associated with that. Lung collapse and pneumothorax combined tobacco and marijuana smoking increases the risk. Aspergillus from the goddess is a very — Aspergillus fumigatus is a mold that is found indoors and outdoors, and it has been shown to be one of the most common spores to be on a cannabis crop. So there is potentially an association between — at least a theoretical association between pulmonary Aspergillosis, a lung condition, and a fungus infection of the lungs, with the — with cannabis. We are just kind of looking at that. Not a benign crop, OK? The aware of that. There are some questionable interactions or potential interactions with or causes with marijuana — Legionella pneumonia, tuberculosis, even COVID-19. Since late 2019, there are some associations with marijuana and COVID pneumonia. We just don’t have the data yet. That is one of the question marks there. There are cancer-causing chemicals in marijuana. There is an acute lung injury that can occur in vaping tobacco or marijuana. And there is a potential cardiovascular risk for patients who smoke marijuana.
I want to transition a little bit. We talked about lung and respiratory index — imparts. There is a cannabis allergy, right? There is a hypersensitivity reaction. There have been reports that any rapid ingestion of smoking and edibles can cause an allergic reaction. This like anaphylaxis, right? Hypersensitive allergic reactions — it is rapid onset. We see it in the clinic all the time. It affects the upper and lower airways, nasal passages — there can be shortness of breath. We see that a lot with anaphylaxis. And cannabis allergy — it has been shown that 20% of patients with cannabis allergy have experienced anaphylaxis. The definition is two or more body systems. There can be lung or respiratory issues,. 1/5 of patients are experiencing anaphylaxis, so be aware of that to read we will talk about that and treatment with epinephrine and things like that for allergic reactions.
So, cannabis adverse events versus cannabis allergy — this is important for us as health care professionals to tease out. Adverse events — smoking marijuana, you could have clear eyes, but with allergic reactions, there is a lot of itching. You don’t see that a lot. Sometimes you have nasal congestion, stuffy nose. But itching is one of the things that can interact a little bit. It can show that it is more of an allergic reaction. There is usually no mouth itching. There is a syndrome called cannabis hyper emesis. You want as a health care professional to look at the history. Is it anaphylaxis? Is it an allergic reaction? If a patient presents with urticaria and angioedema, that is usually more of a cannabis allergy. Just an example to compare and contrast the adverse events or side effects of cannabis versus a true allergic reaction. On the bottom — it can be an adverse event. Anytime you smoke anything — a cough can be the start of an allergic reaction. Tease that out with your history. And there is some data showing that patients who drink alcohol or used nonsteroidal anti-inflammatory medications like ibuprofen — using it within an hour or two of using cannabis has shown potentially more allergic reactions to cannabis. Keep that in mind. When you do your medical history for patients.
So, this gets into the details, but I think it is important to resolve the diagnosis. A lot of us on here are health-care professionals. It is important to know that the protein — usually if you are allergic to something, it is a protein. Like a food or a plant — it is a protein in the food or plant. Can s 3 is a lipid protein that is majorly what has been identified that people are allergic to in patients with cannabis allergy. I think it is important. With will talk about this in the upcoming slides. Can s 3 shares the same molecular features with transfer proteins from other plants and other foods. We will talk about this kind of food allergy/cannabis Association in a second. A couple other proteins that have been postulated to be identified in cannabis — can s 2, can s 4, and this right below’s — this ribuloose 1.5. Rubisco is easier. It reminds me of Nabisco, the cracker company. There is more research going on cannabis reactions.
As I mentioned — I teased this. Cannabis associated food allergy — there is a cross-reactivity between nonspecific lipid transfer proteins like Can s 3 and some plants and fruits. It has been associated — patients sensitized to Can s 3 can develop allergies to a wide variety of foods that share the same protein, that lipid transfer protein, including fruits, vegetables, cereal. Some of the fruits that are there — there is a debate, is tomato a vegetable or fruit, I won’t get into that now. Tomato, kiwi, banana, citrus, grapes, peach. Peach was the first one. It was back in 2007. It was the first one to be associated with a cannabis allergy and peace — and peach allergy. You are sensitized when you smoke cannabis. You can have those reactions. Be aware of that in the history. It is important as we see patients in the office. There is some cross-reactivity between these proteins and grapes. Some case reports. They can cause some reactions to wine and beer. The aware of that. These reactions to these proteins — it can occur or has been associated to occur with exercise and nonsteroidal anti-inflammatory’s like ibuprofen or alcohol. Be aware of that. The
Other cannabis-related allergies — this is stuff that is marketed, right? We see this all the time. Hemp seeds are actually seeds that grow in the cannabis plant. They are high in protein. They are high in omega fatty acids. There is a low THC count and a high CBD oil count or product in it. But it has been marketed as kind of a health — as being healthy. Because of these traits, the protein, the omega fatty acids — case reports have shown allergic reactions to hemp seeds, so be aware of that. Occupational exposure to cannabis — if you are in law enforcement, if you have a store selling cannabis, you may get cross sensitization and be more prone to allergic reactions. Be aware of that.
Allergy testing of cannabis — there are some allergy tests. It is more in a research setting, at least in the United States. We are going to go over the
There is not any standardized test. Some testing we do for rights and allergens in food — there is a blood test for the proteins. You can look at the whole extract of hemp, or cannabis, or Can s 3. There is base fill activation tests — basophil activation tests. It is a research thing. In the United States at least, there is no commercially available standardized testing in the U.S. Skin testing with extracts — it is still a federal one, schedule one, with further classified substance. Theoretically, patients could bring in a skin creek for marijuana, but there is no standardization. And there are legal issues, right? So be aware of that. Every state is different. I’m here in Texas, and California laws and Colorado laws are different from Texas, right? In Texas, it is not recreational legal access.
The cannabis challenge — we talk about food challenges in the office. Challenges to insects things sometimes in a research setting. There are legal issues. If you are allergic, you can tell someone to come in to the office to get their cannabis, and there are legal issues with that. It is tough. It is tough to do in the office. It is a lot different from the food challenge. The other thing — just to be aware, both as patients and talking with patients — is cannabis in commercial stores. All these stores we see, mom-and-pop stores or big stores at the corner — a lot of places in the U.S., there are unknown amounts of THC, and there are unknown amounts of CBD, we don’t know how pure it is. Sometimes, marijuana can be mixed in with other things. Tobacco, things like that, other drugs, LSD, cocaine. There is a lot of issues, unfortunately. So just be careful. Tell her patients just because someone says that there CBD is quote unquote pure or 99% pure or whatever it is, there is not a lot of regulation. It is still ongoing, the federal and state regulation. Just be aware that you get cannabis from a store. If you get it from a pharmacy, if it is an FDA approved medication, like for glaucoma and things, then yes, it has gone through FDA standards. If it is at a local store, you don’t get the amounts of THC or CBD or what it is mixed in. Be aware of that for our patients.
There is not a lot for treatment of cannabis allergy. It is avoidance is the main thing. An epinephrine ejector is important. There is a case for omalizumab. They had an allergy. It is on off label use, not FDA approved. But it was used in a patient with cannabis allergy and they did not have any reactions. For FDA approved food allergy — it is used for severe asthma. Again, I put a question at the bottom — desensitization protocols. We get desensitized to medications. It is FDA approved and off label. Oral immunotherapy, things like that — there are some studies that are going on in Europe. In the U.S., it is still a federal schedule one substance. There is research being done. There is not a lot of data in the U.S. There are other countries, of course, around the world. When talking with patients about cannabis, this may be older, the data. Cannabis is still federally illegal. I’m not sure with the new administration if that is going to change. It is illegal right now. Medical use is legal in 40 states and counting and recreational use is legal in 23 states and counting. Be aware of that. States have different laws regarding cannabis, including indications for medical use. Patients may not be willing to answer questions about cannabis use. I am in Texas, where it is not recreationally legalized. They do not want to talk to me about it. As opposed to Colorado or Washington state, where it has been legalized since 2012. Again, laws are evolving. Check with your state laws on cannabis.
Talking with patients about cannabis — open-ended questions are very important. You want to incorporate cannabis use questions with the same vigor as we do with the history of tobacco and alcohol use which we ask all our patients. There is a cannabis intake form. I will talk about that with another slide. It is in partnership with the American College of asthma and immunology. There are modules on cannabis. We take our forms from there. No judgment. It is important. You want to be an active listener. How and why your patients are using it — I think that is the main thing. As a physician, most of us are health-care professionals, and we are all in different fields. I am always a student, right? I won’t say what I have practiced for. But, yeah, I am always a student. I always consider myself a medical student, always learning. I am open to learning about different conditions, including cannabis allergy.
Again, you want more details here for patients, talking about cannabis. Please be open with your physician, patients. As physicians, I think most of us want to help our patients, right? Please be honest with your physician. We are trying to improve ourselves, not be judge mental. We want to really improve our history taking and things. Be open with your physician. I think it will help out. You can ask questions. Don’t just ask the person who is checking out when your patient is buying something, some cannabis product at the local CBD store. Yes, they have some information, but talk to your health care professional, right? Talk to us. You want to adjust questions according to patient preference and tone. Leave time for questions. That is important. A lot of health professionals are rushed and we are behind. And our bosses, who are oftentimes not physicians, are saying you have to see more patients, and this and that. But just make some time for patients. Even one or two minutes can make a difference. One thing I think is allergist immunology specialists — we tend to spend more time with patients than other specialties. I respect all the other specialties, but one thing I’m proud of, being an allergist, is we spend a lot of time with her patients, and I think that is great. Answer questions as best you can. “I don’t know” is a perfectly valid answer. I am a medical student, always learning. I think it is important. If I say I don’t know, let me check on that for you. Let me research that. And then I can answer. And as I mentioned, take time to research patient questions and concerns. The
The college cannabis education modules — we have some helpful links. There is the foundation of the college. There are six CMA modules on cannabis, cannabis allergy, talking to patients about cannabis. They have the cannabis questionnaire. That is at the website there. And there is a micro CME, cannabis and the allergist. I think you have approximately six units of CME with that. And then there is the international cannabis allergy collaboration, which is the pathologist part of the college of cannabis education and allergy and the European Society of allergy, asthma, and immunology, and the Canadian society. They are all involved in international collaboration to learn more about cannabis allergy and the effect on our patients.
I want to thank all of you. I know I was very I guess you could say brief or quick. I like the word efficient. I like to leave time for questions and things. And discussion from all of you. I want to thank the allergy and asthma network. The college’s dermatology committee — I am the chair at the American College of asthma and allergy. I’m also part of the medicine — integrative medicine committee. I mentioned the international cannabis allergy collaboration with different societies. The United States, the American and European societies. One of my attendees, Dr. William Silvers, he is a pioneer in integrated medicine. He actually was one of the leaders to put together the international cannabis energy collaboration. I wanted to just acknowledge that, Dr. Silvers. And I want to acknowledge all of you. I think you learned for each other. It was great. I want to turn it over to the question and answer. I am Anil Nanda. There are no dots or anything in my name. We had time for questions and a great discussion.
>> we have a lot of questions.
Dr. Nanda: That is great. A lot of engagement. I love it, absolutely.
De De: From Karen, she is a school nurse, and she has seen many students who have — you are post-use of the immediate and long-term effects of the dabbing of cannabis. Can you speak to this on what are the side effects?
Dr. Nanda: I am kind of a nerd a little bit, so dabbing — is that kind of like dipping kind of thing? Is it like tobacco dipping, like chewing it?
Or — De De: You have got me.
Dr. Nanda: I don’t know. But again, I am learning here. But it is an issue. There are different methods here. There his — there is inhalation, eating it, chewing it, things like that.
De De: They say it is a concentrated oil like a wax.
Dr. Nanda: OK, so there is definitely side effects. I’m not aware of why is that in particular, death thing or dabbing, more associated with nausea or vomiting than inflation. I think it is just important to tell our patients what it is. It is not just the Marshall and social — marketing and social media idea that it is a benign thing. It is not. Teenagers will be using it. They get it from their parents, potentially, or others. It is a benign thing. There are a lot of potential side effects. There are asthma and respiratory issues. Great question.
De De: It is a good question. It stumped me. We have a couple others that are asking about the volume and frequency of inhaled cannabis versus the volume and frequency. Are they equal one to one? Is there a difference from volume?
Dr. Nanda: It’s interesting. We don’t know. We are getting more data on that. In tobacco smoking, it is packed years, right? One pack is 20 cigarettes and there are approximately 20 cigarettes and you smoked for a number of years, so we are able to, in research studies, say this is 10 pack years of tobacco, or whatever it is. We don’t have that with cannabis right now. That is a great question because a lot of the research studies, it says how much are you using cannabis. Right now, what the research is — what the research is saying now in the papers is a high, moderate, or low, and there is no standardization. You could be smoking marijuana five times a week. It could be maybe once a week is moderate, and low is once or twice a month. But just like we say, when someone smokes a cigarette, a tobacco cigarette, they cough. That is a sign that it is a lung irritant. The same thing with cannabis and marijuana smoke. We are working on standardization. As more research gets developed on this — it is a great point.
De De: Another concern or question is thinking about secondhand and thirdhand smoke when it comes to tobacco. Is there something similar to this exposure for people who are smoking cannabis? The second part of this is wearing a mask. Would that help to diminish the exposure?
Dr. Nanda: Great. I think wearing a mask can help diminish, just like with pollen. You see it as an allergist. You are mowing the lawn and are allergic to grass. You mask up. It is not perfect. Masks are not perfect. The N95 is good but not perfect. I think masks can be helpful. It is difficult. It is one of those secondhand and thirdhand smoke, secondhand in particular. Yes, there is evidence that any kind of exposure can cause those respiratory symptoms and lung damages. I think just the mindful, just like I tell patients to be mindful of other family members, parents, whatever it is. Be mindful of smoking around others in your family — it is best to avoid if possible. What it is difficult. It is hard. But just remove yourself from the area. Patients know their bodies the best. I see patients every day. They know their perfumes. They know their stimuli. They know what happens and they know what they need to avoid. Try to avoid that environment if possible. That kind of thing.
De De: You did make mention about occupational exposures. Do you play suggestion if a person has respiratory disease like asthma, who is working on — on how to protect themselves?
Dr. Nanda: Absolutely. I think definitely see — first of all, you want to see your asthma specialist, your asthma and allergy specialist. I think being up-to-date with your medications — what we want to see a lot of times — patients with asthma, everyone reaches for their albuterol and short acting inhaler or bronchodilator. It does not have any anti-inflammatory effects. There are inhaled anti-inflammatories. Keep up with your asthma medications. Masks can help. There is not a lot of great data. But I think masks can help a little bit. And of course, it is not really smoking it. There are some vapors potentially. You could wear latex gloves to reduce exposure. It can be helpful. I think consult an allergist for further details. You can get exposure, absolutely.
De De: Are you familiar with a stepwise approach to trying to switch a patient from inhaled cannabis to edibles or something else, to where they are not inhaled? Is there a stepwise approach to do this? Some people are saying in the chat, in the questions — some patients have had success, but others are not having success. Is there any information that you could share?
Dr. Nanda: I’m not aware of any — there is no standardized stepwise approach of going from inhaled to edibles. Just like smoking. It is hard to quit cold turkey. You kind of reduce. I think as physicians and health care professionals, we can just kind of be a coach and do this for our patients, saying it is hard to quit all at once, but at least reduce. Reduce it. Just like outpatients that are smoking tobacco — today, I commended for that. Let’s further reduce. I would suggest encourage — just be encouraging and just applaud them for trying. At least they are talking to you about it, number one. And you are trying to reduce. I think that is great. I think edibles, yes, you are not going to have the inhalation and the respiratory issues. As I mentioned, there are cancer-causing agents in marijuana. It is not the safest thing, you know? Unless you are taking one of the FDA approved where we know the amounts and things and all of that — just be careful about the edibles. How pure are they? How much THC do they have? There are side effects from edibles too. Just be aware of that.
De De: Do you use Pheno as a test? Is it available to inform us if a value is elevated, if a person is using cannabis? Are we aware of this at all?
Dr. Nanda: Interesting. It is fragile excretion of nitric oxide. It is basically a marker of inflammation, of allergic type two inflammation. A lot of times in patients with asthma — it is not all inflammation, but certain types of inflammation, it is elevated. With tobacco smoke, it can elevate Pheno. Sometimes, viruses can do it. I’m not sure how marijuana smoking elevates it. And I use it in my clinic all the time. I would say if you are having a patient — if you are looking at Ph — looking at Pheno with a patient, and they are above 40 or 50, that is inflammation, so you want to put it in inflammation. It is a good marker. It is important. I do it with pulmonary function testing or spirometry. The best test is the history and physical. Just remember to ask questions. About cannabis and cannabis smoking and things. People ask, do you smoke cigarettes? No, never. Go to the next question. How many pets do you have or whatever. As an allergist, that is not great. I usually say open ended, do you smoke? That is very helpful. A great question. I like it to bring up.
De De: I like the fact that you are having an open ended question versus being very specific to only tobacco use. Even when we think about tobacco use, people, when they are dipping or using pouches, if you ask them if they smoke tobacco, the answer is now.
Dr. Nanda: We learned the term — thing — term dapping, or dabbing.
De De: We learned dabbing today. There are a lot of questions that are specific to dosing and switching from cigarettes — people are utilizing vaping is a possibility of reducing their cigarette use. Any thoughts here?
Dr. Nanda: I think the main thing is applauding our patients on reducing — reducing smoking or anything, tobacco and vaping. But just counsel patients that, yeah, vaping is not — there is nicotine. There is dip. That there are bad chemicals in there, and some cancer-causing chemicals. So yes, I would say this. How I would approach it, just seeing a patient — yes, you are going from cigarettes to vaping. That is a positive step, I would say. Then go from vaping to not, you know? Asked encouraging that, you know? I think that is key. Marijuana, cannabis, CBD, vaping — they have side effects and issues with how they are being marketed. You look at social media, whatever platform, and it is marketed as they are kind of healthier. And it is like, no, vaping is unhealthy also.
De De: And we have a number of school nurses on our webinar today.
Dr. Nanda: I appreciate everything you all do. It is awesome. Appreciate it.
De De: They have some pretty specific questions to their community, right, on helping kids understand what the side effects are. You may have mentioned anaphylaxis or allergic reactions. Can you speak to that one more time a little bit, about the allergic reactions to inhaled or edible cannabis?
Dr. Nanda: Typical allergic reactions, you have itching, rash, hives, those kind of things. I would say in a patient that presents that way, included as part of your history. A lot of people think if it is — it is a food. But you never know. Maybe the high school kids, you don’t know. I think it is important to ask about that. Smoking cannabis, edible cannabis, any of this stuff. Allergic reactions have to be up there. Itching is one of those things that differentiates a little bit. A lot of times, allergic reactions are itchy. A lot of times, if someone is not itching, it is not an allergy. Think that is kind of the key. I want to emphasize to your audience and really appreciate the school nurses — the treatment of choice for allergic reactions — the first choice is epinephrine. It is epinephrine intramuscular in the thigh. I think just to mention, don’t hesitate to use epinephrine. My rule of thumb for epinephrine is, if you are thinking about it , bed reactions — should I use epinephrine? Go ahead and use it to be on the safe side. Epinephrine is very safe. The main side effect of epinephrine — it is adrenaline. It is like a strong cup of coffee. You may get jittery after using it, but that is it. There is sometimes a year of using epinephrine, or you have to go to the emergency room. I think using epinephrine early actually is very helpful. It is very safe to use. Don’t hesitate to do that. Definitely.
De De: So, the last question — what affect does the heating from vaping have on the lungs themselves? Are you able to address that?
Dr. Nanda: I don’t know. Great question. I just don’t know what affect. It is not a good affect. I will say that. A lot of times, sometimes — vaping, heating, it tends to release some chemicals sometimes. It is not a good affect. Everyone is always trying to say what is the safest way to use it. Yes, there are some safer ways. Not smoking it is better. But there is risk in using it. I think that is something to mention. Especially a recreational user. Yes, it relaxes you, and things like that. But there are negatives, right? There are rebound affects and withdrawing and withdrawal effects, things like that. Just be aware of that. It is great as health care professionals.
De De: Thank you for your presentation today. This has been extremely informative. We all have learned some new things today. You will receive an email in zoom with a link. We have two webinars in February. The first is another installment of our black people like me webinar that will address barriers in asthma care for the black community. Join us on February 11 at 4:00 p.m., when we will discuss disparities that are persistent in asthma care for that community. The patient Greg Clark will also participate and share his experience, his lived experience, with asthma. On February 25 at 4:00 p.m., we will welcome Dr. Patel for a webinar discussing the micro biome and its role in asthma and allergies. Thank you again for joining us here at allergy asthma network, where we work every day to be your trusted resource for people with allergies, asthma, and integrative conditions. Thank you all.
Dr. Nanda: Appreciated. Stay safe, everyone.