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Indoor cannabis smoke and children’s health

Cannabis use is increasing and cannabis is typically consumed by smoking. This study explored how indoor secondhand cannabis smoke (SCS) was associated with child health. As part of a larger trial, air particle monitors were placed in 298 homes of families with at least one cigarette smoker and one child under 14 years old in San Diego County, California. Assessment included past 7-day indoor cigarette and cannabis use, the youngest child’s exposure to cigarette smoke, and 5 smoke-related past-year child health outcomes: emergency department use for coughing/difficulty breathing; physician diagnosis of ear infection, bronchitis/bronchiolitis, asthma, or eczema/atopic dermatitis. An ordinal measure of adverse health outcomes (0, 1, or ≥2) was regressed on reported indoor cannabis smoking—the main measure of exposure (yes/no). Of 221 parents/guardians asked about cannabis use, 192 (86.9%) provided all required data, and 29 (15.1%) reported indoor cannabis smoking; reports were supported by air particle data. Homes without indoor smoking had lower average 7-day particle concentrations (1968 particles/0.01ft 3 ) than homes with cannabis smoking only (3131 particles/0.01ft 3 ), cigarette smoking only (3095 particles/0.01ft 3 ), or both cigarette and cannabis smoking (6006 particles/0.01ft 3 ). Odds of reporting a greater number of adverse health outcomes were 1.83 (95% CI = 0.89–3.80, p = 0.10) times higher for children of families with indoor cannabis smoking vs families without cannabis smoking, after controlling for exposure to cigarette smoke and other covariates. Our results do not indicate a statistically significant association. However, the magnitude of the (non-significant) association between indoor cannabis smoking and adverse health outcomes warrants more studies.

1. Introduction

An estimated 24.0 million persons were current cannabis users in the United States (U.S.) in 2016 and this number has been increasing (Hasin, 2018; Substance Abuse and Mental Health Services Administration, 2017). As of January 2018, the District of Columbia and 8 states in the U.S. had legalized cannabis for both recreational and medicinal use (Hasin, 2018), a phenomenon that coincides with a steady decline in the perception that cannabis use is “risky” to health (Johnston et al., 2016). Smoking is the most common method of cannabis consumption (Schauer et al., 2015). Cannabis smoking most often occurs indoors (Berg et al., 2018, Berg et al., 2015), where it is associated with high concentrations of air particles (Klepeis et al., 2017) that can be inhaled by children and other nonsmokers in the home. In 2015, 5.3 to 8.0 million children in the U.S. lived with a parent who was a current cannabis user, and among parents, both current cannabis use and daily use are increasing (Goodwin et al., 2018). Despite the expansion of legalization and use, there are no laws or restrictions in place to protect children from exposure to cannabis smoke.

Secondhand smoke (SHS) is the smoke exhaled by a smoker or smoke from combusted products such as cigarettes and cannabis. Current literature supports a causal association of exposure to secondhand tobacco smoke (STS) from cigarettes with illnesses in children such as cardiovascular and respiratory damage (Ferrante et al., 2013; Franklin, 2007; Kumar et al., 2015; Li et al., 1999; Patra et al., 2012; Strachan and Cook, 1998). Tobacco and cannabis smoke contain many of the same chemicals, such as nitric oxide and aldehydes, which are known to have harmful health effects (Moir et al., 2008). Given that STS and secondhand cannabis smoke (SCS) particles are equally capable of entering the body and have a similar chemical composition (Matt et al., 2004; Wilson et al., 2017), studies of the health effects of SCS are warranted.

Children are more sensitive to respiratory insult from STS exposure because of their underdeveloped respiratory and immune systems (Miller et al., 2002; Ostro et al., 2009). According to the U.S. Surgeon General Reports, the most common health outcomes of child exposure to STS are ear infections, asthma attacks, and poor respiratory health (Centers for Disease Control and Prevention (US), 2010; US Department of Health and Human Services, 2006, US Department of Health and Human Services, 2014). Children may also be exposed to thirdhand smoke (THS), which is SHS that accumulates in dust and on surfaces and includes similar carcinogens and toxicants found in SHS (Matt et al., 2011, Matt et al., 2004). THS exposure can result from contact with contaminated surfaces where STS has settled, from re-emitted particles or gasses, or from new pollutants created when residual smoke components react with other environmental factors (Matt et al., 2011, Matt et al., 2004). Children who have been exposed to THS from tobacco had higher odds of atopic eczema (Kramer et al., 2004). It is unknown whether cannabis exposure (either secondhand or thirdhand) is similarly related to health outcomes since few studies have been conducted on the topic, in part due to the federal illegality of cannabis (Drug Enforcement Administration: Diversion Control Division, 2018).

Cannabis smoking is implicated in several adverse health-related outcomes in adults (e.g. symptoms of chronic bronchitis and behavioral change), while evidence of therapeutic effects and the effects of long-term use remain inconsistent (Volkow et al., 2014a, Volkow et al., 2014b). The only evidence of SCS-related cardiovascular health effects is from a recent study in rats that showed SCS exposure reduced vascular function more than STS exposure, suggesting cannabis smoke may have worse cardiovascular consequences than tobacco (Wang et al., 2016). In children, the research literature pertaining to the health consequences of cannabis exposure are limited to cases of accidental ingestion (Amirav et al., 2011; Fried and Watkinson, 1990; Macnab et al., 1989; Wang et al., 2011).

This paper explored the relationship between reported indoor SCS and health outcomes in children. Given that there is no risk-free level of exposure to STS (US Department of Health and Human Services, 2006), and the qualitative similarity in chemical composition between SHS from cigarettes and cannabis (Moir et al., 2008), it is plausible that SCS could cause ear infections, asthma, other respiratory dysfunction, and skin conditions. To our knowledge, there is no research on the effects of indoor SCS exposure on health outcomes in children.

2. Methods

2.1. Study design

We examined data from Project Fresh Air (PFA), a randomized controlled trial of real-time feedback and coaching aimed to reduce indoor SHS and fine particle levels in low-income homes throughout San Diego County, CA. The cross-sectional analyses presented in this paper used data collected during the period of PFA before any intervention took place.

2.2. Participants

Families were eligible for enrollment if the primary adult participant was at least 18 years old, with no plans of moving for 3 months, and if the household included at least one adult cigarette smoker and at least one child under the age of 14. In each household, one parent/guardian and the youngest child were enrolled. Details of participant recruitment and enrollment are reported elsewhere (Hughes et al., 2018). Two hundred and ninety-eight participating families enrolled. Parents (or guardians) provided written informed consent for inclusion in this study. Study procedures were approved by the San Diego State University Institutional Review Board (IRB).

2.3. Measures

Research assistants (RAs) placed customized Dylos DC1700 air particle monitors in participant homes in the room where the most smoking took place. The monitors counted indoor air particles (0.5–2.5 μm in diameter), which have previously been used to detect indoor smoking (United Sates Environmental Protection Agency, 2016). Air particle monitors continuously collected data throughout the period of study participation. After approximately 7 days of air particle monitoring, RAs administered computer-assisted interviews to assess household behaviors that may affect indoor PM2.5 (particulate matter ≤2.5 μm) levels (e.g. smoking and air ventilation), demographic information, and health information about the youngest child in the family.

2.3.1. Primary outcome

Parents (or guardians) reported their child’s 1) past year use of an emergency department (ED) for coughing or difficulty breathing, and whether in the past year the child had a physician-diagnosed 2) ear infection, 3) bronchitis or bronchiolitis, 4) asthma, or 5) skin conditions such as eczema or atopic dermatitis. From these five survey responses, the cumulative number of health outcomes was computed for each child and categorized into three levels (0, 1, or ≥2 outcomes).

2.3.2. Cannabis and tobacco smoke exposure

We measured the enrolled child’s potential exposure to cannabis and cigarette smoke with three dichotomous variables derived from responses to three questions. SCS exposure, the primary exposure of interest for this study, was derived from the question, “How often in the past 7 days did anyone smoke medicinal or recreational marijuana in your home?” Responses were coded 1 if one or more days were reported, and 0 otherwise. Exposure to cigarette smoke, which served as our main measure of STS exposure, was derived from the question: “In the past 7 days, was [child’s name] exposed to any cigarettes in your home, a car, or any other place?” In a sensitivity analysis, we used the response to the following question as an alternate measure of STS exposure: “How often in the past 7 days did anyone smoke cigarettes in your home?” Responses were coded 1 if one or more days were reported, and 0 otherwise.

2.3.3. Air particle concentrations

Reported indoor cannabis and cigarette smoking behaviors were compared to using 7-day mean air particle concentrations. Air particle monitors counted indoor air particles each second and averaged particle counts every 10 s. Arithmetic mean particle concentrations (counts per 0.01 cubic foot) were computed for each day.

2.3.4. Potential covariates

For the child, the main demographics of interest were age (years), gender (male/female), and race/ethnicity (non-Hispanic White, Hispanic, non-Hispanic Black, or non-Hispanic Other). “Other” included Native American, Asian, Pacific Islander, mixed and unspecified. For the parent or guardian, years of education were categorized as <12 years, 12 years, and >12 years and served as a proxy for socioeconomic status.

2.4. Statistical analysis

Of the 298 families enrolled in PFA, 6 participants were asked about cannabis use but declined to answer and 78 were not asked about cannabis because they were either pilot participants (n = 36), or participants (n = 26) recruited from a group for whom we did not have IRB approval to inquire about cannabis use. An additional 16 participants were not asked about cannabis due to interviewer error (administration of the wrong interview). Of those who answered the cannabis use question, 19 did not provide all health information about their youngest child, 2 did not provide information about education, and 1 did not answer the SCS exposure question. Therefore, data from 192 families were available for the present study.

Health outcomes and covariates were summarized using frequencies and means for the total sample and stratified by indoor cannabis smoking. Group differences were tested using Pearson chi-square test, Fisher’s Exact Test, and t-tests.

Reports of indoor smoking behaviors were confirmed using air particle concentrations. Daily arithmetic mean air particle concentrations were log transformed to better approximate normal distributions. Geometric means (GMs) were computed to summarize particle concentrations during the 7-day period corresponding with the interview for each smoking behavior group: no smoking, cigarette smoking only, cannabis smoking only, or both cigarette and cannabis smoking. Overall group differences were tested using one-way ANOVA. To test the hypothesis that any type of indoor smoking, in relation to no smoking, would increase particle concentrations, between-group differences were computed using Tukey multiple comparison tests.

Ordinal logistic regression was used to assess the relationship of indoor cannabis smoking (yes/no) with the ordinal measure of adverse health outcomes (0, 1, or ≥2 outcomes), adjusting for covariates. Covariates were included in the models if they were related to the number of adverse health outcomes using a threshold of p < 0.40 for inclusion. Three ordinal regression models were fit: Model 1 was unadjusted; Model 2 adjusted for two covariates (child’s age and parent’s education); and to test whether associations were independent of exposure to tobacco smoke, Model 3 added a third covariate (reported child exposure to cigarette smoke). As a sensitivity analysis, we repeated our three-model approach, replacing child exposure to cigarette smoke with reported indoor cigarette smoking. Proportional odds assumptions were tested for each model using the brant() function in R (R Foundation for Statistical Computing; Vienna, Austria); no violations were observed (Schlegel and Steenbergen, 2018).

All statistical tests were two-tailed with an alpha of 0.05. Data analysis was performed using R (version 3.5.1 for Mac OS X).

3. Results

3.1. Sample characteristics

Indoor cannabis smoking was reported by 29 (15.1%) parents or guardians ( Table 1 ). Indoor cigarette smoking was most prevalent (48.1%) among those who reported indoor cannabis smoking (p < 0.01). Children in cannabis-smoking homes were significantly older (4.72 years) than those who were not (4.12 years; p < 0.01). Among enrolled parents or guardians who did not report indoor cannabis smoking, most (65.0%) reported >12 years of education (p = 0.03). While enrolled child racial-ethnic backgrounds among households that reported indoor cannabis smoking were relatively evenly distributed, the majority (55.2%) of enrolled children in households that did not report indoor cannabis smoking were Hispanic (p = 0.01). Additional sample characteristics by indoor cannabis smoking status are provided in Table 1 .

Table 1

Child and household characteristics by indoor cannabis smoking status among study participants in San Diego County, CA (N = 192).

Characteristic No indoor cannabis smoking Any indoor cannabis smoking p-value a
(n = 163) (n = 29)
n (%) n (%)
Past 7-day child exposure to cigarette smoke 0.62
 No 51 (31.3) 11 (37.9)
 Yes 112 (68.7) 18 (62.1)
Indoor cigarette smoking b <0.01
 No 127 (78.9) 15 (51.7)
 Yes 34 (21.1) 14 (48.3)
Age of child c (years) 4.12 (3.70) 4.72 (3.84) <0.01 d
Gender of child 0.56
 Male 86 (52.8) 13 (44.8)
 Female 77 (47.2) 16 (55.2)
Parent education (years completed) 0.03
 <12 30 (18.4) 4 (13.8)
 12 27 (16.6) 11 (37.9)
 >12 106 (65.0) 14 (48.3)
Race/ethnicity of child 0.01 e
 Hispanic 90 (55.2) 7 (24.1)
 Non-Hispanic Black 20 (12.3) 6 (20.7)
 Non-Hispanic White 25 (15.3) 7 (24.1)
 Non-Hispanic other f 28 (17.2) 9 (31.0)

Bolded p-values indicate statistical significance at p < 0.05.

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