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Cannabis use was independently linked to adverse cardiovascular outcomes in the general population even after accounting for tobacco cigarette and e-cigarette use, a large national study found.

Using data from the CDC's Behavioral Risk Factor Surveillance System (BRFSS), there was an increase in most incident cardiovascular disease events among adults using cannabis daily compared with non-users:

• Coronary heart disease: adjusted OR 1.16, 95% CI 0.98-1.38
• Myocardial infarction: adjusted OR 1.25, 95% CI 1.07-1.46
• Stroke: adjusted OR 1.42, 95% CI 1.20-1.68
• Composite of the three: adjusted OR 1.28, 95% CI 1.13-1.44

Evidence of an association between cannabis use and cardiovascular events persisted in non-tobacco smokers and younger people at risk of premature cardiovascular disease (men under 55 and women under 65), reported the study authors led by Abra Jeffers, PhD, a data analyst at Massachusetts General Hospital in Boston.

"We also accounted for number of days used per month as a continuous variable. This analysis is important, because it suggests that cannabis use alone may be a risk factor for adverse cardiovascular outcomes," Jeffers and team wrote in the .

Of note, cannabis use has been rising while conventional tobacco use has decreased nationwide. According to the CDC, marijuana is the most commonly used federally illegal drug in the U.S., with 48.2 million people (or 18% of Americans) .

"Despite common use, little is known about the risks of cannabis use and, in particular, the cardiovascular disease risks," said Jeffers in a from the American Heart Association (AHA). "Cannabis smoke is not all that different from tobacco smoke, except for the psychoactive drug: THC versus nicotine. Our study shows that smoking cannabis has significant cardiovascular risks, just like smoking tobacco."

The investigators noted that their study is consistent with older, smaller BRFSS studies supporting a relationship between cannabis and cardiovascular harms. Being three to 17 times larger, however, the present report had an adequate sample to show harms in the subgroup of tobacco and e-cigarette never-users.

"This is an important public health finding, particularly given our ongoing efforts to reduce the burden of heart disease in this country," said David Goff, MD, PhD, director of the National Heart, Lung, and Blood Institute's Division of Cardiovascular Sciences, in a statement.

Outside the CDC survey, other work has suggested that use of cannabis and other recreational substances is associated with early-onset atherosclerotic cardiovascular disease.

Yet cannabis is often undisclosed by patients. One French study showed that many recreational drug users with acute cardiovascular events landed in cardiac intensive care units without disclosing their drug use.

"As cannabis use continues to grow in legality and access across the U.S., practitioners and clinicians need to remember to assess cannabis use at each patient encounter in order to have a non-judgmental, shared decision conversation about potential cardiovascular risks and ways to reduce those risks," commented Robert Page II, PharmD, MSPH, of the University of Colorado School of Medicine in Aurora, in the AHA press release.

"The findings of this study have very important implications for population health and should be a call to action for all practitioners, as this study adds to the growing literature that cannabis use and cardiovascular disease may be a potentially hazardous combination," he added.

The population-based, cross-sectional study was based on data from the BRFSS covering 27 U.S. states and two territories. The analysis relied on data from the 2016 to 2020 telephone surveys, for which there were 434,104 respondents ages 18 to 74 years.

Overall, 55% of the respondents were ages 35-64, and 14.5% were ages 65-74; 51.1% were women, and 60.2% were white. The prevalence of daily and non-daily cannabis use was 4% and 7.1%, respectively.

Jeffers and colleagues acknowledged their reliance on self-reported cardiovascular conditions and cannabis use. Anonymous data also precluded linkage to mortality records for analysis.

Prospective cohort studies are needed to confirm their findings, they said.

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