The prevalence of marijuana smoking among adults in the United States has remained stable, at approx 4%, for the last decade (1). Even that low rate (four times as many Americans smoke cigarettes) still translates into more than 6 million active users. In 2002, an estimated 19.5 million Americans aged 12 years or older admitted to having used illicit drugs during the month before the survey interview, and that number translates into 8.3% of the population over the age of 12 (Fig. 1). Of these individuals, 75% reported using marijuana, and 72 million individuals report having smoked marijuana at least once in their life (2). Given the surprisingly large number of users, it is quite surprising to see how little has been written about marijuana toxic-ity. Reports of acute life-threatening illness, or at least reports emanating from the offices of medical examiners, are extraordinarily rare.

There is, however, no doubt that marijuana smoking does have measurable cardiovascular effects, and cardiovascular disease is the principal cause of death in the United States. (Surprisingly, cardiovascular disease is the third leading cause of death for children under age 15 [3], accounting for at least one in five deaths [approx 2500 deaths per day].) Coronary heart disease alone is the single largest killer of Americans, and stroke is the third. Each year, about 700,000 people experience a new or recurrent stroke. About 500,000 of these are first attacks, and 200,000 are recurrent. Stroke accounted for more than one of every 15 deaths in the country in 2001. In total, cardiovascular disease killed 931,108 Americans in 2001 (compared with 553,768 deaths from cancer, 101,537 accidental deaths, 53,852 deaths from Alzheimer's disease, and 14,175 from HIV).

Because the number of marijuana smokers is very large, it is inevitable that there would be overlap between the two groups. The difficulty for pathologists is deciding

From: Forensic Science and Medicine: Marijuana and the Cannabinoids Edited by: M. A. ElSohly © Humana Press Inc., Totowa, New Jersey

Fig. 1. Current breakdown of illicit drug use in the United States.

when an individual with cardiovascular disease has died "from" their marijuana smoking or "with" marijuana smoking. Currently available diagnostic techniques do not permit making such distinctions. This chapter reviews what is known about the cardiovascular consequences of marijuana smoking, with special emphasis on marijuana as a triggering factor for plaque rupture and sudden cardiac death. Evidence for other marijuana-related illnesses and medical effects will be reviewed, as will postmortem testing methodologies.

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