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9 associated with marijuana use were lowOer than those for tobacco cigarette smoking. Compared with consurmpuon of duce or more drinks per day, manjuma use was associated with a higher risk of total mortality and AIDS mortality in men and a lower risk of total mortality in women. Discussion The main overall findings were an increased risk of total mortality associated with marijuana use in men but not in women. The increased risk of total mortality In men was explained by the strong relationship between manjuana use and AIDS mortality. Marijuana use was unassociated with non -AIDS mortality in men. The question of the effect of mun- juma use on AIDS mortality is an important one. Marijuana use has been advocated as a therapeutic adjunct to ameliorate the nausea and loss of appetite commonly associated with the wasting syndrome in AIDS.10 We have provided substantial evidence that tire increased risk of AIDS mortality in the total study cohort probably resulted from uncon- trolled confounding by homosexual behav- ior. Other studies have reported a substan- tially higher prevalence of manjuana use in homosexual and bisexual men, support- ing the hypothesis that marijuana use is a marker for homosexuality or bisexual- lly. i e -m There are several other potential explanations for the Increased risk of AIDS In manjuana users. Marijuana smoking might theoretically place AIDS patients at increased risk of infection because of its irritative effects on the respiratory system or because of infec- tious contanunants (e.g., fungi) in man- juma. Other potential explanations in- clude marijuana as a marker of hieh-nsk sexual behavior or Intravenous drug use: Initiation of marijuana use as a result of having HIV or AIDS, rather than preced- ing the disease: and possible mrunimosup- pressive propenes of marijuana The use of alcohol and nonmedical psychoactive drugs, including marijuana, is associated with risky sexual behavior such as unprotected intercourse."' but methodological limitations have made It impossible to determine causality." Man- juma use may serve to a ceruun extent as a marker of intravenous drug use. How- ever, the relative risk of AIDS mortality associated with marijuana. use did not dinunish when the analysts was limited to men who were nonsmokers of tobacco April 1997. Vol. 87. No. 4 OMarijuana Lw anal Noruh y and occasional alcohol drinkers, a sub group unlikely to contain many parenteral drug users Additional evidence against marijuana as a marker for parenteral drug use was the finding of only one case of infective eridocardlus in Kinser Pemtan- care hospitalization records of the AIDS decedents. The lack of increased mortality during the first 5 years of follow-up suggests that therapeutic use of marijuana at baseline for AIDS-related symptoms has little. if any, explanatory effect on the association between marijuana use and AIDS. Furdwrrnore, the majority of AIDS patients initiated marijuana use long before the onset of clinical disease, nearly two thirds (6517c) of AIDS patients re- ported uuuadon before 1976, when HIV infection in the San Francisco Bay area was either nonexistent or negligible.= While marijuana and its psychoac- tive cannabanuids possess known immu- nosuppressive qualities, there is no consen- sus as to whether typical doses result in clinical immunosuppression in humans.'- Marijuana use has been associated with a higher prevalence of seropositivity for HIV in sonic cross-sectional studies of homosexual and bisexual men. 1124 but it has nor been shown to be an independent predictor of serocunversion?r nor does it increase the risk of AIDS in seropositive men.=' The nearly significant increase in mortality risk from injury or poisoning for female current marijuana users was consis- tent with our hylxrthesns that marijuana use Is a nsk factor for death due to injury. Marijuana is known to decrease psycho- motor performance; some studies have implicated its use to mutor vehicle crashes."K"-" Marijuana use is also strongly associated with alcohol use, another major risk for accidental death. There were too few deaths to meaning- fully study die odier main hypothesis. that marijuana use would be associated with increased respiratory disease mortality. Another study perforated on a subgroup of this cohort showed that daily or near -daily manjumta users who were not tobacco cigarette smokers had a 19% higher risk of outpatient visits for respira- tory disorders than nonusers of both substmces.'° The major limitations of this study Include Its reliance on self-report for ascerunment of matlju:ma use .talus: the Inability to study changes in marijuana use status during follow-up: a lack of lengthy follow-up Into the geriatric age range (m=ruuu lullow-up, 12.5 years: maximum age reached. 63 years): a lack of information regarding other illegal drug use. and potential underascertain- ment of mortality (noted earlier). Esu - males of manju:ma use were similar to diose obtained during this period by the National Household Survey on Drug Abuse, the most authoritative source of illegal drug use information for US adults.= The lack of longitudinal data regarding use status is common to many cohort studies. It seems unlikely that "ever" marijuana use status would have changed substantially over titre, because relatively few adults in this cohort are likely to have initiated marijuana use during follow-up in a period (the 1980s) when there was a marked secul,u decline In self-reported marijuana use in the United States.' It is possible that relation- ships between marijuana use and mortal - ay might be found with longer -tens follow-up or later in life It is likely that if information on subjects' use of other illegal drugs had been available, adjust- ment for other drug use would have lowered the relative risk estimates for marijuana use. As noted earlier, relatively few ad- verse clinical health effects front the chronic use of marijuana have been documented in humans.lip"' The cnminal- ization of marijuana use may itself be a health hazard. since it may expose the consumer to violence and criminal activ- ity.'" While reducing the prevalence of drug abuse is a laudable goal, we nwst recognize that marijuana use is wide- spread despite the lung -term, multibillion dollar War on Drugs. Therefore, medical guidelines regarding its prudent use should be esiabhshed. akin to the commonsense guidelines that apply to alcohol use. Unfortunately, clinical research on prnen- tml therapeutic uses for marijuana has been difficult to accomplish in the United States, despite reasonable evidence for the eflicacv of tcuahydrmannabmol (1 -HC) and nianjuma as antiemetic and antiglau- coma agent -5 and the suegcstive evidence for then efficacy In the treatment of other medical conditions- mcludme AIDS.-"'n�]n]i In sununary, flus study showed little. If any, effect of marijuana use on nun - AIDS mortihty to men and on total mor- tality In women. The Increased risk of AIDS mortality In male marijuana users probably did not reflect a causal relation- ship. but most likely represented uncon- trolled confounding by male homosexual behavior. The risk of mortality associated with manjuana use was lower than that Arnencan Joumal of Public Health 589