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In a cross-sectional study of 7716 US adults from the National Health And Nutrition Examination Study cohort, Kempker [34] showed no effect on FEV1/FVC up to 20 joint-years, but in those with greater than 20 joint-years there was a 2.1-fold risk for FEV1/FVC ratio 40 years) residing in Vancouver, Canada, as part of the Burden of Obstructive Lung Diseases (BOLD) study [41], the odds ratio (OR) for chronic respiratory symptoms was not increased among the 49% of respondents who reported ever using marijuana alone and importantly the concurrent use of marijuana and tobacco was associated with a higher OR for respiratory symptoms (OR, 2.59