A detailed description is given of the various modes of consumption of cannabis, bhang as a drink and charas for smoking, in Pakistan, a society in which cannabis is socially accepted.
The study includes preliminary social and medical investigations of 70 healthy male subjects, all of whom had consumed cannabis for at least 20 years. These examinations showed no significant abnormalities and in no case was there evidence that the use of cannabis interfered with the subjects' ability to work. There was no suggestion that either tolerance to the drug or physical dependence on it occurred.
Observations made on subjects indicated that the drug tended to cause a slight fall in the blood pressure and an increase in the heart rate. Some transient dryness of the oral mucosa and a tendency to develop an irritant cough occurred after smoking.
Such extensive studies on a much larger scale are required on a population which is well adjusted and where cannabis is socially accepted, and where only cannabis is used.
There is a vast literature on the subject of cannabis as a drug, although of uneven quality. A need was felt to study a society where cannabis use is accepted as a normal phenomenon similar to that of alcohol in Western countries. Only a few such studies have been performed by indigenous investigators having a thorough knowledge of the language and culture of the population. In addition, the long-term effects of cannabis have rarely been the object of study in a normal population.
The present paper describes an attempt to fill these gaps, as it reports a pilot study performed in Pakistan from January to March, 1973.
Pakistan is largely a rural country, with a population of approximately 55 million, is 803,420 sq. km. in extent, and the economy is mainly based on agriculture. Cannabis has been traditionally used for centuries. In some parts of the country and in some sections of the community cannabis is used and, although not totally approved, is not socially prohibited. In contrast, alcohol is looked down upon, apart from a tiny minority of Westernized people. The use of cannabis is equally prevalent in both urban and rural areas and is virtually confined to adult males.
Our aim was to study the long-term effects of cannabis in a socially well-adjusted population in contrast to many previous investigations which were usually concerned with special subgroups. The inevitable conclusion of such studies is that the use of cannabis, mental illness and criminality are causally related. We feel, however, that it is unjustifiable to generalize from subgroups of deviants, hence the reason for this pilot study.
There are vast regional and local differences in the habits and modes of cannabis consumption as well as the venues where cannabis is consumed. For this reason we selected two areas, one urban and one rural. Thirty-five subjects were selected from each area. Lahore, the urban area, is one of the oldest and largest cities in Pakistan and has a population of approximately 2.6 million inhabitants. We did not contact the subjects ourselves, as we thought that a direct approach might result in suspicion on their part. Instead, the subjects were contacted through a man who is active in community voluntary work. He is also esteemed by the local residents as a successful entrepreneur. The rural sample was drawn from nine villages near the city of Khanpur in the erstwhile state of Bahawalpur. The population of these villages ranged from 100 to 500 inhabitants.
In Lahore, 19 subjects were totally illiterate, 10 could barely read and write and 6 had had ten years of schooling. In the Khanpur area, 31 were totally illiterate, 3 could barely read and write, and only one had had ten years of schooling.
Fifteen of the subjects in Lahore were unmarried and 20 were married; 16 of the latter had an average of 5 children. In the Khanpur villages, 4 were unmarried and 31 married, 24 of these had an average of 6 children.
It is difficult to describe social class in the context of Pakistan economy. In Lahore most of our subjects belonged to the working class: 11 were skilled artisans, 14 were shopkeepers, 2 were laborers, 2 were clerks, 2 professional wrestlers, 1 was a beggar and 3 were well-to-do contractors. In Khanpur, 2 were beggars, 2 were laborers, 9 skilled artisans, 5 mirasees (traditional professional musicians who have a special social function in village life), 15 farm workers, 1 landowner and 1 restaurant owner.
The only criterion for the selection of the subjects was that they must have been taking cannabis regularly for a minimum period of twenty years. They were not interviewed or checked for their physical, mental or social background before the selection. The urban sample was, therefore, taken from the old city of Lahore, which represents the traditional Pakistani way of living. Likewise, the rural sample was selected from the nine neighboring villages near the city of Khanpur.
Our assistant selected a group of thirty-five suitable subjects in Lahore who were asked to come in the morning without taking cannabis. The subjects were picked up by taxi in the morning at their homes, two at a time, and were remunerated in order to maintain interest in the study.
In Khanpur the subjects gathered at the Dera (landlord's house) of the village. The investigation was divided into the following three phases: before, during, and after the consumption of cannabis. Before the consumption of cannabis, each subject was medically examined and interviewed about his social background, work habits, history of cannabis use, etc. [Appendix I]. He was then offered either charas (which is smoked), or bhang (which is drunk) [Appendix II]. A questionnaire for assessment of subjective feelings was completed for both charas smokers and bhang drinkers [Appendix III]. For the charas smokers it was first completed half an hour after smoking (it takes about 5-7 minutes to smoke one cigarette), and for bhang drinkers it was first completed an hour after drinking (the glass is emptied at once). The questionnaire was filled in at hourly intervals for the next four hours. Blood pressure, pulse and general neurological examinations were carried out at the same time.
The modes of cannabis consumption were found to be different in urban and rural areas. In Lahore cannabis was taken in both forms, i.e., 7 out of 35 were only charas smokers but 28 used both charas and bhang. In Khanpur the villagers were almost exclusively bhang drinkers, with two exceptions who occasionally smoked charas as well. The average number of charas cigarettes smoked in Lahore was 14 a day. Each cigarette contains approximately between 1/2-1 gram of cannabis. In Khanpur where bhang was consumed, the average number of tumblers taken was 6. The amount of bhang varies per glass but, on an average 6 glasses would contain approximately 60 grams of dried leaves. There was also a seasonal variation in the consumption of bhang; in the summer when long cool drinks are popular the intake is higher. Drinking bhang usually took place before meals, while smoking charas was not related to any special time of the day.
The average age of the subjects in Lahore was 44 years, with a range of 29-75. The average age at which the subjects started smoking was 16 years with a range of 8-25 years. The average length of time they had been smoking was 28 years with a range of 21-57 years. The average age in Khanpur was 53 years, ranging from 32-80 years. The average starting age was 17 years with a range of 10-25 years, and the number of years they had been drinking was 35, the range being 20-65 years.
Respondents were asked about the history and present mode of consuming cannabis. The picture which emerged corresponded very closely to alcohol drinking. All our respondents from both areas commenced drinking or smoking cannabis in a very unseif-conscious way, again rather like an average Westerner starting to drink alcohol. The reasons given were medical and social, but rather unspecific. Four of the subjects from Lahore and two from Khanpur had a previous history of alcohol or opium consumption. We must, however, point out that this is a regional variation and this picture would not be obtained in all parts of Pakistan. We found that in Lahore the respondents mainly used what are known as uddasi for drinking bhang in the company of their friends but smoked charas at work.
In the rural groups, the places known as Deras (the landlord's house) were found to be the focal point of social activities for villagers and were regarded as the centre of village political life. A certain group of people known as the mirasees [the musicians] were found to be the only group who were drinking bhang within the family.
All seventy subjects were given a full physical examination. No significant abnormalities could be detected and the previous medical histories were also negative. So was the family history. As can be seen from Appendix I, a lot of information was recorded but we have not discussed it here due to the lack of control groups. One very interesting medical point that emerged is that bhang drinkers, particularly from rural areas, pointed out that they had never suffered from dysentery, which is very common in Pakistan.
In no case was loss of libido reported. All the subjects thought that there was no effect on sexual desire, but some (50%) felt that ejaculation was delayed. No impairment was reported by the subjects in work functions; in any case, all subjects led a normal active life. No one reported having to cease or curtail any occupational or other activity because of taking cannabis. Some subjects even remarked that their ability to concentrate was better after they had consumed cannabis. Again nothing very suggestive medically was discovered, except for the blood pressure and pulse. In all cases, the systolic pressure fell while the diastolic pressure rose and the pulse rate was increased. With regard to the systolic pressure, the pattern of change varied slightly in some cases. Nothing abnormal was found in the neurological examinations.
Other findings revealed that symptoms such as pupillary reactions (myosis), irritative cough, shortness of breath, dryness of mucosa of the mouth, etc., were present after smoking charas. Difficulty in breathing also occurred after bhang consumption and the blood pressure and pulse showed a similar pattern, after drinking and smoking. The other symptoms, however, were only present after smoking. Conjunctival injection was observed in both charas smokers and bhang drinkers but this complaint is common among Pakistanis due to various local conditions and we have, therefore, excluded this symptom.
In the third stage of the study, a questionnaire that was completed on the following day revealed that a hangover never occurs after charas or bhang as is seen with alcohol [Appendix IV].
The most significant point which emerged was that in a society such as Pakistan where cannabis consumption is socially accepted, habituation does not lead to any undesirable results. We have deliberately used the word habituation rather than addiction because we did not find either increased tolerance or withdrawal symptomatology, which are the essential prerequisites for addiction.
We are aware of the fact that our sample is not random; we feel, however, that it was the best that could be obtained for a pilot study under the given circumstances.
In the areas we have described, the use of cannabis is as prevalent as alcohol drinking in Western countries, and it seems to be a lesser problem than alcohol. Our study appears to show that cannabis does not produce any serious long-term effects.
There appears to be a growing fear of the ill effects of cannabis among the educated classes in Pakistan. This attitude is unquestionably borrowed from Western publications in this field. The older generation tends to see cannabis in a different perspective and is perturbed about the sporadic cases of drug addiction among the young generation.
As has been pointed out, this is a pilot study; however, we availed ourselves of cultural background information in making sure that the sample of subjects in our study was as representative as possible of the population at large and was not drawn from deviant groups.
It can be concluded that:
1. No signs were found of physical or mental damage after 20 years consumption of cannabis.
2. Cannabis use does not seem to lead to addiction or any conditions resembling alcoholism.
3. There were no findings of mental disease, criminal offences or social, working or family breakdowns in any of our subjects.
4. All subjects had myosis after cannabis consumption; the systolic blood pressure fell whereas the diastolic pressure rose and the pulse increased.
We feel strongly that this kind of study on a much larger scale is essential in order to answer a whole range of questions relating to the medical, cultural and social aspects of cannabis use.
1 An udda is either a shop which specializes in selling cannabis, opiates, etc., or a meeting place attached to the local mazar [shrine].