CBD (Cannabidiol) Product Attitudes, Knowledge, and Use Among Young Adults
Meghann Wheelera, Julie Williams Mertena, Benjamin T Gordonb, and Hanadi Hamadic
SUBSTANCE USE & MISUSE, 2020, VOL. 55, NO. 7, 1138–1145
doi : 10.1080/10826084.2020.1729201
Background : Cannabidiol (CBD), a non-psychoactive component of cannabis is marketed as a potential treatment for many conditions and widely available to purchase as a dietary supplement. In 2017, sales of CBD exceeded 820 million dollars despite many unconfirmed health claims, murky legality, and limited product efficacy and safety testing.
Purpose/Objectives : This study aims to explore cannabidiol (CBD) knowledge, attitudes, and use among young adults.
Methods : The anonymous 36-item survey developed using Qualtrics was distributed via social media from November 2018 to January 2019 with 340 respondents.
Results : Of the 340 respondents, 242 reported they had heard of CBD, and 135 reported using CBD products. CBD users were primarily white, female, without children, made less than $25,000 per year, and unmarried. Most commonly used CBD products were edibles (56.30%), tinctures (54.07%), and vape (38.52%). Top reasons for use included stress relief (65.39%), relaxation (54.81%), and sleep improvement (42.22%). Many respondents reported using guesswork to determine dosage, and over half of respondents reported at least one unanticipated side effect.
Conclusions/Importance : This study revealed that many users are not responsibly using CBD products, many believe CBD products provide health benefits that are not yet scientifically proven, and they are not knowledgeable about legal and regulatory issues. Until CBD use is more thoroughly researched and has more comprehensive regulation, public health professionals should address alternative stress and anxiety treatment methods.
KEYWORDS : Cannabidiol; young adults; dietary supplements; patient education; CBD
The use of cannabis for medicinal and therapeutic purposes has become commonplace in recent years. The source of the purported therapeutic effects of cannabis are believed to be cannabinoids, which are secondary metabolites produced by the cannabis plant (Zuk-Golaszewska & Golaszewski, 2018). Since the discovery of the first cannabinoid, cannabinol, in 1899 (Pain, 2015), researchers have found that cannabis contains at least 113 types of cannabinoids; the two most widely known cannabinoids are tetrahydrocannabinol (THC) and cannabidiol (CBD) (Aizpurua-Olaizola et al., 2016). THC and CBD produce dramatically different effects; THC is the only known psychoactive component of cannabis, while CBD is the most popularized non-psychoactive component of cannabis (Hlozek et al., 2017).
Recently, CBD has been widely promoted as a natural remedy for many health issues including anxiety, depression, pain management, inflammation and sleep disorders (Campos, Fogac¸a, Sonego, & Guimar~aes, 2016). Although the purported medical and therapeutic effects of CBD are promising, currently there is only significant clinical evidence to support the use of CBD as an effective treatment method for epilepsy (Campos et al., 2016; Pavlovic et al., 2018; Schoedel et al., 2018). There are other preliminary studies that show potential for CBD to be an effective treatment method for a multitude of mental and physical health issues such as pain management, anxiety, insomnia, depression, schizophrenia, and opioid abuse (Abrams et al., 2007; Bergamaschi et al., 2011; Devinsky et al., 2017; Hurd et al., 2019; McGuire et al., 2018; Shannon, Lewis, Lee, & Hughes, 2019; Silote et al., 2019; World Health Organization, 2018; Zhomitsky & Potvin, 2012; Zuardi, Cosme, Graeff, & Guimaraes, 1993; Zuardi et al., 2017). Still, much of the current research analyzing the therapeutic potential of CBD has not advanced to the point of clinical significance (Hurd et al., 2019; Shannon et al., 2019). However, this is subject to change given there are nearly 200 active randomized control trials (RCTs) exploring the medicinal and therapeutic potential of CBD for conditions including bipolar disorder, Parkinson’s disease, alcohol abuse, Crohn’s disease, and drug dependence (World Health Organization, 2017; ClinicalTrials,gov, 2019).
While research evidence is mounting, there are public health concerns surrounding the CBD products that are currently available to consumers. First, the legality of hempderived CBD in the US is delicate given its close relationship with marijuana. Currently, CBD is still classified as a Schedule I substance under the Controlled Substances Act (CSA) if CBD is isolated from marijuana, and CBD is only legal if it is extracted from hemp (Corroon & Kight, 2018; Mead, 2017). The difference between marijuana and hemp as defined by the CSA is solely dependent on the amount of cannabinoids found in the plant; cannabis plants with less than 0.3% THC are considered to be hemp, and those over 0.3% THC are considered to be marijuana (Mead, 2017).
Nevertheless, it is important to understand that once CBD has been isolated from the plant it is impossible to know the origins of the chemical. This classification is poised to change within the next few years, and the FDA has begun to hold hearings to discuss the potential federal legality of cannabis and its constituents, including CBD (New York Times, 2019). In the meantime, CBD products currently on the market are loosely regulated because they are categorized as dietary supplements (Corroon & Kight, 2018). Dietary supplements are currently regulated under the Food and Drug Administration (FDA), specifically under the Dietary Supplement Health and Education Act (DSHEA).Yet they are not held to any pre-market regulation, and vendors are only required to notify the FDA if a new ingredient is used
in the manufacturing of their product (Starr, 2015). The FDA did attempt to rectify this issue with the issuance of the cGMP guidelines in 2007, which established standards for quality assurance such as routine product testing, label accuracy, and manufacturing standards. However, in the case of CBD and other plant-based supplements, there are multiple environmental influences such as plant environment,
genetic variability, and variations in farming technique.
These differences can affect the quality and strength of plant extracts in supplements due to multiple phytochemicals being present in a single extract, making it difficult for the cGMP guidelines to be enforced (Starr, 2015). These loose regulation standards have contributed to a general belief that CBD products currently on the market are safe for consumers, although that may not always be the case.
Another public health concern surrounding CBD is the common discrepancy between a product label’s projected contents and actual product content. Multiple studies have evaluated CBD products for quality and content and have found significant inaccurate labels among many brands.
Common label discrepancies included CBD content being incorrectly labeled, products containing THC even though the label stated the product had no THC, and the inclusion of ethanol that was not noted on the product label (Bonn-Miller et al., 2017; Pavlovic et al., 2018; Peace, Butler, Wolf, Poklis, & Poklis, 2016). The FDA has taken action on some of these vendors, and in the past several years the FDA has issued several warning letters to CBD vendors that addressed the medical claims made and the inaccurate labels of the products (Bonn-Miller et al., 2017; Mead, 2017; U.S. Food & Drug Administration, 2019). However, with hundreds (potentially thousands) of CBD products available to consumers all over the world, it is unlikely that the FDA has uncovered and addressed all vendors with content discrepancies.
Furthermore, analysis has shown that warning letters do little to deter dietary supplement vendors. For instance, one study found that 66.7% of dietary supplements that were recalled by the FDA were still available for consumer purchase 6 months afterwards, with no changes made to the product (Cohen, Maller, DeSouza, & Neal-Kababick, 2014).
Despite the problems revolving around legality and product quality, the CBD market continues to grow, and sales of hemp-derived CBD are expected to reach $1.9 billion by 2020 (Corroon & Kight, 2018). This projection would make CBD products roughly 5% of the total dietary supplement sales, higher than any other supplement (Axon, Vanova, Edel, & Slack, 2017; Homer & Mukherjee, 2018; Knapik et al., 2016; Massad, Hamdan, Agha, & Amr, 2017).
Although CBD has blossomed into one of the highest grossing dietary supplements on the market, there is limited research focusing on how CBD is used, purchased, and understood among users. Corroon and Phillips (2018) conducted the first comprehensive cross-sectional survey examining CBD among US adults; specifically medical conditions treated, methods of administration, stated use, use patterns,
side effects, and treatment efficacy. The current study is aimed to further the data of the Corroon and Phillips study and thus analyzed a young adult population. We chose to examine participant’s drug interactions, CBD product dosage, knowledge of CBD legality, drug classification, and regulations
to provide healthcare and public health professionals more extensive information to better understand patients who use CBD products.