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Usage and health perception of cannabidiol-containing products among the population in Germany: a descriptive study conducted in 2020 and 2021

Authors:
  • German Federal Institute for Risk Assessment

Abstract and Figures

Background Cannabidiol (CBD), a non-intoxicating substance of Cannabis sativa L ., is gaining consumer attention. Yet, legal regulations in the EU are complex and questions of potential health risks remain partly unanswered. In Germany, little is known about people who use CBD products. The aim of this cross-sectional study was to gain insight into the user group of CBD, reasons for consumption and risk perception towards CBD-containing products. Methods The study consisted of two parts: In the first part of the study, the prevalence of CBD awareness and usage in Germany was estimated using a telephone survey and a population-representative sample of n = 1,011 respondents. Based on these results, n = 2,000 participants being aware of CBD were surveyed with an online questionnaire in the second part of the study to examine usage and perception of CBD in users and non-users. Results When the study was conducted at the end of 2020 and beginning of 2021, 40.2% of the German participants had already heard of products containing CBD, and 11.4% had actually used them. 42.1% of the users consumed such products regularly, at least once a week, primarily orally via oils or tinctures, and purchased them mainly online. Besides curiosity – addressed especially in young adults – anticipated health benefits including pain and stress relief were main reasons for use. More than half of the study participants perceived the health benefits of CBD use as high or very high. In contrast, the health risks were rated as low or very low by most respondents. Assumptions about official testing for safety as well as physical effects of CBD-containing products varied between users and non-users. Conclusion About one in nine people in Germany uses CBD-containing products. Given reasons for consumption and perception of potential health risks and benefits suggest that people are insufficiently informed about CBD-containing products. The results of the study indicate that risk communication is needed to raise awareness for the topic and to inform (potential) users.
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Geppertetal. BMC Public Health (2023) 23:2318
https://doi.org/10.1186/s12889-023-17142-0
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BMC Public Health
Usage andhealth perception ofcannabidiol-
containing products amongthepopulation
inGermany: adescriptive study conducted
in2020 and2021
Johanna Geppert1*, Julika Lietzow1, Stefanie Hessel‑Pras1, Fabian Kirsch1, Bernd Schäfer1 and Benjamin Sachse1
Abstract
Background Cannabidiol (CBD), a non‑intoxicating substance of Cannabis sativa L., is gaining consumer attention.
Yet, legal regulations in the EU are complex and questions of potential health risks remain partly unanswered. In Ger‑
many, little is known about people who use CBD products. The aim of this cross‑sectional study was to gain insight
into the user group of CBD, reasons for consumption and risk perception towards CBD‑containing products.
Methods The study consisted of two parts: In the first part of the study, the prevalence of CBD awareness and usage
in Germany was estimated using a telephone survey and a population‑representative sample of n = 1,011 respond‑
ents. Based on these results, n = 2,000 participants being aware of CBD were surveyed with an online questionnaire
in the second part of the study to examine usage and perception of CBD in users and non‑users.
Results When the study was conducted at the end of 2020 and beginning of 2021, 40.2% of the German participants
had already heard of products containing CBD, and 11.4% had actually used them. 42.1% of the users consumed
such products regularly, at least once a week, primarily orally via oils or tinctures, and purchased them mainly online.
Besides curiosity – addressed especially in young adults – anticipated health benefits including pain and stress relief
were main reasons for use. More than half of the study participants perceived the health benefits of CBD use as high
or very high. In contrast, the health risks were rated as low or very low by most respondents. Assumptions about offi‑
cial testing for safety as well as physical effects of CBD‑containing products varied between users and non‑users.
Conclusion About one in nine people in Germany uses CBD‑containing products. Given reasons for consumption
and perception of potential health risks and benefits suggest that people are insufficiently informed about CBD‑con‑
taining products. The results of the study indicate that risk communication is needed to raise awareness for the topic
and to inform (potential) users.
Keywords Cannabidiol, CBD, Consumption, Risk perception, Online survey, Germany
Introduction
In recent years, cannabidiol (CBD) is gaining growing
consumer attention [1]. e substance belongs to one of
at least 130 naturally occurring phytocannabinoids that
have been identified in Cannabis sativaL. [2]. In indus-
trial hemp, CBD is the main cannabinoid [3]. In contrast
to tetrahydrocannabinol (THC), CBD is not intoxicating
*Correspondence:
Johanna Geppert
Johanna.Geppert@bfr.bund.de
1 German Federal Institute for Risk Assessment (BfR), Max‑Dohrn‑Str. 8–10,
Berlin 10589, Germany
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Geppertetal. BMC Public Health (2023) 23:2318
[4] and – according to a decision of the Court of Justice
of the European Union – should therefore not be consid-
ered a narcotic [5]. Notwithstanding, CBD interacts with
several molecular targets in the organism, potentially
resulting in beneficial but also adverse health effects [6].
In consequence, products containing high CBD doses
clearly exerting a pharmacological activity or being
intended for the treatment of diseases are considered to
be medicinal products in the European Union (EU). ey
require authorization according to EU regulations on
pharmaceuticals [7]. e rationale behind this is to pro-
tect consumers from potential health risks that may arise
from the products themselves or use of non-approved
products with unproven effects instead of effective
medicines.
Only low-dose CBD products without a pharmaco-
logical activity and without the intention to treat diseases
may potentially considered to be foods. Such CBD-con-
taining foods, however, are generally classified as novel in
the EU [8]. ey require a safety assessment carried out
by the European Food Safety Authority (EFSA), followed
by authorization by the European Commission before
they can be marketed in the EU [9]. Numerous novel
food applications for CBD and CBD extracts have been
submitted during the last years and are partly under risk
assessment [10]. EFSA recently identified some potential
hazards but was not able to fully assess the actual risks
due to several data gaps. Consequently, it was concluded
that “the safety of CBD as a novel food cannot currently
be established” [11]. erefore, no foods containing CBD
have yet been authorized and the marketing of such prod-
ucts as foods, including supplements, is currently consid-
ered illegal. Despite these rules, consumers can buy an
increasing number of illegally marketed CBD-containing
products, also in the form of food supplements, that are
available mostly online or in retail stores. In some cases,
such products are mislabeled, for example as “aroma oils”
or “cosmetics” to circumvent legal rules [12].
As described, the regulatory context for CBD is com-
plex and it might be put into question whether con-
sumers are aware of both the legal aspects as well as the
potential health risks. erefore, the aim of the current
study was to gain insight into the user group of CBD in
Germany, to investigate reasons for consumption, and to
gain information about the risk perception of the popu-
lation and its knowledge about CBD-containing prod-
ucts in order to target risk communication and increase
awareness for the substance.
Methods
Study design andparticipants
e study was conducted in two parts: In study part I the
prevalence for CBD awareness and usage was determined
while study part II examined the usage and perception
of CBD for users vs. non-users in detail. e two stud-
ies consisted of independent samples. Data collection
was conducted by German market research institutes. All
respondents expressed their consent to participate in the
surveys.
Study part I was carried out in Germany via telephone
survey from November 25 to November 26, 2020 by
trained market research assistants. e survey was con-
ducted with a sample of n = 1,011 respondents aged 14
years and older who were randomly selected via a ran-
dom digit dialing procedure including mobile and lan-
dline telephone numbers. For mobile phone numbers,
the person answering the call was selected for the inter-
view. For landline telephone numbers, the Kish selection
method [13] was used to choose the respondent within
a household. To achieve population representativeness,
data were statistically weighted using an iterative pro-
cess and a 2-step-procedure: [14] In a first step, weight-
ing took into account the number of mobile and landline
telephone numbers respondents could be reached by
(design weighting). In a second step, data were weighted
based on the German microcensus regarding gender,
education, age, employment, size of household and city,
West-/East-Germany and German federal state (adjust-
ment weighting). Within the questionnaire, participants
were asked whether they had already heard of products
containing CBD and, if so, whether they had consumed
or used such products (Suppl. A, Questionnaire Q1).
Study part II was carried out in Germany via an online
panel survey from March 11 to March 23, 2021, using a
quota sample. Quotas for gender, age, and education were
determined based on the results of study part I. Respond-
ents were randomly selected from the panel until the
desired number of participants meeting the quota targets
were obtained. An online questionnaire was developed
to determine CBD-containing product consumption
patterns, frequency and reasons for use, the perception
of health risks and benefits, and knowledge about CBD-
containing products. Respondents received remunera-
tion in accordance with the usual incentive structure of
a panel. e sample consisted of n = 2,000 resp ondents
with an age of 16 years and older that indicated that they
had already heard of products containing CBD.
Online questionnaire
e online questionnaire of study part II included ques-
tions on sociodemographic measures such as gender,
age, and education, as well as use, product groups, its
purchase, and frequency of use. Additional questions
addressed the intention of future use and the percep-
tion of health risks and benefits. Furthermore, open
questions asked participants about reasons for use and
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assumed health risks and benefits. Responses to these
open-ended questions were coded using code frames
that were developed within an inductive process. Multi-
ple codes were used for responses that consisted of more
than one aspect. e coding was cross-validated by two
researchers.
All questions included “don’t know” and/or “no
answer” options. For more details see the questionnaire
(Suppl. A).
Statistical analysis
Data were processed and analyzed using SPSS (Ver-
sion 26). Descriptive statistics including the calculation
of means (M) and standard deviations (SD) were used
to describe socio-demographics as well as product and
usage characteristics. In addition to descriptive statis-
tics, differences were analyzed for sociodemographic
groups (gender, age, education) and user status (user vs.
non-user). For these analyses, we grouped respondents
into three age categories (up to 29 years, 30 to 59 years,
60 years and older) as well as three educational catego-
ries (low: without graduation / student / lower secondary
school; medium: secondary school without high school
diploma; high: high school / university degree). Analy-
ses for Study part I are based on a weighted sample (see
“Study design and participants”). erefore, we applied
Rao-Scott adjustment [15] for complex survey data for all
tests of significance within study part I. Effect sizes were
calculated using common thresholds for interpretation
(Suppl. B, TableS1).
Results
Awareness andusage ofproducts containing CBD
Study part I revealed that 40.2% of the participants
between 14 and 95 years (M = 49.4 years, SD = 19.8)
have already heard of CBD-containing products. Of
them, 28.5% have already used such products. is cor-
responds to a proportion of 11.4% of the total number
of respondents (see Fig.1). Further analysis for usage
behavior revealed sociodemographic differences, with
the youngest age group of under 30 years being sig-
nificantly more likely to use such products than older
age groups (F[1.7, 1727.7] = 4.79, V = 0.15, p = .01).
ere were no significant differences for gender (F[1,
1010] = 0.83, V = 0.05, p = .36) and education (F[2,
2013] = 2.30, V = 0.11, p = .10). Further demographic
characteristics of the study part I are summarized in
TableS2 of the Supplemental material B.
Based on these findings, 2,000 subjects with prior
awareness of CBD-containing products were recruited
for study part II. Participants were between 16 and
85 years (M = 43.6 years, SD = 16.2). 26.8% had prior
experience using CBD (Fig.2 and Suppl. B, TableS3).
ose who gave no response or were not sure if they
had consumed or used CBD (9.7%) were excluded from
analysis comparing users (respondents with prior expe-
rience using CBD) vs. non-users (respondents without
prior experience using CBD). Non-users (n = 1,271)
were asked whether they could imagine consuming
CBD-containing products in the future, of which 48.3%
answered affirmatively (Suppl. B, TableS4).
Fig. 1 Study part I: Percentage of participants answering “yes”, “no” or don’t know / no response” to the question “Have you already heard of any
products that contain CBD?”, Percentage of participants subsequently answering “yes” to the question “Have you already consumed or used any
products that contain CBD?”; Details in Suppl. B, Table S2. Base: All respondent (n = 1,011) and respondents who have already consumed/had used
CBD (n = 116)
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Purchase behavior
Study part II revealed that of all users (n = 535), the
majority obtained CBD-containing products via online
stores (55.3%). In addition, pharmacies (21.1%), special-
ized stores for CBD and hemp products (20.0%) and
drug stores (19.6%) were also reported as sources of sup-
ply (Suppl. B, TableS5). CBD-containing products used
included oils and tinctures (58.1%), foods (20.0%), cos-
metic and skin care products (17.8%), flowers (16.6%),
beverages (16.1%), as well as capsules or pills (15.1%,
see Fig. 3). If gender distribution is considered, female
users indicated significantly more often than male
users that they use CBD-containing oils and tinctures
( Χ² [1] = 23.18, V = 0.21, p < .001,) as well as skin care
products (Χ² [1] = 10.98, p < .001), whereas male users
reported using CBD-containing flowers ( Χ² [1] = 12.57,
V = 0.15, p < .001), be verages (Χ² [1] = 5.80, V = 0.10,
p = .02), and liquids for e-cigarettes or vaporizers (Χ²
[1] = 5.89, V = 0.11, p = .02) significantly more often than
female users. Gender differences were of small effect size.
Frequency andreasons foruse ofCBD‑containing products
In study part II, when asked about the frequency of use,
42.1% of users indicated that they currently use CBD-
containing products at least once a week and 17.6% use
CBD-containing products daily. Of those with prior
experience with CBD, 19.8% reported that they do not
currently use any product.
Considering demographic differences, respondents
in higher compared to lower age groups (Χ² [2] = 26.33,
V = 0.22, p < .001) and those with a lower compared
to a higher level of education (Χ² [2] = 18.53, V = 0.19,
p < .001) reported more often to consume CBD products
at least once a week (Suppl. B, TableS6). Group differ-
ences were of medium effect size.
e main motivation for consuming CBD-contain-
ing products stated in an open-ended question is pain
relief (27.7%), followed by curiosity (20.7%), stress relief
and relaxation (16.6%) as well as improved sleep quality
(14.2%, Fig. 4). Reasons for use are differently distrib-
uted among the age groups, partly with large effect sizes:
Compared to the youngest age group (16–29 years), older
age groups significantly more often mentioned pain relief
(Χ² [2] = 69.07, V = 0.36, p < .001) and improved sleep (Χ²
[2] = 7.23, V = 0.12, p = .03). Conversely, the youngest age
group mentioned significantly more often curiosity (Χ²
[2] = 12.89, V = 0.16, p = .002) and stress relief/relaxation
(Χ² [2] = 11.11, V = 0.14, p = .004) as reasons for use. Also,
the youngest age group was less likely to respond to the
question (Χ² [2] = 21.22, V = 0.20, p < .001).
Perception ofhealth risks andbenets
Across all participants in study part II, health benefits
were rated to be much higher than health risks (t[1689]
= -33.86, d = -0.82, p < .001; Fig. 5). While 54.7% of all
respondents consider the health risks of CBD products
to be low or very low, 55.3% perceive the health benefits
of CBD-products to be high or very high. Comparing
users versus non-users, non-users significantly consider
health risks to be greater than users (t[1139.4] = -10.51, d
= -0.54, p < .001), whereas users consider health benefits
to be somewhat greater than non-users (t[1577] = 4.34,
d = 0.23, p < .001). Notably, the percentage of respondents
who did not give an answer was higher among non-users
than among users for both health benefits (Χ² [1] = 81.99,
V = 0.21, p < .001) and health risks (Χ² [1] = 64.48,
Fig. 2 Study part II: Percentage of all participants answering “no”, “not sure / no response, “yes” to the question “Have you already consumed or used
any products that contain CBD?”; Main demographic characteristics of the respondents that already consumed or used any products that contain
CBD (details in Suppl. B, Table S3). Base: All respondents (n = 2,000) and respondents who have already consumed/had used CBD (n = 535)
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V = 0.19, p < .001), with medium effect sizes. For further
details see Suppl. B, TableS7.
Respondents who rated the health risk of CBD prod-
ucts as at least 3 (on a scale of 1 = very low to 5 = ver y
high) were further asked to name health risks that they
see in such products using an open-ended question
(n = 639; Fig.6). About one third (32.9%) of the respond-
ents were concerned about habituation and addiction,
followed at a great distance by negative mental effects
(6.9%) and negative physical effects (5.9%).
Respondents who rated the health benefits of CBD
products as at least 3 (on a scale of 1 = very low to
5 = very high) were further asked to name health benefits
that they see in such products using an open-ended ques-
tion (n = 1,497; Fig.7). e most commonly cited benefit
is the anticipated pain-relieving effect of CBD (34.7%).
Just under a quarter of respondents (23.1%) cite stress
reduction and relaxation. Further health benefits stated
by the respondents were better sleep (5.9%) and the natu-
ralness of CBD (5.8%).
In study part II, all participants were asked about gen-
eral safety aspects of CBD-containing products (Fig.8). In
this context, 47.1% of the respondents assume that CBD-
containing products have been tested to ensure their safety.
is proportion is somewhat higher amongst users of
CBD-containing products than non-users (59.1% vs. 42.5%;
Χ² [1] = 41.51, V = 0.15, p < .001). While 71.2% of users dis-
agree that CBD can be physically addictive, only 38.9% of
non-users make that assumption. Considerably more users
than non-users assume that CBD cannot provoke a feeling
Fig. 3 Study part II: Product groups containing CBD used by consumers/users; separated by gender. Base: Respondents who have already
consumed/had used CBD (n = 535), male (n = 256) and female (n = 277); multiple answers possible. Respondents indicating “divers” as gender are
included in the total sample
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of being “high” (73.5% vs. 42.9%; Χ² [1] = 141.03, V = 0.28,
p < .001) and also think that CBD-containing products may
contain THC (49.0% vs. 23.0%; Χ² [1] = 119.67, V = 0.26,
p < .001). 39.6% of all respondents assume that CBD may
interact with medicinal products. For all items, proportion
for “don’t know / no response” was quite high (between
25.2 and 48.6% across the total sample) and significantly
more often indicated by non-users compared to users (Χ²s
[1] 50.93, Vs 0.17, ps 0.001).
Discussion
e results of the study provide insights into gen-
eral awareness and use of CBD-containing products
in the German population. 40.2% of the respondents
had already heard of such products. is proportion is
slightly lower than observed in other studies. In France,
about 69% had already heard of CBD [16], while a recent
German study found a proportion of approximately 48%
[17]. Looking at the prevalence of users in the different
studies, a relatively consistent picture emerges for Euro-
pean countries with about one in ten who already has
used CBD-containing products among the general pop-
ulation (Germany: 11.4% according to our study; France:
10.1%.; UK: 10.9%) [16, 18]. In contrast, a substantially
lower usage rate of 4.3% was observed for Germany
in a recently published study by Alayli etal. [17]. is
deviation may be due to a specific focus on recreational
use of CBD products in this study whereas our study as
Fig. 4 Study part II: Reasons for the consumption or use of CBD‑containing products (open question) separated by age groups. Base: Respondents
who have already consumed/had used CBD (n = 535), 16–29 years (n = 196), 30–59 years (n = 254) and 60 years and older (n = 85)
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well as the other European studies considered a broader
product range. In contrast, the proportion of users
(just within the past 12 months) was higher in a non-
representative study conducted in the US (26.1%) and in
Canada (16.2%) [19]. Classification and accessibility var-
ies strongly between these countries [20, 21] which – in
part – might explain the varying proportions of users
between countries. In addition, due to the generally
more liberal approach to cannabis in some parts of the
US and Canada, it might also be assumed that consumer
acceptance to CBD products is higher in North Ameri-
can Countries than in Europe.
In the present study, the age group under 30 years
had the largest proportion of users. is finding is con-
sistent with another study that observed a proportion
of approximately 34% users among adults aged 18–24
years in the US [22] pointing out that the use of CBD
products is relatively prominent among young adults.
ese results give valuable insights with regard to rel-
evant target groups for risk communication measures.
Fig. 5 Study part II: Perception of health risks and benefits. Answers to the question “How do you rate the health risks and health benefits
of products containing CBD (cannabidiol)?” on a scale from 1 = very low to 5 = very high. Base: All respondents (n = 2,000), users (n = 535)
and non‑users (n = 1,271)
Fig. 6 Study part II: Perceived health risks. Base: Respondents who rated health risks of CBD products as at least 3 on a scale of 1 (very low) to 5
(very high) (n = 639). Open‑ended question
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More than half of the users interviewed consume
CBD orally via oils or tinctures, to a lesser extent via
other products like foods or cosmetic and skin care
products. Further, almost 13% indicated to use liquids
with CBD for e-cigarettes and vaporizers. Interestingly,
a study by Alayli etal. [17] showed that awareness and
consumption of recreational CBD products is generally
associated with e-cigarette use. At the same time, syn-
thetic cannabinoids in e-liquids have been associated
with several health risks including neurological symp-
toms [23]. e use of CBD in this form should therefore
receive special attention in risk communication.
Beyond, a relatively large part of the users consume
CBD products at least once a week (42.0%), indicating
a rather regular than occasional usage pattern. Results
from the current study and other studies clearly show
that, beside curiosity, anticipated health benefits such
as pain-relief, stress reduction, and improvement of
sleep are important reasons for consumption [17, 19,
22]. In the present study, main reasons for consumption
significantly differed between age groups. While curios-
ity and stress relief were commonly cited by the young-
est age group (16–29 years), pain relief and improved
sleep were important motivators for the older respond-
ents, especially those of 60 years and older.
In the present study, health benefits of CBD-contain-
ing products were mentioned more often by the par-
ticipants than potential health risks, especially among
users of such products. Similar results were obtained by
others [19, 18]. Indeed, scientific data show that CBD
interacts with several molecular targets [6]. erefore, it
is frequently assumed that CBD can be used as a thera-
peutic agent [24]. However, only one medicinal product
solely containing CBD as the active ingredient is cur-
rently authorized in the US and in the EU, intended for
the treatment of certain forms of epilepsy or tuberous
sclerosis [20, 25]. Although there are first indications for
therapeutic effects also for other disorders, the clinical
efficacy of CBD for those indications has not yet been
finally proven [26, 27].
Health risks were considered as being low or very low
by the majority of participants in the present study, espe-
cially among users. Similar observations were made in
other studies [16, 19]. However, following the motto “no
effects without side effects”, various adverse effects have
already been associated with CBD exposure. Results from
animal studies and the use as a drug indicate potential
hazards like hepatotoxicity, gastrointestinal complaints,
neurological symptoms, a negative impact on the endo-
crine system, reproductive toxicity, as well as potential
Fig. 7 Study part II: Perceived health benefits. Base: Respondents who rated health benefits of CBD products as at least 3 on a scale of 1 (very low)
to 5 (very high) (n = 1,497). Open‑ended question
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drug-drug interactions – at least at higher doses [4, 11].
However, due to data gaps health risks cannot be finally
evaluated at the time [11]. Interestingly, the most fre-
quently mentioned concern among the respondents,
namely addiction, has no relevance from a scientific
point of view, as long as products are not contaminated
with THC. ese results indicate that consumers are
insufficiently informed about the scientific uncertainties
regarding the effects of CBD. Here, targeted risk com-
munication measures could prevent consumers from
being misinformed by advertisement and non-scientific
sources.
Although CBD-containing foods are currently not
legal, a variety of illegally marketed products declared as
foods, food supplements, or otherwise intended for oral
consumptions can be purchased from several sources
– especially online. Beyond potential risks of CBD, the
quality of such products may vary. is is of particular
note, as almost half of the respondents assume that CBD-
containing products have been tested to ensure their
safety. However, this is generally not the case for con-
sumer products and foods including food supplements,
since these product categories are not tightly regulated
by official bodies. In addition to targeted information
about potential health risks, clarifying the regulatory cir-
cumstances can enable consumers to make an informed
decision about whether or not to use CBD-containing
products.
Strengths andlimitations
One of the study’s strength is its sample size and account-
ing for various socio-demographic variables. Using a
two-stage study design, we were able to assess the usage
rate for CBD-containing products based on a population
representative sample (study part I), while focusing on
more detailed information on usage and perception for
specific groups of users vs. non-users within the study
part II. However, since the survey for study part II was
conducted via an online questionnaire and using quota
sampling, generalizability of our findings is restricted to
the characteristics of the recruited sample (e.g., people
with low affinity for online applications or without inter-
net access are underrepresented). Also, as participants
self-reported their behavior, there might be a bias in their
Fig. 8 Study part II: Knowledge about CBD. Percentage of respondents answering “In your opinion, does each of the following statements apply
or not?” Base: All respondents (n = 2,000), users (n = 535) and non‑users (n = 1,271)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 11
Geppertetal. BMC Public Health (2023) 23:2318
answers due to desirability. As this has been a cross-
sectional study, the data represent a selective moment.
Statements about trends are therefore not possible.
Conclusion
About 40% of the German population have already
heard of CBD-containing products and about 11% have
actually used them. However, as already observed in
previous studies, it may be concluded from data in the
present study that consumers are insufficiently informed
about CBD-containing products. is includes regula-
tory aspects – but even more important – awareness of
potential health risks and the insufficient scientific data
basis regarding health benefits. It appears that consum-
ers may underestimate health risks while overestimating
beneficial effects. Independent consumer information is
highly needed.
Abbreviations
CBD Cannabidiol
EU European Union
M Means
SD Standard deviation
THC Tetrahydrocannabinol
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12889‑ 023‑ 17142‑0.
Additional le1.
Acknowledgements
The authors would like to thank Kantar GmbH and hopp Marktforschung for
managing data collection and the respondents for their participation in our
study.
Authors’ contributions
JG and FK drafted the study design and the online survey and were given
feedback by the other authors, JL, BSA, BSC and SHP. JG and FK conducted
the analysis. JG wrote the methods, results and parts of the discussion. JL,
BSA, BSC and SHP wrote the introduction, conclusion, parts of the discussion
and contributed to the results. All authors approved the final version of the
manuscript.
Funding
Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The datasets generated and analyzed during the current study are not pub‑
licly available due to institutional restrictions. Information on data are available
from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical principles and appropriate consent procedures were applied in the
study. Formal approval by an institutional review board could not be obtained
as such an approval procedure is not yet in place at our institution for this type
of research. Based on the guidelines of the DFG (https:// www. dfg. de/ en/ resea
rch_ fundi ng/ faq/ faq_ human ities_ social_ scien ce/ index. html), ethical approval
was not required for this study: The study did not include experimental
manipulation or psychological tests. No person‑identifiable data, sensitive or
confidential data were collected. In addition, respondents could always quit
the survey before completion and had the possibility to refuse to answer one
or more questions. All data were recorded and processed anonymously and all
respondents involved in the study provided their consent to participate. Also,
the study was conducted in accordance with the ICC/ESOMAR International
Code on Market, Opinion and Social Research and Data Analytics (https://
www. ipsos. com/ sites/ defau lt/ files/ 2017‑ 11/ ICCES OMAR_ Code_ Engli sh. pdf)
and the regulations of the Association of German Market Research Institutes
(https:// www. adm‑ ev. de/ en/ stand ards‑ guide lines/). The latter include a
“Guideline on Interviewing Minors” supported by the German Association of
Social Science Institutes (ASI) and the German Society of Online Research. It
states, that informed consent of the custodian for minors between the ages
of 14 and up to and including 17 years is only mandatory for interviews that
includes sensitive topics. Based on the considerations described above and
because the study did not investigate a sensitive topic (such as illegal behav‑
ior), custodian consent was waived. For internet‑based surveys, processing
personal data of minors up to and including the age of 15, the custodian’s
consent is required in accordance with Art. 8(1) EU‑GDPR. The study adheres
to these guidelines. Persons under 16 years of age did not participate in the
online survey of the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 17 April 2023 Accepted: 2 November 2023
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... Sales in Europe are predicted to reach EUR 3.47 billion by 2024 [28]. Various surveys from Germany [29], the UK and Ireland [30], the USA [31,32], and Canada [32] have examined the number of users, reasons for use, and public perception of CBD. CBD appears to be most popular in the USA, where 26% of respondents [32] stated that they had used CBD, compared to 11% in Germany [29]. ...
... Various surveys from Germany [29], the UK and Ireland [30], the USA [31,32], and Canada [32] have examined the number of users, reasons for use, and public perception of CBD. CBD appears to be most popular in the USA, where 26% of respondents [32] stated that they had used CBD, compared to 11% in Germany [29]. However, there is also some time between the studies (2022 USA, 2020 Germany), and the number of consumers in Germany may have increased in the meantime. ...
... However, there is also some time between the studies (2022 USA, 2020 Germany), and the number of consumers in Germany may have increased in the meantime. The most prevalent method of oral CBD administration is via oils, tinctures, and edibles [29,31,33], and the Internet, including social media, appears to be a popular source of information [31,34,35]. ...
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Full-text available
Cannabidiol (CBD), a non-psychotropic main component of the Cannabis plant, has been approved as a drug in the European Union (EU) under the name “Epidyolex”. However, its approval process as a food ingredient under the Novel Food Regulation was paused by the European Food Safety Authority (EFSA) due to a lack of safety data. Nevertheless, there is a growing, unregulated market in which CBD is advertised with various health claims and dosage instructions. Of particular concern is its toxic effect on the liver and possible reproductive toxicity in humans. Studies suitable for calculating the benchmark dose were identified from the available data. Animal studies yielded a benchmark dose lower confidence limit (BMDL) of 43 mg/kg bw/day, which translates into a safe human dose of approximately 15 mg/day. Only the Lowest-Observed-Adverse-Effect Level (LOAEL) of 4.3 mg/kg bw/day could be identified from the human data. This updated risk assessment confirmed a health-based guidance value (HBGV) of 10 mg/day based on human LOAEL. Despite the existing data gaps, preliminary regulation appears advisable because the current form of the gray CBD market is unacceptable from the standpoint of consumer safety and protection.
... Various surveys from Germany [29], UK and Ireland [30], and the USA [31,32] and Canada [32] have looked at the number of users, reasons for use and public perception of CBD. CBD appears to be most popular in the USA, where 26% of respondents [32] stated that they had used CBD, compared to 11% in Germany [29]. ...
... Various surveys from Germany [29], UK and Ireland [30], and the USA [31,32] and Canada [32] have looked at the number of users, reasons for use and public perception of CBD. CBD appears to be most popular in the USA, where 26% of respondents [32] stated that they had used CBD, compared to 11% in Germany [29]. However, there is also some time in between the studies (2022 USA, 2020 Germany), and the number of consumers in Germany may have increased in the meantime. ...
... However, there is also some time in between the studies (2022 USA, 2020 Germany), and the number of consumers in Germany may have increased in the meantime. The most prevalent method of oral administration of CBD is in the form of oils, tinctures, and edibles [29,31,33], and the internet, including social media, seems to be a popular source of information [31,34,35]. ...
Preprint
Full-text available
Cannabidiol (CBD), a non-psychotropic main component of the Cannabis plant, is approved as a drug in the European Union (EU) under the name “Epidyolex”. However, the approval process as a food ingredient under the Novel Food Regulation was paused by the European Food Safety Authority (EFSA) due to a lack of safety data. Nevertheless, there is a growing, unregulated market in which CBD is advertised with various health claims and different dosage instructions. Of particular concern is its toxic effect on the liver and possible reproductive toxicity in humans. Studies suitable for calculating a benchmark dose were identified from the available data. Animal studies yielded a Benchmark Dose Lower Confidence Limit (BMDL) of 43 mg/kg bw/day, which translates into a safe human dose of approximately 15 mg/day. Only a Lowest Observed Adverse Effect Level (LOAEL) of 4.3 mg/kg bw/day could be identified from the human data. This updated risk assessment confirmed the Health-based Guidance Value (HBGV) of 10 mg/day based on human LOAEL. Despite existing data gaps, preliminary regulation appears advisable as the current form of the gray CBD market is unacceptable from the standpoint of consumer safety and protection.
... Indeed, there have been notable increases in the use of CBD for medicinal purposes reported globally (World Health Organization, 2018). Although CBD is not yet established as a pharmacological treatment for psychiatric conditions (Black et al., 2019;World Health Organization, 2018) , a primary motive for non-medical CBD use appears to be its purported anxiolytic and stress-dampening effects (Geppert et al., 2023;Gournay et al., 2024). Among healthy individuals, stress and anxiety represent adaptive responses to challenges that arise during daily living, and it is estimated that on average healthy individuals will elicit a stress response once every 3 days (Stawski et al., 2013). ...
... Among healthy individuals, stress and anxiety represent adaptive responses to challenges that arise during daily living, and it is estimated that on average healthy individuals will elicit a stress response once every 3 days (Stawski et al., 2013). Healthy individuals often engage in efforts to dampen stress-related effects when they occur, and there is growing evidence that CBD is commonly used for relaxation and stress relief among the general population (Geppert et al., 2023;Gournay et al., 2024). ...
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... A recent study conducted in Germany reported that approximately 40% of the German population are aware of products containing CBD, while around 11% also use these products [8]. Additionally, this study indicated that consumers are insufficiently informed about products containing CBD, i.e., there is limited awareness of potential health risks and of the insufficient scientific data base for the claimed health benefits. ...
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... Compared to nonusers, prior cannabis users also rated all cannabinoids higher for many non-therapeutic positive effects including enhanced mood, creativity, and social and sexual facilitation, and were less likely to endorse negative effects including the risks for impaired cognition, addiction, and psychosis. CBD users mostly report high perceived positive health and wellness effects (Binkowska et al., 2024;Corroon & Phillips, 2018;Fedorova et al., 2021;Geppert et al., 2023;Goodman et al., 2022;R. Kaufmann et al., 2023;Leas et al., 2020;Moltke & Hindocha, 2021). ...
... General population surveys I am aware of do not explicitly distinguish medical from recreational use (e.g., Germany: [28]; Austria: [35]; Spain: [34]). As for low-THC/ high-CBD products, the rising popularity has resulted in about 1 in 10 adults in Germany reporting using those products, with a sizeable share (18%) reporting daily consumption [16]. In Austria, the prevalence of high-THC and low-THC/high-CBD products was comparable in 2020 (3-5%: [35]). ...
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Cannabis use and treatment demand has risen in the past decade. Previous analyses of treatment demand are limited by methodological constraints or are outdated. Cross-country differences and trends in cannabis treatment demand are described using data from the European Monitoring Centre for Drugs and Drug Addiction. Two novel indicators are employed: firstly, the cannabis-attributable treatment fraction (CATF) is obtained by dividing the number of treatment entrants for cannabis use problems by the number of treatment entrants for any substance use problem, accounting for possible changes in the reporting system. Secondly, comparing the number of treatment entrants for cannabis use problems to the number of people who use cannabis (near) daily yields the treated-user-ratio (TUR), which considers a proxy for treatment need (frequent use). Across 30 countries with available data, the importance of cannabis in European treatment facilities varies greatly (CATF: min = 3%; max = 65%), with lower estimates in Eastern European countries. Across 20 countries with complete data, the CATF has risen from 29.4% in 2013 to 37.1% in 2020. The TUR calculated on 26 countries suggests that about 3 in 100 frequent users have sought treatment for their cannabis use problems. Over time, treatment demand has increased at a slower pace than treatment need in most countries. One in three treatment entrants for substance use problems in Europe are due to cannabis, with large variations between countries. There are indications for a widening treatment gap for cannabis use problems. In countries liberalising cannabis laws, monitoring changes in treatment access and demand is warranted.
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Introduction Cannabis and cannabidiol (CBD) may potentially alleviate symptoms and improve the quality of life of people with Parkinson’s disease (PD), although clinical results to date have provided conflicting evidence. In France, cannabis use is illegal outside the current restricted medical cannabis experimental framework which does not include PD as an eligible condition. In contrast, CBD products are legal and are easily available. We aimed to evaluate the acceptability of therapeutic cannabis and CBD use, and to assess cannabinoid-related attitudes among people with PD in France, with a view to assessing the potential inclusion of medical cannabinoids in PD treatment options. Methods We conducted a French nationwide online survey among people with PD. Cannabis and CBD acceptability levels were derived from the answers to four questions. Logistic regressions were performed to identify factors associated with these levels. We also collected data on knowledge, information-seeking, and barriers to self-medication. Results Of 1136 participants, acceptability levels of medical cannabis and CBD use were 81.7% and 87.4%, respectively. For both substances, acceptability was associated with the presence of anxiety symptoms, greater knowledge about cannabinoids, seeking information on medical cannabis, and considering the risk of cannabis dependence to be low. A fear of dependence was one of the main barriers to using either substance; healthcare providers were rarely mentioned as sources of information on medical cannabis. Conclusions Acceptability levels of cannabis and CBD were high. Acceptability was associated with knowledge and perceptions of cannabinoids. Given ongoing misconceptions about the effects and risks associated with CBD, disseminating accurate information could increase its acceptability in people with PD.
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Abstracts Background Cannabidiol (CBD) use has been increasing for its putative therapeutic potential for various health conditions. Research using a nationally representative sample is needed to examine characteristics of CBD users. Methods Data came from the adult sample (N=47,100) of the 2022 U.S. National Survey on Drug Use and Health. We fitted generalized linear models to examine the sociodemographic, health, other substance use, and cannabis risk perception as correlates of CBD-only use and CBD-cannabis co-use, compared to cannabis-only use. Results In 2022, 20.6 % and 23.0 % of U.S. adults reported using CBD and cannabis, respectively, in the preceding 12 months, and 63 % of CBD users also used cannabis. CBD use was significantly higher among women (CBD-only vs. cannabis-only use: IRR=1.43, 95 % CI=1.31–1.57), but significantly lower among Black and Hispanic individuals compared to non-Hispanic White individuals (CBD-only vs. cannabis-only use: IRR=0.71, 95 % CI=0.60–0.85 for Black individuals; IRR=0.79, 95 % CI=0.65–0.96 for Hispanic individuals). Older ages, higher SES, chronic medical conditions, mental illness, and high cannabis risk perception were also associated with higher likelihood of CBD-only use versus cannabis-only use. CBD-cannabis co-users were at most risk in terms of chronic illness, mental illness, cannabis use disorder, and other substance use problems. Conclusions The high prevalence of self-reported CBD use among those with physical and mental health problems warrants public health warnings about potential side effects and drug interactions. The high CBD-cannabis co-use rate also calls for more research on potential benefits and negative effects of the co-use.
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Background Cannabidiol (CBD), a safe, non-intoxicating cannabis component, is growing in popularity in Europe and worldwide. However, CBD EU regulation is blurry, and consequent labelling and product quality issues may have implications for public health. There is therefore a need to assess the prevalence and perceived harmfulness of CBD use in EU countries, as well as to characterise CBD users. We aimed to do so in the French population. Methods In December 2021, an online survey was conducted in a sample respecting the French adult population structure for key demographic variables. Sociodemographic, behavioural and CBD perception data were collected. Three separate regressions were performed to identify correlates of i) having heard of CBD, ii) using CBD, iii) perceived harmfulness of CBD. A hierarchical classification was also performed to identify profiles of CBD users. Results The study sample comprised 1969 adults, of whom 69.2% had heard of CBD and 10.1% used it. Less than half (46.8%) of the former considered it harmful. Having heard of CBD was associated with younger age, being born in France, tobacco use, and cannabis use. CBD use was associated with younger age, tobacco use, cannabis use, poor self-reported general health status, and positive perception of alternative medicines. Cluster analysis revealed four different CBD user profiles based on socio-demographics and behavioural characteristics. Conclusion Ten percent of the adults in this French study used CBD, and several user profiles emerged. Our results indirectly advocate clearer European CBD regulations to ensure safe and high-quality products.
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Cannabidiol (CBD) is the second most abundant component of the Cannabis plant and is known to have effects distinct from Δ9 -tetrahydrocannabinol (THC). Many studies that examined the behavioral effects of CBD concluded that it lacks the psychotomimetic effects attributed to THC. However, CBD was shown to have a broad spectrum of effects on several conditions such as anxiety, inflammation, neuropathic pain, and epilepsy. It is currently thought that CBD engages different targets and hence CBD's effects are thought to be due to multiple molecular mechanisms of action. A well-accepted set of targets include GPCRs and ion channels, with the serotonin 5-HT1A receptor and the transient receptor potential cation channel TRPV1 channel being the two main targets. CBD has also been thought to target G protein-coupled receptors (GPCRs) such as cannabinoid and opioid receptors. Other studies have suggested a role for additional GPCRs and ion channels as targets of CBD. Currently, the clinical efficacy of CBD is not completely understood. Evidence derived from randomized clinical trials, in vitro and in vivo models and real-world observations support the use of CBD as a drug treatment option for anxiety, neuropathy, and many other conditions. Hence an understanding of the current status of the field as it relates to the targets for CBD is of great interest so, in this review, we include findings from recent studies that highlight these main targets.
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Cannabidiol (CBD) is an abundant non-psychoactive phytocannabinoid in Cannabis extracts which has high affinity on a series of receptors, including type 1 cannabinoid receptor (CB1), type 2 cannabinoid receptor (CB2), GPR55, transient receptor potential vanilloid (TRPV), and peroxisome proliferator-activated receptor gamma (PPARγ). By modulating the activities of these receptors, CBD exhibits multiple therapeutic effects, including neuroprotective, antiepileptic, anxiolytic, antipsychotic, anti-inflammatory, analgesic and anti-cancer properties. CBD could also be applied to treat or prevent COVID-19 and its complications. Here, we provide a narrative review of CBD's applications in human diseases: from mechanism of action to clinical trials.
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The popularity of cannabidiol (CBD) in consumer products is soaring as consumers are using CBD for general health and well-being as well as to seek relief from ailments especially pain, inflammation, anxiety, depression, and sleep disorders. However, there is limited data currently in the public domain that provide support for these benefits. By contrast, a significant amount of safety evaluation data for CBD has been obtained recently from pre-clinical and clinical studies of the CBD therapeutic Epidiolex®. Yet some key data gaps concerning the safe use of CBD still remain. Furthermore, current regulations on CBD use in consumer products remain uncertain and often conflict between the state and federal level. In light of the rapidly expanding popularity of CBD-related products in the marketplace, here we review the current understanding of the benefits, safety, and regulations surrounding CBD in consumer products. This review does not advocate for or against the use of CBD in consumer products. Rather this review seeks to assess the state-of-the-science on the health effects and safety of CBD, to identify critical knowledge gaps for future studies, and to raise the awareness of the current regulations that govern CBD use in consumer products.
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The market value of cannabidiol (CBD) is growing as people seek holistic ways of managing their health. The aim of this study was to explore the public's perceptions and use of CBD products, including where products were sourced, knowledge transfer and opinions on quality, safety and efficacy of CBD products. An online questionnaire was distributed via social and professional networks, in addition to face-to-face data collection days, which employed convenience and snowball sampling methods. A total of 597 participant responses were analysed, of which 10.9% (n = 65) claimed to use CBD products for a range of ailments, including anxiety and pain. CBD products were bought from healthcare stores, vape stores, pharmacies and online. Of those who did not personally use CBD (n = 532), 35% claimed they would like to try it. A positive attitude towards the safety and efficacy of CBD was attributed to CBD being a natural product. The study highlighted that the public continue to seek natural alternatives to supplement and maintain their health; hence, the popularity of CBD continues to rise. The lack of clinical evidence and regulation of CBD needs to be addressed to facilitate safe and effective use of CBD.
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Objectives: This study aimed to characterize use and perceptions of cannabidiol (CBD) products. Materials and Methods: Participants aged 16-65 years in Canada (n=15,042) and the United States (n=30,288) completed measures on prevalence and patterns of CBD product use and perceptions of CBD oil as part of the 2019 International Cannabis Policy Study online survey. Results: Past 12-month CBD product use was significantly more prevalent among respondents in the United States (26.1%) than in Canada (16.2%). Consumers in the United States and Canada reported using a range of CBD products, including drops (46.3% vs. 47.3%, respectively), topicals (26.0% vs. 16.7%), edibles/foods (23.8% vs. 17.6%), vape oils (18.9% vs. 13.3%), capsules (13.3% vs. 16.7%), and dried flower (10.1% vs. 16.1%). CBD was most commonly reported for management of pain, anxiety, and depression. Over half of CBD consumers in both countries reported that CBD oil was beneficial for health. Conclusions: Use of CBD products is common in both the United States and Canada, primarily to manage self-reported health conditions for which there is little or no evidence of efficacy. Clearer public health messaging regarding the therapeutic effects of CBD is warranted.