Received: 26 May 2021 Revised: 14 July 2021 Accepted: 14 July 2021

DOI: 10.1002/ptr.7232

RESEARCH ARTICLE

The emerging role of cannabidiol (CBD) products; a survey

exploring the public's use and perceptions of CBD

Sukvinder Kaur Bhamra | Ankita Desai | Parmis Imani-Berendjestanki |

Maeve Horgan

Medway school of Pharmacy, University of

Kent and University of Greenwich, Chatham The market value of cannabidiol (CBD) is growing as people seek holistic ways of
Maritime, Kent, UK
managing their health. The aim of this study was to explore the public's perceptions
Correspondence and use of CBD products, including where products were sourced, knowledge trans-
Sukvinder Kaur Bhamra, Medway school of
fer and opinions on quality, safety and efficacy of CBD products. An online question-
Pharmacy, University of Kent and University
of Greenwich, Chatham Maritime, Kent, UK. naire was distributed via social and professional networks, in addition to face-to-face
Email: [email protected]
data collection days, which employed convenience and snowball sampling methods.
Funding information A total of 597 participant responses were analysed, of which 10.9% (n = 65) claimed
Medway School of Pharmacy, University of
to use CBD products for a range of ailments, including anxiety and pain. CBD prod-
Kent
ucts 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 natu-
ral 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.

KEYWORDS
cannabidiol, cannabis, ethnopharmacology, mental health, pain, wellbeing

1 | I N T RO DU CT I O N body of evidence-based literature, which demonstrates the anxiolytic,

antiemetic and anticonvulsant effects, as well as its use in muscle
Cannabis sativa L. (cannabis) has traditionally been used for food, med- spasticity, bronchodilation in asthma and treatment of glaucoma
icine, industrial fibre and recreation. It contains over 700 chemicals, (Kalant, 2001; Satterlund, Lee, & Moore, 2015). The legalisation of
including tetrahydrocannabinol (THC) and cannabidiol (CBD), which medicinal cannabis has also recently been accepted for some condi-
are two primary compounds known as cannabinoids (Radwan tions such as multiple sclerosis and epilepsy in countries such as the
et al., 2015). THC is the main psychoactive component of the plant, United Kingdom (UK) (MS Society, 2019).
which is why cannabis is classified as a controlled drug. The altered CBD does not have any psychoactive effects, but instead has
sensory perception ‘high’ associated with THC had led to the been associated with numerous health benefits, including its use in
stigmatisation of cannabis as a recreational drug. The World Health anxiety, depression, epilepsy, insomnia, muscle disorders and pain
Organization (WHO) identified cannabis as one of the most commonly relief (White, 2019). CBD products with less than 0.3% THC have
used illicit substances worldwide (Hall, Renstrom, & Poznyak, 2016). been exempt from controlled drug classification by The WHO Expert
In several countries, such as Australia, Brazil, Canada, Jamaica and the Committee on Drug Dependence (ECDD) (EMCDDA, 2019). Availabil-
Netherlands, the recreational use of cannabis has been decriminalised ity of CBD products as food supplements and cosmetics has increased
(EMCDDA, 2021). Despite this, the longstanding historical use of can- as people have become more familiar with and interested in the natu-
nabis for medicinal purposes is now being supported by a growing ral medicinal properties of CBD. The rise in awareness of the

5734 © 2021 John Wiley & Sons Ltd. wileyonlinelibrary.com/journal/ptr Phytotherapy Research. 2021;35:5734–5740.
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BHAMRA ET AL. 5735

therapeutic benefits and use of CBD products has led to a global complete the survey. Leaflets were given to passers-by, with a QR code,
increase in demand for CBD. In 2020, the global market value of CBD which enabled remote access to the online survey.
was $2.8 billion with an anticipated 21% growth over the next 7 years The inclusion criteria required participants to be over 18 years old
(Grand view research, 2021). to consent for their own participation. As the survey was only available
As the market value for CBD products continues to gain momen- in English, participants were required to be fluent in English to complete
tum, due to the increased demand and interest in CBD, a consideration the survey. The survey was aimed at the general public, not just people
of the public's perceptions of CBD was insufficient in the literature. The who used or knew about CBD to capture general perspectives.
aim of this study was to explore the publics' perceptions of CBD prod-
ucts. The objectives of the study included: (a) identify why and how
CBD was being used, by whom and how it was sourced to develop an 2.4 | Data analysis
understanding of the current use of CBD; (b) explore where people
learnt about CBD and what interested them in CBD; (c) obtain an insight The Statistical Package for the Social Sciences (SPSS) software (V.27)
into perceptions on quality, safety and efficacy of CBD products. was used for analysis of closed-questions (i.e., descriptive frequencies).
Microsoft Excel was used to create the graphical representations. NVivo
was used for content and thematic analysis of open-ended questions.
2 | METHODS The thematic analysis involved coding responses to identify emerging
themes, which were cross checked by the authors. Quantitative and
2.1 | Questionnaire design qualitative data were considered alongside each other where appropri-
ate. A reference number was assigned to each participant (e.g., P001).
A 25-item questionnaire designed for self-completion, was distributed Where known, the gender (M = male; F = female) and age range
online using SurveyMonkey® (Appendix S1). A range of open and (1 = under 20 years old; 2 = 21–30 years old; 3 = 31–40 years old;
closed questions, and scaled responses were used to gain quantitative 4 = 41–50 years old; 5 = 51–60 years old; 6 = 61+ years), have been
and qualitative perspectives. A pilot study was conducted (n = 8), specified when quotes have been presented.
which provided feedback for improvements of the questionnaire.
After amending the questionnaire, the refined survey was repiloted
(n = 6) before the link was distributed. The questionnaire was sub- 3 | RE SU LT S
divided into three sections, including personal use of CBD, non-users'
knowledge of CBD and perspectives on safety and efficacy of CBD. The initial sample comprised 795 participants, of which 198 were
An optional demographics section was also included at the end of the removed; as four did not provide consent thus were disqualified and the
survey. The participant information leaflet preceded the questionnaire other 194 participants dropped out after answering the first question.
so participants could make an informed decision as to their participa- This left a sample of 597 participants for the final analysis, with a 95%
tion. Participants were asked to consent before completing the sur- completion rate. Table 1 summarises the demographic data of partici-
vey. No personal data were collected, so responses were anonymous. pants: a larger proportion of respondents were female (n = 358, 63.6%),
White-British (n = 225, 40.2%) and from the UK (n = 387, 71.3%).

2.2 | Ethics
3.1 | The use of CBD products
Ethical approval was obtained from the Medway School of Pharmacy
Research Ethics Committee (REF020719) before commencing. Of the total sample (n = 597), 10.9% (n = 65) used CBD based prod-
ucts for managing and treating various ailments. CBD was most com-
monly used for pain relief (n = 20) and prevention/management of
2.3 | Participant recruitment anxiety (n = 20). Other uses stated included sleep disorders (n = 8),
stress (n = 7), arthritis (n = 5), relaxation (n = 4), post-exercise recov-
A combination of opportunity and snowball sampling was employed for ery (n = 4) and as a general health supplement (n = 2). There was one
participant recruitment. The link for the online survey was shared by the reference each to the use of CBD for cancer therapy, managing ten-
research team via personal and professional networks and using social dinopathy and recreational use. CBD products used to manage and
media (i.e., LinkedIn and Twitter). As the link was re-shared by partici- prevent ailments were often used daily (n = 28) or weekly (n = 19);
pants it led to snowball sampling. The questionnaire was available for while relief of intermittent conditions such as anxiety or pain, was
6 weeks from November to December 2019. In addition to online pro- treated on a when-required basis (n = 11).
motion of the survey, the research team spent 5 days in local shopping A variety of CBD formulations were used including oils for inges-
centres around Kent (Southeast England) recruiting participants. The tion (n = 29), oral drops (n = 21) and vaporise/vapes (n = 15); other
face-to-face recruitment process adopted a convenience sampling tech- forms used included topical oils (n = 4), capsules/tablets (n = 4), cre-
nique. Researchers had electronic devices participants could use to ams/lotions (n = 4). Some participants specified use of the dried
 10991573, 2021, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ptr.7232 by Uni Federico Ii Di Napoli, Wiley Online Library on [29/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5736 BHAMRA ET AL.

T A B L E 1 Demographic data of
Number of Proportion of
participants (n) sample (%)
participants

Gender (n = 563)
Male 201 35.7
Female 358 63.6
Non-binary 1 0.2
Prefer not to say 3 0.5
Age (n = 561)
<20 56 10
21–30 237 42.3
31–40 90 16.0
41–50 66 11.8
51–60 70 12.5
61+ 42 7.5
Ethnicity (n = 560)
White: British 225 40.2
White: Other 164 29.3
Black/Black British: African/Caribbean 20 3.6
Black/Black British: Other 8 1.4
Asian/Asian British: 125 22.3
Indian/Pakistani/Bangladeshi/Sri
Lankan
Asian/Asian British: Chinese 2 0.4
Asian/Asian British: Other 16 2.9
Country of residence (n = 543)
United Kingdom 387 71.3
Ireland 141 26.0
Canada 5 0.9
Spain 2 0.4
Australia 2 0.4
United Arab Emirates 1 0.2
India 1 0.2
Romania 1 0.2
Sweden 1 0.2
Poland 1 0.2
Grand Cayman 1 0.2

herbs, which were consumed in food, infused in tea or smoked. CBD P427 [F:2]: Doctor said if it helps, he's happy for me to
products were commonly bought from healthcare stores (n = 33), continue.
online (n = 15), pharmacies (n = 10), vape stores (n = 5) or shared Some negative responses (n = 2) from HCPs, about the
amongst friends (n = 9) and family (n = 3). One participant acquired use of CBD, were noted:
products from a homeopath while three revealed illicit sources. P046 [M:2]: Medicine is a conservative profession with
Participants who consumed CBD were asked if they were taking any modernisation so not every doctor is fine with CBD.
regular prescribed medicines; 22 participants gave detailed accounts of P458 [F:5]: They didn't know much about it.
their co-morbidities and prescribed medicines. The list of medicines CBD
users was prescribed included: analgesics, antacids, anti-coagulants, anti- While most participants (n = 56) were not aware of any reasons
depressants, anti-epileptics, anti-hypertensives and mood stabilisers. The why CBD products should not be taken with other medicines, nine
majority of CBD users (n = 46, 70.8%) claimed not to tell their healthcare participants said there were risks of interactions with other medicines
professionals (HCPs) about their use of CBD products. Those who had or potential for adverse effects. Just two participants who used CBD
spoken to their HCPs about CBD, generally claimed a neutral (n = 12) or claimed to have experienced adverse effects after using CBD, which
positive (n = 10) response: was mild symptoms associated with gastrointestinal complaints.
 10991573, 2021, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ptr.7232 by Uni Federico Ii Di Napoli, Wiley Online Library on [29/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BHAMRA ET AL. 5737

3.2 | Non-users experience of CBD products effectiveness for treating and managing various conditions
(in particular pain), curiosity, CBD being a natural product and an alter-
Of the 532 participants who did not use CBD products personally, native to conventional medicines.
42.6% (n = 226) claimed to know somebody else who did. These par-
ticipants detailed 494 accounts for the various uses of CBD
expressing awareness of the potential uses of CBD. The uses of 3.3 | General knowledge and perceptions of CBD
CBD listed by non-users included: pain relief (n = 248), anxiety
(n = 96), epilepsy (n = 68), general health and wellbeing (n = 33), can- The most prominent source for learning about CBD was social media
cer (n = 22), seizure control (n = 21), depression (n = 18), relaxation (n = 320); this was followed by the news (n = 283), friends (n = 171),
(n = 31), arthritis (n = 12), recreational use (n = 10), Parkinson's dis- family (n = 100) and HCPs (n = 98). Other sources of learning about
ease (n = 4) and nausea (n = 3). CBD included: place of education (i.e., school/university) (n = 5), per-
When participants, who did not use CBD, were asked if they sonal research (n = 4), adverts (n = 3), the television (n = 8) and
would like to try CBD products themselves 35.3% (n = 187) said ‘yes’, healthcare stores (n = 6). CBD users more often said they learnt about
33.8% (n = 179) said ‘no’, while 29.8% (n = 158) were ‘not sure’ CBD from friends while non-users commonly identified social media
(Table 2). A willingness to try CBD if there was a medical need, if it as the primary source of learning about CBD.
was prescribed or only under medical guidance were documented as Largely, participants deemed CBD products to be safe (69.9%,
some of the conditions under which participants would consider try- n = 359) and effective (57.8%, n = 319) (Figure 1). Efficacy was attrib-
ing CBD. Other participants commented on a lack of personal knowl- uted to personal experience, anecdotes of its efficacy from others,
edge or an occupation, which prohibited their use of CBD. Thematic reports on social media (including the television and news), the type
analysis identified key reasons participants (n = 420) expressed inter- of CBD products used and conditions being treated. Some partici-
est in CBD products, including health benefits, recommendations, pants (13.5%, n = 76) believed there were no risks associated with

TABLE 2 Participants' views of their willingness to try CBD

Willingness to try Participant

CBD products: reference: Participants views:
Yes P071 [F:2] ‘Firstly I would like to know if it's necessary, or would help my nerves. My hands shake constantly because of
nerves and stress’.
P195 [F:2] ‘If I was in a position where I needed it or thought it would help, yes I would use it’.
P282 [F:4] ‘I have severe back pain and also have severe pain from slipping rib syndrome’.
No P358 [F:5] ‘I'm not sure if it interacts with other drugs’.
P385 [F:2] ‘Unsure of effects and if this is addictive. They take the ingredient which makes it a high yet unsure of more than
that’.
P580 [M:2] ‘I have no need of getting high nor do I have any medical conditions’.
Not sure P018 [F:2] ‘I don't have enough knowledge regarding it and not sure if it would be useful to me in any way’.
P091 [F:2] ‘If I read up more about the benefits of CBD products and if their use applied to me I would’.
P381 [M:3] ‘Not unless I suffered from a condition where it would help me’.

F I G U R E 1 Perceptions of safety
and efficacy of CBD products
(n = 552–565)
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5738 BHAMRA ET AL.

the use of CBD, while 27.5% (n = 155) acknowledged there were risks quality’ CBD products was primarily considered to be the obligation of
(such as herb-drug interaction and adverse effects); a larger propor- regulatory bodies (n = 438), followed by manufacturers (n = 252), sup-
tion (59.0%, n = 333) were uncertain of the risks associated with pliers (n = 136) and finally the person using the product (n = 85). Sev-
CBD. A lack of research was recurrently highlighted as a concern by eral references were made to responsibility being shared by all involved
participants; 258 participants said there was not enough research or in manufacturing, supply, sale and use of CBD products:
evidence to help make informed decisions about how to use CBD
or what products to use. P071 [F:2]: The person who consumes the product should
An important theme, which emerged throughout the study was be the last person to determine its safety. The manufac-
the regulation of CBD products; most participants (n = 268) were turer has to be 100% satisfied by product safety before it
unsure of the regulation of CBD products (Figure 1). Reference to var- moves any further. Safety checks should be carried out.
iable regulatory requirements and products being sold as food supple- As with any product sold to consumers.
ments to avoid regulation were made (Table 3). P321 [M:2]: If there is a regulatory body like the FDA or
When considering whether a CBD product was ‘good quality’ the MHRA it would give me more trust and confidence to use
top three factors, which determined quality were: (a) products made by CBD products. If there is no one regulating and ensuring
a well-known manufacturer (n = 261); (b) Products, which had market- it is safe, then I am reluctant to try it.
ing authorisations (n = 227); (c) products based on recommendation
(n = 179). Although the price of CBD was mentioned in previous ques- A thematic analysis of the qualitative responses identified three
tion as being high, price and packing were not ranked as important significant topics: (a) use of CBD, (b) barriers to using CBD, (c) future
when determining the quality of a product. The responsibility of ‘good requirements (Figure 2).

TABLE 3 Participants' views on the regulation of CBD products

Are CBD products well Participant

regulated? reference: Participants views:
Yes - CBD products are well P317 [F:4] ‘I know some products meet the strict regulations, but I do worry about the safety of all vaping
regulated (n = 129) products’.
P451 [M:2] ‘In certain countries yes’.
P455 [F:4] ‘More so now, but more research is needed’.
No - CBD products are not P202 [M:2] ‘Doesn't seem to be any regulation in the supplement market’.
well regulated (n = 168) P278 [F:5] ‘Most products are either not regulated or are regulated as food supplements. None are regulated as
medicines, despite making medical claims’.
P517 [M:2] ‘Could be better regulated and more research is needed’.
Unsure of the regulation of P135 [F:2] ‘Read mixed things online. Not being readily available on the NHS makes me feel more sceptical of the
CBD products (n = 267) benefits’.
P222 [F:2] ‘To be sold in stores I hope that they have to pass certain guidelines, however I am dubious of how
effective they are and how much CBD is in these products’.
P300 [F:4] ‘Depends where you buy from, it varies’.

F I G U R E 2 Thematic analysis of
qualitative response; uncovering
three core themes, including the use
of CBD, barriers to using CBD and
future requirements
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BHAMRA ET AL. 5739

4 | DISCUSSION the potential for misuse and limited clinical evidence, many HCPs
remain reluctant to recommend medicinal cannabis-based products
CBD is widely becoming accepted and incorporated into people's lives (Satterlund et al., 2015). Commonly the use of cannabis-based prod-
as a supplement to prevent, treat and manage health and wellbeing. ucts has been stigmatised as recreational drugs (Hall et al., 2016;
As the range of CBD products available has expanded and products Satterlund et al., 2015) likewise, several participants in this study
have become readily available in high street stores and pharmacies it claimed to use CBD for recreational purposes. However, CBD does
has made access to herbal medicines (HMs) easier. Despite some bar- not cause the ‘high’ associated with THC in cannabis. This could
riers to using CBD such as a lack of research, clinical evidence and lit- mean participants were using cannabis rather than CBD-based
erature to enable informed decisions; it is clear people want products. Some of the key barriers to using CBD, identified by par-
affordable and appropriately regulated products to be able to use ticipants, were the association of CBD as a recreational drug and
CBD safe and effectively. the fear of the stigma of using an illicit substance; this illustrates
The study was designed to review the general public's views of that clear information on what CBD is and more education is
CBD; using a range of data collection methods, a diverse sample was required.
recruited, who gave insights into their perceptions and use of CBD. Participants made the correlation of CBD being a natural prod-
The face-to-face recruitment allowed participants who may not have uct to perceptions of safety, relaying opinions of the benefits of tak-
been able to access the link to take part and encouraged promotion of ing plant-based remedies as opposed to conventional medicines.
the survey. The online distribution may have targeted motivated indi- Only two participants reported adverse effects after using CBD,
viduals to take part; however, the results represented unbiased views which was relatively mild gastrointestinal effects. The concept of
from participants. The use of both open and closed questions enabled natural medicines being safer and free from adverse effects has fre-
a wealth of data to be collated and reported. quently been documented (Bhamra et al., 2017; Ipsos MORI, 2008);
The clinical uses of CBD identified by participants (i.e., pain relief this further highlights the need for more research and better educa-
and anxiety) were in line with historical uses, which have been well tion. Some of the other barriers to using CBD included a lack of
documented (Grotenhermen & Müller-Vahl, 2012; Masataka, 2019; research and evidence on the safety and efficacy of CBD products,
National Academies of Sciences, 2017). Detailed accounts of the suc- poor regulation of products and a lack of clarity as to the quality of
cess stories of using CBD for various ailments were recorded, includ- products available. Participants were unsure of what sources of
ing from non-users who shared experiences of people they knew who CBD were reliable and whether the cost of products was linked to
used CBD. References to management of seizures, muscle recovery, their quality. Regulation of products could help clarify some of these
Parkinson's disease and nausea were also made; demonstrating a vast issues and help people make informed decisions when buying CBD
awareness of the uses of CBD amongst participants. A great interest products (Heinrich, 2015).
in using CBD was expressed by participants who did not personally
use it, but many claimed they would if needed and more importantly if
there was more evidence to support the use of CBD. Where once the 5 | CONC LU SION
primary source of knowledge transmission for HMs was the family,
whereby traditional remedies were shared across generations The continued rise in popularity and demand for CBD products has
(Bhamra, Slater, Howard, Johnson, & Heinrich, 2017), now there been encouraged by social media and people's interest in managing
appears to be a shift in how people are learning about HMs. Despite their own health holistically. A lack of clinical evidence, regulation of
the long-standing medicinal use of cannabis around the world products and consumer information were identified as key limiting
(Kalant, 2001), in this study social media was the most popular factors, which require more consideration to enable better-informed
method by which participants learnt about CBD. As online influencers decisions. Further research to ascertain the safety and efficacy pro-
promote HMs, such as CBD products, it appears to have enhanced files of CBD products needs to be communicated in lay terms, which
interest and use of CBD (Barker, 2021). will facilitate the appropriate use of CBD; as well as access to afford-
The majority of CBD users claimed not to tell their HCPs about able and regulated products.
their use of CBD. The potential for CBD-induced herb-drug interac-
tions and the effects on cytochrome P450 (CYP) enzymes, which AC KNOW LEDG EME NT S
can impact efficacy and induce toxicity of co-administered medica- The authors would like to thank the participants who completed the
tions, must be considered (Nelson et al., 2020). Without consulting online survey and colleagues who helped in distributing the question-
HCPs this could have detrimental effects on patients' pharmacologi- naire link. This project received no external funding and was funded
cal care. However, participants claimed HCPs were unaware of the by the Medway School of Pharmacy, University of Kent.
risks or benefits of using CBD. This highlights the importance of
HCPs being aware of the safety and efficacy of CBD before they CONFLIC T OF INT ER E ST
can advise patients (Van Dolah, Brent, & Mauck, 2019). This aligns The authors declare that the research was conducted in the absence
with other studies, which have looked at information sharing of any commercial or financial relationships that could be construed
between HCPs and people using HMs (Bhamra et al., 2017). Due to as a potential conflict of interest.
 10991573, 2021, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ptr.7232 by Uni Federico Ii Di Napoli, Wiley Online Library on [29/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5740 BHAMRA ET AL.

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