Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2024 Apr 1.
Published in final edited form as: Drug Alcohol Depend. 2023 Feb 26;245:109826. doi: 10.1016/j.drugalcdep.2023.109826

A Cross-Sectional Survey on Cannabis: Characterizing Motives, Opinions, and Subjective Experiences Associated with the use of Various Oral Cannabis Products

Ashley N Dowd a, C Austin Zamarripa a, Dennis J Sholler a, Justin C Strickland a, Elia Goffi a, Jacob T Borodovsky b, Elise M Weerts a, Ryan Vandrey a, Tory R Spindle a
PMCID: PMC10044512  NIHMSID: NIHMS1881370  PMID: 36871378

Abstract

Background:

Cannabis-infused products available for oral consumption include food and drink items (i.e., edibles) (e.g., baked goods, gummy-, chocolate-, and hard-candies, beverages/drinks) as well as non-food formulations (e.g., oils/tinctures, pills/capsules). This study characterized the motives, opinions, and subjective experiences associated with the use of these seven subtypes of oral cannabis products.

Methods:

This web-based survey collected cross-sectional, self-report data from a convenience sample of 370 adults regarding various use-motives, self-reported cannabinoid content, subjective experiences, and opinions related to ingesting oral cannabis products with alcohol and/or food. Advice participants had received about modifying oral cannabis product effects, in general, was also collected.

Results:

Participants reported consuming cannabis baked goods and gummy candies most frequently over the past year (68% and 63%, respectively). Participants were less likely to use oils/tinctures for enjoyment/desire relative to other product types and more likely to use oils/tinctures for therapeutic purposes (e.g., medication-replacement). Self-reported cannabinoid content was highly variable across participants and within product subtype. Participants reported feeling stronger and longer-lasting effects when consuming oral cannabis products on an empty stomach and 43% received advice to “eat a snack or meal” to mitigate effects that are too strong, which contrasts with controlled studies. Finally, 43% of participants reported modifying their experiences with alcohol at least some of time.

Conclusions:

These findings underscore the need to further evaluate use-motives as well as the interaction between dietary factors, cannabinoid pharmacokinetics, and subjective drug effects and the interactive effects of oral cannabis products and alcohol in a controlled laboratory setting.

Keywords: cannabis, cross-sectional survey, tetrahydrocannabinol, edible, cannabidiol (CBD)

1. INTRODUCTION

Global expansions to cannabis (i.e., marijuana) legalization have given rise to a growing retail marketplace, with incredible diversity in cannabis products with respect to chemical composition, intended administration route, and formulation. Part of this product expansion includes cannabinoid-infused food and drink products (i.e., edibles) (e.g., baked goods, gummy-, chocolate-, and hard-candies, beverages/drinks) as well as non-food formulations (e.g., oils/tinctures, pills/capsules). Importantly, oral ingestion of cannabis edibles is currently the second most popular route of cannabis administration behind smoked cannabis (Peng and Shahidi, 2021). The predominant cannabinoids found in oral cannabis products are the phytocannabinoids Δ−9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD), though products that primarily contain other phytocannabinoids (e.g. cannabigerol [CBG]) or isomers of THC (e.g., Δ8-THC) have recently emerged (Spindle et al., 2019). There is some evidence that certain subtypes of oral cannabis products are more popular than others. For example, in focus groups, participants have reported “usually” buying baked goods, hard-candies, and gummy-candies (Giombi et al., 2018). However, updated research is needed considering the evolving cannabis legal landscape and retail marketplace. To help address this need, the current study examined seven different subtypes of oral cannabis products, which included both food- (e.g., “edibles” like baked goods, gummy-, chocolate-, and hard-candies, and beverages/drinks) and non-food based (e.g., oils/tinctures, pills/capsules) formulations.

Oral cannabis products are responsible for the majority of emergency room visits related to over-intoxication from cannabis (Barrus et al., 2016; Monte et al., 2019; Volkow and Baler, 2019; Wong and Baum, 2019), potentially because the acute drug effects are often unpredictable (i.e., either too weak or too strong). The unpredictability of oral cannabis product effects may stem from a lack of knowledge regarding cannabinoid dose (Friese et al., 2017), onset and/or duration of effects (Giombi et al., 2018), inaccurate product labeling with respect to THC (Vandrey et al., 2015; Bonn-Miller et al., 2017; Friese et al., 2017; Giombi et al., 2018; Borodovsky et al., 2017; Peng and Shahidi, 2021) and/or CBD content (Cerino et al., 2021), or other factors (e.g., differences in product formulation or food intake). For example, THC and CBD (Spindle et al., 2020; Bergeria et al., 2022) bioavailability is markedly increased in lipid-based drug formulations (Zgair et al., 2016; McClements, 2020), in the presence of alcohol (Peng and Shahidi, 2021), and following the consumption of food, particularly high-fat meals (Trevaskis et al., 2009; Lunn et al., 2019; Crockett et al., 2020). Research regarding why (i.e., use-motives) individuals consume different oral cannabis products and/or prefer specific oral modes of cannabis delivery (i.e., food- or non-food based) is critically needed to develop a comprehensive understanding of product type choice- and use-behaviors and mitigate the public health impact of over-intoxication from these products.

Further, as research suggests use of alcohol and cannabis during the same occasion is associated with an increase in social and behavioral consequences (e.g., driving while intoxicated; Yurasek et al., 2017), quantifying alcohol and oral cannabis product co-use is vital. There is currently a dearth of information regarding the simultaneous ingestion of alcohol and oral cannabis products, as previous research has focused predominantly on smoked cannabis and alcohol interactions (Yurasek et al., 2017). It is also largely unknown if those who use oral cannabis products hold beliefs on how to mitigate unwanted effects and, if so, what advice they received and from where. Finally, while previous studies suggest that product formulation and use-behaviors may influence the acute effects of oral cannabis products (Bergeria et al., 2022; Crockett et al., 2020; Lunn et al., 2019; McClements, 2020; Peng and Shahidi, 2021; Spindle et al., 2020; Stott et al., 2013a; Trevaskis et al., 2009; Zgair et al., 2016), few studies have been conducted to understand if such factors impact perceived effects among oral cannabis product-experienced individuals. Because controlled studies generally utilize methodology that may not reflect how these products are consumed in the natural environment (e.g., providing standardized meals), perceived effects are an important component for further examination. Overall, understanding how product choice- and use-behaviors influence oral cannabis product effects, and whether individuals have accurate/inaccurate beliefs on how to alter these effects, is critical to developing appropriate interventions and public health messaging.

The current cross-sectional, web-based survey study aimed to characterize rates of use for seven product types (i.e., baked goods, gummy-, chocolate-, and hard-candies, beverages/drinks, oils/tinctures, pills/capsules) among a convenience sample of adults who reported using oral cannabis products within the past year, as well as examine relevant use motives, self-reported formulation and doses of THC and CBD, perceived impact of food and macronutrients on several subjective effects, use with alcohol, and advice participants had received regarding mitigating acute drug effects.

2. MATERIALS AND METHODS

2.1. Participants and Procedures

Survey participants were recruited using the online crowdsourcing platform Amazon Mechanical Turk (mTurk) from July 2020 to September 2020. A purposive cross-sectional convenience sample was deemed appropriate given the primary aims of this project, the relatively novel nature of the topic areas, and the intent to provide foundational information to build upon within future research examining oral cannabis products. Participant eligibility criteria included: 1) ≥18 years of age, 2) used ≥1 cannabis edible in the past year, 3) reside in the U.S., 4) read/write in English fluently, 5) have an mTurk approval rating of ≥99%, and 6) have completed at least 100 prior mTurk tasks (i.e., “HITs”; Strickland and Stoops, 2019). Respondents provided informed consent and were required to pass a brief screener to assess English fluency and deter use of autonomous programs (i.e., “bots”). Participants completed the survey through Qualtrics (Provo, UT). On average (SD), participants completed the survey in 25 (48) minutes. Participants who completed the study were paid $1.00. Participants who passed two embedded attention checks earned an additional $4.00.

2.2. Measures

2.2.1. Demographics

Participants provided basic demographic information (e.g., age) and reported past 30-day cannabis and alcohol use, age of first cannabis use, and tobacco and/or electronic cigarette (e-cigarette) use-status.

2.2.2. Rates of Use

Participants were asked if they had used any of the following seven oral cannabis products within the past year: baked goods, gummy-, hard-, or chocolate-candies, beverages/drinks, pills/capsules, and/or oils/tinctures (participants were instructed that this referred to cannabis oils/tinctures that were eaten or taken by mouth, but not inhaled).

2.2.3. Motives for Use

A modified 12-item version of the Comprehensive Marijuana Motives Questionnaire (CMMQ) Short Form (Lee et al., 2009) was used to evaluate motives associated with the use of participant-endorsed oral cannabis product(s) with 3 items added (for a total of 15 items) related to therapeutic use (i.e., “To replace the use of another drug or medication,” “For pain relief,” and “To improve symptoms or manage the effects of a health problem”). Participants were asked the following question for each product endorsed: “Thinking of all the times you have used [relevant oral cannabis product(s)], how often would you say that you used them for each of the following reasons?” Answer choices included: “because it is there,” “to help you sleep,” “because you didn’t want to be the only one not doing it,” “for pain relief,” “to see what it felt like,” “to forget your problems,” “to enjoy the effects of it,” “to improve your symptoms or manage the effects of a health problem,” “because you wanted something to do,” “because it relaxes you when you are in an insecure situation,” “because you were under control,” “to replace the use of another drug or medication,” “because it was a special occasion,” “because it is safer than using alcohol,” and “so you can look at the world differently.” Participants responded using a Likert scale, ranging from 1 (almost never/never) to 5 (almost always/always). The CMMQ has demonstrated satisfactory reliability and validity (Lee et al., 2009) in measuring use-motives within samples that have a medical cannabis certification (Bohnert et al., 2018) or use recreationally (Blevins et al., 2016). Of note, though the CMMQ is a validated instrument, other questions created for this study have not been validated given the novel nature of this topic area.

2.2.4. Self-Reported Cannabinoid Content

For each endorsed edible type, participants were asked “what is the dose of THC (in mg) and CBD (in mg) that you usually use?” Participants were then asked to report the THC-to-CBD ratio that they usually use from the following answer choices: “THC-dominant,” “balanced amounts of CBD and THC (e.g., 1:1 ratio),” “CBD-dominant,” or “Not sure.”

2.2.5. Subjective Experiences: Time to Onset, Duration, and Effect Intensity

Participants characterized subjective effects they typically experienced during the use of endorsed oral cannabis product(s). Participants were asked “how long (in minutes) does it take for you to feel any effects?” Participants then indicated how often they experienced the following: “stronger than I expected,” “weaker than I expected,” “last longer than I expected,” “last shorter than I expected,” “kick in faster than I expected,” and “kick in slower than I expected.” Answers ranged from 0 (“never”) to 100 (“always”).

2.2.6. Perceived Impact of Food and Alcohol

Participants were asked about their experiences using oral cannabis products with or without food/alcohol. First, participants responded to: “on the occasions when you use cannabis edibles, how often do you use cannabis edibles and alcohol together so that you experience the effects of both at the same time (i.e., “cross-faded”)?” Second, participants were asked two questions about using oral cannabis products with/without food: (1) “based on your experiences, does using a cannabis edible on an empty stomach impact the effects?” and (2) “based on your experiences, does eating food within an hour of or at the same time as using a cannabis edible impact the effects?” Participants who responded “yes” to both questions were then asked to report how these factors impact effects: (1) “how does [(1) and/or (2)] impact the strength/intensity of the effects?” anchored from “0” (“weaker”) to “100” (“stronger”) with “50” labeled as “no effect”; (2) “how does [(1) and/or (2)] impact the duration of the effects?”; and (3) “how does [(1) and/or (2)] impact onset of the effects? (i.e., how long they take to “kick in”).”

2.2.7. Perceived Impact of Macronutrients

Participants were asked three questions regarding the influence of macronutrients on oral cannabis product effects: “in your opinion, how do each of these factors [“higher calories,” “higher fat,” and “higher carbohydrates”] change the: 1) strength/intensity, 2) onset, and 3) duration of cannabis edible effects?” Responses ranged from 0 (“weaker”) to 100 (“stronger”) with “50” labeled as “no effect.”

2.2.8. Advice

Participants reported whether they had ever looked for advice about using oral cannabis products. For those who said yes, they responded to: “if you experience effects that are too strong or get “too high,” what advice have you received about counteracting those effects?” Participants were then asked, “what advice have you received about using cannabis edibles?” Possible answer choices were “start with the lowest amount possible to achieve desired effects (i.e., start low and go slow),” “the effects take a while to kick in,” “read the label/package dosing guidelines carefully,” “eat a snack/meal and drink water before using edibles,” “do not take edibles on an empty stomach,” “consult a doctor or physician before using,” “wait at least 24 hours before taking a second dose,” “none of the above,” and “other.”

2.3. Data Analysis

Data were first screened for systematic responding. Of the total 590 participants that met inclusion criteria, 168 were excluded because they did not pass the attention checks, and 52 were excluded for endorsing the use of a fake drug product, resulting in the inclusion of 370 participants in the final analysis. Two variables (time to onset of effects and typical THC dose) had minimal amounts of missing data (range: 0% [pills/capsules] to 3% [beverages/drinks] and 0% [gummy-, hard-, and chocolate-candies, beverages/drinks, oils/tinctures] to 4% [pills/capsules], respectively). No other variables of interest contained missing data.

Data were analyzed to determine normality. Parametric tests were utilized for data with normal distributions. Specifically, linear mixed-effects models were used to compare the overall values for use-motives, time to onset of effects, and subjective experiences across each oral cannabis product type; these were followed by post-hoc Tukey’s comparisons. Nonparametric tests were employed for data with non-normal distributions. Chi-squared tests of independence were used to evaluate the relationship between product type and typical THC-to-CBD ratio. Wilcoxon matched-pairs signed rank tests were employed to compare experiences using an oral cannabis product on an empty stomach versus eating food within an hour of or at the same time for: (1) strength/intensity, (2) duration, and (3) time to onset of effects; with Cohen’s d effect sizes (Cohen, 1988) reported. Friedman’s test, followed by Dunn’s multiple comparisons tests compared opinions about the effects of higher calories, higher fat, and higher carbohydrates on participant-reported: (1) strength/intensity, (2) duration, and (3) time to onset of effects. Analyses were conducted using GraphPad Prism version 9.4.1. The α (p) level for all tests was set at 0.05.

3. RESULTS

3.1. Participant Demographics

On average (SD), participants (N=370) were 32 (10) years of age and had first used cannabis at age 21 (8). A roughly equal proportion of participants were male (47%) or female (50%) and the majority of participants (% of total sample) identified as White/Caucasian (75%) without Hispanic/Latinx/Spanish origin (88% of total sample). Many participants (% of total sample) reported working full-time (57%) and almost half had attained a bachelor’s degree (46%). Data were collected from participants residing in 43 U.S. states as well as the District of Columbia. Less than half of participants (41%) resided in states where recreational cannabis was legal and active in the retail marketplace by September 2020 (e.g., Maine was not considered a legal state as retail sales did not begin until October 2020). On average (SD), participants used cannabis 9 (11) out of the past 30 days (Table 1).

Table 1:

Participant demographics (N = 370)

Demographic
Age Mean (SD) 32 (10)
Range 18 – 69
Male 174 (47%)
Gender [n, (%)] Female 185 (50%)
Transgender Male 1 (0.3%)
Transgender Female 3 (0.8%)
Self-described 7 (2%)
Ethnicity [n, (%)] Hispanic/Latinx/Spanish Origin 45 (12%)
NOT Hispanic/Latinx/Spanish Origin 325 (88%)
American Indian/Alaska Native 5 (1.4%)
Asian 33 (9%)
Race [n, (%)] Black/African American 31 (8%)
Native Hawaiian/Pacific Islander 0 (0%)
White/Caucasian 276 (75%)
More than one race 22 (6%)
Self-described 3 (0.8%)
Past 30 Day Number of days [Mean (SD)] 9 (11)
Cannabis Use Days [Range (% past month use)] 0 – 30 (75%)
Age of First Cannabis Use Mean (SD) 21 (8)
Tobacco Cigarette Use [n, (%)] Yes, daily Yes, but not daily 41 (11%) 40 (11%)
No 289 (78%)
Electronic Cigarette Yes, daily 21 (6%)
Use [n, (%)] Yes, but not daily 39 (11%)
No 310 (84%)
Past 30 Day Alcohol Use n (%) 290 (78%)
Open in a new tab

3.2. Rates of Use

Most participants endorsed past-year use of cannabis baked goods (68%, n = 250) and/or gummy candies (63%, n = 234) and a smaller percentage reported using oils/tinctures (22%, n = 80), chocolate candies (17%, n = 64), hard candies (11%, n = 39), beverages/drinks (10%, n = 38), and/or pills/capsules (6%, n = 23). The age of first use for cannabis baked goods was significantly lower than the other six product types (p’s < 0.05). No significant differences in age of first use were observed between other product types.

3.3. Motives for Use

There were significant differences across product types (p’s < 0.05) for three use-motives (Figure 1A–F). First, the use of oils/tinctures “to enjoy the effects of it” was lower relative to baked goods, gummy-, hard-, and chocolate-candies, and beverage/drinks (p’s < 0.05; Figure 1A). Additionally, the use of oils/tinctures “because you wanted something to do” was lower relative to baked goods, chocolate candies, and beverage/drinks (p’s < 0.05; Figure 1B). Finally, participants used oils/tinctures more often “to help you sleep” (Figure 1C), “for pain relief” (Figure 1D), “to replace the use of another drug or medication” (Figure 1E), and “to improve your symptoms or manage the effects of a health problem” (Figure 1F) relative to baked goods and gummy candies (p’s < 0.05).

Figure 1.

Figure 1.

Open in a new tab

The subjective rating for (A) “to enjoy the effects of it” and (B) “because you wanted something to do” was lower for the use of oils/tinctures relative to several other oral cannabis product types. Ratings for (C) “to help you sleep,” (D) “for pain relief,” (E) “to replace the use of another drug or medication,” and (F) “to improve your symptoms or manage the effects of a health problem” were higher for the use of oils/tinctures relative to baked goods and gummy candies. Error bars depict SEM. Left y-axis indicates verbiage associated with each Likert scale option (1–5). * indicates p < .05 vs. oils/tinctures and # indicates p < .05 vs. pills/capsules.

3.4. Self-Reported Cannabinoid Content

There were no significant differences across product type for self-reported doses of THC or CBD (p = 0.51). Notably, self-reported doses for both THC and CBD were highly variable within each product type (depicted in Supplemental Figure 1A–B) and ranged from 0 to 500mg; however, many participants reported that they did not know their typical THC dose (range: 26% [hard candies] to 50% [baked goods]) and/or CBD dose (range: 26% [pills/capsules] to 66% [baked goods]).

A chi-square test revealed a significant relationship between product type and THC-to-CBD ratio typically used, X2 (18, N=370) = 68.5, p < .0001 (Table 2). Those who endorsed use of oils/tinctures typically used CBD-dominant products over THC-dominant products or products with a 1:1 ratio of THC:CBD. For all other oral cannabis product types, use of THC-dominant products was more prevalent than CBD-dominant products or products with a 1:1 ratio of THC:CBD.

Table 2:

Self-reported THC-to-CBD Ratio Typically Used.

(n, [%]) endorsing THC-Dominant 1-to-1 Ratio CBD-Dominant Not sure
Baked Goods (N = 250) 112 (45%) 54 (22%) 17 (7%) 67 (27%)
Gummy Candies (N = 234) 101 (43%) 53 (23%) 24 (10%) 56 (24%)
Hard Candies (N = 39) 18 (46%) 5 (13%) 7 (18%) 9 (23%)
Chocolate Candies (N = 64) 27 (42%) 12 (19%) 10 (16%) 15 (23%)
Beverages/Drinks (N = 38) 13 (34%) 9 (24%) 7 (18%) 9 (24%)
Pills/Capsules (N = 23) 12 (52%) 1 (4%) 6 (26%) 4 (17%)
Oils/Tinctures (N = 80) 25 (31%) 15 (19%) 31 (39%) 9 (11%)
X2 (18, n=370) = 68.5, p < .0001
Open in a new tab

Table notes: Column percentages range from 99–101% due to rounding approximations

3.5. Subjective Experiences: Time to Onset, Duration, and Effect Intensity

On average (SD), participants reported it taking approximately 33 (20) minutes to feel effects from baked goods (n = 240), 33 (20) minutes for gummy candies (n = 219), 32 (21) minutes for chocolate candies (n = 62), 29 (23) minutes for pills/capsules (n = 23), 27 (20) minutes for hard candies (n = 36), 24 (19) minutes for oils/tinctures (n = 77), and 19 (15) minutes for beverages/drinks (n =35). Results from mixed-effects models indicated a significant difference across product type for self-reported time to onset of effects (p < .0001). Specifically, participants reported less time to feel the effects of oils/tinctures than baked goods (p < .0001), gummy- (p < .0001), and chocolate-candies (p = .0009). Additionally, participants reported less time to feel the effects of beverages/drinks relative to both baked goods (p = .0026) and gummy candies (p = .024). Time to onset of effects was highly variable within product type (Supplemental Figure 2).

There were significant differences across oral cannabis product type (p’s < 0.005) for two subjective experiences. Participants reported feeling that baked goods “lasted longer than I expected,” more often relative to oils/tinctures (p < 0.05). Participants reported feeling that baked goods “kicked in slower than I expected,” more often relative to oils/tinctures as well as gummy candies (p’s < 0.05). No significant differences were detected across product types for other subjective experiences examined (e.g., “stronger than I expected”) For all subjective effects, responses were highly variable within product type (depicted in Supplemental Figure 3A–F).

3.6.1. Experiences Using Oral Cannabis Products with or without Food

Based on their experiences, 57% of participants reported that using an oral cannabis product on an empty stomach (i.e., fasted-state) impacts the effects and 50% reported eating food within an hour of, or at the same time as using an oral cannabis product (i.e., fed-state) impacts the effects. For participants who responded “Yes” to both questions (n = 137), we assessed how using oral cannabis products in a fasted- versus fed-state impacts strength/intensity, duration of action, and time to onset of effects. Results derived from Wilcoxon matched-pairs signed rank tests indicated that for strength/intensity (Figure 2A), using an oral cannabis product in a fasted state was associated with stronger self-reported effects and in a fed state was associated with weaker effects (W = −7944, p < .0001); this comparison yielded a “medium” effect size (Cohen’s d = −0.64). For duration of action (Figure 2B), using an oral cannabis product in a fasted state was associated with a longer duration of perceived effects but in a fed state was associated with having little to no impact on the overall drug effect (W = −4586, p < .0001). For time to onset (Figure 2C), using an oral cannabis product in a fasted state was associated with a faster onset of effects and in a fed state was associated with a slower onset of effects (W = 5685, p < .0001). Comparisons for duration of action and time to onset yielded “small” effect sizes (Cohen’s d = −0.32 and 0.42, respectively).

Figure 2.

Figure 2.

Open in a new tab

The subjective rating for (A) strength/intensity was higher for “using on an empty stomach” (fasted-state) than “eating food within an hour of or at the same time” (fed-state) as consuming an oral cannabis product. The rating for (B) duration of action was higher within a fasted-state than in a fed-state. The rating for (C) time to onset of effects was lower within a fasted-state than in a fed-state. Error bars depict SEM and d’s indicate Cohen’s d effect sizes. Left y-axis indicates VAS ratings. Right y-axis indicates verbiage associated with ratings of “0,” “50,” and “100.”

3.6.2. Co-Use with Alcohol

Most participants (57%) reported that they “almost never/never” use oral cannabis products and alcohol together. However, roughly one-third of participants (32%) reported that they use oral cannabis products and alcohol together “some of the time.” Participant endorsement of “half of the time” (6%), “most of the time” (5%), or “almost always/always” (1%) was relatively lower. Thus, collectively, roughly 43% of participants reported modifying their oral cannabis product experience with alcohol at least some of the time.

3.7. Opinions about Oral Cannabis Products: Influence of Macronutrients

Friedman’s tests revealed significant differences between the macronutrient groups for strength/intensity (Fr = 6.718, p = .0348), duration of effects (Fr = 20.31, p < .0001), and onset of effects (Fr = 6.165, p = .0459). Dunn’s multiple comparisons test revealed that participants believed higher fat content was associated with a longer duration of action (but not strength/intensity or onset of effects) relative to higher calories (p = .0016) and higher carbohydrates (p = .0098). These differences were modest, and responses were highly variable (depicted in Supplemental Figure 4A–C).

3.8. Advice

Many participants (78%) reported seeking advice about using oral cannabis products, including: “start with the lowest amount possible to achieve desired effects (i.e., start low and go slow)” (76%), “the effects take a while to kick in” (71%), “read the label/package dosing guidelines carefully” (44%), “eat a snack/meal and drink water before using edibles” (31%), “do not take edibles on an empty stomach” (30%), “consult a doctor/physician before using” (13%), “wait at least 24 hours before taking a second dose” (8%), and “other” (2%) (e.g., “Google”). Sources of advice included: “friend/family” (69%), “cannabis website” (39%), “budtender/dispensary staff” (29%), “social media website” (25%), “doctor/physician” (10%), “black-market dealer” (7%), and “other” (2%) (e.g., “google search”). Advice about what to do if a drug effect is too strong included: “find a comfortable place and try to relax” (64%), “drink water/hydrate” (62%), “go to sleep” (47%), “eat a snack/meal” (43%), “take a shower/bath” (21%), “use cannabidiol (CBD)” (11%), “drink citrus fruit juice” (10%), and “other” (2%) (e.g., “vigorous exercise”).

4. DISCUSSION

This study addressed important research gaps by characterizing rates of use and use motives for seven product types (i.e., baked goods, gummy-, chocolate, and hard-candies, beverages/drinks, oils/tinctures, pills/capsules) within a convenience sample of adults who reported using oral cannabis products within the past year, as well as by examining the perceived impact of product formulation and use behaviors on subjective effects. Advice received regarding mitigating oral cannabis product effects were also delineated. These factors are vital to elucidate as cannabinoid content, food intake, use with alcohol, and/or misinformation regarding how to moderate psychoactive effects may contribute to the relatively high rate of adverse events related to over-intoxication after oral cannabis product use.

Characterizing use motives revealed several key insights. Specifically, those who endorsed using cannabis oils/tinctures reported typically utilizing CBD-dominant products over THC-dominant products and these products were more highly associated with therapeutic- versus recreational-motives, which is in-line with previous findings (Hammond and Goodman, 2022). Thus, individuals motived for therapeutic purposes (e.g., pain/symptom relief) may choose products based on cannabinoid content (with a preference towards CBD-containing products) and/or oral mode of delivery (with a preference for non-food-based options); however, future research could help elucidate more nuanced use motives across oral cannabis product types.

As in previous research (Giombi et al., 2018), cannabis baked goods and gummy candies were the two most commonly used oral cannabis product types within this sample. Notably, many participants reported not knowing their typical dose and, for those that did, self-reported doses were highly variable across participants and within product type. This finding may support previous concerns (Hammond and Goodman, 2022) regarding the reliance on self-reported cannabinoid levels, in general, including those that live in jurisdictions with legalized recreational cannabis (41% of participants in the present study) that would be more likely to have access to labeled oral cannabis products. This finding should also be considered within the context of the notable discrepancies between labelled and actual dosages (Vandrey et al., 2015; Peng and Shahidi, 2021) as well as differences among product dose labeling (e.g., some indicate overall dose while others indicate unit dose). Consumer uncertainty regarding dose, inconsistent product labeling, and discrepancies between labelled and actual content, could contribute to the reported difficulties predicting oral cannabis product effects. To help mitigate the adverse impact of overdose/over-intoxication, it is vital that cannabinoid quantity be accurately labeled on packaging and that consumers are provided information regarding dosing guidelines and safety.

Importantly, this is the first survey to characterize participants’ opinions on whether the perceived impact of oral cannabis products is influenced by dietary factors. Based on previous preclinical and clinical studies (Crockett et al., 2020; Lunn et al., 2019; Stott et al., 2013b; Trevaskis et al., 2009), we expected that eating food within an hour of, or at the same time as using an oral cannabis product would be associated with greater self-reported strength/intensity and longer effect duration. However, participants self-reported that eating food within this time frame was associated with lesser strength/intensity of effects compared with ingesting oral cannabis products on an empty stomach; further, using these products on an empty stomach was associated with greater self-reported strength/intensity as well as a longer effect-duration.

Moreover, 43% of participants reported receiving advice that they should “eat a snack/meal” if they experience effects that are too strong. It is unclear whether the incongruence between controlled laboratory studies and self-report in this survey is due to recall bias, differences between consumption in studies versus the natural environment, participant assumptions based on experiences with other drugs (e.g., alcohol and some medications have stronger and more immediate effects when taken on an empty stomach), or if there are manufacturing characteristics of commonly used oral cannabis products (e.g., “nano-emulsion”) that overcome the impact of food on cannabinoid absorption. Additional research on the effect of food consumption, product formulation, and oral mode of delivery (food- versus non-food-based) is needed to better understand the variance in subjective experiences.

Finally, the present data are in-line with research demonstrating that a substantial number of individuals simultaneously use both alcohol and cannabis (Yurasek et al., 2017), though, importantly, this study explicitly quantified alcohol and oral cannabis product use while previous research has focused mostly on other routes of administration. In this sample, approximately 43% of participants reported modifying oral cannabis product effects with alcohol “at least some of the time.” This suggests that there is a need for controlled laboratory studies examining the interactive effects of alcohol and oral cannabis products.

Limitations

There are several limitations that should be noted. First, this study employed a purposive (i.e., nonrandom) sampling technique and, though there are advantages with this approach (e.g., permits some control over the degree of sample heterogeneity), there are also limitations (e.g., selection mechanisms) worth consideration (Borodovsky, 2022). For example, this cross-sectional study included a relatively small online convenience sample recruited from mTurk, a platform in which financial incentives may be the primary motivator for participants and lead to the provision of inaccurate data (Borodovsky, 2022). It is unclear whether or how this affected the data. To mitigate the collection of inaccurate data, we included several attention checks throughout the survey and required a high approval rating on mTurk to participate. Further, use of mTurk may have yielded a sample biased towards technologically adept and/or younger individuals (Strickland and Victor, 2020). Therefore, the extent to which this sample accurately represents those who use the types of oral cannabis products examined is unclear and results should be generalized with caution. Second, participants retrospectively reported on their experiences, and we did not ask where they obtained information regarding cannabinoid content. Thus, some participants may have misremembered their experiences and/or reported inaccurately on product contents. Relatedly, though the CMMQ is a validated assessment tool, other questions created for use in this study and have not been validated given the novel nature of this topic area. A productive endeavor to explore in future research would be to develop and validate assessments specific to oral cannabis product use, which is of increasing importance given the continual expansion of cannabis legalization and access. Third, participants did not describe the types of food eaten with/within an hour of consuming oral cannabis products, the macronutrient contents of which may have affected relevant subjective experiences. Finally, it is plausible that those in this sample who had used oral cannabis products more frequently may have demonstrated less response variability (e.g., self-report cannabinoid levels more accurately; Hammond and Goodman, 2022) compared to participants that used less frequently. However, the range of use-frequencies available to compare was relatively small in this sample, as participants were, on average, considered “light users” (less than 10 days of use in the past 30; Ong et al., 2021). It may be that the variability of participant-reported cannabinoid doses was somewhat a function of the relatively “light use” endorsed. It would be fruitful for future research to explore whether use frequency differentially impacts outcomes of interest both within and across oral cannabis product types.

Conclusions

Overall, participants self-reported that oral cannabis product effects were blunted when consumed with food, which contrasts controlled studies demonstrating increased bioavailability of cannabinoids under fed (versus fasted) conditions. Cannabis baked goods and gummy candies were used most frequently in this sample and 43% of participants reported modifying their oral cannabis product experience with alcohol at least some of the time. Participants that reported use of oils/tinctures endorsed higher rates of therapeutic use-motives (e.g., pain relief) and utilizing CBD-dominant products, though self-reported cannabinoid content was highly variable across participants and within product type. These findings underscore the need to further evaluate use motives, the interaction between dietary factors, cannabinoid pharmacokinetics, and subjective drug effects, as well as interactive effects of oral cannabis products and alcohol in a controlled laboratory setting. Future research could directly target specific areas of concern (e.g., use of oral cannabis products with alcohol) to support the development of appropriate interventions and public health messaging. Overall, additional research is needed to further understand factors that impact use and the acute effects associated with these products. Such research is of increasing importance given the continual expansion of cannabis legalization, the growing diversity of oral cannabis products, and high rates of over-intoxication associated with this route of administration.

Supplementary Material

1

Supplemental Figure 1. Individual participant ratings for typical doses of (A) THC and (B) CBD were highly variable within each oral cannabis product type. Error bars depict SEM. Left y-axis indicates self-reported doses (in mg).

Supplemental Figure 2. Individual participant ratings for “how long does it take for you to feel any effects” were highly variable within each oral cannabis product type. Error bars depict SEM. Left y-axis indicates self-reported time (in minutes).

Supplemental Figure 3. Individual participant ratings for (A) “stronger than I expected,” (B) “weaker than I expected,” (C) “lasts longer than I expected,” (D) “lasts shorter than I expected,” (E) “kicks in faster than I expected,” and (F) “kicks in slower than I expected” were highly variable within each oral cannabis product type. Error bars depict SEM. Left y-axis indicates VAS ratings. Right y-axis indicates verbiage associated with ratings of “0,” “50,” and “100.”

Supplemental Figure 4. Individual participant ratings for (A) strength/intensity, (B) duration (of action), and (C) time to onset of effects were highly variable within macronutrient group (“higher calories,” “higher fat,” and “higher carbohydrates”). Error bars depict SEM. Left y-axis indicates VAS ratings. Right y-axis indicates verbiage associated with ratings of “0,” “50,” and “100.”

Highlights.

  • Cannabis baked goods and gummy candies were the most frequently used

  • Oils/tinctures were used for therapeutic purposes more often than other subtypes

  • Self-reported THC and CBD doses were highly variable within each edible type

  • 43% of participants modified edible effects with alcohol at least some of the time

Acknowledgements:

The authors would like to acknowledge the time and effort research and medical staff from the Johns Hopkins Cannabis Science Lab and BPRU contributed to this project, as well as our research participants.

Role of Funding Source:

This work was supported by the National Institute on Drug Abuse [grant numbers T32DA07209, R01DA043475] and the National Institute on Alcohol Abuse and Alcoholism [grant numbers F32AA027941 and R21DA057535]. This funding source has no role in analysis concept, data analysis, or preparation and submission of the manuscript.

Dr. Vandrey has served as a consultant or received honoraria from Canopy Health Innovations Inc., MyMD Pharmaceuticals, Mira1a Therapeutics Inc, WebMD, Syqe Medical Ltd., and Radicle Science. Dr. Weerts has preclinical contracts with Mira1a Therapeutics and MyMD pharmaceuticals. Dr. Spindle has served as a consultant for Canopy Health Innovations Inc. Dr. Borodovsky is a member of the board of directors and treasurer of MySafeRx Inc., a non-profit scientific research organization. He receives no financial compensation from this organization.

Footnotes

Conflicts of Interest: The remaining authors have no conflicts of interest to declare.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

REFERENCES

  1. Barrus DG, Capogrossi KL, Cates SC, Gourdet CK, Peiper NC, Novak SP, Lefever TW, Wiley JL, 2016. Tasty THC: promises and challenges of cannabis edibles. Methods report (RTI Press) 2016. 10.3768/rtipress.2016.op.0035.1611 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bergeria CL, Spindle TR, Cone EJ, Sholler D, Goffi E, Mitchell JM, Winecker RE, Bigelow GE, Flegel R, Vandrey R, 2022. Pharmacokinetic Profile of Δ9-tetrahydrocannabinol, Cannabidiol and Metabolites in Blood following Vaporization and Oral Ingestion of Cannabidiol Products. Journal of Analytical Toxicology. 10.1093/jat/bkab124 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Blevins CE, Banes KE, Stephens RS, Walker DD, Roffman RA, 2016. Motives for marijuana use among heavy-using high school students: An analysis of structure and utility of the Comprehensive Marijuana Motives Questionnaire. Addictive behaviors 57, 42–47. 10.1016/j.addbeh.2016.02.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bohnert KM, Bonar EE, Arnedt JT, Conroy DA, Walton MA, Ilgen MA, 2018. Utility of the comprehensive marijuana motives questionnaire among medical cannabis patients. Addictive Behaviors 76, 139–144. 10.1016/j.addbeh.2017.08.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bonn-Miller MO, Loflin MJ, Thomas BF, Marcu JP, Hyke T, Vandrey R, 2017. Labeling accuracy of cannabidiol extracts sold online. Jama 318(17), 1708–1709. 10.1001/jama.2017.11909 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Borodovsky JT, 2022. Generalizability and representativeness: Considerations for internet-based research on substance use behaviors. Experimental and Clinical Psychopharmacology 30(4), 466. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Borodovsky JT, Lee DC, Crosier BS, Gabrielli JL, Sargent JD, Budney AJ, 2017. US cannabis legalization and use of vaping and edible products among youth. Drug and alcohol dependence 177, 299–306. 10.1016/j.drugalcdep.2017.02.017 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cerino P, Buonerba C, Cannazza G, D’Auria J, Ottoni E, Fulgione A, Di Stasio A, Pierri B, Gallo A, 2021. A review of hemp as food and nutritional supplement. Cannabis and cannabinoid research 6(1), 19–27. 10.1089/can.2020.00019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Cohen J, 1988. Statistical power analysis for the behavioral sciences. 10.4324/9780203771587 [DOI] [Google Scholar]
  10. Crockett J, Critchley D, Tayo B, Berwaerts J, Morrison G, 2020. A phase 1, randomized, pharmacokinetic trial of the effect of different meal compositions, whole milk, and alcohol on cannabidiol exposure and safety in healthy subjects. Epilepsia 61(2), 267–277. 10.1111/epi.16419 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Friese B, Slater MD, Battle RS, 2017. Use of marijuana edibles by adolescents in California. The journal of primary prevention 38(3), 279–294. 10.1007/s10935-017-0474-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Giombi KC, Kosa KM, Rains C, Cates SC, 2018. Consumers’ perceptions of edible marijuana products for recreational use: likes, dislikes, and reasons for use. Substance use & misuse 53(4), 541–547. 10.1080/10826084.2017.1343353 [DOI] [PubMed] [Google Scholar]
  13. Hammond D, Goodman S, 2022. Knowledge of tetrahydrocannabinol and cannabidiol levels among cannabis consumers in the United States and Canada. Cannabis and cannabinoid research 7(3), 345–354. 10.1089/can.2020.0092 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Lee CM, Neighbors C, Hendershot CS, Grossbard JR, 2009. Development and preliminary validation of a comprehensive marijuana motives questionnaire. Journal of studies on alcohol and drugs 70(2), 279–287. 10.15288/jsad.2009.70.279 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Lunn S, Diaz P, O’Hearn S, Cahill SP, Blake A, Narine K, Dyck JR, 2019. Human pharmacokinetic parameters of orally administered Δ9-tetrahydrocannabinol capsules are altered by fed versus fasted conditions and sex differences. Cannabis and cannabinoid research 4(4), 255–264. 10.1089/can.2019.0037 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. McClements DJ, 2020. Enhancing Efficacy, Performance, and Reliability of Cannabis Edibles: Insights from Lipid Bioavailability Studies. Annual Review of Food Science and Technology 11, 45–70 [DOI] [PubMed] [Google Scholar]
  17. Monte AA, Shelton SK, Mills E, Saben J, Hopkinson A, Sonn B, Devivo M, Chang T, Fox J, Brevik C, 2019. Acute illness associated with cannabis use, by route of exposure: an observational study. Annals of internal medicine 170(8), 531–537. 10.7326/M18-2809 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Ong LQ, Bellettiere J, Alvarado C, Chavez P, Berardi V, 2021. Cannabis use, sedentary behavior, and physical activity in a nationally representative sample of US adults. Harm reduction journal 18(1), 1–10. 10.1186/s12954-021-00496-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Peng H, Shahidi F, 2021. Cannabis and cannabis edibles: A review. Journal of Agricultural and Food Chemistry 69(6), 1751–1774. 10.1021/acs.jafc.0c07472 [DOI] [PubMed] [Google Scholar]
  20. Spindle TR, Bonn-Miller MO, Vandrey R, 2019. Changing landscape of cannabis: novel products, formulations, and methods of administration. Current opinion in psychology 30, 98–102. 10.1016/j.copsyc.2019.04.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Spindle TR, Cone EJ, Goffi E, Weerts EM, Mitchell JM, Winecker RE, Bigelow GE, Flegel RR, Vandrey R, 2020. Pharmacodynamic effects of vaporized and oral cannabidiol (CBD) and vaporized CBD-dominant cannabis in infrequent cannabis users. Drug and alcohol dependence 211, 107937. 10.1016/j.drugalcdep.2020.107937 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Stott C, White L, Wright S, Wilbraham D, Guy G, 2013a. A phase I study to assess the effect of food on the single dose bioavailability of the THC/CBD oromucosal spray. European journal of clinical pharmacology 69(4), 825–834. 10.1007/s00228-012-1393-4 [DOI] [PubMed] [Google Scholar]
  23. Stott C, White L, Wright S, Wilbraham D, Guy G, 2013b. A phase I study to assess the single and multiple dose pharmacokinetics of THC/CBD oromucosal spray. European journal of clinical pharmacology 69(5), 1135–1147 [DOI] [PubMed] [Google Scholar]
  24. Strickland JC, Stoops WW, 2019. The use of crowdsourcing in addiction science research: Amazon Mechanical Turk. Experimental and Clinical Psychopharmacology 27(1), 1. 10.1037/pha0000235 [DOI] [PubMed] [Google Scholar]
  25. Strickland JC, Victor GA, 2020. Leveraging crowdsourcing methods to collect qualitative data in addiction science: Narratives of non-medical prescription opioid, heroin, and fentanyl use. International Journal of Drug Policy 75, 102587. 10.1016/j.drugpo.2019.10.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Trevaskis NL, Shackleford DM, Charman WN, Edwards GA, Gardin A, Appel-Dingemanse S, Kretz O, Galli B, Porter CJ, 2009. Intestinal lymphatic transport enhances the post-prandial oral bioavailability of a novel cannabinoid receptor agonist via avoidance of first-pass metabolism. Pharmaceutical research 26(6), 1486–1495. 10.1007/s11095-009-9860-z [DOI] [PubMed] [Google Scholar]
  27. Vandrey R, Raber JC, Raber ME, Douglass B, Miller C, Bonn-Miller MO, 2015. Cannabinoid dose and label accuracy in edible medical cannabis products. Jama 313(24), 2491–2493. 10.1001/jama.2015.6613 [DOI] [PubMed] [Google Scholar]
  28. Volkow ND, Baler R, 2019. Emergency department visits from edible versus inhalable cannabis. Annals of internal medicine 170(8), 569–570 [DOI] [PubMed] [Google Scholar]
  29. Wong KU, Baum CR, 2019. Acute cannabis toxicity. Pediatric emergency care 35(11), 799–804. 10.1097/PEC.0000000000001970 [DOI] [PubMed] [Google Scholar]
  30. Yurasek AM, Aston ER, Metrik J, 2017. Co-use of alcohol and cannabis: A review. Current Addiction Reports 4(2), 184–193. 10.1007/s40429-017-0149-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Zgair A, Wong JC, Lee JB, Mistry J, Sivak O, Wasan KM, Hennig IM, Barrett DA, Constantinescu CS, Fischer PM, 2016. Dietary fats and pharmaceutical lipid excipients increase systemic exposure to orally administered cannabis and cannabis-based medicines. American journal of translational research 8(8), 3448. PMC5009397 [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1

Supplemental Figure 1. Individual participant ratings for typical doses of (A) THC and (B) CBD were highly variable within each oral cannabis product type. Error bars depict SEM. Left y-axis indicates self-reported doses (in mg).

Supplemental Figure 2. Individual participant ratings for “how long does it take for you to feel any effects” were highly variable within each oral cannabis product type. Error bars depict SEM. Left y-axis indicates self-reported time (in minutes).

Supplemental Figure 3. Individual participant ratings for (A) “stronger than I expected,” (B) “weaker than I expected,” (C) “lasts longer than I expected,” (D) “lasts shorter than I expected,” (E) “kicks in faster than I expected,” and (F) “kicks in slower than I expected” were highly variable within each oral cannabis product type. Error bars depict SEM. Left y-axis indicates VAS ratings. Right y-axis indicates verbiage associated with ratings of “0,” “50,” and “100.”

Supplemental Figure 4. Individual participant ratings for (A) strength/intensity, (B) duration (of action), and (C) time to onset of effects were highly variable within macronutrient group (“higher calories,” “higher fat,” and “higher carbohydrates”). Error bars depict SEM. Left y-axis indicates VAS ratings. Right y-axis indicates verbiage associated with ratings of “0,” “50,” and “100.”

NIHMS1881370-supplement-1.docx (2.8MB, docx)

RESOURCES