The present study reports the knowledge, attitude, and expectancies about cannabis use among college students in urban Bangalore. In India, prior authors have documented the use of cannabis among young people. These studies, although sporadic, have reported important trends in cannabis use among youth in the country concerning prevalence, reasons for use, and other associated factors.^5,7,9 Some of these trends are noteworthy and in line with the present study’s findings. For instance, in the present study, the overall knowledge and attitude scores indicated that the students seemed fairly knowledgeable about the harmful effects of cannabis use and were not very favorable toward use. However, most of the current sample were unaware that cannabis use can cause driving impairment and lower academic performance. Similar findings were noted in a prior study among college students in Mumbai, where about half were unaware that cannabis use could cause cognitive and behavioral impairment. ⁹ Further, in the present study, a significant proportion of students opined that cannabis use is safe for recreational purposes and that cannabis use is part of college life, which helps them to relax, be more creative, and feel more romantic. Similar findings were noted in studies from overseas where recreational motives influenced use, and positive perceptions were noted among cannabis users, including relief from anxiety and stress.^2,16 Prior studies among college students from India also had noted positive expectancies as well as ambivalent attitudes from use.^8,9,20

There can be several reasons for favorable attitudes or positive expectancies from cannabis use. For example, prior studies found that the students believed/used cannabis for relaxation, stress relief, enhancing creative abilities, better socialization, and increasing sexual desire.^8,9,20 Prior authors from overseas and India have also highlighted the role of social motives, peer influence, and lack of adequate supervision, which can fuel cannabis use for various reasons.^6,21 Furthermore, such positive attitudes or expectancies can place individuals at a higher risk for use. This was also reflected in the present study, where cannabis users had significantly more favorable attitudes toward cannabis use and had more positive expectancies from use. Prior literature has also documented positive expectancies and engagement in high-risk behaviors among cannabis users.^2,14 It is also important to remember that inadequate knowledge can lead to more favorable attitudes and more positive expectancies from cannabis use. This was reflected in the present study’s findings, where knowledge about health harms was associated with a significantly less favorable attitude toward cannabis use and more negative expectancies from use. This fact can be very important when planning preventive interventions for this group.

One-fourth of our sample supported the legalization of cannabis, claiming it helps to relieve stress. Similar findings were found in a recent qualitative study among college students in urban Bangalore, ²⁰ where the students said that cannabis and tobacco go hand in hand, that there is “research evidence” about the medical benefits of cannabis, and that its use should be legalized. These findings are important, given the debate surrounding the legalization of cannabis use worldwide, with countries like Uruguay, Canada, and several states in the United States having enacted laws allowing the use of cannabis for medical or recreational purposes. In general, public opinion on the legalization of cannabis use is increasingly becoming favorable, ⁴ which may be attributed to a growing literature alluding to the potential medical benefits of cannabis without exposing people to the health risks.^14,22,23 Prior authors from India also have suggested that legalization can help curb young people from using unknown products. ⁶ However, research has documented the increasing use of cannabis among young people following legalization, with associated high-risk behaviors.^3,4 There is also growing evidence of the significant negative impact of cannabis use on the education and career of young people through impairment of executive functions.^{2,4,7,8,14,24} Prior literature emphasizes that cannabis use during adolescence can cause long-lasting changes in brain functions, jeopardizing educational, professional, and social achievements. ¹⁴ The harms from use may also extend to others since there is an increased risk of accidents due to impaired driving ability.^12,13

Another concern is the cannabis-related information available to young people via the media or online. For instance, in the present study, 42% had viewed cannabis-related content in movies or television, and more than one-third had browsed the internet for information on cannabis products. The influence of mass media on cannabis use and negative health outcomes in young people has been documented in prior literature. ²⁵ In a study, the college students spoke at length about the influence of the media: “Today’s youth is educated and searches online. And there is a lot of information… including studies supporting the medical benefits of cannabis and that its use should be legalized….” ²⁰

Given that prior literature in India focusing on awareness among youth with regard to cannabis use and associated risks is scanty, the current findings add to the literature and emphasize the need for targeted interventions for this group. However, this brings to question the content that should be included in such interventions and the strategies that should be adopted to convey this content. For instance, how does one convince youngsters to quit cannabis in the face of an onslaught of questions backed by purported claims or “research” about the benefits of use? In India, there has been a significant increase in the promotion of medicinal cannabis products, as in overseas, where prior authors have documented medicinal cannabis advertisement and marketing by medical cannabis dispensaries. ²⁵ Further, considering that there are no clear-cut health warnings about cannabis use in India, the plethora of cannabis-related information on various platforms seems to be catching on among youngsters. College students asked the present authors why cannabis use should be restricted, particularly when alcohol and tobacco are legally available to the public despite their well-established health harms. They explained that in India, cannabis is part of the culture and that if cannabis becomes more acceptable in society, they can access it and benefit without worrying about punishment. The present study’s findings also reflect this, as the participants seemed ambivalent and divided regarding their knowledge of, attitude toward, and expectancies from cannabis use.

The above findings have several critical implications for planning preventive educational strategies for college students, a highly vulnerable group, given that they are going through a turbulent developmental stage of life, coupled with various academic and other challenges. First, there is a need for a balanced perspective about the potential adverse health impact of cannabis and an informed approach toward prevention and harm reduction. Specific interventions and youth awareness strategies to strengthen cannabis-protective behavioral strategies can reduce the quantity and frequency of use and minimize harm. ²⁶ Second, planning youth awareness/intervention programs can help to increase knowledge about the health harms of cannabis and clarify any misconceptions that the students may have about cannabis use by providing authentic health information, which can, in turn, enhance youth health and safety. A prior study from India indicated that college students who were aware of the harmful effects and legal status were more motivated to quit cannabis. ⁹ Third, such awareness programs also need to consider any demographic trends associated with use (e.g., in the present study, cannabis users tended to be older, male, from higher-income families, and pursuing postgraduate courses). The finding that the cannabis users tended to be older or postgraduates could be because students may be non-users when they join college and gradually pick up the habit as they go through their courses of study due to various influences (e.g., peers). This points to the need for prevention/intervention programs to be introduced early as part of college student development initiatives. Fourth, the present findings can help sensitize college peer volunteers, teachers, and administrators regarding these trends among students and train them to identify cannabis use, provide necessary clarifications and advice, and make referrals as necessary. Fifth, the information can aid in developing and delivering primary prevention interventions through community youth outreach programs and incorporated into workshops and training programs conducted periodically in colleges. Such programs should also reiterate to the students that cannabis use is not exactly part of the Indian culture—its ritualistic use is restricted to very specific sub-cultural groups. This should not be equated with “safety” or “acceptability” of cannabis. Cannabis is recognized as an intoxicant and a drug of dependence, with attendant health harms, adversely impacting young people’s education and careers. Another important fact that needs to be featured in youth health education programs is that the high levels of tetrahydrocannabinol (THC, the main psychoactive ingredient of cannabis) present in the high-potency forms of street cannabis have been linked to a variety of mental disorders, including psychotic, bipolar, depressive, anxiety disorders, as well as suicide. ²⁷ Conversely, cannabidiol, the other important ingredient of traditional cannabis, which is being explored for its medicinal value, is not present in street cannabis. Thus, the notion that cannabis use can be made more acceptable or supported for health benefits is grossly misplaced, and it is important to clarify this important distinction. This would help young people to be cognizant of the health harms associated with the various street forms of cannabis that are becoming increasingly available.

Lastly, the present study can provide some direction for policymaking in the context of the legalization of cannabis. Prior studies have documented that post-legalization of cannabis, there was a significant increase in the use of cannabis, high-risk behaviors among users, and decreased risk perception about cannabis use.^2,4 Cannabis is not a legal drug in India; however, as indicated by the present study’s findings and prior literature,^6,10 there appears to be some support or argument regarding legalization. Tobacco and alcohol are legal drugs, which probably is the reason why they contribute to a huge morbidity and mortality burden. If cannabis use is also legalized, would it result in more young people consuming it? Would there be a manifold increase in the existing disease burden, also keeping in mind that cannabis and tobacco are often smoked together? At a time when the adolescent brain is more vulnerable (compared to a mature brain) to long-term environmental insults such as THC in cannabis, ¹⁴ would our youth be at a much higher risk of contracting major illnesses as well as face a higher risk of fatal accidents due to its adverse influence on driving ability? These are significant concerns to be pondered upon, which can inform preventive programs and social policy about social/cultural permissiveness and legal sanctions for cannabis. Future research should examine the kinds of repercussions legalization of cannabis can lead to, particularly in the Indian context. For example, how do we operationalize the legalization of cannabis in India? This is important because the available experience of cannabis legalization is from other countries. But in India, where implementing laws regulating substance use may not be very stringent, the possible impact and potential consequences on our society must be thoroughly examined. Further research can also focus on designing a tailor-made intervention/primary prevention program for youth and examine its impact on their knowledge, attitude, perceptions, and expectancies about cannabis use, as well as cannabis consumption trends among youth over some time.

The present study was the first phase of a parent investigation to develop an intervention for college students in the context of cannabis use, which is informed by the student’s knowledge, attitudes, and expectancies. However, the study has some limitations. First, it was conducted among English-speaking urban college-going youth, which limits generalizability to other student groups (e.g., rural/non-English speaking). Another limitation is that the data obtained with regard to the students’ cannabis use, knowledge, attitude, and expectancies are based on self-report measures. Self-report data can be subject to social desirability or recall biases, under- or over-reporting, which can limit the generalizability of the findings. Nevertheless, the study has provided important information that builds on existing literature on cannabis use among young people. Based on this information, as well as inputs obtained from the students from focus groups, which were also conducted, the intervention has been developed and tested for feasibility among the students. The authors intend to report the findings shortly.