Demographic, Economic, and Social Status and Knowledge of Medical and Alternative Cannabis Use among Northeastern Thai Citizens: A Case Study of Outpatients atCommunity Hospitals along the Thai–Cambodian Border

Demographic, Economic, and Social Status and Knowledge of Medical and Alternative Cannabis Use among Northeastern Thai Citizens: A Case Study of Outpatients atCommunity Hospitals along the Thai–Cambodian Border | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Demographic, Economic, and Social Status and Knowledge of Medical and Alternative Cannabis Use among Northeastern Thai Citizens: A Case Study of Outpatients atCommunity Hospitals along the Thai–Cambodian Border Pattarachit Choompol Gozzoli, Suyanee Pongthananikorn, Tanattha Kitisopee, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6940512/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Oct, 2025 Read the published version in Journal of Cannabis Research → Version 1 posted 9 You are reading this latest preprint version Abstract Objectives: This study aimed to examine the demographic, economic, and social characteristics of the population in relation to their experiences with cannabis use and their accurate knowledge regarding its therapeutic properties and side effects when used in conjunction with conventional and alternative medicine and analyze the legal clarity concerning cannabis regulations and to propose communication strategies for effectively disseminating knowledge about its therapeutic properties and potential side effects when used for medical purposes. Method: A cross-sectional quantitative survey was conducted between March and August 2024 at a 30-bed community hospital along the Thai-Cambodian border. The sample included 618 Thai outpatients (429 females, 189 males) aged 18–86 years, selected via convenience sampling. Data were collected through face-to-face structured interviews using a validated questionnaire covering demographics, cannabis use history, and knowledge of medical uses and side effects. Results: Only 14.24% of respondents had prior cannabis use experience. While most were aware of cannabis legalization, a large proportion showed limited understanding of its approved medical indications or side effects. Over 60% of participants answered "do not know" about therapeutic benefits or adverse effects. Differences in knowledge were found across age groups and education levels, but awareness was relatively low among health volunteers (Village Health Volunteers). Conclusions: Despite policy liberalization, knowledge gaps concerning medical cannabis remain widespread, especially regarding its safe and appropriate use. The findings highlight the need for targeted public education, regulatory clarity, and culturally appropriate communication strategies to ensure safe usage and minimize health risks, particularly in sensitive border areas. Cannabis Thai-Cambodian border Cannabis use Introduction The decriminalization of cannabis from a Category 5 narcotic under the Narcotic Code B.E. 2564 (2021) marked a significant turning point in Thailand's drug policy, traditional medicine, and economic landscape. The government's initiative aimed to increase the economic value of herbal plants, beginning with the enactment of the Narcotic Act (No. 7), B.E. 2562 (2019), which allowed cannabis to be used for medical purposes and encouraged both biomedical and socio-humanistic research for the first time 1 . On June 9, 2022, the Ministry of Public Health officially removed cannabis from the list of controlled narcotics, making Thailand the first country in Asia to legalize the use of cannabis for both medicinal and recreational purposes. This legalization facilitated cannabis use in commercial, medical, and research domains without contravening prior laws 2 – 4 . This policy shift was driven mainly by increasing evidence supporting the medicinal benefits of cannabis, such as pain relief in cancer patients 5 , treatment of epilepsy, and management of depression. It also created opportunities in industries producing dietary supplements and cosmetics. In 2021, the Department of Thai Traditional and Alternative Medicine promoted the medical use of cannabis through over 893 clinics nationwide, serving more than 7,200 patients 6 . Economically, the Bank of Thailand estimated the cannabis market in 2023 to be worth approximately 28 billion THB and projected continued growth 7 . As a result, numerous cannabis retail points have emerged nationwide. By April 2024, there were 7,747 such outlets, with Bangkok alone hosting 1,122 8 . A 2023 survey revealed that 20% of the population had used cannabis, and 9% cultivated it at home. However, cannabis use among youth has rapidly increased, especially among those outside the formal education system, where usage rates reached 47.6%. This often involved concurrent use with other substances such as alcohol, tobacco, and kratom 9 – 11 . Although cannabis legalization was expected to yield more positive than adverse outcomes in the medical and commercial sectors, unforeseen negative consequences have emerged, particularly in public health and social domains. Hospitals have reported increasing cases of cannabis-related side effects. Public concern about cannabis misuse, especially among youth, is growing. A 2023 survey by the National Statistical Office found that 68% of the population supported stricter cannabis regulations 12 . Consequently, there have been calls for new legislation, such as the Cannabis and Hemp Bill, to provide clearer regulatory frameworks 13 . This aligns with findings from the Center for Addiction Studies, which identified the northeastern region as having the highest cannabis usage rates. For example, nearly two-thirds of males aged 30–59 reported using cannabis for recreational purposes, and youths aged 15–19 were found to use cannabis without restriction 14 . In this region, cannabis users also experienced mental health issues and anxiety and engaged in poly-substance use 15 . The Thai-Cambodian border, part of the northeastern region, has deep historical, cultural, and economic ties, influencing local cannabis usage across various dimensions, including commerce, product mobility, and daily consumption 16 – 17 . Cannabis is commonly used as an herbal remedy and food ingredient, such as in chicken soup, spicy soups, noodles, and cookies, to relieve muscle pain through traditional recipes. However, following Thailand's 2022 legalization, cannabis usage and trade dynamics along the border have shifted dramatically, especially in terms of product movement, as Cambodia still classifies cannabis as an illicit drug 18 . This has led to smuggling activities, and cannabis entering Thailand through unofficial channels often escapes quality control, posing consumer risks. Youths in this area have easy access, leading to improper usage that may result in long-term mental health issues and risky behaviors 8 , 19 . Therefore, while cannabis legalization has spurred the development of medical and industrial products, cultivation and production must be tightly regulated. National measures and bilateral cooperation between Thailand and Cambodia remain crucial. Moreover, the knowledge and understanding of cannabis, its benefits, risks, and side effects among local populations, from youth to older people, remain unclear. This knowledge gap is particularly significant given the fragile, risky, and potentially dangerous nature of cannabis use, especially for both users and healthcare providers in both Thailand and Cambodia. Hence, there is a pressing need to explore the demographic, economic, and social factors that influence cannabis knowledge and usage, including its applications in modern and alternative medicine and associated side effects areas that have not been systematically studied in terms of valid measurements and question formulation. This is particularly true for border regions where cannabis use predates legalization 20 . Lessons from the U.S.–Mexico border illustrate how legal changes in the U.S. cannabis policy affected smuggling patterns, as legalization led to decreased demand in the black market but increased health-related side effects among users 21 – 24 . Similar patterns have been observed in Canada, where liberalization increased cannabis use across various demographics, particularly among youth with easy access 25 – 26 . These decisions are often influenced by misinformation, unawareness of potential side effects, misconceptions, or social trends 27 – 29 . Therefore, it is vital to investigate the demographic, economic, and social determinants of cannabis knowledge and use, especially in the context of modern and alternative medicine, among northeastern residents along the Thai-Cambodian border. Without proper knowledge assessment, unregulated cannabis use could lead to adverse physical and mental health outcomes similar to those seen in U.S. or Canadian border regions 30 . This study aims to address the current knowledge gap by generating critical insights that inform accurate public education, highlight cannabis-related side effects, and support informed decision-making for therapeutic cannabis use. This is particularly important in increasing cannabis availability in border areas. Another key motivation is the limited research on cannabis use in the Thai-Cambodian border context. To date, no studies have analyzed response accuracy regarding approved medical uses of cannabis or associated side effects. Therefore, this study also aims to assess the clarity of laws related to cannabis use and propose effective communication strategies for public health messaging. These elements are essential for fostering a more accurate understanding of cannabis, ultimately guiding safe usage practices in the future. Method This study adopted a quantitative cross-sectional survey design, complemented by a document-based analysis of primary legal sources issued by Thai government agencies concerning the medical and alternative medicinal use of cannabis. Data collection occurred between March 10 and August 31, 2024, during the transitional period between northeastern Thailand's hot and rainy seasons, specifically in border districts adjacent to Cambodia. Participants were Thai outpatients aged 18–86 from a 30-bed community hospital in a border district. The study focused on this region due to its unique socio-cultural and economic with Cambodia, as well as its active cannabis usage. The sample comprised 618 respondents, including 189 men (30.6%) and 429 women (69.4%), with an average age of 50.8 years. A convenience sampling method was employed to ensure practical feasibility. All interviews were conducted face-to-face by a single trained field researcher, allowing for quality control and ensuring confidentiality. The interviewer received one-day training focused on research ethics, participant rights, data accuracy, and handling sensitive topics. The study addressed questions about cannabis use for both medical and recreational purposes, which are considered legally and socially sensitive, particularly in a border context where cannabis is legal in Thailand but remains illegal in Cambodia. Participants provided informed, voluntary consent, and confidentiality was strictly maintained. The rest of the research team contributed to questionnaire design, data coding, entry, and analysis. This methodology enabled reliable data collection while protecting respondents from potential legal or social risks. Research instrument A structured, close-ended questionnaire was employed for data collection, administered through face-to-face interviews by a trained field researcher in private and convenient outpatient settings. The questionnaire consisted of four sections: (1) demographic information (age, sex, education, occupation, income); (2) knowledge of cannabis's therapeutic properties in conventional and alternative medicine 5 , 31 – 32 , measured using three response options (correct, incorrect, unknown); (3) knowledge of cannabis-related side effects 33 – 36 , also measured using the same three response categories; and (4) cannabis use experiences, covering medical, recreational, culinary, and commercial purposes. For analysis, use experience was dichotomized into "ever used" and "don't know" to better assess trends following legalization in June 2022. Content validity was reviewed by four experts, two in pharmaceutical sciences, one in medicine, and one in behavioral science, yielding an Index of Congruence (IOC) of 0.9. Reliability analysis for the knowledge items produced a Cronbach's alpha of 0.83, indicating a reliability level of approximately 69% 37 . Descriptive statistics, including frequencies, percentages, and means, were used to illustrate distribution patterns and support comparative analysis. A content analysis of legal documents examined the clarity and coherence of cannabis-related laws. Results 1. Sample Characteristics Among the 618 participants, an apparent gender disparity was observed: 429 respondents (69.4%) were female, while only 189 (30.6%) were male. This imbalance reflects a broader societal trend in which women are generally more proactive in health-seeking behaviors and outpatient service engagement. Age groups were categorized into three generational cohorts for comparative analysis: youth and young adults (ages 18–39, Generation Y and Z) accounted for 73 participants; adults (ages 40–54, Generation X) represented the majority with 457 participants; and older adults (ages 55–77, Baby Boomers) comprised 88 participants. This classification facilitates an exploration of generational differences in legal consciousness, social norms, and ideological tendencies, liberal versus conservative, shaped by distinct sociolegal environments during formative years. Occupationally, the sample was skewed toward village health volunteers (VHVs), who play a significant role in Thailand's public health infrastructure, particularly in disease surveillance and community-based health promotion. Other professions, such as farmers and daily laborers, were represented in smaller proportions. Regarding education, respondents who had completed at least compulsory education were more likely to demonstrate cognitive competencies, including legal awareness, literacy in foreign languages (especially English), and analytical reasoning. Cannabis use experience categorized as medical, recreational, culinary, or commercial was considered a proxy for practical knowledge and understanding of cannabis's benefits and side effects. As detailed in subsequent sections, these experiences were further analyzed across demographic, economic, and social variables. Demographic, Economic, and Social Characteristics and Cannabis Use Experience Cannabis use experience was considered a critical behavioral indicator in this study, reflecting not only actual consumption but also its potential correlation with knowledge accuracy regarding therapeutic benefits and side effects. Before its decriminalization in 2021, cannabis use in Thailand was a criminal offense punishable by up to five years imprisonment or a fine of 500,000 THB 1 . Analysis of usage patterns alongside demographic, economic, and social variables revealed a significant disparity, with non-users outnumbering users nearly five to one among female and male respondents. Generation X (ages 40–54) reported the highest usage rates compared to other cohorts. Yet, overall cannabis use remained low, especially among village health volunteers (VHVs), who are closely affiliated with state health services and likely cautious due to lingering legal ambiguity. Education level also influenced behavior, with those having more than basic education reporting the lowest usage. Even among participants with primary education or less, cannabis use remained minimal. These trends suggest that historical legal restrictions and sustained confidence in conventional medicine continue to shape public attitudes. As detailed in Table 1, most respondents were women over 40, working in community health roles with limited formal education, and only 88 individuals (14.24%), approximately one in seven, reported any prior cannabis use. Demographic, Economic, and Social Characteristics and Knowledge of Cannabis's Therapeutic Properties in Conventional Medicine Although only 88 of 618 participants (14.24%) reported prior cannabis use, their responses revealed that direct experience did not strongly correlate with accurate knowledge of cannabis's therapeutic applications. This group's most common uses were muscle inflammation and sleep aids, while recreational, culinary, and commercial uses were less frequent. Despite Thailand's legalization of cannabis in June 2022 38 , knowledge of its medical indications, such as treating chemotherapy-induced nausea, improving quality of life in terminal illness, and alleviating muscle spasticity, remained limited, with correct responses comprising only about one-sixth of the sample and "don't know" being the dominant answer across all items. Interestingly, cannabis use history, gender, education level, or occupation did not significantly improve accuracy. However, older respondents (Generation X and Baby Boomers) showed slightly better knowledge, potentially due to accumulated experience or caregiving roles. Uncertainty prevailed even among village health volunteers (VHVs), who are typically expected to possess greater health literacy. These findings highlight a widespread knowledge gap across all demographic sectors and underscore the urgent need for structured, evidence-based public education strategies to support informed decision-making regarding medical cannabis use. Demographic, Economic, and Social Characteristics and Cannabis Use Experience concerning Knowledge of Cannabis's Therapeutic Properties in Alternative Medicine This section explores participants' knowledge of cannabis's therapeutic properties in alternative medicine, including traditional Thai and local healing practices. Although cannabis has historically been used to treat conditions such as drug-resistant epilepsy in children and chronic insomnia in adults, this study found that accurate knowledge of such uses remains limited across all demographics. A significant number of participants responded with "don't know," a trend consistent across age, occupation, education level, and cannabis use history. Notably, prior cannabis use did not significantly correlate with correct responses regarding these therapeutic applications, suggesting that residual stigma and legal ambiguity continue to hinder public understanding. Older participants, who might be expected to demonstrate greater insight due to life experience or caregiving roles, showed similarly low knowledge levels, implying that entrenched legal and cultural taboos remain influential. Although village health volunteers (VHVs) expected to have higher exposure to medical education performed slightly better than other occupational groups, uncertainty still dominated their responses. This pattern underscores a broader failure of both formal and informal communication systems, such as public announcements, community outreach, and local government messaging, to deliver clear, evidence-based information about cannabis in alternative medicine. Ongoing regulatory uncertainty and the absence of national policy integration limit the diffusion of accurate knowledge. Table 3 presents a detailed breakdown of participant responses on cannabis's role in managing epilepsy and insomnia, revealing persistent knowledge gaps across demographic and occupational segments. Knowledge of Cannabis's Therapeutic Properties and Side Effects When Used in Conventional Medical Treatment Understanding both the therapeutic benefits and side effects of cannabis when used alongside conventional medicine is essential, particularly for healthcare providers, patients, caregivers, and village health volunteers (VHVs), who often gain firsthand insights into patient outcomes through follow-up visits and clinical interactions. Therefore, it is expected that those engaged in patient care would possess more accurate knowledge of cannabis's therapeutic applications and potential risks. However, this study revealed significant knowledge gaps in all areas assessed, including three medical cannabis applications endorsed by Thailand's Department of Medical Services managing chemotherapy-induced nausea, improving quality of life in terminal illness, and alleviating muscle spasticity in multiple sclerosis and four common side effects: constipation, dizziness and nausea, hallucinations, and dry mouth 33-36 . The data show that "don't know" was the most frequent response across all items, even among VHVs, suggesting a broader deficit in public cannabis health literacy. For example, only 159 respondents correctly identified cannabis's role in treating chemotherapy-induced nausea, and just 181 and 148 respondents answered correctly regarding its effectiveness in improving end-of-life care and relieving muscle spasticity, respectively. Likewise, knowledge of side effects was similarly limited; in the case of chemotherapy-induced nausea, where constipation is a known adverse effect, only 87 participants answered correctly, compared to 333 who were unsure and 27 who responded incorrectly. Similar uncertainty was observed regarding dizziness, hallucinations, and dry mouth. Notably, those with correct knowledge of therapeutic applications were also more likely to recognize associated side effects, highlighting the influence of experiential learning. These findings underscore the compounded impact of legal ambiguity, fragmented regulatory messaging, and insufficient health communication, all of which hinder the development of accurate, community-level understanding of cannabis in medical contexts. As summarized in Table 4, this limited awareness highlights the urgent need for targeted, evidence-based educational strategies and clearer public policy to support informed and safe cannabis use, particularly in border regions where access to formal health information may be constrained. Knowledge of Cannabis's Therapeutic Properties in Alternative Medicine and Associated Side Effects The findings reveal that public knowledge regarding the side effects of cannabis use, particularly in the context of alternative medicine such as traditional Thai and folk healing, remains limited. Despite cannabis's longstanding role in community-based practices informed by local wisdom, few participants in this study demonstrated accurate knowledge of its therapeutic use for conditions like treatment-resistant epilepsy in children or severe seizures. Only 112 participants correctly identified these applications, while 99 answered incorrectly and 407, approximately two-thirds responded with "don't know," underscoring that only one in six held accurate information despite increasing national discourse on medical cannabis. This knowledge gap is likely the result of insufficient public communication about cannabis's therapeutic potential for complex neurological conditions. A similar pattern was observed regarding insomnia, with only 208 participants (about one-third) answering correctly and 330 again selecting "don't know," suggesting that informational outreach remains ineffective. Table 5 confirms respondents were likelier to admit uncertainty than to provide incorrect answers, highlighting a lack of exposure to validated, evidence-based knowledge. Awareness of side effects was equally poor; few participants recognized common adverse reactions such as constipation, dizziness, nausea, hallucinations, and dry mouth. These results underscore a widespread lack of understanding regarding both the therapeutic and physiological impacts of cannabis. Particularly concerning are neurological side effects, which affect the central nervous system, and autonomic side effects, such as dry mouth and constipation, which can pose risks if not adequately understood. Promoting cannabis's integration into alternative medicine thus requires not only legal clarity but also transparent, culturally relevant, and medically accurate public education to ensure safe and informed use. Legal Clarity Regarding Cannabis Use and Communication Strategies for Its Therapeutic Properties and Side Effects Based on the findings presented above, one of the key observations of this study is that limited experience with cannabis and poor knowledge regarding its therapeutic properties and side effects may be attributed mainly to the lack of legal clarity surrounding its use in Thailand. Historically classified as a narcotic, cannabis possession or consumption was a criminal offense. Despite recent legislative changes, ambiguities regarding its legal definition and permissible uses may hinder public understanding and acceptance. The following section outlines the legal framework of cannabis, highlighting aspects that are or remain explicitly illegal. It presents communication strategies aimed at enhancing public awareness of both therapeutic benefits and potential risks of medical cannabis use. Legal Framework Related to Cannabis Use This study reveals not only a low prevalence of cannabis use among participants but also a troubling lack of accurate knowledge regarding its therapeutic applications in both conventional and alternative medicine. Across all survey dimensions, "don't know" emerged as the most frequent response, suggesting widespread public disengagement or uncertainty, likely driven by ongoing legal ambiguity surrounding cannabis in Thailand. Although the country has decriminalized cannabis for medical and limited recreational use, its historical classification as a narcotic has perpetuated confusion about what is legally permissible. Inconsistent terminology, undefined legal boundaries, and overlapping regulatory frameworks continue to hinder public understanding of both cannabis's medical benefits and associated risks. The study proposes a structured communication strategy to clarify legal definitions and regulatory interpretations, particularly in border provinces adjacent to Cambodia, where regulatory enforcement may be uneven and misinformation more pervasive. A foundational step involves mapping current cannabis-related laws into three categories: permitted, ambiguous, and prohibited, and communicating these distinctions to the public. This legal mapping should be disseminated by trusted sources, including senior officials from the Ministry of Public Health and Ministry of Justice, local community leaders, and spiritual authorities. As summarized in Table 6, clear legal guidance paired with culturally sensitive public education can provide a critical foundation for safe, informed, and lawful cannabis use, particularly as the country explores cannabis's potential for medical, economic, and tourism-related applications. Communication Strategies for Disseminating Knowledge on Therapeutic Properties and Side Effects Effective communication is essential to promote safe and informed cannabis use, particularly in border regions such as those between Thailand and Cambodia. To this end, the study proposes utilizing the SMCR model (Source–Message–Channel–Receiver) to guide the design and delivery of public health information on medical cannabis. The findings suggest that knowledge gaps are especially prominent among individuals with limited education or no prior cannabis use, making tailored communication strategies necessary. In the Source component, trusted figures from policy-level organizations, such as senior executives from the Ministry of Public Health, Ministry of Justice, Ministry of Interior, and Ministry of Agriculture, should serve as primary messengers. These figures should be supported by community-level medical professionals such as doctors and pharmacists. Equally important are local authority figures, provincial governors, district chiefs, village leaders, and spiritual leaders, including traditional healers and religious figures. These individuals should be trained to convey both the therapeutic potential and risks of cannabis based on scientific evidence, such as the National Academies of Sciences 47 report, which recognizes cannabis's effectiveness in alleviating chemotherapy-induced nausea and chronic pain. In the Message dimension, content must present a balanced perspective on benefits and risks. While some participants were aware of cannabis's usefulness in treating specific conditions such as chronic pain or epilepsy, few understood the potential side effects of dizziness, nausea, hallucinations, dry mouth, and constipation. Therefore, communication materials, print, digital media, and infographics should integrate dual-framing techniques 48 , presenting positive and negative aspects to support informed decision-making. Messages should be phrased in simple language, accompanied by visual aids suitable for audiences with basic literacy levels. In terms of Channel, person-centered communication remains paramount. Policy leaders and community figures should disseminate information directly, supplemented by institutional platforms such as hospital Facebook pages, community LINE groups, local radio stations, village meetings, and public address systems. These diverse formats ensure broad reach, particularly in rural areas with limited digital infrastructure. Finally, the Receiver refers to the target audience of adults aged 18 to 77 with basic literacy and no hearing impairments, including many VHVs. Since most respondents reported limited prior cannabis use and little knowledge of its side effects, communication strategies must consider their socio-cultural and educational background. Thus, knowledge dissemination must focus on message content and give equal attention to the credibility and accessibility of messengers and communication channels. Discussion This study revealed that most respondents were female village health volunteers (VHVs) aged 40 and older, representing the Generation X cohort, who have lived through Thailand's digital and technological transformation. Despite being part of a generation that is highly integrated into the digital world, often described as digitally literate and attuned to the Internet of Things and artificial intelligence, these individuals reported limited experience with cannabis, whether for medical, recreational, or culinary purposes. This finding suggests that even within a technologically connected population, trust in conventional medicine remains dominant, mainly due to the widespread perception that modern medical technologies are more reliable and safe 49 – 51 . The prevailing public health message, "Do not self-medicate consult a physician or pharmacist," reinforces this perspective and discourages unsupervised cannabis use 52 – 55 . The data also showed that relatively few respondents could accurately identify cannabis's therapeutic benefits or its side effects when used alongside conventional or alternative medicine. This limited knowledge reflects a lack of engagement with cannabis-related content, likely resulting from longstanding social and legal stigmas. Similar patterns have been reported in countries such as Colombia 56 – 58 , Uruguay 59 , Brazil 60 – 61 , and Venezuela 62 , where public confusion over cannabis-related laws has contributed to poor health literacy and low utilization of medical cannabis 63 – 64 . In the Thai context, the public remains uncertain about what constitutes legal or illegal cannabis use. Kamnoedrit emphasized the need for legal clarity under Thai sovereignty to enable the integration of cannabis products into both conventional and alternative medical practices 65 . Similarly, Sornpaisarn et al. found that overlapping and complex legal texts have led to widespread confusion, discouraging people from learning about or using cannabis safely 66 . Samorapoom, Pewchan, & Promrit added that ambiguous legal language has created distrust, causing the public to avoid the topic entirely 67 . This confusion extends to the legal status of cross-border cannabis transport. Many are unaware of which countries permit or prohibit cannabis imports and exports, and this lack of clarity impacts willingness to learn about its therapeutic uses 68 – 70 . Public hesitancy may also stem from fears that cannabis policy is politically contested and unstable or subject to change 51 , 72 – 73 . For example, some countries such as Japan and the United Kingdom strictly prohibit cannabis importation, while in the United States, it is allowed only in specific states 74 – 76 . These findings suggest that legal uncertainty, both domestic and international, significantly undermines public interest in cannabis's medical potential and contributes to inconsistent knowledge about its uses and effects. For residents in Thailand' northeastern border regions, special ambiguity and undefined terms related to both medical and recreational cannabis have had a measurable impact on how individuals engage with cannabis-related information. As such, the study recommends that communication strategies be developed using the SMCR model (Source–Message–Channel–Receiver), emphasizing the need for clear legal frameworks and the dissemination of accurate, accessible information. The Thai government, particularly the Ministers of Public Health and the Ministers of Justice, should publicly define legal cannabis usage and publish an official list of countries where cross-border cannabis transport is permitted. Educational guides should also be created to improve public interest, knowledge, and safe usage of cannabis. Additionally, influential figures such as provincial governors, district officers, village heads, traditional healers, and religious leaders should play a central role in providing centrality-based information to the public. Their involvement will not only enhance community trust but also ensure that cannabis education reaches rural populations who are most affected by inconsistent laws and limited access to health information. Implications and Future Directions The implications of this study are twofold: first, it calls for the Thai government to urgently address the legal and informational gaps that hinder public understanding and safe use of medical cannabis, particularly in rural and border communities where misinformation thrives. Legal reforms should prioritize harmonizing terminology, clarifying permissible uses, and publishing user-friendly guidelines on what is allowed, ambiguous, or prohibited—especially regarding cross-border transport. Second, future research should expand to qualitative investigations that explore how cultural, spiritual, and generational factors influence cannabis perceptions and behaviors, particularly among youth and local healers. Educational interventions should be developed using the SMCR communication model to ensure that messages are contextually relevant, delivered by trusted community figures, and sensitive to literacy levels. A longitudinal follow-up study could assess whether such interventions improve cannabis health literacy and lead to more equitable and evidence-based use in both modern and traditional healthcare systems. Conclusion This study highlights the persistent and widespread lack of accurate knowledge regarding the therapeutic properties and side effects of cannabis among outpatients in northeastern Thailand, particularly those residing near the Thai–Cambodian border. Despite the legal liberalization of cannabis for medical and limited recreational use, over two-thirds of respondents answered “don’t know” to most knowledge-based items, including those related to both conventional and alternative medicine. The findings indicate that prior cannabis use, occupation as a village health volunteer, or even higher levels of education do not significantly improve health literacy concerning cannabis. These knowledge gaps are further exacerbated by legal ambiguities, cultural taboos, and fragmented regulatory communication. Consequently, the results underscore an urgent need for targeted public education campaigns, clearer legal frameworks, and accessible community-based health communication to promote safe, informed, and lawful cannabis use—especially in regions vulnerable to misinformation and cross-border trade challenges. Declarations Funding No funding. Contributions PC.G. contributed to the study design, conceptual framework development, and critical revision of the manuscript for important intellectual content. S.P. contributed to the validation of the questionnaire instrument, data quality assurance, and interpretation of cannabis pharmacological properties in traditional and modern contexts. T.K. led the document-based legal analysis of cannabis-related legislation and contributed to the synthesis of regulatory recommendations. S.P. contributed to quantitative data analysis, demographic categorization, and the preparation of visual data presentations (tables and figures). K.T. participated in the fieldwork coordination, assisted with participant recruitment, and contributed to the ethical review process. P.T. contributed to questionnaire design, data entry supervision, and manuscript formatting according to journal requirements. K.KN. supported the literature review on cross-border cannabis policy, cultural beliefs, and traditional medicine practices in northeastern Thailand. K.C. facilitated access to the field site at Phayu Hospital, coordinated with local health authorities, and provided feedback on community engagement strategies. NK.A. offered policy expertise, supervised the integration of findings into public health recommendations, and critically revised the manuscript for health systems implications. S.S. conceived the research idea, supervised the overall project administration, conducted the statistical analyses, drafted the initial manuscript, and finalized the submission based on co-author feedback. Ethical consolidation Ethics approval and consent to participate This study was reviewed and approved by the Human Research Ethics Committee of the Sisaket Provincial Public Health Office, Thailand (Approval No. SPPH 2024-40), granted on March 5, 2024. All participants were fully informed about the study’s purpose, data confidentiality, and voluntary participation. Written informed consent was obtained from all participants prior to data collection. Consent for publication All authors reviewed and approved the final version of the manuscript for submission. Competing interests The authors declare that they have no competing interests. Data a vailability declaration The datasets generated and analyzed during the current study are not publicly available due to participant confidentiality agreements but are available from the corresponding author on reasonable request. Acknowledgments The authors thank the Drug System Monitoring and Development Centre, Social Research Institute, Chulalongkorn University, and the Thai Health Promotion Foundation, for supporting this research. References Royal Thai Government. Narcotic Act (No. 7) B.E. 2562 (2019). Government Gazette. 2019. Available from: https://cannabisinfo.fda.moph.go.th/กฎหมาย/ Amarin TV. The Ministry of Public Health removes cannabis from Category 5 narcotics list [Internet]. 2022 [cited 2024]. Available from: https://www.amarintv.com/news/social/221193 Nantaratipob N. Possession and use of cannabis after legalization [Internet]. Bangkok: Secretariat of the House of Representatives; 2022 [cited 2024]. Available from: https://www.parliament.go.th/ewtadmin/ewt/parliament_parcy/ewt_dl_link.php?filename=The_House_of_Representatives&nid=88480 iLaw. The first day of cannabis decriminalization in Thailand [Internet]. 2022 Jun 9 [cited 2024]. Available from: https://www.ilaw.or.th/articles/5257 American Cancer Society. Cannabis and cancer: Benefits of cannabis [Internet]. 2023 [cited 2024]. Available from: https://www.cancer.org/cancer/managing-cancer/treatment-types/complementary-and-integrative-medicine/marijuana-and-cancer/benefits-of-cannabis.html Department of Thai Traditional and Alternative Medicine. Report on the situation of medical cannabis use in Thailand. Bangkok: Department of Thai Traditional and Alternative Medicine; 2021. Thai. Bank of Thailand. Cannabis market value report. Bangkok: Bank of Thailand; 2023. Thairath. The number of cannabis retail points nationwide has increased to 7,747. Thairath. 2024. Thai. Hfocus. Cannabis use among youth increases [Internet]. 2024 [cited 2024]. Available from: https://www.hfocus.org/content/2024/05/30411 Suranatwatchawong S, Naenudorn N, Sirited P, Wongtienlai M, Chuseewan C, Duch C, et al. Cannabis and teenagers. Burapha J Med. 2023;11(1):115-27. Langka W, Satjapiboon S. A survey of cannabis and other substance use behaviors, access, knowledge and attitudes towards cannabis among students in the secondary school and out-of-school youth. Bangkok: Srinakharinwirot University; 2024 Aug. Funded by the Health Systems Research Institute (HSRI), Thailand. National Statistical Office. Public opinion survey on cannabis use in Thailand. Bangkok: National Statistical Office; 2023. Thai. Thailand Development Research Institute. Recommendations for cannabis regulation [Internet]. Bangkok: Thailand Development Research Institute; 2024 [cited 2024]. Available from: https://tdri.or.th/2024/03/seminar-cannabis-suggestion Center for Addiction Studies. Study report on cannabis use in Thailand [Internet]. 2019 [cited 2024]. Available from: https://www.cads.in.th/cads/content?id=102 Ritmontree S, Loeiyood J, Boontoch K. A study of cannabis use behavior and health impacts in the Northeastern health service region. J Community Health. 2024;26(4):1-15. Available from: https://he01.tci-thaijo.org/index.php/CUTJ/article/view/266821 Aroonsrimorakot S, Laiphrakpam M, Metadilogkul O. Social, religious, recreational, and medicinal usage of cannabis in India and Thailand. Interdisciplinary Research Review. 2019;14(4):43-50. French L. From politics to economics at the Thai–Cambodian border: Plus ça change... Int J Politics Cult Soc. 2002;15(3):427-70. Pearshouse R, Klein A. Detaining people who use drugs in Cambodia: A dual-track system. Int J Drug Policy. 2021;89:103258. Thai Medical Council. Medical advisory: Risks of cannabis use in adolescents and youth [Internet]. Bangkok: Thai Medical Council; 2022 [cited 2024]. Available from: https://tmc.or.th/pdf/att-dn-233.pdf Unhavaithaya J, Ditthapan S. A study of Thai legislations regarding the control of the cannabis-based drug produced by folk physicians [Preprint]. ResearchGate. 2023 Feb. Available from: https://www.researchgate.net/publication/368395908 Morris RG, TenEyck M, Barnes JC, Kovandzic TV. The effect of medical marijuana laws on crime: Evidence from state panel data, 1990-2006. PLoS One. 2014;9(3):e92816. Sideli L, Quigley H, La Cascia C, Murray RM, Di Forti M. Cannabis use and the risk of psychosis and affective disorders. Front Psychiatry. 2021;12:640222. Gobbi G, Atkin T, Zytynski T, Wang S, Askari S, Boruff J, et al. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: A systematic review and meta-analysis. JAMA Psychiatry. 2019;76(4):426-34. Kroon E, Kuhns L, Hoch E, Cousijn J. Heavy cannabis use, dependence and the brain: A clinical perspective. Addiction. 2020;115(3):559-72. Rotermann M. Analysis of trends in the prevalence of cannabis use in Canada before and after legalization. Health Rep. 2020;31(2):3-14. Health Canada. Import and export of cannabis [Internet]. Ottawa: Government of Canada; 2023 [cited 2024]. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/industry-licensees-applicants/manage-licence-cultivation-processing-sale-medical-purposes/apply-import-export.html Urada D, Shoptaw S, Montoya ID, Hawes M, Rawson RA. Cannabis use and health knowledge: A survey of Californian adults. Subst Abuse Res Treat. 2020;14:1178221820959363. Goodman S, Wadsworth E, Leos-Toro C, Hammond D. Prevalence and forms of cannabis use among youth in Canada, England, and the United States, 2017–2019. Addict Behav. 2020;110:106529. Bone C, Zlotorzynska M, Kingston L, Gorfinkel L. The information needs of older adults using cannabis for medical purposes: A narrative review. Drugs Aging. 2024;41(1):1-10. Mize M. Cannabis legalization and cross-border policy in the Cascadia region. Bellingham (WA): Border Policy Research Institute, Western Washington University; 2020. Available from: https://cedar.wwu.edu/bpri_publications/109 Department of Medical Services, Ministry of Public Health. Guidance on cannabis for medical use: Updated version 5 (September 2022) [Internet]. Bangkok: Department of Medical Services; 2022 [cited 2024]. Available from: https://www.dms.moph.go.th Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015;313(24):2456-73. Pasha A, Clements C, Reynolds C, Lopez M, Lugo C, Gonzalez Y, et al. Cardiovascular Effects of Medical Marijuana: A Systematic Review. Am J Med. 2021;134(2):182-93. Kichloo A, Albosta M, Aljadah M, El-Amir Z, Goldar G, Khan M, et al. Marijuana: A systems-based primer of adverse effects associated with use and an overview of its therapeutic utility. SAGE Open Med. 2021;9:20503121211000909. Johns A. Psychiatric effects of cannabis. Br J Psychiatry. 2001;178:116-22. Hall W, Solowij N. Adverse effects of cannabis. Lancet. 1998;352:1611-6. Cronbach LJ, Rajaratnam N, Gleser GC. Theory of generalizability: A liberalization of reliability theory. Br J Stat Psychol. 1963;16(2):137-63. Ministry of Public Health. Notification on specifying narcotic substances in Category 5, B.E. 2565 (2022). Royal Thai Government Gazette. 2022. Available from: https://www.ratchakitcha.soc.go.th/DATA/PDF/2565/E/035/T_0008.PDF Ministry of Public Health. Act Promulgating the Narcotics Code B.E. 2564 (2021). Royal Thai Government Gazette. 2021 Nov 8;138(73G):1-20. Available from: https://ratchakitcha.soc.go.th/ Ministry of Public Health. Ministerial Regulation on Licensing Procedures for the Production, Import, Export, Distribution, or Possession of Category 5 Narcotics (Cannabis), B.E. 2564 (2021). Royal Thai Government Gazette. 2021 Nov 26;138(79G):1-16. Available from: https://ratchakitcha.soc.go.th/ Ministry of Public Health. Notification on Prescribed Formulations of Category 5 Narcotics Containing Cannabis for Medical Use or Research (No. 4), B.E. 2564 (2021). Royal Thai Government Gazette. 2021 Dec 7;138(299 Ngor):10. Available from: https://ratchakitcha.soc.go.th/ Ministry of Public Health. Notification of the Ministry of Public Health on Controlled Herbs (Cannabis), B.E. 2565 (2022). Royal Thai Government Gazette. 2022 Nov 23;139(Special Section 272 Ngor):1-4. Available from: https://www.ratchakitcha.soc.go.th Ministry of Public Health. Notification on the Name, Type, Kind, or Characteristics of Herbal Products Prohibited from Importation, B.E. 2565 (2022). Royal Thai Government Gazette. 2022 Jun 2;139(129 Ngor):21. Available from: https://ratchakitcha.soc.go.th/ Department of Health. Notification on the Use of Cannabis Leaves in Food Preparation in Restaurants, B.E. 2565 (2022) [Internet]. Bangkok: Department of Health; 2022 [cited 2024]. Available from: https://www.anamai.moph.go.th/ Ministry of Public Health. Notification of the Ministry of Public Health on designating cannabis, hemp, or other plant smoke or odor as a public nuisance, B.E. 2565 (2022). Royal Thai Government Gazette. 2022 Jun 14;139(Special Section 134 Ngor):1-2. Available from: https://www.ratchakitcha.soc.go.th Ministry of Education. Announcement on Guidelines for Cannabis and Hemp in Educational Institutions and Government Agencies under the Ministry of Education. Royal Thai Government Gazette. 2022 Jun 16;139(156 Ngor):20-1. Available from: https://ratchakitcha.soc.go.th/ National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington (DC): National Academies Press; 2017. Chong D, Druckman JN. Framing theory. Annu Rev Political Sci. 2007;10(1):103-26. Headset. Gen X cannabis demographic trends [Internet]. 2018 [cited 2024]. Available from: https://www.headset.io/blog/gen-x-cannabis-demographic-trends MNI Targeted Media Inc. Cannabis and generational marketing [Internet]. 2020 [cited 2024]. Available from: https://www.mni.com/blog/cannabis-and-generational-marketing Jampathong N, Kaewprom C, Sawangjit R, Srisurapanont M, Saokaew S. Perspectives of Thai traditional medicine practitioners on the medical cannabis policy: A qualitative study. BMC Complement Med Ther. 2022;22:43. Hughes CM, McElnay JC, Fleming GF. Benefits and risks of self medication. Drug Saf. 2001;24(14):1027-37. Ruiz ME. Risks of self-medication practices. Curr Drug Saf. 2010;5(4):315-23. Li X, Fang F, Liu T. Analysis of over-the-counter medication misuse: A systematic review. Front Public Health. 2023;11:1176730. Ahmed M, Mohsin SF, Alshammari R, Aljuaid M, Kassem MA. Patterns and risks of self-medication: Evidence from a population-based study. BMC Public Health. 2023;23:83. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9936784/ Garcia DO, Aranzales JKB, Herrera GE. What do university students think about cannabis regulation? Perspectives from a Colombian university. Análisis Político. 2024;37(109):155-82. Orjuela-Rojas JM, García Orjuela X, Ocampo Serna S. Medicinal cannabis: Knowledge, beliefs, and attitudes of Colombian psychiatrists. J Cannabis Res. 2021;3:26. López López W, Pineda Marín C, Sorum PC, Van Hoof J, Ruiz Gómez F. Prohibition, regulation or free market: A mapping of Colombian people's perspectives regarding national drug policies. Soc Indic Res. 2016;126:689-710. Dominguez H. Marijuana regulation in Colombia and Uruguay: A comparative policy analysis [master's thesis]. Prague: Charles University, Faculty of Social Sciences, Institute of Sociological Studies; 2021. Available from: https://dspace.cuni.cz/handle/20.500.11956/124742 Laranjeira R, Martin D. Traps in cannabis policies in Brazil. Braz J Psychiatry. 2019;41(6):475-6. de Souza MR, Henriques AT, Limberger RP. Medical cannabis regulation: An overview of models around the world with emphasis on the Brazilian scenario. J Cannabis Res. 2022;4:33. Kronick D. Profits and violence in illegal markets: Evidence from Venezuela. J Conflict Resolut. 2020;64(7-8):1499-523. Rodríguez-Llach A, Pereira-Arana I, Cruz-Olivera LF. Peasants' rights after the war on drugs: The case for transformative justice. In: Barrett D, Lines R, editors. Towards drug policy justice: Harm reduction, human rights and the future of drug policy. London: Routledge; 2021. p. 199-213. Durán-Martínez A, Pennell C. Change from above or pressure from below? The diffusion of cannabis reform in Latin America. Bull Lat Am Res. 2024;43(3):347-61. Kamnoedrit P. Buddhist principles and medical cannabis laws. J MCU Peace Stud. 2022;10(5):2326-35. Sornpaisarn B, Phiphatnachat W, Lamyai W, Silawan T, Detchiangkhraikul N, Thitiprasert W, et al. Facts and analysis of Thailand's cannabis policies: A public health perspective. J Health Sci Thailand. 2023;32(2):375-88. Samorapoom C, Pewchan C, Promrit A. Unlocking cannabis: Past to present of laws. J Local Gov Innov. 2023;7(1):285-9. Mead A. (2017). The legal status of cannabis (marijuana) and cannabidiol (CBD) under U.S. law. Epilepsy & behavior : E&B, 70(Pt B), 288–291. https://doi.org/10.1016/j.yebeh.2016.11.021 Cannabis Legal News. International trade regulations for cannabis products [Internet]. 2023 [cited 2024]. Available from: https://cannabislegalnews.b-cdn.net/international-trade-regulations-for-cannabis-products.html Curaleaf Clinic. Travelling with medical cannabis: What you need to know before you go [Internet]. 2023 [cited 2024]. Available from: https://curaleafclinic.com/travelling-with-medical-cannabis-what-you-need-to-know-before-you-go/ Suphanchaimat R, Tisayaticom K, Pudpong N, Hanefeld J. Cannabis liberalization in Thailand: The need for evidence-informed policies. Lancet Reg Health Southeast Asia. 2023;3:100076. Thammarangsri S, Buathong R, Panyasiri K, Apidechkul T. Trends and determinants of cannabis use in the Thai population: Evidence from the national household survey. BMC Public Health. 2023;23:1834. Inkhiew R, Songkram N, Suwanvajokkasikit C, Wongkaew P. Public concerns about cannabis consumption in Thailand: A Twitter-based analysis. BMC Public Health. 2023;23:1121. Nukulkij S. Law problems of cannabis liberalization of Thailand compared with Japan, United Kingdom, and the United States. Pañña Panithan J. 2020;5(2):151-9. U.S. Food and Drug Administration. FDA regulation of cannabis and cannabis-derived products, including cannabidiol (CBD) [Internet]. Silver Spring (MD): U.S. Food and Drug Administration; 2023 [cited 2024]. Available from: https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd Jaeger K. Federal court rules that state-level marijuana legalization creates exemption to ban on paraphernalia imports. Marijuana Moment [Internet]. 2022 Oct 25 [cited 2024]. Available from: https://www.marijuanamoment.net/federal-court-rules-that-state-level-marijuana-legalization-creates-exemption-to-ban-on-paraphernalia-imports/ Tables Tables 1 to 6 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 23 Oct, 2025 Read the published version in Journal of Cannabis Research → Version 1 posted Editorial decision: Revision requested 21 Jul, 2025 Reviews received at journal 20 Jul, 2025 Reviews received at journal 14 Jul, 2025 Reviewers agreed at journal 29 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers invited by journal 24 Jun, 2025 Editor assigned by journal 24 Jun, 2025 Submission checks completed at journal 24 Jun, 2025 First submitted to journal 20 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6940512","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475865302,"identity":"bb691ad8-3e32-4315-970a-af15ce704f66","order_by":0,"name":"Pattarachit Choompol Gozzoli","email":"","orcid":"","institution":"Mahidol University","correspondingAuthor":false,"prefix":"","firstName":"Pattarachit","middleName":"Choompol","lastName":"Gozzoli","suffix":""},{"id":475865303,"identity":"9e7bfc6c-f21a-475a-b7bb-12978715a6f5","order_by":1,"name":"Suyanee Pongthananikorn","email":"","orcid":"","institution":"Chulalongkorn University","correspondingAuthor":false,"prefix":"","firstName":"Suyanee","middleName":"","lastName":"Pongthananikorn","suffix":""},{"id":475865304,"identity":"e5adf03a-e813-40f6-ab83-09d2e6d84809","order_by":2,"name":"Tanattha Kitisopee","email":"","orcid":"","institution":"Siam University","correspondingAuthor":false,"prefix":"","firstName":"Tanattha","middleName":"","lastName":"Kitisopee","suffix":""},{"id":475865305,"identity":"60f2b071-eba7-4864-9d21-1fbe1e537787","order_by":3,"name":"Sathian Phunpon","email":"","orcid":"","institution":"Siam University","correspondingAuthor":false,"prefix":"","firstName":"Sathian","middleName":"","lastName":"Phunpon","suffix":""},{"id":475865306,"identity":"1b47ea97-325f-4530-9324-afdd6fbc9938","order_by":4,"name":"Kamolwan Tantipiwattanasakul","email":"","orcid":"","institution":"Siam University","correspondingAuthor":false,"prefix":"","firstName":"Kamolwan","middleName":"","lastName":"Tantipiwattanasakul","suffix":""},{"id":475865307,"identity":"ea4768ae-1edd-4909-8190-e62aa9bf1d61","order_by":5,"name":"Phakarat Tangkheunkan","email":"","orcid":"","institution":"Siam University","correspondingAuthor":false,"prefix":"","firstName":"Phakarat","middleName":"","lastName":"Tangkheunkan","suffix":""},{"id":475865308,"identity":"882c4900-5b36-4a8b-bb61-fff1154a600a","order_by":6,"name":"Kannikar Khaw-ngern","email":"","orcid":"","institution":"Mahachulalongkornrajavidyalaya University","correspondingAuthor":false,"prefix":"","firstName":"Kannikar","middleName":"","lastName":"Khaw-ngern","suffix":""},{"id":475865309,"identity":"e2290e5d-32cf-4d88-b955-603871107290","order_by":7,"name":"Kritsada Chakchai","email":"","orcid":"","institution":"Phayu hospital","correspondingAuthor":false,"prefix":"","firstName":"Kritsada","middleName":"","lastName":"Chakchai","suffix":""},{"id":475865310,"identity":"abc13793-7482-4571-a91d-9447dad9a242","order_by":8,"name":"Niyada Kiattiying-Angsulee","email":"","orcid":"","institution":"Chulalongkorn University","correspondingAuthor":false,"prefix":"","firstName":"Niyada","middleName":"","lastName":"Kiattiying-Angsulee","suffix":""},{"id":475865311,"identity":"180e435e-dee2-4a59-9fab-7c9cc2edcca9","order_by":9,"name":"Shinnawat Saengungsumalee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYDACCcYGCIO9geEAmHGAWC08PAeI1gKleSQSoCxCWuRnN7c9Lqg5LG8v+fzhgZ85DHJ8NxLwazG4c7DdeMaxw4Y90jkGB3u3MRhLEtQikdgmzcN2mxGoheEA7zaGxA2EtMjPAGn5d9u+R/L4g4N/tzHUE9TCcAOohbftdmKPBIPBYaAtCQYEHQbW0vc/uedMjsFh2W0ShjPPPCDksPRn0jzf0mzb248//vh2m40833FCDkMDEoSVjIJRMApGwSggDABl10lscN7GEgAAAABJRU5ErkJggg==","orcid":"","institution":"Siam University","correspondingAuthor":true,"prefix":"","firstName":"Shinnawat","middleName":"","lastName":"Saengungsumalee","suffix":""}],"badges":[],"createdAt":"2025-06-20 16:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6940512/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6940512/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s42238-025-00326-3","type":"published","date":"2025-10-23T16:17:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":94490754,"identity":"2f9d4c62-3e0b-453c-adf0-1e5d731a8344","added_by":"auto","created_at":"2025-10-27 17:14:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":997339,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6940512/v1/25237e9b-bc88-43f2-ada4-9b64c136a106.pdf"},{"id":85553987,"identity":"ba6079df-61ff-4ef5-88f9-92e9d35baed9","added_by":"auto","created_at":"2025-06-27 10:37:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":66725,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6940512/v1/6e6fd63ebe28ffe2e9269f01.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDemographic, Economic, and Social Status and Knowledge of Medical and Alternative Cannabis Use among Northeastern Thai Citizens: A Case Study of Outpatients atCommunity Hospitals along the Thai–Cambodian Border\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe decriminalization of cannabis from a Category 5 narcotic under the Narcotic Code B.E. 2564 (2021) marked a significant turning point in Thailand's drug policy, traditional medicine, and economic landscape. The government's initiative aimed to increase the economic value of herbal plants, beginning with the enactment of the Narcotic Act (No. 7), B.E. 2562 (2019), which allowed cannabis to be used for medical purposes and encouraged both biomedical and socio-humanistic research for the first time\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. On June 9, 2022, the Ministry of Public Health officially removed cannabis from the list of controlled narcotics, making Thailand the first country in Asia to legalize the use of cannabis for both medicinal and recreational purposes. This legalization facilitated cannabis use in commercial, medical, and research domains without contravening prior laws\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis policy shift was driven mainly by increasing evidence supporting the medicinal benefits of cannabis, such as pain relief in cancer patients\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, treatment of epilepsy, and management of depression. It also created opportunities in industries producing dietary supplements and cosmetics. In 2021, the Department of Thai Traditional and Alternative Medicine promoted the medical use of cannabis through over 893 clinics nationwide, serving more than 7,200 patients\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Economically, the Bank of Thailand estimated the cannabis market in 2023 to be worth approximately 28\u0026nbsp;billion THB and projected continued growth\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. As a result, numerous cannabis retail points have emerged nationwide. By April 2024, there were 7,747 such outlets, with Bangkok alone hosting 1,122\u003csup\u003e8\u003c/sup\u003e. A 2023 survey revealed that 20% of the population had used cannabis, and 9% cultivated it at home. However, cannabis use among youth has rapidly increased, especially among those outside the formal education system, where usage rates reached 47.6%. This often involved concurrent use with other substances such as alcohol, tobacco, and kratom\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough cannabis legalization was expected to yield more positive than adverse outcomes in the medical and commercial sectors, unforeseen negative consequences have emerged, particularly in public health and social domains. Hospitals have reported increasing cases of cannabis-related side effects. Public concern about cannabis misuse, especially among youth, is growing. A 2023 survey by the National Statistical Office found that 68% of the population supported stricter cannabis regulations\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Consequently, there have been calls for new legislation, such as the Cannabis and Hemp Bill, to provide clearer regulatory frameworks\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. This aligns with findings from the Center for Addiction Studies, which identified the northeastern region as having the highest cannabis usage rates. For example, nearly two-thirds of males aged 30\u0026ndash;59 reported using cannabis for recreational purposes, and youths aged 15\u0026ndash;19 were found to use cannabis without restriction\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. In this region, cannabis users also experienced mental health issues and anxiety and engaged in poly-substance use\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe Thai-Cambodian border, part of the northeastern region, has deep historical, cultural, and economic ties, influencing local cannabis usage across various dimensions, including commerce, product mobility, and daily consumption\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Cannabis is commonly used as an herbal remedy and food ingredient, such as in chicken soup, spicy soups, noodles, and cookies, to relieve muscle pain through traditional recipes. However, following Thailand's 2022 legalization, cannabis usage and trade dynamics along the border have shifted dramatically, especially in terms of product movement, as Cambodia still classifies cannabis as an illicit drug\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. This has led to smuggling activities, and cannabis entering Thailand through unofficial channels often escapes quality control, posing consumer risks. Youths in this area have easy access, leading to improper usage that may result in long-term mental health issues and risky behaviors\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTherefore, while cannabis legalization has spurred the development of medical and industrial products, cultivation and production must be tightly regulated. National measures and bilateral cooperation between Thailand and Cambodia remain crucial. Moreover, the knowledge and understanding of cannabis, its benefits, risks, and side effects among local populations, from youth to older people, remain unclear. This knowledge gap is particularly significant given the fragile, risky, and potentially dangerous nature of cannabis use, especially for both users and healthcare providers in both Thailand and Cambodia. Hence, there is a pressing need to explore the demographic, economic, and social factors that influence cannabis knowledge and usage, including its applications in modern and alternative medicine and associated side effects areas that have not been systematically studied in terms of valid measurements and question formulation. This is particularly true for border regions where cannabis use predates legalization\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLessons from the U.S.\u0026ndash;Mexico border illustrate how legal changes in the U.S. cannabis policy affected smuggling patterns, as legalization led to decreased demand in the black market but increased health-related side effects among users\u003csup\u003e\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Similar patterns have been observed in Canada, where liberalization increased cannabis use across various demographics, particularly among youth with easy access\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. These decisions are often influenced by misinformation, unawareness of potential side effects, misconceptions, or social trends\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Therefore, it is vital to investigate the demographic, economic, and social determinants of cannabis knowledge and use, especially in the context of modern and alternative medicine, among northeastern residents along the Thai-Cambodian border. Without proper knowledge assessment, unregulated cannabis use could lead to adverse physical and mental health outcomes similar to those seen in U.S. or Canadian border regions\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study aims to address the current knowledge gap by generating critical insights that inform accurate public education, highlight cannabis-related side effects, and support informed decision-making for therapeutic cannabis use. This is particularly important in increasing cannabis availability in border areas. Another key motivation is the limited research on cannabis use in the Thai-Cambodian border context. To date, no studies have analyzed response accuracy regarding approved medical uses of cannabis or associated side effects. Therefore, this study also aims to assess the clarity of laws related to cannabis use and propose effective communication strategies for public health messaging. These elements are essential for fostering a more accurate understanding of cannabis, ultimately guiding safe usage practices in the future.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThis study adopted a quantitative cross-sectional survey design, complemented by a document-based analysis of primary legal sources issued by Thai government agencies concerning the medical and alternative medicinal use of cannabis. Data collection occurred between March 10 and August 31, 2024, during the transitional period between northeastern Thailand's hot and rainy seasons, specifically in border districts adjacent to Cambodia. Participants were Thai outpatients aged 18\u0026ndash;86 from a 30-bed community hospital in a border district. The study focused on this region due to its unique socio-cultural and economic with Cambodia, as well as its active cannabis usage. The sample comprised 618 respondents, including 189 men (30.6%) and 429 women (69.4%), with an average age of 50.8 years.\u003c/p\u003e \u003cp\u003eA convenience sampling method was employed to ensure practical feasibility. All interviews were conducted face-to-face by a single trained field researcher, allowing for quality control and ensuring confidentiality. The interviewer received one-day training focused on research ethics, participant rights, data accuracy, and handling sensitive topics. The study addressed questions about cannabis use for both medical and recreational purposes, which are considered legally and socially sensitive, particularly in a border context where cannabis is legal in Thailand but remains illegal in Cambodia.\u003c/p\u003e \u003cp\u003eParticipants provided informed, voluntary consent, and confidentiality was strictly maintained. The rest of the research team contributed to questionnaire design, data coding, entry, and analysis. This methodology enabled reliable data collection while protecting respondents from potential legal or social risks.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch instrument\u003c/h2\u003e \u003cp\u003eA structured, close-ended questionnaire was employed for data collection, administered through face-to-face interviews by a trained field researcher in private and convenient outpatient settings. The questionnaire consisted of four sections: (1) demographic information (age, sex, education, occupation, income); (2) knowledge of cannabis's therapeutic properties in conventional and alternative medicine\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, measured using three response options (correct, incorrect, unknown); (3) knowledge of cannabis-related side effects\u003csup\u003e\u003cspan additionalcitationids=\"CR34 CR35\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e, also measured using the same three response categories; and (4) cannabis use experiences, covering medical, recreational, culinary, and commercial purposes. For analysis, use experience was dichotomized into \"ever used\" and \"don't know\" to better assess trends following legalization in June 2022. Content validity was reviewed by four experts, two in pharmaceutical sciences, one in medicine, and one in behavioral science, yielding an Index of Congruence (IOC) of 0.9. Reliability analysis for the knowledge items produced a Cronbach's alpha of 0.83, indicating a reliability level of approximately 69%\u003csup\u003e37\u003c/sup\u003e. Descriptive statistics, including frequencies, percentages, and means, were used to illustrate distribution patterns and support comparative analysis. A content analysis of legal documents examined the clarity and coherence of cannabis-related laws.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e1. Sample Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 618 participants, an apparent gender disparity was observed: 429 respondents (69.4%) were female, while only 189 (30.6%) were male. This imbalance reflects a broader societal trend in which women are generally more proactive in health-seeking behaviors and outpatient service engagement. Age groups were categorized into three generational cohorts for comparative analysis: youth and young adults (ages 18\u0026ndash;39, Generation Y and Z) accounted for 73 participants; adults (ages 40\u0026ndash;54, Generation X) represented the majority with 457 participants; and older adults (ages 55\u0026ndash;77, Baby Boomers) comprised 88 participants. This classification facilitates an exploration of generational differences in legal consciousness, social norms, and ideological tendencies, liberal versus conservative, shaped by distinct sociolegal environments during formative years. Occupationally, the sample was skewed toward village health volunteers (VHVs), who play a significant role in Thailand\u0026apos;s public health infrastructure, particularly in disease surveillance and community-based health promotion. Other professions, such as farmers and daily laborers, were represented in smaller proportions.\u003c/p\u003e\n\u003cp\u003eRegarding education, respondents who had completed at least compulsory education were more likely to demonstrate cognitive competencies, including legal awareness, literacy in foreign languages (especially English), and analytical reasoning. Cannabis use experience categorized as medical, recreational, culinary, or commercial was considered a proxy for practical knowledge and understanding of cannabis\u0026apos;s benefits and side effects. As detailed in subsequent sections, these experiences were further analyzed across demographic, economic, and social variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic, Economic, and Social Characteristics and Cannabis Use Experience\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCannabis use experience was considered a critical behavioral indicator in this study, reflecting not only actual consumption but also its potential correlation with knowledge accuracy regarding therapeutic benefits and side effects. Before its decriminalization in 2021, cannabis use in Thailand was a criminal offense punishable by up to five years imprisonment or a fine of 500,000 THB\u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAnalysis of usage patterns alongside demographic, economic, and social variables revealed a significant disparity, with non-users outnumbering users nearly five to one among female and male respondents. Generation X (ages 40\u0026ndash;54) reported the highest usage rates compared to other cohorts. Yet, overall cannabis use remained low, especially among village health volunteers (VHVs), who are closely affiliated with state health services and likely cautious due to lingering legal ambiguity. Education level also influenced behavior, with those having more than basic education reporting the lowest usage. Even among participants with primary education or less, cannabis use remained minimal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese trends suggest that historical legal restrictions and sustained confidence in conventional medicine continue to shape public attitudes. As detailed in Table 1, most respondents were women over 40, working in community health roles with limited formal education, and only 88 individuals (14.24%), approximately one in seven, reported any prior cannabis use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic, Economic, and Social Characteristics and Knowledge of Cannabis\u0026apos;s Therapeutic Properties in Conventional Medicine\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough only 88 of 618 participants (14.24%) reported prior cannabis use, their responses revealed that direct experience did not strongly correlate with accurate knowledge of cannabis\u0026apos;s therapeutic applications. This group\u0026apos;s most common uses were muscle inflammation and sleep aids, while recreational, culinary, and commercial uses were less frequent. Despite Thailand\u0026apos;s legalization of cannabis in June 2022\u003csup\u003e38\u003c/sup\u003e, knowledge of its medical indications, such as treating chemotherapy-induced nausea, improving quality of life in terminal illness, and alleviating muscle spasticity, remained limited, with correct responses comprising only about one-sixth of the sample and \u0026quot;don\u0026apos;t know\u0026quot; being the dominant answer across all items. Interestingly, cannabis use history, gender, education level, or occupation did not significantly improve accuracy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, older respondents (Generation X and Baby Boomers) showed slightly better knowledge, potentially due to accumulated experience or caregiving roles. Uncertainty prevailed even among village health volunteers (VHVs), who are typically expected to possess greater health literacy. These findings highlight a widespread knowledge gap across all demographic sectors and underscore the urgent need for structured, evidence-based public education strategies to support informed decision-making regarding medical cannabis use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic, Economic, and Social Characteristics and Cannabis Use Experience concerning Knowledge of Cannabis\u0026apos;s Therapeutic Properties in Alternative Medicine\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis section explores participants\u0026apos; knowledge of cannabis\u0026apos;s therapeutic properties in alternative medicine, including traditional Thai and local healing practices. Although cannabis has historically been used to treat conditions such as drug-resistant epilepsy in children and chronic insomnia in adults, this study found that accurate knowledge of such uses remains limited across all demographics. A significant number of participants responded with \u0026quot;don\u0026apos;t know,\u0026quot; a trend consistent across age, occupation, education level, and cannabis use history. Notably, prior cannabis use did not significantly correlate with correct responses regarding these therapeutic applications, suggesting that residual stigma and legal ambiguity continue to hinder public understanding. Older participants, who might be expected to demonstrate greater insight due to life experience or caregiving roles, showed similarly low knowledge levels, implying that entrenched legal and cultural taboos remain influential.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough village health volunteers (VHVs) expected to have higher exposure to medical education performed slightly better than other occupational groups, uncertainty still dominated their responses. This pattern underscores a broader failure of both formal and informal communication systems, such as public announcements, community outreach, and local government messaging, to deliver clear, evidence-based information about cannabis in alternative medicine.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOngoing regulatory uncertainty and the absence of national policy integration limit the diffusion of accurate knowledge. Table 3 presents a detailed breakdown of participant responses on cannabis\u0026apos;s role in managing epilepsy and insomnia, revealing persistent knowledge gaps across demographic and occupational segments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of Cannabis\u0026apos;s Therapeutic Properties and Side Effects When Used in Conventional Medical Treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnderstanding both the therapeutic benefits and side effects of cannabis when used alongside conventional medicine is essential, particularly for healthcare providers, patients, caregivers, and village health volunteers (VHVs), who often gain firsthand insights into patient outcomes through follow-up visits and clinical interactions. Therefore, it is expected that those engaged in patient care would possess more accurate knowledge of cannabis\u0026apos;s therapeutic applications and potential risks. However, this study revealed significant knowledge gaps in all areas assessed, including three medical cannabis applications endorsed by Thailand\u0026apos;s Department of Medical Services managing chemotherapy-induced nausea, improving quality of life in terminal illness, and alleviating muscle spasticity in multiple sclerosis and four common side effects: constipation, dizziness and nausea, hallucinations, and dry mouth\u003csup\u003e33-36\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe data show that \u0026quot;don\u0026apos;t know\u0026quot; was the most frequent response across all items, even among VHVs, suggesting a broader deficit in public cannabis health literacy. For example, only 159 respondents correctly identified cannabis\u0026apos;s role in treating chemotherapy-induced nausea, and just 181 and 148 respondents answered correctly regarding its effectiveness in improving end-of-life care and relieving muscle spasticity, respectively. Likewise, knowledge of side effects was similarly limited; in the case of chemotherapy-induced nausea, where constipation is a known adverse effect, only 87 participants answered correctly, compared to 333 who were unsure and 27 who responded incorrectly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilar uncertainty was observed regarding dizziness, hallucinations, and dry mouth. Notably, those with correct knowledge of therapeutic applications were also more likely to recognize associated side effects, highlighting the influence of experiential learning. These findings underscore the compounded impact of legal ambiguity, fragmented regulatory messaging, and insufficient health communication, all of which hinder the development of accurate, community-level understanding of cannabis in medical contexts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs summarized in Table 4, this limited awareness highlights the urgent need for targeted, evidence-based educational strategies and clearer public policy to support informed and safe cannabis use, particularly in border regions where access to formal health information may be constrained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of Cannabis\u0026apos;s Therapeutic Properties in Alternative Medicine and Associated Side Effects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings reveal that public knowledge regarding the side effects of cannabis use, particularly in the context of alternative medicine such as traditional Thai and folk healing, remains limited. Despite cannabis\u0026apos;s longstanding role in community-based practices informed by local wisdom, few participants in this study demonstrated accurate knowledge of its therapeutic use for conditions like treatment-resistant epilepsy in children or severe seizures. Only 112 participants correctly identified these applications, while 99 answered incorrectly and 407, approximately two-thirds responded with \u0026quot;don\u0026apos;t know,\u0026quot; underscoring that only one in six held accurate information despite increasing national discourse on medical cannabis. This knowledge gap is likely the result of insufficient public communication about cannabis\u0026apos;s therapeutic potential for complex neurological conditions. A similar pattern was observed regarding insomnia, with only 208 participants (about one-third) answering correctly and 330 again selecting \u0026quot;don\u0026apos;t know,\u0026quot; suggesting that informational outreach remains ineffective.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5 confirms respondents were likelier to admit uncertainty than to provide incorrect answers, highlighting a lack of exposure to validated, evidence-based knowledge. Awareness of side effects was equally poor; few participants recognized common adverse reactions such as constipation, dizziness, nausea, hallucinations, and dry mouth. These results underscore a widespread lack of understanding regarding both the therapeutic and physiological impacts of cannabis. Particularly concerning are neurological side effects, which affect the central nervous system, and autonomic side effects, such as dry mouth and constipation, which can pose risks if not adequately understood. Promoting cannabis\u0026apos;s integration into alternative medicine thus requires not only legal clarity but also transparent, culturally relevant, and medically accurate public education to ensure safe and informed use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegal Clarity Regarding Cannabis Use and Communication Strategies for Its Therapeutic Properties and Side Effects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the findings presented above, one of the key observations of this study is that limited experience with cannabis and poor knowledge regarding its therapeutic properties and side effects may be attributed mainly to the lack of legal clarity surrounding its use in Thailand. Historically classified as a narcotic, cannabis possession or consumption was a criminal offense. Despite recent legislative changes, ambiguities regarding its legal definition and permissible uses may hinder public understanding and acceptance. The following section outlines the legal framework of cannabis, highlighting aspects that are or remain explicitly illegal. It presents communication strategies aimed at enhancing public awareness of both therapeutic benefits and potential risks of medical cannabis use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegal Framework Related to Cannabis Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study reveals not only a low prevalence of cannabis use among participants but also a troubling lack of accurate knowledge regarding its therapeutic applications in both conventional and alternative medicine. Across all survey dimensions, \u0026quot;don\u0026apos;t know\u0026quot; emerged as the most frequent response, suggesting widespread public disengagement or uncertainty, likely driven by ongoing legal ambiguity surrounding cannabis in Thailand. Although the country has decriminalized cannabis for medical and limited recreational use, its historical classification as a narcotic has perpetuated confusion about what is legally permissible. Inconsistent terminology, undefined legal boundaries, and overlapping regulatory frameworks continue to hinder public understanding of both cannabis\u0026apos;s medical benefits and associated risks. The study proposes a structured communication strategy to clarify legal definitions and regulatory interpretations, particularly in border provinces adjacent to Cambodia, where regulatory enforcement may be uneven and misinformation more pervasive. A foundational step involves mapping current cannabis-related laws into three categories: permitted, ambiguous, and prohibited, and communicating these distinctions to the public. This legal mapping should be disseminated by trusted sources, including senior officials from the Ministry of Public Health and Ministry of Justice, local community leaders, and spiritual authorities.\u003c/p\u003e\n\u003cp\u003eAs summarized in Table 6, clear legal guidance paired with culturally sensitive public education can provide a critical foundation for safe, informed, and lawful cannabis use, particularly as the country explores cannabis\u0026apos;s potential for medical, economic, and tourism-related applications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication Strategies for Disseminating Knowledge on Therapeutic Properties and Side Effects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEffective communication is essential to promote safe and informed cannabis use, particularly in border regions such as those between Thailand and Cambodia. To this end, the study proposes utilizing the SMCR model (Source\u0026ndash;Message\u0026ndash;Channel\u0026ndash;Receiver) to guide the design and delivery of public health information on medical cannabis. The findings suggest that knowledge gaps are especially prominent among individuals with limited education or no prior cannabis use, making tailored communication strategies necessary.\u003c/p\u003e\n\u003cp\u003eIn the Source component, trusted figures from policy-level organizations, such as senior executives from the Ministry of Public Health, Ministry of Justice, Ministry of Interior, and Ministry of Agriculture, should serve as primary messengers. These figures should be supported by community-level medical professionals such as doctors and pharmacists. Equally important are local authority figures, provincial governors, district chiefs, village leaders, and spiritual leaders, including traditional healers and religious figures. These individuals should be trained to convey both the therapeutic potential and risks of cannabis based on scientific evidence, such as the National Academies of Sciences\u003csup\u003e47\u003c/sup\u003e report, which recognizes cannabis\u0026apos;s effectiveness in alleviating chemotherapy-induced nausea and chronic pain.\u003c/p\u003e\n\u003cp\u003eIn the Message dimension, content must present a balanced perspective on benefits and risks. While some participants were aware of cannabis\u0026apos;s usefulness in treating specific conditions such as chronic pain or epilepsy, few understood the potential side effects of dizziness, nausea, hallucinations, dry mouth, and constipation. Therefore, communication materials, print, digital media, and infographics should integrate dual-framing techniques\u003csup\u003e48\u003c/sup\u003e, presenting positive and negative aspects to support informed decision-making. Messages should be phrased in simple language, accompanied by visual aids suitable for audiences with basic literacy levels.\u003c/p\u003e\n\u003cp\u003eIn terms of Channel, person-centered communication remains paramount. Policy leaders and community figures should disseminate information directly, supplemented by institutional platforms such as hospital Facebook pages, community LINE groups, local radio stations, village meetings, and public address systems. These diverse formats ensure broad reach, particularly in rural areas with limited digital infrastructure.\u003c/p\u003e\n\u003cp\u003eFinally, the Receiver refers to the target audience of adults aged 18 to 77 with basic literacy and no hearing impairments, including many VHVs. Since most respondents reported limited prior cannabis use and little knowledge of its side effects, communication strategies must consider their socio-cultural and educational background. Thus, knowledge dissemination must focus on message content and give equal attention to the credibility and accessibility of messengers and communication channels.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study revealed that most respondents were female village health volunteers (VHVs) aged 40 and older, representing the Generation X cohort, who have lived through Thailand's digital and technological transformation. Despite being part of a generation that is highly integrated into the digital world, often described as digitally literate and attuned to the Internet of Things and artificial intelligence, these individuals reported limited experience with cannabis, whether for medical, recreational, or culinary purposes. This finding suggests that even within a technologically connected population, trust in conventional medicine remains dominant, mainly due to the widespread perception that modern medical technologies are more reliable and safe\u003csup\u003e\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. The prevailing public health message, \"Do not self-medicate consult a physician or pharmacist,\" reinforces this perspective and discourages unsupervised cannabis use\u003csup\u003e\u003cspan additionalcitationids=\"CR53 CR54\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe data also showed that relatively few respondents could accurately identify cannabis's therapeutic benefits or its side effects when used alongside conventional or alternative medicine. This limited knowledge reflects a lack of engagement with cannabis-related content, likely resulting from longstanding social and legal stigmas. Similar patterns have been reported in countries such as Colombia\u003csup\u003e\u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e, Uruguay\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e, Brazil\u003csup\u003e\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e, and Venezuela\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e, where public confusion over cannabis-related laws has contributed to poor health literacy and low utilization of medical cannabis\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the Thai context, the public remains uncertain about what constitutes legal or illegal cannabis use. Kamnoedrit emphasized the need for legal clarity under Thai sovereignty to enable the integration of cannabis products into both conventional and alternative medical practices\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e. Similarly, Sornpaisarn et al. found that overlapping and complex legal texts have led to widespread confusion, discouraging people from learning about or using cannabis safely\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. Samorapoom, Pewchan, \u0026amp; Promrit added that ambiguous legal language has created distrust, causing the public to avoid the topic entirely\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis confusion extends to the legal status of cross-border cannabis transport. Many are unaware of which countries permit or prohibit cannabis imports and exports, and this lack of clarity impacts willingness to learn about its therapeutic uses\u003csup\u003e\u003cspan additionalcitationids=\"CR69\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e. Public hesitancy may also stem from fears that cannabis policy is politically contested and unstable or subject to change\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e. For example, some countries such as Japan and the United Kingdom strictly prohibit cannabis importation, while in the United States, it is allowed only in specific states\u003csup\u003e\u003cspan additionalcitationids=\"CR75\" citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThese findings suggest that legal uncertainty, both domestic and international, significantly undermines public interest in cannabis's medical potential and contributes to inconsistent knowledge about its uses and effects. For residents in Thailand' northeastern border regions, special ambiguity and undefined terms related to both medical and recreational cannabis have had a measurable impact on how individuals engage with cannabis-related information.\u003c/p\u003e \u003cp\u003eAs such, the study recommends that communication strategies be developed using the SMCR model (Source\u0026ndash;Message\u0026ndash;Channel\u0026ndash;Receiver), emphasizing the need for clear legal frameworks and the dissemination of accurate, accessible information. The Thai government, particularly the Ministers of Public Health and the Ministers of Justice, should publicly define legal cannabis usage and publish an official list of countries where cross-border cannabis transport is permitted. Educational guides should also be created to improve public interest, knowledge, and safe usage of cannabis.\u003c/p\u003e \u003cp\u003eAdditionally, influential figures such as provincial governors, district officers, village heads, traditional healers, and religious leaders should play a central role in providing centrality-based information to the public. Their involvement will not only enhance community trust but also ensure that cannabis education reaches rural populations who are most affected by inconsistent laws and limited access to health information.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications and Future Directions\u003c/h2\u003e \u003cp\u003eThe implications of this study are twofold: first, it calls for the Thai government to urgently address the legal and informational gaps that hinder public understanding and safe use of medical cannabis, particularly in rural and border communities where misinformation thrives. Legal reforms should prioritize harmonizing terminology, clarifying permissible uses, and publishing user-friendly guidelines on what is allowed, ambiguous, or prohibited\u0026mdash;especially regarding cross-border transport. Second, future research should expand to qualitative investigations that explore how cultural, spiritual, and generational factors influence cannabis perceptions and behaviors, particularly among youth and local healers. Educational interventions should be developed using the SMCR communication model to ensure that messages are contextually relevant, delivered by trusted community figures, and sensitive to literacy levels. A longitudinal follow-up study could assess whether such interventions improve cannabis health literacy and lead to more equitable and evidence-based use in both modern and traditional healthcare systems.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the persistent and widespread lack of accurate knowledge regarding the therapeutic properties and side effects of cannabis among outpatients in northeastern Thailand, particularly those residing near the Thai\u0026ndash;Cambodian border. Despite the legal liberalization of cannabis for medical and limited recreational use, over two-thirds of respondents answered \u0026ldquo;don\u0026rsquo;t know\u0026rdquo; to most knowledge-based items, including those related to both conventional and alternative medicine. The findings indicate that prior cannabis use, occupation as a village health volunteer, or even higher levels of education do not significantly improve health literacy concerning cannabis. These knowledge gaps are further exacerbated by legal ambiguities, cultural taboos, and fragmented regulatory communication. Consequently, the results underscore an urgent need for targeted public education campaigns, clearer legal frameworks, and accessible community-based health communication to promote safe, informed, and lawful cannabis use\u0026mdash;especially in regions vulnerable to misinformation and cross-border trade challenges.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;No funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePC.G. contributed to the study design, conceptual framework development, and critical revision of the manuscript for important intellectual content. S.P. contributed to the validation of the questionnaire instrument, data quality assurance, and interpretation of cannabis pharmacological properties in traditional and modern contexts. T.K. led the document-based legal analysis of cannabis-related legislation and contributed to the synthesis of regulatory recommendations. S.P. contributed to quantitative data analysis, demographic categorization, and the preparation of visual data presentations (tables and figures). K.T. \u0026nbsp;participated in the fieldwork coordination, assisted with participant recruitment, and contributed to the ethical review process. P.T. contributed to questionnaire design, data entry supervision, and manuscript formatting according to journal requirements. K.KN. supported the literature review on cross-border cannabis policy, cultural beliefs, and traditional medicine practices in northeastern Thailand. K.C. facilitated access to the field site at Phayu Hospital, coordinated with local health authorities, and provided feedback on community engagement strategies. NK.A. offered policy expertise, supervised the integration of findings into public health recommendations, and critically revised the manuscript for health systems implications. S.S. \u0026nbsp;conceived the research idea, supervised the overall project administration, conducted the statistical analyses, drafted the initial manuscript, and finalized the submission based on co-author feedback.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical consolidation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Human Research Ethics Committee of the Sisaket Provincial Public Health Office, Thailand (Approval No. SPPH 2024-40), granted on March 5, 2024.\u0026nbsp;All participants were fully informed about the study’s purpose, data confidentiality, and voluntary participation. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of the manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003evailability declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to participant confidentiality agreements but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Drug System Monitoring and Development Centre, Social Research Institute, Chulalongkorn University, and the Thai Health Promotion Foundation, for supporting this research.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRoyal Thai Government. Narcotic Act (No. 7) B.E. 2562 (2019). Government Gazette. 2019. Available from: https://cannabisinfo.fda.moph.go.th/กฎหมาย/\u003c/li\u003e\n \u003cli\u003eAmarin TV. The Ministry of Public Health removes cannabis from Category 5 narcotics list [Internet]. 2022 [cited 2024]. Available from: https://www.amarintv.com/news/social/221193\u003c/li\u003e\n \u003cli\u003eNantaratipob N. Possession and use of cannabis after legalization [Internet]. Bangkok: Secretariat of the House of Representatives; 2022 [cited 2024]. Available from: https://www.parliament.go.th/ewtadmin/ewt/parliament_parcy/ewt_dl_link.php?filename=The_House_of_Representatives\u0026amp;nid=88480\u003c/li\u003e\n \u003cli\u003eiLaw. The first day of cannabis decriminalization in Thailand [Internet]. 2022 Jun 9 [cited 2024]. Available from: https://www.ilaw.or.th/articles/5257\u003c/li\u003e\n \u003cli\u003eAmerican Cancer Society. Cannabis and cancer: Benefits of cannabis [Internet]. 2023 [cited 2024]. Available from: https://www.cancer.org/cancer/managing-cancer/treatment-types/complementary-and-integrative-medicine/marijuana-and-cancer/benefits-of-cannabis.html\u003c/li\u003e\n \u003cli\u003eDepartment of Thai Traditional and Alternative Medicine. Report on the situation of medical cannabis use in Thailand. Bangkok: Department of Thai Traditional and Alternative Medicine; 2021. Thai.\u003c/li\u003e\n \u003cli\u003eBank of Thailand. Cannabis market value report. Bangkok: Bank of Thailand; 2023.\u003c/li\u003e\n \u003cli\u003eThairath. The number of cannabis retail points nationwide has increased to 7,747. Thairath. 2024. Thai.\u003c/li\u003e\n \u003cli\u003eHfocus. Cannabis use among youth increases [Internet]. 2024 [cited 2024]. Available from: https://www.hfocus.org/content/2024/05/30411\u003c/li\u003e\n \u003cli\u003eSuranatwatchawong S, Naenudorn N, Sirited P, Wongtienlai M, Chuseewan C, Duch C, et al. Cannabis and teenagers. Burapha J Med. 2023;11(1):115-27.\u003c/li\u003e\n \u003cli\u003eLangka W, Satjapiboon S. A survey of cannabis and other substance use behaviors, access, knowledge and attitudes towards cannabis among students in the secondary school and out-of-school youth. Bangkok: Srinakharinwirot University; 2024 Aug. Funded by the Health Systems Research Institute (HSRI), Thailand.\u003c/li\u003e\n \u003cli\u003eNational Statistical Office. Public opinion survey on cannabis use in Thailand. Bangkok: National Statistical Office; 2023. Thai.\u003c/li\u003e\n \u003cli\u003eThailand Development Research Institute. Recommendations for cannabis regulation [Internet]. Bangkok: Thailand Development Research Institute; 2024 [cited 2024]. Available from: https://tdri.or.th/2024/03/seminar-cannabis-suggestion\u003c/li\u003e\n \u003cli\u003eCenter for Addiction Studies. Study report on cannabis use in Thailand [Internet]. 2019 [cited 2024]. Available from: https://www.cads.in.th/cads/content?id=102\u003c/li\u003e\n \u003cli\u003eRitmontree S, Loeiyood J, Boontoch K. A study of cannabis use behavior and health impacts in the Northeastern health service region. J Community Health. 2024;26(4):1-15. Available from: https://he01.tci-thaijo.org/index.php/CUTJ/article/view/266821\u003c/li\u003e\n \u003cli\u003eAroonsrimorakot S, Laiphrakpam M, Metadilogkul O. Social, religious, recreational, and medicinal usage of cannabis in India and Thailand. Interdisciplinary Research Review. 2019;14(4):43-50.\u003c/li\u003e\n \u003cli\u003eFrench L. From politics to economics at the Thai\u0026ndash;Cambodian border: Plus \u0026ccedil;a change... Int J Politics Cult Soc. 2002;15(3):427-70.\u003c/li\u003e\n \u003cli\u003ePearshouse R, Klein A. Detaining people who use drugs in Cambodia: A dual-track system. Int J Drug Policy. 2021;89:103258.\u003c/li\u003e\n \u003cli\u003eThai Medical Council. Medical advisory: Risks of cannabis use in adolescents and youth [Internet]. Bangkok: Thai Medical Council; 2022 [cited 2024]. Available from: https://tmc.or.th/pdf/att-dn-233.pdf\u003c/li\u003e\n \u003cli\u003eUnhavaithaya J, Ditthapan S. A study of Thai legislations regarding the control of the cannabis-based drug produced by folk physicians [Preprint]. ResearchGate. 2023 Feb. Available from: https://www.researchgate.net/publication/368395908\u003c/li\u003e\n \u003cli\u003eMorris RG, TenEyck M, Barnes JC, Kovandzic TV. The effect of medical marijuana laws on crime: Evidence from state panel data, 1990-2006. PLoS One. 2014;9(3):e92816.\u003c/li\u003e\n \u003cli\u003eSideli L, Quigley H, La Cascia C, Murray RM, Di Forti M. Cannabis use and the risk of psychosis and affective disorders. Front Psychiatry. 2021;12:640222.\u003c/li\u003e\n \u003cli\u003eGobbi G, Atkin T, Zytynski T, Wang S, Askari S, Boruff J, et al. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: A systematic review and meta-analysis. JAMA Psychiatry. 2019;76(4):426-34.\u003c/li\u003e\n \u003cli\u003eKroon E, Kuhns L, Hoch E, Cousijn J. Heavy cannabis use, dependence and the brain: A clinical perspective. Addiction. 2020;115(3):559-72.\u003c/li\u003e\n \u003cli\u003eRotermann M. Analysis of trends in the prevalence of cannabis use in Canada before and after legalization. Health Rep. 2020;31(2):3-14.\u003c/li\u003e\n \u003cli\u003eHealth Canada. Import and export of cannabis [Internet]. Ottawa: Government of Canada; 2023 [cited 2024]. Available from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/industry-licensees-applicants/manage-licence-cultivation-processing-sale-medical-purposes/apply-import-export.html\u003c/li\u003e\n \u003cli\u003eUrada D, Shoptaw S, Montoya ID, Hawes M, Rawson RA. Cannabis use and health knowledge: A survey of Californian adults. Subst Abuse Res Treat. 2020;14:1178221820959363.\u003c/li\u003e\n \u003cli\u003eGoodman S, Wadsworth E, Leos-Toro C, Hammond D. Prevalence and forms of cannabis use among youth in Canada, England, and the United States, 2017\u0026ndash;2019. Addict Behav. 2020;110:106529.\u003c/li\u003e\n \u003cli\u003eBone C, Zlotorzynska M, Kingston L, Gorfinkel L. The information needs of older adults using cannabis for medical purposes: A narrative review. Drugs Aging. 2024;41(1):1-10.\u003c/li\u003e\n \u003cli\u003eMize M. Cannabis legalization and cross-border policy in the Cascadia region. Bellingham (WA): Border Policy Research Institute, Western Washington University; 2020. Available from: https://cedar.wwu.edu/bpri_publications/109\u003c/li\u003e\n \u003cli\u003eDepartment of Medical Services, Ministry of Public Health. Guidance on cannabis for medical use: Updated version 5 (September 2022) [Internet]. Bangkok: Department of Medical Services; 2022 [cited 2024]. Available from: https://www.dms.moph.go.th\u003c/li\u003e\n \u003cli\u003eWhiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015;313(24):2456-73.\u003c/li\u003e\n \u003cli\u003ePasha A, Clements C, Reynolds C, Lopez M, Lugo C, Gonzalez Y, et al. Cardiovascular Effects of Medical Marijuana: A Systematic Review. Am J Med. 2021;134(2):182-93.\u003c/li\u003e\n \u003cli\u003eKichloo A, Albosta M, Aljadah M, El-Amir Z, Goldar G, Khan M, et al. Marijuana: A systems-based primer of adverse effects associated with use and an overview of its therapeutic utility. SAGE Open Med. 2021;9:20503121211000909.\u003c/li\u003e\n \u003cli\u003eJohns A. Psychiatric effects of cannabis. Br J Psychiatry. 2001;178:116-22.\u003c/li\u003e\n \u003cli\u003eHall W, Solowij N. Adverse effects of cannabis. Lancet. 1998;352:1611-6.\u003c/li\u003e\n \u003cli\u003eCronbach LJ, Rajaratnam N, Gleser GC. Theory of generalizability: A liberalization of reliability theory. Br J Stat Psychol. 1963;16(2):137-63.\u003c/li\u003e\n \u003cli\u003eMinistry of Public Health. Notification on specifying narcotic substances in Category 5, B.E. 2565 (2022). Royal Thai Government Gazette. 2022. Available from: https://www.ratchakitcha.soc.go.th/DATA/PDF/2565/E/035/T_0008.PDF\u003c/li\u003e\n \u003cli\u003eMinistry of Public Health. Act Promulgating the Narcotics Code B.E. 2564 (2021). Royal Thai Government Gazette. 2021 Nov 8;138(73G):1-20. Available from: https://ratchakitcha.soc.go.th/\u003c/li\u003e\n \u003cli\u003eMinistry of Public Health. Ministerial Regulation on Licensing Procedures for the Production, Import, Export, Distribution, or Possession of Category 5 Narcotics (Cannabis), B.E. 2564 (2021). Royal Thai Government Gazette. 2021 Nov 26;138(79G):1-16. Available from: https://ratchakitcha.soc.go.th/\u003c/li\u003e\n \u003cli\u003eMinistry of Public Health. Notification on Prescribed Formulations of Category 5 Narcotics Containing Cannabis for Medical Use or Research (No. 4), B.E. 2564 (2021). Royal Thai Government Gazette. 2021 Dec 7;138(299 Ngor):10. Available from: https://ratchakitcha.soc.go.th/\u003c/li\u003e\n \u003cli\u003eMinistry of Public Health. Notification of the Ministry of Public Health on Controlled Herbs (Cannabis), B.E. 2565 (2022). Royal Thai Government Gazette. 2022 Nov 23;139(Special Section 272 Ngor):1-4. Available from: https://www.ratchakitcha.soc.go.th\u003c/li\u003e\n \u003cli\u003eMinistry of Public Health. Notification on the Name, Type, Kind, or Characteristics of Herbal Products Prohibited from Importation, B.E. 2565 (2022). Royal Thai Government Gazette. 2022 Jun 2;139(129 Ngor):21. Available from:\u0026nbsp;\u003ca href=\"https://ratchakitcha.soc.go.th/\"\u003ehttps://ratchakitcha.soc.go.th/\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eDepartment of Health. Notification on the Use of Cannabis Leaves in Food Preparation in Restaurants, B.E. 2565 (2022) [Internet]. Bangkok: Department of Health; 2022 [cited 2024]. Available from: https://www.anamai.moph.go.th/\u003c/li\u003e\n \u003cli\u003eMinistry of Public Health. Notification of the Ministry of Public Health on designating cannabis, hemp, or other plant smoke or odor as a public nuisance, B.E. 2565 (2022). Royal Thai Government Gazette. 2022 Jun 14;139(Special Section 134 Ngor):1-2. Available from: https://www.ratchakitcha.soc.go.th\u003c/li\u003e\n \u003cli\u003eMinistry of Education. Announcement on Guidelines for Cannabis and Hemp in Educational Institutions and Government Agencies under the Ministry of Education. Royal Thai Government Gazette. 2022 Jun 16;139(156 Ngor):20-1. Available from: https://ratchakitcha.soc.go.th/\u003c/li\u003e\n \u003cli\u003eNational Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington (DC): National Academies Press; 2017.\u003c/li\u003e\n \u003cli\u003eChong D, Druckman JN. Framing theory. Annu Rev Political Sci. 2007;10(1):103-26.\u003c/li\u003e\n \u003cli\u003eHeadset. Gen X cannabis demographic trends [Internet]. 2018 [cited 2024]. Available from: https://www.headset.io/blog/gen-x-cannabis-demographic-trends\u003c/li\u003e\n \u003cli\u003eMNI Targeted Media Inc. Cannabis and generational marketing [Internet]. 2020 [cited 2024]. Available from: https://www.mni.com/blog/cannabis-and-generational-marketing\u003c/li\u003e\n \u003cli\u003eJampathong N, Kaewprom C, Sawangjit R, Srisurapanont M, Saokaew S. Perspectives of Thai traditional medicine practitioners on the medical cannabis policy: A qualitative study. BMC Complement Med Ther. 2022;22:43.\u003c/li\u003e\n \u003cli\u003eHughes CM, McElnay JC, Fleming GF. Benefits and risks of self medication. Drug Saf. 2001;24(14):1027-37.\u003c/li\u003e\n \u003cli\u003eRuiz ME. Risks of self-medication practices. Curr Drug Saf. 2010;5(4):315-23.\u003c/li\u003e\n \u003cli\u003eLi X, Fang F, Liu T. Analysis of over-the-counter medication misuse: A systematic review. Front Public Health. 2023;11:1176730.\u003c/li\u003e\n \u003cli\u003eAhmed M, Mohsin SF, Alshammari R, Aljuaid M, Kassem MA. Patterns and risks of self-medication: Evidence from a population-based study. BMC Public Health. 2023;23:83. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9936784/\u003c/li\u003e\n \u003cli\u003eGarcia DO, Aranzales JKB, Herrera GE. What do university students think about cannabis regulation? Perspectives from a Colombian university. An\u0026aacute;lisis Pol\u0026iacute;tico. 2024;37(109):155-82.\u003c/li\u003e\n \u003cli\u003eOrjuela-Rojas JM, Garc\u0026iacute;a Orjuela X, Ocampo Serna S. Medicinal cannabis: Knowledge, beliefs, and attitudes of Colombian psychiatrists. J Cannabis Res. 2021;3:26.\u003c/li\u003e\n \u003cli\u003eL\u0026oacute;pez L\u0026oacute;pez W, Pineda Mar\u0026iacute;n C, Sorum PC, Van Hoof J, Ruiz G\u0026oacute;mez F. Prohibition, regulation or free market: A mapping of Colombian people\u0026apos;s perspectives regarding national drug policies. Soc Indic Res. 2016;126:689-710.\u003c/li\u003e\n \u003cli\u003eDominguez H. Marijuana regulation in Colombia and Uruguay: A comparative policy analysis [master\u0026apos;s thesis]. Prague: Charles University, Faculty of Social Sciences, Institute of Sociological Studies; 2021. Available from: https://dspace.cuni.cz/handle/20.500.11956/124742\u003c/li\u003e\n \u003cli\u003eLaranjeira R, Martin D. Traps in cannabis policies in Brazil. Braz J Psychiatry. 2019;41(6):475-6.\u003c/li\u003e\n \u003cli\u003ede Souza MR, Henriques AT, Limberger RP. Medical cannabis regulation: An overview of models around the world with emphasis on the Brazilian scenario. J Cannabis Res. 2022;4:33.\u003c/li\u003e\n \u003cli\u003eKronick D. Profits and violence in illegal markets: Evidence from Venezuela. J Conflict Resolut. 2020;64(7-8):1499-523.\u003c/li\u003e\n \u003cli\u003eRodr\u0026iacute;guez-Llach A, Pereira-Arana I, Cruz-Olivera LF. Peasants\u0026apos; rights after the war on drugs: The case for transformative justice. In: Barrett D, Lines R, editors. Towards drug policy justice: Harm reduction, human rights and the future of drug policy. London: Routledge; 2021. p. 199-213.\u003c/li\u003e\n \u003cli\u003eDur\u0026aacute;n-Mart\u0026iacute;nez A, Pennell C. Change from above or pressure from below? The diffusion of cannabis reform in Latin America. Bull Lat Am Res. 2024;43(3):347-61.\u003c/li\u003e\n \u003cli\u003eKamnoedrit P. Buddhist principles and medical cannabis laws. J MCU Peace Stud. 2022;10(5):2326-35.\u003c/li\u003e\n \u003cli\u003eSornpaisarn B, Phiphatnachat W, Lamyai W, Silawan T, Detchiangkhraikul N, Thitiprasert W, et al. Facts and analysis of Thailand\u0026apos;s cannabis policies: A public health perspective. J Health Sci Thailand. 2023;32(2):375-88.\u003c/li\u003e\n \u003cli\u003eSamorapoom C, Pewchan C, Promrit A. Unlocking cannabis: Past to present of laws. J Local Gov Innov. 2023;7(1):285-9.\u003c/li\u003e\n \u003cli\u003eMead A. (2017). The legal status of cannabis (marijuana) and cannabidiol (CBD) under U.S. law. Epilepsy \u0026amp; behavior : E\u0026amp;B, 70(Pt B), 288\u0026ndash;291.\u0026nbsp;\u003ca href=\"https://doi.org/10.1016/j.yebeh.2016.11.021\"\u003ehttps://doi.org/10.1016/j.yebeh.2016.11.021\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eCannabis Legal News. International trade regulations for cannabis products [Internet]. 2023 [cited 2024]. Available from: https://cannabislegalnews.b-cdn.net/international-trade-regulations-for-cannabis-products.html\u003c/li\u003e\n \u003cli\u003eCuraleaf Clinic. Travelling with medical cannabis: What you need to know before you go [Internet]. 2023 [cited 2024]. Available from: https://curaleafclinic.com/travelling-with-medical-cannabis-what-you-need-to-know-before-you-go/\u003c/li\u003e\n \u003cli\u003eSuphanchaimat R, Tisayaticom K, Pudpong N, Hanefeld J. Cannabis liberalization in Thailand: The need for evidence-informed policies. Lancet Reg Health Southeast Asia. 2023;3:100076.\u003c/li\u003e\n \u003cli\u003eThammarangsri S, Buathong R, Panyasiri K, Apidechkul T. Trends and determinants of cannabis use in the Thai population: Evidence from the national household survey. BMC Public Health. 2023;23:1834.\u003c/li\u003e\n \u003cli\u003eInkhiew R, Songkram N, Suwanvajokkasikit C, Wongkaew P. Public concerns about cannabis consumption in Thailand: A Twitter-based analysis. BMC Public Health. 2023;23:1121.\u003c/li\u003e\n \u003cli\u003eNukulkij S. Law problems of cannabis liberalization of Thailand compared with Japan, United Kingdom, and the United States. Pa\u0026ntilde;\u0026ntilde;a Panithan J. 2020;5(2):151-9.\u003c/li\u003e\n \u003cli\u003eU.S. Food and Drug Administration. FDA regulation of cannabis and cannabis-derived products, including cannabidiol (CBD) [Internet]. Silver Spring (MD): U.S. Food and Drug Administration; 2023 [cited 2024]. Available from: https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd\u003c/li\u003e\n \u003cli\u003eJaeger K. Federal court rules that state-level marijuana legalization creates exemption to ban on paraphernalia imports. Marijuana Moment [Internet]. 2022 Oct 25 [cited 2024]. Available from: https://www.marijuanamoment.net/federal-court-rules-that-state-level-marijuana-legalization-creates-exemption-to-ban-on-paraphernalia-imports/\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cannabis-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcan","sideBox":"Learn more about [Journal of Cannabis Research](https://jcannabisresearch.biomedcentral.com/)","snPcode":"42238","submissionUrl":"https://submission.springernature.com/new-submission/42238/3","title":"Journal of Cannabis Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cannabis, Thai-Cambodian border, Cannabis use","lastPublishedDoi":"10.21203/rs.3.rs-6940512/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6940512/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003eThis study aimed to examine the demographic, economic, and social characteristics of the population in relation to their experiences with cannabis use and their accurate knowledge regarding its therapeutic properties and side effects when used in conjunction with conventional and alternative medicine and analyze the legal clarity concerning cannabis regulations and to propose communication strategies for effectively disseminating knowledge about its therapeutic properties and potential side effects when used for medical purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e A cross-sectional quantitative survey was conducted between March and August 2024 at a 30-bed community hospital along the Thai-Cambodian border. The sample included 618 Thai outpatients (429 females, 189 males) aged 18–86 years, selected via convenience sampling. Data were collected through face-to-face structured interviews using a validated questionnaire covering demographics, cannabis use history, and knowledge of medical uses and side effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOnly 14.24% of respondents had prior cannabis use experience. While most were aware of cannabis legalization, a large proportion showed limited understanding of its approved medical indications or side effects. Over 60% of participants answered \"do not know\" about therapeutic benefits or adverse effects. Differences in knowledge were found across age groups and education levels, but awareness was relatively low among health volunteers (Village Health Volunteers).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eDespite policy liberalization, knowledge gaps concerning medical cannabis remain widespread, especially regarding its safe and appropriate use. The findings highlight the need for targeted public education, regulatory clarity, and culturally appropriate communication strategies to ensure safe usage and minimize health risks, particularly in sensitive border areas.\u003c/p\u003e","manuscriptTitle":"Demographic, Economic, and Social Status and Knowledge of Medical and Alternative Cannabis Use among Northeastern Thai Citizens: A Case Study of Outpatients atCommunity Hospitals along the Thai–Cambodian Border","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-27 10:37:18","doi":"10.21203/rs.3.rs-6940512/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-21T19:38:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-20T17:51:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T13:15:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186524577686010636783727377352952389115","date":"2025-06-29T16:41:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29127220250468567262135731788492330406","date":"2025-06-24T15:40:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T14:46:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-24T14:15:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-24T12:59:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cannabis Research","date":"2025-06-20T16:10:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cannabis-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcan","sideBox":"Learn more about [Journal of Cannabis Research](https://jcannabisresearch.biomedcentral.com/)","snPcode":"42238","submissionUrl":"https://submission.springernature.com/new-submission/42238/3","title":"Journal of Cannabis Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6db32d91-b225-40df-b62c-c83719cdc70d","owner":[],"postedDate":"June 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:28:39+00:00","versionOfRecord":{"articleIdentity":"rs-6940512","link":"https://doi.org/10.1186/s42238-025-00326-3","journal":{"identity":"journal-of-cannabis-research","isVorOnly":false,"title":"Journal of Cannabis Research"},"publishedOn":"2025-10-23 16:17:21","publishedOnDateReadable":"October 23rd, 2025"},"versionCreatedAt":"2025-06-27 10:37:18","video":"","vorDoi":"10.1186/s42238-025-00326-3","vorDoiUrl":"https://doi.org/10.1186/s42238-025-00326-3","workflowStages":[]},"version":"v1","identity":"rs-6940512","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6940512","identity":"rs-6940512","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}