Author reply Re: Knowledge and attitude of college students towards cannabis use in urban India: A comparative perspective of users and non-users

We thank the readers for their patient and thorough assessment and welcome their comments and inputs regarding our study. While we have tried to highlight the shortcomings of our study in its limitations section, further clarifications are given below.

While it is true that self-administered questionnaires lack direct oversight by the investigator, dismissing their validity on this basis alone overlooks several important strengths and safeguards inherent in their use. First, anonymity and the absence of a researcher can actually increase the likelihood of honest and uninfluenced responses, particularly when dealing with sensitive topics. This can lead to more accurate data than might be obtained in a face-to-face setting where social desirability bias is a concern. Second, concerns about respondent identity and mental capacity can be mitigated through careful questionnaire design, clear instructions, and the use of screening questions to ensure eligibility. Moreover, in many contexts—especially large-scale or remote studies—direct oversight is impractical or unnecessary, and the logistical and ethical advantages of self-reported methods outweigh their limitations. Therefore, while no data collection method is without flaws, self-administered questionnaires remain a reliable, cost-effective, and scalable tool in modern research when implemented correctly.

It is valid to consider the potential for under-reporting in self-reported data on illicit behaviours such as cannabis use; this limitation is a well-recognized challenge in behavioural research and is typically addressed through methodological safeguards. The argument that the prevalence of cannabis use among students is underestimated due to fear of legal repercussions, though plausible, lacks empirical substantiation unless supported by evidence demonstrating significant response bias in the given study context. Anonymity and confidentiality— core principles in ethical research involving sensitive topics— are specifically designed to mitigate such biases. When participants are assured that their identities will not be linked to their responses and that no legal consequences will follow, the likelihood of obtaining honest answers increases substantially. Numerous studies have demonstrated that, under conditions of anonymity, self-reports of substance use can be sufficiently reliable for estimating prevalence, even in contexts where such use is illegal.

Furthermore, if under-reporting is assumed, it should also be acknowledged that over-reporting or exaggeration, particularly in peer-influenced populations such as university students, is also possible. Without objective biochemical verification, neither under-reporting nor over-reporting can be conclusively quantified, and speculation about the ‘true’ prevalence remains hypothetical.

Therefore, while caution is warranted in interpreting self-reported figures on illegal behaviour, the claim that the actual prevalence of cannabis use is ‘much higher’ than reported remains speculative unless supported by triangulated data from alternative sources such as qualitative interviews, focus groups, or biological testing.

While it is true that cannabis holds a historical and religious presence in certain cultural practices, the assertion that cannabis use in India is trivialized due to its cultural and religious importance oversimplifies a complex socio-legal and public health issue. Furthermore, the cited statistic—31 million cannabis users in India (2.8% of the population aged 10 to 75)—should be interpreted in context. Prevalence figures alone do not imply social trivialization. High usage rates can exist alongside strong social stigma, legal penalties, and negative health or legal consequences for users. Additionally, equating cultural familiarity with trivialization overlooks the important distinction between traditional, often ritualistic use of substances and modern, non-contextual recreational consumption. Specific norms and limitations typically bind the former, whereas the latter may raise public health concerns that warrant careful study and regulation. Therefore, while cultural context is important in understanding patterns of substance use, it should not be assumed that such context leads to trivialization or a lack of awareness regarding the potential risks associated with cannabis consumption.

It is accurate that cannabis use can pose a range of health risks but it would be reductive to claim that users are categorically uninformed or unaware of these effects. In recent years, public discourse, educational campaigns, and increasing research dissemination have contributed to a more informed population, particularly among university students and young adults who tend to have higher exposure to scientific literature, social media, and health-related content. Furthermore, the inclusion of cannabis-related health risks in educational curricula, government advisories, and mainstream media has made information more accessible. Several studies have shown that while knowledge gaps may exist in certain demographic groups, a significant proportion of users are aware of potential side-effects, particularly the short-term cognitive and psychological effects, such as impaired coordination, mood changes, and attention deficits.

A more nuanced understanding would differentiate between levels of awareness, patterns of use, and user intentions (e.g recreational vs. medicinal). Rather than assuming a lack of knowledge, public health efforts should focus on targeted, evidence-based education to close existing knowledge gaps further and promote safer, informed decision-making among potential and current users.