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Background  Little is known about how cannabis knowledge and attitudes impact cannabis use behavior.    Objective  To test the knowledge-attitudes-behavior paradigm in active adult athletes.    Design  The Athlete Pain, Exercise, and Cannabis Experience (PEACE) Survey, a cross-sectional survey study, used social media and email blasts to recruit participants and SurveyGizmo to collect data.    Participants  Self-defined active adult athletes ( n  = 1161).    Main measures  Knowledge about cannabis was evaluated with four questions. Attitudes toward cannabis was evaluated with 11 questions. The attitudes questions were used in a TwoStep Cluster analysis in SPSS to assign group membership by attitudes. Chi-square was used to determine if there were differences in cluster membership by demographic factors and if knowledge about cannabis differed by cluster membership. Regression analysis was performed to determine if cannabis attitudes mediated the relationship between cannabis knowledge and cannabis use.    Key results  A three-cluster solution was the best fit to the data. The clusters were named Conservative ( n  = 374, 32.2%), Unsure ( n  = 533, 45.9%), and Liberal ( n  = 254, 21.9). There was a significant difference among the clusters for all 11 attitude s  items (all  p  < 0.001). Attitude cluster membership was significantly different by age ( p  < 0.001), primary sport ( p  < 0.05), and knowledge about cannabis ( p  < 0.001). Athletes in the liberal cluster answered the knowledge questions correctly most often. Attitudes mediated the relationship between cannabis knowledge and cannabis use [Never (32.4%), Past (41.6%), Current (26.0%)] with athletes in the liberal cluster showing more knowledge and greater likelihood to be a current cannabis user ( p  < 0.001). Among current cannabis users there were differential patterns of cannabis use depending on their attitudes and knowledge; liberal athletes tended to co-use THC and CBD and used cannabis longer. ( p  < 0.001).    Conclusions  Cannabis education needs to consider attitudes about cannabis, especially among those who might benefit from medical cannabis.

Attitudes about cannabis mediate the relationship between cannabis knowledge and use in active adult athletes