Cannabis Social Clubs in Barcelona

JODXXX10.1177/0022042619852780Journal of Drug IssuesParés-Franquero et al. research-article8527802019

Article

Journal of Drug Issues 2019, Vol. 49(4) 607–624 Use and Habits of the © The Author(s) 2019 Article reuse guidelines: Protagonists of the Story: sagepub.com/journals-permissions https://doi.org/10.1177/0022042619852780DOI: 10.1177/0022042619852780 Cannabis Social Clubs in journals.sagepub.com/home/jod Barcelona

Òscar Parés-Franquero1, Xavier Jubert-Cortiella1, Sergi Olivares-Gálvez1, Albert Díaz-Castellano1, Daniel F. Jiménez-Garrido1, and José Carlos Bouso1

Abstract In Spain, cannabis users are turning to Cannabis Social Clubs (CSCs) as an alternative for obtaining supplies of the substance, free from the risks of the illegal market. The current study aims to establish the profile of a sample (N = 155) of Spanish CSC members and identify the impacts that these clubs have had on their consumption. To conduct the study, we developed a questionnaire structured around various issues related to the socioeconomic profile of users, their patterns of use, and the practical consequences of being a member of a CSC. The most important findings were that belonging to a CSC did not increase cannabis use and that the services that CSCs offer have favorable impacts on CSC members in terms of reducing health risks, providing legal protection, and improving their general well-being. Based on our data, the regulation of CSCs is warranted as a public health strategy regarding cannabis use.

Keywords Cannabis Social Clubs (CSC), quantitative research, cannabis legislation, cannabis consumption, drug policy

Introduction Cannabis is the most widely used illegal substance in the world. In 2014, 2.4% of the world’s population used it (United Nations Office on Drugs and Crime, 2017). In 2016, 7.2% of Europeans had used cannabis in the previous 12 months (European Monitoring Centre for Drugs and Drug Addiction, 2018), and in Spain, 9.5% of Spaniards between 15 and 64 years of age reported also having consumed it in the previous 12 months (Observatorio Español de las Drogas y las Adicciones [OEDA], 2017). Furthermore, cannabis and its derivatives account for 69% of drug seizures reported in Europe in 2015 (European Monitoring Centre for Drugs and Drug Addiction, 2018). As its use is common among the population, users in some countries, such as Spain, have come together to form a social movement to defend their right to use cannabis and to contest the current prohibitionist policy (Marín, 2008). Groups of users have also set up associations called

1International Center for Ethnobotanical Education, Research & Service, Barcelona, Spain Corresponding Author: José Carlos Bouso, International Center for Ethnobotanical Education, Research & Service, Carrer de Sepúlveda, 65, bajos 2, 08015 Barcelona, Spain. Email: [email protected] 608 Journal of Drug Issues 49(4)

Cannabis Social Clubs (CSCs). CSCs are made up of cannabis users who organize themselves to ensure that their own supply is maintained without having to resort to the illegal market. Their main objective is to avoid the risks of the illegal market, such as the lack of information on the origin and composition of the cannabis, and to avoid supporting the criminal organizations that run it (Transnational Institute, 2011). This movement has grown exponentially in the past 20 years in the Spanish territory, especially in Catalonia and the Basque Country (Parés & Bouso, 2015; Transnational & Institute, 2011, 2014a, 2014b). These clubs have appeared in Spain, thanks to a legal loophole generated by two circum- stances. The first is a Supreme Court ruling that determined that collective consumption does not constitute a crime under the Spanish Criminal Code (LOCP 10/1995 of November 23). The second is the law on nonprofit organizations (LODA 1/2002 of March 22). Using these two elements as their legal backing, the CSCs argue that their activities cannot be considered a crime because they do not encourage others to consume, nor do they generate profit by causing harm to the health of others (Parés & Bouso, 2015). Furthermore, UN conventions do not criminalize growing and possessing cannabis for personal use (Belackova & Wilkins, 2018; Kilmer, Kruithof, Pardal, Caulkins, & Rubin, 2013; Transnational Institute, 2014b). According to Carmena (2012), the activities of CSCs are permitted by the jurisprudence of the Spanish legal system. Currently in Spain, no CSC legislation has been approved at the national level. In Spain, dozens of city councils (especially in Catalonia) have approved municipal bylaws to regulate the activities of the CSCs’ head offices (aspects related to hygiene, hours of operation, capacity, safety, the built environment, etc.) due to a lack of regulation. Also, the parliaments of three autonomous communities passed laws to regulate the activities of CSCs: the Basque Country, Navarra (LFRCUCN 24/2014 of December 2), and Catalonia. In the case of the latter, the law further covers aspects related to growing and transporting cannabis (LACC 13/2017 of July 6). Both Navarra and Catalonia’s legislative initiatives were declared null and void by the Constitutional Court. As for the Basque Country, the law has not been canceled because it does not regulate cannabis use, possession, cultivation, or supply; it only states that the courts could eventually develop regulations for the operations of cannabis associations. The national government has taken a belligerent stance toward the CSC phenomenon, which it manifests through the Attorney General’s Office and the National Drug Plan. In 2013, the Attorney General’s Office issued an order (Fiscalía General del Estado, Instrucción Nº. 2/2013 of August 5) instruct- ing prosecutors to accuse CSCs of being criminal organizations. This strategy sought to have cases brought before the Supreme Court so that the court would establish whether the CSCs’ activities fall within or outside of the scope of the collective consumption doctrine. In 2015, the Supreme Court quashed the acquittal of four members of the Pannagh Association by the Court of Bilbao, condemning known activist Martín Barriuso and three other members of the association to 1 year and 8 months in prison. This ruling was appealed at the Constitutional Court, which overturned it due to issues of procedure, but the original ruling nonetheless ratified that CSCs’ activities are criminal. Although the judge absolved the convicted on the grounds that they were mistaken about or unaware of the unlawfulness of their activities, this ruling opened the door for other CSCs to be brought before the Supreme Court, which has happened on another five occasions. This creates some confusion about how the state should deal with CSCs, an issue that becomes even more complex when one considers the range of situations prevailing in the country, as regions with several CSCs alternate with ones that have only a few, and each club faces different levels of legal vulnerability and social tolerance. A thoughtful explanation of the complex legal context that CSCs face in Spain can be found in Marks (2019). Other objectives pursued by CSCs include developing techniques to reduce risks and prevent the harm associated with cannabis use, such as providing access to substance information (risks of cannabis use and tetrahydrocannabinol–cannabidiol [THC-CBD] content), or promoting healthier methods for using cannabis, such as vaporizers (Hazekamp, 2015). Moreover, most CSCs are attentive to the quality of the cannabis, educate users on the effects of each variety, Parés-Franquero et al. 609 maintain an official control of consumption, and, by bringing consumers together, offer opportunities for research to be conducted on their behavior and consumption (Belackova, Tomkova, & Zabransky, 2016). Currently, in the United States, 28 states and the District of Columbia (DC) have legalized cannabis for medicinal use; of these, nine states plus DC have legalized it for recreational purposes (Drug Policy Alliance, 2018). In 2014, Uruguay passed a law that regulates production, distribution, and places of sale or consumption; one of the legal ways to obtain cannabis there is by belonging to a CSC (Queirolo, Boidi, & Cruz, 2016). In Europe, however, policies remain fixed on the persecution of conduct related to this substance. Although the Netherlands can be considered the most progressive country in the region on this subject, as it does not criminalize the use or possession of cannabis in public places, its model only regulates the sale and possession of small amounts in “coffee shops.” It does not regulate the growing of cannabis or its supply to these establishments, which leaves the door open for organized crime to participate in this market (Transnational Institute, 2014). We also have the case of Belgium, whose situation is somewhere between Spain’s and the one in Uruguay. In Belgium, CSCs do not offer places for people to consume cannabis (due to legal constraints), but some of them organize activities for members, and there are opportunities for social contact among the members (Decorte et al., 2017; Pardal, 2018). A recent study describing the sociodemographic characteristics, patterns of use, and supply of a sample of 190 Belgian CSC members found that securing cannabis was the primary reason for joining a CSC (Pardal & Decorte, 2018). Another noteworthy result was the presence of self-declared medical users in the study sample. Up until now, at least two studies have assessed the impact of CSCs on users’ behavior and health; both were conducted in the Spanish context. One study involving a sample of 94 members divided into 14 discussion groups concluded that CSCs are a viable option for reducing the harm and risks associated with cannabis use (Belackova et al., 2016). The second study, promoted by Fundación Renovatio (2016), used a mixed-methods design to compare 458 cannabis-using members of CSC, with 135 users not belonging to a CSC regarding patterns of cannabis use and harm reduction strate- gies. This study found that club members’ concerns about the quality of the cannabis they used led them to acquire the substance through CSCs more often. They also reported that, in the previous year, they consumed other substances less, tended to use cannabis in private places, and used vaporizers more. Our study, presented below, aims to analyze in greater depth the impacts of CSCs on concrete indicators related to cannabis use and its psychosocial effects on club members.

Method The city of Barcelona has the highest number of CSCs in the entire Spanish state, with a total of approximately 250 clubs in 2015 (Parés & Bouso, 2015). This study was carried out with a sample recruited from 20 CSCs in Barcelona with the following objectives: (a) describe the sociodemographic characteristics of club members; (b) assess the frequency and prevalence of members’ consumption of legal and illegal drugs; (c) analyze certain indicators related to the consumption of cannabis, namely, the context of use, preferences, motives for use, perceived effects of use, fines, trends in acquisition, and perceptions on the supply of cannabis and other drugs; (d) study risk behaviors related to cannabis use; (e) evaluate the credibility of the sources of information on use; and (f) analyze the motives for belonging to a CSC, members’ patterns of consumption, and their assessment of the services. For the recruitment of subjects, we contacted the two CSC Federations located in Catalonia and then randomly selected 20 different CSCs. Subjects were interviewed in the CSC facilities. All subjects were at least 21 years of age. The data were collected in 2015 using a questionnaire that was developed on the basis of two questionnaires used in earlier studies (Decorte, 2015; Fundación Renovatio, 2016). The questionnaire was organized into the following sections: (a) sociodemographic description: age, 610 Journal of Drug Issues 49(4)

gender, nationality, category of membership (recreational or medicinal1), education, employment status, income, socioeconomic level, housing situation, and relationship status; (b) cannabis consumption patterns; (c) places where CSC members use cannabis; (d) consumption methods; (e) reasons for using cannabis; (f) positive and negative effects of cannabis use; (g) sources for obtaining cannabis after joining a CSC and the supply; (h) problematic cannabis use (according to the Cannabis Abuse Screening Test [CAST]); (i) legal problems derived from cannabis use; (j) members’ assessment of the CSCs’ risk reduction services; (k) therapeutic counseling; and (l) self-perception and information on cannabis use. The time it took to complete the questionnaire was approximately 20 to 30 min. Regarding the assessment of problematic use, responses to the CAST can be scored in two different ways. The first is called CAST–binary (CAST-b), in which a score of either 0 or 1 is allocated to participants’ answers. For the first two questions in this section, when a participant responds “occasionally,” “often,” or “very often,” a score of 1 is given; for responses of “rarely” or “never,” a score of 0 is given. As there are six questions in the questionnaire, the total score cannot go over 6, and totals of 4 or higher are classified as problematic use. The second way of evaluating responses is called CAST–full (CAST-f), in which the answers are given a score from 0 to 4 depending on the frequency of the action. In this case, the total of the scores can reach a maximum of 24. Cuenca-Royo et al. (2012) classified a score of 7 as indicating moderate addiction, and scores of 9 or higher indicate dependence. The majority of the questions on the questionnaire were built using a Likert-type scale with five answer options. For certain questions, to gather information on the method of use, the different sources of cannabis, and the personal or legal problems derived from its use, we offered an open answer option. Finally, open-ended questions were employed to assess each interviewee’s knowledge and point of view—for example, participants were asked to identify three positive effects and three negative effects of cannabis. The open-ended questions were analyzed themati- cally (Braun & Clarke, 2012). The questionnaires were completed with at least one researcher present. Prior to completing the questionnaire, participants were informed of the nature, objectives, and procedures of the study; they were guaranteed that their responses and anonymity would be kept confidential and they signed an informed consent form. The data were processed in accordance with Spanish data protection laws (LOPDCP 15/1999 of December 13). With regard to the limitations of this study, the sample comes from CSCs in Catalonia and, therefore, is neither fully transposable to other autonomous communities in Spain nor to other cultural contexts. It is also possible that the CSCs that were willing to inform their members about this study are precisely those whose praxis is closer to the codes of good conduct outlined by the federations of cannabis associations. Therefore, it is also possible that the data gathered here are not fully transposable to the entire range of CSCs that exist in Spain. Finally, some indicators that we used are not identical to the ones used in the drug use surveys that the Government of Spain conducts on the general population. Consequently, for some indicators, it may not be possible to compare our results with those obtained for the general population. The government’s biannual surveys are centered on all drugs and ask about more general indicators, whereas our study focuses on cannabis exclusively. Due to the descriptive objective of this study, we performed a descriptive analysis of all study variables. The study variables are also described in each table of the “Results” section.

Results Sociodemographic Profile of CSC Members Of the 155 participants of this study, 134 (86.45%) were of Spanish nationality and 19 (12.25%) were foreigners residing in Catalonia. Women made up 29.68% (n = 46) of the sample, whereas Parés-Franquero et al. 611 the remaining 70.32% (n = 109) were men. Respondents’ average age was 31.67 years. With regard to their membership category, 90.32% (n = 140) were recreational members and 9.68% (n = 15) stated that they were medicinal members. A description of the other sociodemographic variables can be seen in Table 1.

Table 1. Sociodemographic Data.

n (N = 155) % Level of education . Postgraduate studies 19 12.26 . University studies 51 32.9 . Vocational training 34 21.94 . Preuniversity studies 25 16.13 . Secondary studies 13 8.39 . Primary studies 10 6.45 . Others 3 2 Employment status . Unemployed 26 16.77 . Retired 7 4.52 . Employed 122 78,70 Monthly income . No income 15 9.68 . €650 or less 30 19.35 . Between €651 and €1,000 35 22.58 . Between €1,001 and €1,500 45 29.02 . Between €1,501 and €2,000 17 10.97 . Between €2,001 and €2,500 6 3.87 . Between €2,501 and €3,000 4 2.58 . €3,001 or more 2 1.3 . Variable income 1 0.65 Living situation . Living alone 31 20 . Living with parents 43 27.74 . Living with their own family 16 10.32 . Living with their partner 30 19.35 . Living with other relatives 3 1.94 . Living with friends 22 14.19 . Other 10 6.45 Relationship status . Formal couple 64 41.29 . No formal status, but serious relationship 23 14.84 . Not serious relationship 9 5.81 . Unrelated 59 38.06

Patterns of Consumption Most participants (68.39%) were daily cannabis users, whereas 96.13% of the sample used cannabis in the previous month and 98.06% in the previous year. Among the consumption habits adopted by participants since joining a CSC, the most common one—adopted by 47.66% (n = 612 Journal of Drug Issues 49(4)

74)—was Pattern 3, which corresponds to the response, “When I joined the club, I continued consuming the same amount of cannabis as before. The amount and frequency have not changed.” Table 2 shows the percentages for each of the defined consumption patterns.

Table 2. Consumption Patterns.

Pattern Answer Results

“My cannabis use 4.52% (n = 7) increased gradually over the years after I joined the club.”

“Immediately after joining 6.45% (n = 10) the club, I began to consume large amounts of cannabis, which have since decreased.”

“When I joined the club, I 47.66% (n = 74) continued consuming the same amount of cannabis as before. The amount and frequency have not changed.”

“My consumption 7.10% (n = 11) gradually increased when I joined the club, until it reached a peak and then decreased.”

(continued) Parés-Franquero et al. 613

Table 2. (continued)

Pattern Answer Results “I have stopped and 23.87% (n = 37) started using cannabis again many times after joining the club.”

“Since I joined the club, 6.45% (n = 10) my consumption has changed over the years.”

Other patterns 3.87% (n = 6)

Places Where CSC Members Consume Cannabis Members were asked to specify the frequency of their cannabis use in each of the following five contexts: private places of leisure, public places of leisure, place of work/study, at CSCs, or in their private vehicle. For this question, they were given five response options: never, rarely, occasionally, usually, and only. The results in Table 3 indicate that the places most commonly (“usually”) used are private places and CSCs (by 78% and 67%, respectively). About 15% of respondents indicate occasionally using cannabis in a car.

Table 3. Places of Consumption.

Place Only Usually Occasionally Rarely Never

Private places 8% (n = 13) 78% (n = 120) 11% (n = 17) 3% (n = 5) 0% (n = 0) Public places 1% (n = 2) 14% (n = 22) 36% (n = 56) 36% (n = 55) 13% (n = 20) Place of work or study 1% (n = 1) 10% (n = 15) 15% (n = 24) 17% (n = 26) 57% (n = 89) Cannabis Social Clubs 5% (n = 8) 67% (n = 104) 20% (n = 31) 5% (n = 8) 3% (n = 4) In a car 1% (n = 1) 8% (n = 12) 15% (n = 24) 24% (n = 38) 52% (n = 80)

Methods of Consumption Regarding the methods used to consume cannabis, in Table 4, one can observe that the method most commonly (“usually”) used is smoking cannabis mixed with tobacco (64.52%). This practice is deeply ingrained in Spanish culture, probably due to the long-standing tradition of using hashish, which originated in the neighboring country of Morocco. 614 Journal of Drug Issues 49(4)

Table 4. Methods of Consumption.

Method Only Usually Occasionally Rarely Never

Smoke cannabis 21.29% (n = 33) 64.52% (n = 100) 5.81% (n = 9) 4.52% (n = 7) 3.87% (n = 6) mixed with tobacco Smoke cannabis 3.23% (n = 5) 9.03% (n = 14) 27.10% (n = 42) 38.06% (n = 59) 22.58% (n = 35) without tobacco Eaten in sweets 1.29% (n = 2) 3.23% (n = 5) 29.03% (n = 45) 50.32 (n = 78) 16.13% (n = 25) Vaporized 0% (n = 0) 4.52% (n = 7) 32.26% (n = 50) 32.90% (n = 51) 30.32% (n = 47)

Reasons for Using Cannabis A list of different reasons for using cannabis was presented to subjects, who were asked to score each item using a Likert-type score with five answer options (from “very important” to “not important”). The most common responses were “to relax” (83.87%) and “to sleep better” (57.42%). “To challenge authority” (76.13%) and “to treat symptoms while following medical advice” (83.87%) were also common responses, but ones that the survey participants considered less important. Table 5 shows the results obtained, which are listed by the number of responses.

Table 5. Reasons for Using Cannabis.

Important reasons Neutral reasons Unimportant reasons Relax (83.87%) To be sociable Symptoms treatment with medical advice (83.87%) Sleep better (57.42%) (32.90%) Challenge to authority (76.13%) Enjoy music, movies, and Get stoned Communicate better (75.48%) TV (52.9%) (31.61%) Inhibition (69.68%) Improve creativity (51.61%) Fight depression (64.51%) Feel good (48.38%) Symptoms treatment without medical advice (55.48%) Feel less anxious (43.87%) Cure for boredom (62.58%)

One interesting finding is that 52.26% (n = 81) responded that they used cannabis “without medical advice” to treat muscular, joint, or bone pain, such as chronic injuries or back pain. Furthermore, there are club members who also use cannabis for headaches in general (headaches, migraines, etc.). In relation to gender, of the 28 female respondents, 50% (n = 14) mentioned using cannabis to treat menstrual pain. In addition, 21.94% (n = 34) stated that they used cannabis “with medical advice.” The symptoms, pains, and illnesses that users treat with cannabis upon the recommendation of medical professionals are muscular, articular, and bone pain; nausea; hypertension; bulimia; treatment for cancer of the lacrimal gland; depression; epilepsy; hepatitis C; sclerosis; and migraine headaches.

Positive and Negative Effects of Cannabis Use Participants were asked in an open-ended question to identify in their own words the “three positive effects that consuming cannabis has on you that you consider important” and “three negative Parés-Franquero et al. 615 effects that consuming cannabis has on you that you consider important.” The three effects most often reported as positive were “relaxation,” “creativity,” and “ease of falling asleep.” On the contrary, the three most often reported negative effects were “lack of concentration,” “pulmonary effects,” and “effects caused at the mental level.”

Sources for Obtaining Cannabis After Joining a CSC and the Supply According to the results for where participants normally obtain cannabis from, 56.77% of the CSC members interviewed stated that, since joining the club, they “usually” obtain cannabis from the CSC. Table 6 shows the different sources of cannabis “usually” used before and after joining the club.

Table 6. Sources of Cannabis.

Source Before joining CSC (%) After joining CSC (%) Street/square 36.78 1.94 My home 17.32 10.32 Vender’s house 47.09 6.45 Bar 4.52 0.65 Pub/night club 3.23 0.65 Place of study 5.16 0 At work 1.94 3.23 Other 1.94 2.59

Note. CSC = Cannabis Social Clubs.

Furthermore, users informed us that at the place where they previously obtained cannabis before joining a CSC, they could also acquire other substances. For example, 34.19% responded that they could obtain ecstasy, 32.90% were able to get amphetamines, 38.06% had access to cocaine, 27.10% could access LSD (lysergic acid diethylamide), and 11.61% said they were also able to get opiates from their cannabis source. In addition, 9.68% of users chose the answer “others,” suggesting that they could access other drugs not listed here, and three participants specified that they could have obtained whatever they wanted from their source.

Problematic Cannabis Use In this study, questions were also used to inquire about possible problematic use of cannabis over the past year. For this section of the questionnaire, the CAST scale was used. The results are presented in Table 7.

Table 7. Cannabis Abuse Screening Test.

Very Often Occasionally Rarely Never Behaviors often (%) (%) (%) (%) (%) Smoke cannabis before midday 26.45 18.06 22.58 23.23 9.68 Smoke cannabis alone 50.97 23.23 14.84 7.10 3.87 Memory problems from using cannabis 5.16 18.84 40.65 21.29 18.06 Your friends or family have told you that you 7.74 8.39 21.29 30.97 31.36 should reduce cannabis use You have tried to stop or reduce cannabis use, 1.29 7.74 20.65 19.35 50.97 but were unable to You have had problems due to your cannabis use 1.94 2.58 6.4 18.06 70.97

Note. CSC = Cannabis Social Clubs. 616 Journal of Drug Issues 49(4)

When CAST-b was used to assess the results of our survey, it was found that 61.93% of the sample showed signs of cannabis abuse (CAST ≥4), although the average score is 3.84, with a deviation of 1.67. Using the CAST-f method, the scores of 13.54% of participants placed them in the “moderate addiction” category—Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013)—and 58.70% were in the “dependence” category—Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000. The average score in this case was 9.71, with a standard deviation of 4.48. It was observed that although some interviewees used cannabis before noon and the majority used it when alone, the incidence of self-perceived memory problems and of unsuccessful attempts to stop consuming cannabis is relatively low. The incidence drops substantially when the interviewees were asked whether they have had problems (altercations, fights, accidents, poor academic performance, etc.) stemming from cannabis consumption.

Legal Problems Derived From Cannabis Use Members were also asked how many fines they received for “consuming or possessing illegal psychoactive substances in public before and after joining a CSC.” As can be seen in Table 8, the number of fines declines significantly after joining a CSC.

Table 8. Fines for Possession or Consumption Before and After Joining a CSC.

Before joining a CSC, n (%) After joining a CSC, n (%) People fined 48 (30.97) 17 (10.97) People fined once 25 (16.12) 14 (9.03) People fined 2 or more times 23 (14.83) 3 (1.93)

Note. CSC = Cannabis Social Clubs.

Members’ Assessment of the CSCs’ Risk Reduction Services When asked about “the differences that they notice between using the services offered by the association and using cannabis obtained on the illegal market,” a large majority of users noted positive differences. The main benefits of joining a CSC were that they offer more information regarding the quality of the product and the risks of cannabis use, plus the protection, safety, and tranquility that the CSC offers. Close to half of the people interviewed (48.38%) indicated that the CSC had “provided them resources to reduce their regular consumption patterns,” such as daily or monthly evaluations of cannabis consumption. When asked an open-ended question about “what has the ongoing evaluation of consumption patterns meant for them,” 100% of interviewees said it was positive. Examples of these responses include the following: “They told me how much I consumed per month and this made me more aware of my use,” “Knowing more about my use helps me control it better,” “Reduce consumption until no more is consumed, as I am currently an activist who believes in the movement,” and “Improved my management of my use.” For 30.86% of the interviewees, assessing their consumption on a regular basis helped them to reduce their use. Over a quarter (27.74%) of the interviewees participated in workshops on responsible use organized by the CSCs. In addition to the issue of responsible use, CSCs also held workshops on other matters rele- vant to their members. Although only 28 of the interviewees reported participating in one of these workshops, 93.18% affirmed that they had “received the quality information they needed”; Parés-Franquero et al. 617

93.18% responded that the workshop helped “prevent health risks”; 75.00% stated that “after participating in the workshop, they have adopted healthier alternatives for use”; and for 90.91%, the workshop “was satisfactory.” The results of the participants’ assessments of other services offered by CSCs can be seen in Table 9.

Table 9. Assessment of the Risk Reduction Services.

Service Assessment The availability of credible, objective information on the Very positive and positive (57.47%) risks of cannabis use Since you have been a member of the association, you have Strongly agree and agree (56.77%) reflected more on the risks associated with cannabis use and the possible harm from which they are derived. You consider that self-management of cannabis provided Strongly agree and agree (64.52%) by the club (using the dispensary, etc.) reduces the risks associated with cannabis use. The dispensary service helped prevent health risks. Strongly agree and agree (64.20%) Using the dispensary has increased healthier consumption Strongly agree and agree (60.49%) alternatives.

Counseling Services Some CSCs employ physicians who offer services to individuals suffering from illnesses who self-medicate with cannabis, which in our sample was 10%. The physicians also provide counseling to CSC members on aspects of cannabis use that may be of concern to them. A total of 41 interviewees used this service. Their answers to questions about their impressions and level of satisfaction regarding various aspects of the counseling are presented in Table 10.

Table 10. Assessment of Therapeutic Services.

Questions Assessment Does the therapeutic counseling service provide you Yes (90.48%) with the quality information that you needed? Have you received personalized assistance? Yes (90.48%) Has it helped to prevent health risks? Yes (88.10%) Have you considered healthier consumption measures? Yes (76.19%) Are you satisfied with this service? Yes (90.48%)

Self-Perception on Information on Cannabis Use Finally, participants in the study were asked, “do you feel you are sufficiently informed about cannabis?” While 82% of interviewees responded “fully” or “adequately informed,” 17% answered “partly,” and 1% responded, “no, I am poorly informed.”

Discussion This study aims to profile cannabis users who belong to CSCs, in terms of why they become members, what their opinion of the CSCs and their services is, and what influence these 618 Journal of Drug Issues 49(4) establishments have had on the quality of the cannabis used. The sociodemographic profile shows a group that is primarily male, middle class, educated, and employed, a result that is very similar to the one obtained by the survey of Belgian CSC members (Pardal & Decorte, 2018). Regarding gender, the majority of participants are men (70.32%), whereas 31.67% are women, which is also similar to the Belgian members (Pardal & Decorte, 2018). According to the Spanish Observatory on Drugs and Drug Addictions (OEDA, 2017), 26% of people who have consumed cannabis in the previous 30 days are women. Cannabis use is therefore more widespread among men than women. According to Romo (2006), women suffer from greater stigma associated with the use of illegal drugs than men do because of the construction of gender roles, which could be the reason for the lower prevalence of use among women. Furthermore, these results are similar to the results from the study by Fundación Renovatio (2016) mentioned earlier, which used a similar methodology. In that study, the majority of the members who participated were men (73.4%), and only 26.6% were women. This latter figure is closer to the data obtained by the government concerning use among the general population. According to the results of our study, only 18.07% (Phase 1 + Phase 2 + Phase 4, Table 2) reported an increase in use after becoming a CSC member, whereas 13.55% (Phase 2 + Phase 4, Table 2) stated that this increase in use reached a peak and then diminished. This means that only 4.52% of participants reported that their cannabis use had continued to increase since they joined the club. Of the sample, 47.66% responded that they continued to use the same amount as before, and almost 25% of the sample reported intermittent cannabis use. This is congruent with the data showing that only 68.39% of the sample of CSC members use cannabis daily. About 96% used cannabis in the previous month, which is a difference of 28 points between the former and the latter. That difference may explain why 15% of the sample uses cannabis intermittently. In general terms, the different prevalence between using cannabis daily, in the previous month, and in the previous year shows that most cannabis users use it intermittently. Our result is especially interesting because it was found among a sample of CSC members who may be popularly considered as the ones who engage in more intense cannabis use (as reflected by the higher prevalence of use in the previous year and month as compared with the general population). In that sense, even between that population we can observe that there is a very high prevalence of intermittent frequency of use. The study conducted by Fundación Renovatio (2016) obtained similar results: 53% of CSC members reported having stable consumption patterns, and the group of nonmembers was said to have more unstable patterns. This could be related to the risk and harm reduction measures implemented by the CSCs, such as daily and monthly assessments of consumption, workshops, and counseling on use. These types of services have been positively assessed by the CSC members (Table 9), as they allowed them to become more conscious of their cannabis use, assess it, and take measures to self-regulate use. Despite the information and risk reduction measures, no participants in the sample consumed cannabis only using the vaporization method, and about 60% used this method rarely or never. This is in accord with other survey studies on medical users (Hazekamp, Ware, Muller-Vahl, Abrams, & Grotenhermen, 2013), which show that despite the health risks, smoking cannabis is the most favorite method of use. Another aspect to consider is that 15% of the sample used cannabis in a car “occasionally,” and 8% used it in a car “usually.” Although using cannabis in a car does not necessarily imply driving under its effects, it seems plausible that many of these individuals drive while experiencing the effects of cannabis. One important element to highlight is that these spaces do not offer psychoactive substances other than cannabis and its derivates. According to the interviewees, many dealers have other, more harmful substances to offer. This makes it easier for people who use cannabis to obtain other, more toxic substances without any knowledge or professional advice about them. By joining a CSC, most interviewees have stopped buying from underground sources, as they now usually get their supplies from the CSCs (see Table 6). Similarly, after joining a CSC, the Parés-Franquero et al. 619 number of fines per member decreased significantly, which can be explained by a reduction in the use and acquisition of cannabis in public spaces. The members’ evaluation of CSCs as compared with the illegal market is very positive, as the clubs provide more information on the quality of the cannabis and its effects, as well as providing some degree of legal protection. We observed coincidences with the study by Fundación Renovatio (2016), where the quality of cannabis, avoiding contact with the illegal market, and legal protection were the most important motives for joining a CSC. In the study by Belackova et al. (2016), similar reasons were given for joining a CSC, namely, the quality of the cannabis, the information provided, the regulation of use, and safety from criminalization. The CSCs offer cannabis users a new space to consume. This may lead to decreased use in public places (see Table 3), an act that has been criminalized in Spain by point 16 of Art. 45 LOPSC 4/2015 of March 24. It is the legislators’ understanding that promoting cannabis use disrupts public order and harms the health of people around the clubs. However, these spaces do not encourage people to consume it or promote its use to obtain new clients. All members affirmed being regular cannabis users at the time of joining a CSC. Furthermore, to become a new member, one must have an invitation or recommendation from an already-registered member; registering nonusers and minors is prohibited (Belackova & Wilkins, 2018). Despite this result, a recent survey done on Spanish CSC man- agers found that some CSCs actually try to expand their market to new users (Jansseune, Pardal, Decorte, & Parés, 2018). Due to cannabis’s use to alleviate certain pains and illnesses (Hazekamp, 2015), some CSCs collaborate with clinicians who specialize in the medicinal use of cannabis, to offer professional care to therapeutic members. Almost 10% of members in our sample used cannabis for therapeutic purposes. Pardal and Decorte (2018) found that half of their Belgian sample were self-reported medical users. The difference may be due to Spanish CSCs requiring a medical certificate stating that an individual’s pathology may benefit from cannabis use, in order for them to become a medicinal member, whereas in Belgium the requirement is simply to self-report medical use. The therapeutic services were assessed positively by participants (Table 10), with 90.48% being satisfied with it, and 88.10% reporting that served to reduce health risks. Although these services were mainly for the medicinal users (10% of the sample), in our sample 41 subjects (26%) actually used them. So, besides the predominant method of using cannabis was to smoke it, maybe those who use the counseling services practice healthier methods. It should be highlighted that there is currently no medicinal cannabis program in Spain, and the only drug based on legal cannabis is Sativex, which is similar to Epidiolex (a CBD-based drug for the compassionate use in treatment of refractory childhood epilepsy) and is used for multiple sclerosis and in compassionate use for other diseases, namely, chronic pain (Devilat, Manterola, & Moya, 2014). Until now, patients’ only alternative is to buy cannabis from the illegal market and/or to grow their own, which requires them to have enough space and money to grow it either outside or inside of their home. This exposes them, however, to problems in terms of thieves or the police when grown outside, and when grown inside, there is the high cost of building the infrastructure to grow it. There is also the need to have the gardening abilities required to produce an adequate amount of cannabis of an appropriate potency (Feldman & Mandel, 1998). When we asked users whether they were aware of the negative effects that cannabis may have, the results were similar to those reported by Volkow, Baler, Compton, and Weiss (2014), mainly regarding cognitive impairment and addiction. This variable could be strengthened by the CSCs’ information services. Also, in response to the questions using the CAST scale, interviewees gave a low rating to family members’ recommendations for them to stop using cannabis, to self-perceived memory problems, to frustrated attempts to stop using it, and to problems associated with use, such as fights, accidents, and poor academic performance. According to the OEDA (2017), 19% of people who used cannabis in the past 12 months are problematic users (CAST ≥4). In our study, this figure was as high as 61.93%. However, it is 620 Journal of Drug Issues 49(4) necessary to consider the fact that the OEDA (2017) survey is based on a sample of individuals who answered that they used cannabis in the previous 12 months, whereas in our sample, many participants were daily cannabis users. This makes drawing comparisons difficult. Furthermore, the OEDA (2017) evaluated responses to the CAST using the binary form, which is more biased toward finding a problematic use than CAST-f. The latter scoring method offers more information, which allows for a more accurate diagnosis of disorders related to abusive cannabis use (Cuenca-Royo et al., 2012). That said, both CAST-b and CAST-f tend to overestimate the prevalence of dependence on cannabis, while underestimat- ing cannabis use disorders (Legleye, Piontek, & Kraus, 2011). Finally, figures derived by using a rating scale during interviews via telephone, without any additional data or in-depth interviews with interviewees, are, at best, a rough approximation of the situation and inade- quate for diagnosing a mental disease. The results found in the CAST survey developed by the OEDA (2017) should be examined carefully before drawing any conclusions about cannabis abuse among the Spanish population. In our study, when we place the CAST scores from our sample into context with the rest of the indicators, it is difficult to confirm definitively that the problematic use of cannabis is common among our study participants. Besides the difficulties just explained concerning the correct interpretation of the CAST, the fact is that our sample shows a high rate of problematic cannabis use. The problem is that we obtain different prevalences of problematic use depending on how we interpret the term “problematic.” The CAST-b refers to problematic use as “abuse,” with 61.93% of our sample meeting the criteria. If we interpret the CAST-f according to DSM-IV criteria, the term for problematic use is “dependence,” with 58.70% of our sample meeting the criteria. Finally, if we interpret the CAST-f according to DSM-V criteria, the term for problematic use is “moderate addiction,” with 13.54% of our sample meeting the criteria. A previous Spanish study only found that subjects, in that case adolescents, met the criteria for problematic use assessed by the CAST when they also had a psychiatric problem (Cuenca-Royo et al., 2012). In the study by Fundación Renovatio (2016), the figure was 29.9% for “dependence” and 55% for “abuse,” but using the DSM-IV criteria, not the CAST. Although the CAST-f offers score equivalences with DSM-IV and DSM-V, the two instruments do not capture the same dimensions (Legleye, 2018). So, it is not easy to compare the results from the two Spanish studies, beyond saying that both of them show a high prevalence of problematic use. However, as we said above, to define problematic use simply from using a rating scale is complicated due to not being able to account for other aspects. As we also have said above, the more problematic areas of the CAST are scored low. However, more importantly, our sample has a high educational level (only about 8% has primary studies or the equivalent), and the majority are employed (78.70%). This sociodemographic profile is similar to the one found in the Fundación Renovatio (2016) study, as well as the Belgian study (Pardal & Decorte, 2018). Considering all of these data together leads us to conclude that that eventual problematic use does not imply problems in the daily life of cannabis users. Moreover, we can see the deficiencies in terms of classifying problematic use using a questionnaire that is con- structed for use as a screening method, not for diagnosis. In fact, the majority of the sample maintained the same use or even reduced their use since joining a CSC, which may also be indi- rect evidence that these users are not engaged in problematic cannabis use. Notably, however, we have not recorded the exact quantities the study participants use, which could offer a better indi- cator of eventual problematic use. As Belackova et al. (2016) found, the fact that the CSCs offer the substance itself and not a substitute has been used to generate the discourse that claims that the clubs are promoting cannabis use. “Agenda-setting” theories point to the media’s tremendous capacity to influence public opinion and the priority of issues of political importance (McCombs & Shaw, 1972). In the case of the CSCs, however, the clubs only gain visibility when they are involved in a court case or police intervention, where they are treated as criminals and not as a response to the current Parés-Franquero et al. 621 drug policies (Martínez, 2015; Pardal & Tieberghien, 2017). In the results of our study, it is clear that these establishments improve consumers’ quality of life. They are the first ones to value them as a positive alternative. However, there are associations that do not have risk reduction measures in place or that do not restrict access only to members who are of legal age. This is due to the lack of regulations for these associations and standardized state control. Although parliament debates whether the clubs should be regulated or banned, profit-seeking investors are taking advantage of legal loopholes to do business and try to pass their for-profit activities off as CSCs. Currently, the lack of laws regulating these associations is producing the large diversity in praxis and objectives. Regulations would allow for the homogenization of these spaces’ praxis and establish control over their activities in an organized and structured manner, with the goal of preventing activities that cause harm to public health. A new legal framework is needed to address the issue of drug trafficking, money laundering, and the criminalization of users (Transnational Institute, 2012). In conclusion, following the negative ruling of the Spanish state’s judicial authorities, the CSCs find themselves in a paradigm marked by confusion and insecurity. The literature and research in this field prove the potential contribution that these establishments could make to risk reduction policy. Our study also contributes to this and encourages placing the users in a leader- ship role. We have seen how only a minority of members continue to increase their use after joining CSCs, and how members see the CSCs and their risk reduction measures in a very positive light, especially in comparison with the illegal market. We have also shown that CSCs offer counseling to people who use cannabis to alleviate the symptoms of illnesses or disease. Moreover, we found that although the majority of participants had scores indicating problematic use, this is not actually the case, as is evident when that data are analyzed in the context of other study indicators, and these users are aware of the negative effects of cannabis use.

Acknowledgments We would like to thank the federations of associations of cannabis users of Catalonia, CATFAC and FEDCAC, for facilitating access to their members. We also extend our gratitude to several Cannabis Social Clubs in the city of Barcelona that do not belong to the federation and that opened their doors to us so that we could conduct our study. Last, but not least, we give many thanks to the users who participated in our study.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research has been carried out at the ICEERS Foundation during the hours of practical work done by students of the Bachelor of Criminology program of the Universidad Autónoma de Barcelona. This research project did not receive any contribution from the funding sources that support this institution.

Note 1. A medicinal member is an individual who uses cannabis for medical reasons, and, generally, the stated use is supported by a medical report. Medicinal members usually pay lower fees and some Cannabis Social Clubs even give them cannabis for free as an act of solidarity by the other members.

ORCID iD José Carlos Bouso https://orcid.org/0000-0003-1115-9407 622 Journal of Drug Issues 49(4)

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Belackova, V., Tomkova, A., & Zabransky, T. (2016). Qualitative research in Spanish cannabis social clubs: “The moment you enter the door, you are minimising the risks.” International Journal of Drug Policy, 34, 49-57. Belackova, V., & Wilkins, C. (2018). Consumer agency in cannabis supply: Exploring auto-regulatory documents of the cannabis social clubs in Spain. International Journal of Drug Policy, 54, 26-34. Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper, P. M. Camic, D. L. Long, A. T. Panter, D. Rindskopf & K. J. Sher (Eds.), APA handbook of research methods in psychology, Vol. 2. Research designs: Quantitative, qualitative, neuropsychological, and biological (pp. 57-71). Washington, DC: American Psychological Association. Carmena, M. (2012). La jurisprudencia sobre la ilicitud del tráfico del hachís [The jurisprudence on the ille- gality of the traffic of hashish]. In Cannabis, usos, seguridad jurídica y políticas [Cannabis, uses, legal security and policies] (pp. 89-98). Vitoria-Gasteiz: Ararteko. Retrieved from http://www.ararteko.net/ RecursosWeb/DOCUMENTOS/1/0_2771_3.pdf Cuenca-Royo, A.M., Sanchez-Niubo, A., Forero, C.G., Torrens, M., Suelves, J.M., & Domingo-Salvany, A. (2012). Psychometric properties of the CAST and SDS scales in young adult cannabis users. Addictive Behaviors, 37, 709-715. Decorte, T. (2015). Cannabis Social Clubs in Belgium: Organizational strengths and weaknesses, and threats to the model. International Journal of Drug Policy, 26, 122-130. Decorte, T., Pardal, M., Queirolo, R., Boidi, M. F., Sánchez, C., & Parés, Ò. (2017). Regulating Cannabis Social Clubs: A comparative analysis of legal and self-regulatory practices in Spain, Belgium and Uruguay. International Journal of Drug Policy, 43, 44-56. Devilat, M., Manterola, J., & Moya, J. (2014). Tratamiento compasivo y de acompañamiento con Cannabis en niños con Epilepsia Resistente. Una presentación de 2 pacientes y revisión de la literatura [Tratamiento compasivo y de acompañamiento con Cannabis en niños con Epilepsia Resistente. Una presentación de 2 pacientes y revisión de la literatura]. Revista Chilena de Epilepsia [Chilean Magazine of Epilepsy], 14, 6-17. Retrieved from http://www.revistachilenadeepilepsia.cl/wp-content/ uploads/2015/04/201403_tratamiento_compasivo_cannabis_epilepsia_resistente.pdf Drug Policy Alliance. (2018). Marijuana legalization and regulation. Retrieved from http://www.drug- policy.org/issues/marijuana-legalization-and-regulation European Monitoring Centre for Drugs and Drug Addiction. (2018). European Drug Report: Trends and developments 2017. Retrieved from https://publications.europa.eu/en/publication-detail/-/ publication/722b76f0-3f64-11e7-a08e-01aa75ed71a1/language-en/format-PDF/source-94757811 Feldman, H., & Mandel, J. (1998). Providing medical marijuana: The importance of cannabis clubs. Journal of Psychoactive Drugs, 30, 179-186. Fiscalía General del Estado, Instrucción 2/2013, de 5 de agosto, sobre algunas cuestiones relativas a asociaciones promotoras del consumo de cannabis [State Prosecutor’s Office, Instruction 2/2013, of August 5, on some issues related to associations promoting the use of cannabis] (2013). Fundación Renovatio [Renovatio Foundation]. (2016). Observatorio de Cannabis: Estudio de las pau- tas de consumo de cannabis en los clubes sociales de cannabis y evaluación de su eficacia. [State Prosecutor’s Office, Instruction 2/2013, of August 5, on some issues related to associations promoting the use of cannabis]. Retrieved from http://docs.wixstatic.com/ugd/1bbd46_860b4d80f0a24ac39e20d de40404a79d.pdf Hazekamp, A. (2015). Introducción al cannabis medicinal [Introduction to medical cannabis] (1st ed.). Barcelona, Spain: International Center for Ethnobotanical Education, Research and Service. Hazekamp, A., Ware, M. A., Muller-Vahl, K. R., Abrams, D., & Grotenhermen, F. (2013). The medicinal use of cannabis and cannabinoids—An international cross-sectional survey on administration forms. Journal of Psychoactive Drugs, 45, 199-210. Parés-Franquero et al. 623

Jansseune, L., Pardal, M., Decorte, T., & Parés, O. (2018). Revisiting the birthplace of the Cannabis Social Club model and the role played by Cannabis Social Club federations. Journal of Drug Issues, 49, 338- 354. Kilmer, B., Kruithof, K., Pardal, M., Caulkins, J. P., & Rubin, J. (2013). Multinational overview of cannabis production regimes. Brussels, Belgium: Rand Europe. Legleye, S. (2018). The Cannabis Abuse Screening Test and the DSM-5 in the general population: Optimal thresholds and underlying common structure using multiple factor analysis. International Journal of Methods in Psychiatric Research, 27(2), e1597. Legleye, S., Piontek, D., & Kraus, L. (2011). Psychometric properties of the Cannabis Abuse Screening Test (CAST) in a French sample of adolescents. Drug Alcohol Dependence, 113, 229-235. Ley 13/2017, de 6 de julio, de las asociaciones de consumidores de cannabis (LACC), Boletín Oficial del Estado, 187 § 9367 [Law 13/2017, of July 6, of cannabis consumer associations (LACC), Official State Gazette, 187 § 9367] (2017). Ley Foral 24/2014, de 2 de diciembre, reguladora de los colectivos de usuarios de cannabis en Navarra (LFRCUCN), Boletín Oficial del Estado, 315 § 13626 [Provincial Law 24/2014, of December 2, regulating cannabis user groups in Navarra (LFRCUCN), Official State Gazette, 315 § 13626] (2014). Ley Orgánica 1/2002, de 22 de marzo, reguladora del Derecho de Asociación (LODA), Boletín Oficial del Estado, 73 § 5852 [Organic Law 1/2002, of March 22, regulating the Right of Association (LODA), Official State Gazette, 73 § 5852] (2002). Ley Orgánica 10/1995, de 23 de noviembre, del Código Penal (LOCP), Boletín Oficial del Estado, 281 § 25444 [Organic Law 10/1995, of November 23, of the Penal Code (LOCP), Official State Gazette, 281 § 25444] (2015). Ley Orgánica 15/1999 de 13 de diciembre, de Protección de Datos de Carácter Personal (LOPDCP), Boletín Oficial del Estado, 298 § 23750 [Organic Law 15/1999 of December 13, Protection of Personal Data (LOPDCP), Official State Gazette, 298 § 23750] (1999). Ley Orgánica 4/2015, de 30 de marzo, de protección de la seguridad ciudadana (LOPSC), Boletón Oficial del Estado, 77 § 3442 [Organic Law 4/2015, of March 30, for the protection of citizen security (LOPSC), Official Bulletin of the State, 77 § 3442] (2015). Marín, I. (2008). La cultura “Cannábica” en España (1991-2007) [The “Cannabis” culture in Spain (1991- 2007)] (Tesis Doctoral) [Doctoral Thesis]. Universidad de Granada [University of Granada], España [Spain]. Marks, A. (2019). Defining “personal consumption” in drug legislation and Spanish cannabis clubs. International & Comparative Law Quarterly, 68, 193-223. Martínez, D. P. (2015). Clubs Sociales de Cannabis: normalización, neoliberalismo, oportunidades políti- cas y prohibicionismo [Cannabis Social Clubs: normalization, neoliberalism, political opportunities and prohibition]. Revista Clivatge Estudis i testimonis sobre el conflicte i el canvi socials [Clivatge Magazine Studies and testimonies about social conflict and change], 3, 92-112. Retrieved from http:// revistes.ub.edu/index.php/clivatge/article/view/11985 McCombs, M., & Shaw, D. (1972). The agenda-setting function of mass media. Public Opinion Quarterly, 36, 176-187. Observatorio Español de las Drogas y las Adicciones. (2017). Informe 2017: alcohol, tabaco y drogas ile- gales en España. Retrieved from http://www.pnsd.mscbs.gob.es/profesionales/sistemasInformacion/ informesEstadisticas/pdf/2017OEDA-INFORME.pdf Pardal, M. (2018). An analysis of Belgian Cannabis Social Clubs’ supply practices: A shapeshifting model? International Journal of Drug Policy, 57, 32-41. Pardal, M., & Decorte, T. (2018). Cannabis use and supply patterns among Belgian Cannabis Social Club members. Journal of Drug Issues, 48, 689-709. Pardal, M., & Tieberghien, J. (2017). An analysis of media framing of and by Cannabis Social Clubs in Belgium: Making the news? Drugs: Education, Prevention and Policy, 24, 348-358. Parés, Ò., & Bouso, J. C. (2015). Hacer de la necesidad, virtud. política de drogas en Cataluña, de la acción local hacia el cambio global [Innovation Born of Necessity: Pioneering Drug Policy in Catalonia, from de local action to the global change] (1st ed.). New York, NY: Open Society Foundation. Queirolo, R., Boidi, M. F., & Cruz, J. M. (2016). Cannabis clubs in Uruguay: The challenges of regulation. International Journal of Drug Policy, 34, 41-48. 624 Journal of Drug Issues 49(4)

Romo, N. (2006). Genero y uso de drogas: la invisibilidad de las mujeres [Gender and use of drugs: the invisibility of women]. Monografias Humanitas [Humanitas monographs], 5, 69-83. Retrieved from http://www.drogasextremadura.com/archivos/NRomoInvisibilizMujeres.pdf Transnational Institute. (2011). Los Clubes Sociales de Cannabis en España: una alternativa normaliza- dora en marcha [The Cannabis Social Clubs in Spain: a normalizing alternative in progress]. Retrieved from http://www.regulacionresponsable.es/wp-content/uploads/2015/08/TNI-CSC_copia2.pdf Transnational Institute. (2012). Hacia una revisión de las convenciones de drogas de la ONU. La logica y los dilemas de los grupos afines [Towards a review of the UN drug conventions. The logic and the dilemmas of the related groups]. Retrieved from https://www.tni.org/files/download/dlr19s.pdf Transnational Institute. (2014a). Cannabis policy reform in Europe: Bottom up rather than top down. Retrieved from https://www.tni.org/files/download/dlr28.pdf Transnational Institute. (2014b). The rise and decline of cannabis prohibition. Retrieved from https://www. tni.org/files/download/rise_and_decline_web.pdf United Nations Office on Drugs and Crime. (2017). World Drug Report 2017. Retrieved from https://www. unodc.org/wdr2017/en/exsum.html Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. B. (2014). Adverse health effects of marijuana use. New England Journal of Medicine, 370, 2219-2227.

Author Biographies Òscar Parés-Franquero has a degree in philosophy and anthropology from the University of Barcelona and has a master’s degree in drug addiction from the same university. Currently, as deputy director of the International Center for Ethnobotanical Education, Research & Service (ICEERS) Foundation, he promotes educational projects, drug policy reform, and research in the field of Cannabis Social Club. Xavier Jubert-Cortiella has a degree in criminology from the Autonomous University of Barcelona. In his final dissertation, he specialized in the field of cannabis policy. He is currently collaborating with the ICEERS Foundation in the investigation of the use of cannabis and its possible legal reforms. Sergi Olivares-Gálvez has a degree in criminology from the Autonomous University of Barcelona. He did his undergraduate internship at the ICEERS Foundation, carrying out studies and research documents. Albert Díaz-Castellano graduated in criminology from the Autonomous University of Barcelona. He col- laborated with the ICEERS foundation in different research studies related to drug policy. Daniel F. Jiménez-Garrido studied psychology at the University of Barcelona; his interest in the field of psychopharmacology and ethnobotany led him to work as a technical assistant in the scientific department of ICEERS, a task he has been carrying out since 2013. José Carlos Bouso is a psychologist and holds a PhD in pharmacology. He has developed his scientific activity in the Autonomous University of Madrid, in the Sant Pau Biomedical Research Institute (IIB Sant Pau) of Barcelona, and in the Institute Hospital del Mar de Investigaciones Médicas of Barcelona (IMIM). He is currently the director of Scientific Projects at the ICEERS Foundation.