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Official websites use. Share sensitive information only on official, secure websites. We tested the premise that punishment for cannabis use deters use and thereby benefits public health. We compared representative samples of experienced cannabis users in similar cities with opposing cannabis policies—Amsterdam, the Netherlands decriminalization , and San Francisco, Calif criminalization. We compared age at onset, regular and maximum use, frequency and quantity of use over time, intensity and duration of intoxication, career use patterns, and other drug use. With the exception of higher drug use in San Francisco, we found strong similarities across both cities. We found no evidence to support claims that criminalization reduces use or that decriminalization increases use. Drug policies may have less impact on cannabis use than is currently thought. There is a trend among Western democracies toward liberalization of cannabis laws. Cannabis includes both marijuana and hashish. In , the Netherlands adopted de facto decriminalization. Under Dutch law, possession remains a crime, but the national policy of the Ministry of Justice is to not enforce that law. Portugal decriminalized cannabis in , and England similarly reclassified cannabis in Canada and New Zealand are currently considering cannabis decriminalization. These shifts constitute the first steps away from the dominant drug policy paradigm advocated by the United States, which is punishment-based prohibition. Moving in the opposite direction, the United States has stiffened criminal penalties for drug offenses and has increased arrests for cannabis offenses. Since , voters in 8 states and the District of Columbia have passed medical-marijuana initiatives, but the federal government has resisted implementation. In , people were arrested for marijuana offenses. Such policies are designed to deter use. The core empirical claim made by criminalization proponents is that, absent the threat of punishment, the prevalence, frequency, and quantity of cannabis use will increase and will threaten public health. It is possible that the causal arrow points the other way—that user behavior affects laws and policies, which has been the case with alcohol policies in some countries. But Dutch policymakers decided that cannabis use was unlikely to lead to deeper deviance and that criminalization could lead to greater harm to users than the drug itself. The presumed effects of cannabis policies have been explored by those who are critical of criminalization in the United States 22 and by those who are skeptical of Dutch decriminalization. Our study compared the career use patterns of representative samples of experienced cannabis users in 2 cities with many similarities but with different drug-control regimes—Amsterdam, the Netherlands decriminalization , and San Francisco, Calif criminalization. San Francisco was selected as the US comparison city not because it is representative of the United States but because it is the US city most comparable to Amsterdam. Both cities are large, highly urbanized port cities with diverse populations of slightly more than They are financial and entertainment hubs for larger regional conurbations, and they have long been perceived within their home countries as cosmopolitan, politically liberal, and culturally tolerant. Law enforcement officials in San Francisco are not as zealous about enforcing marijuana laws as law enforcement officials are in most other US cities. Nonetheless, San Francisco is embedded in the drug policy context of criminalization, which is a markedly different drug policy context than that of Amsterdam. In San Francisco, there is strong proactive and reactive policing of sales, and there is moderate reactive policing of use. These differences in drug policy context are palpable to users. San Francisco students are suspended from schools and are placed in treatment for marijuana use. San Francisco users risk citations, fines, and arrests if they are detected buying, possessing, or using marijuana. In Amsterdam, users face none of these risks. The use and sale of other illicit drugs sometimes used by cannabis users is proactively policed in San Francisco. In Amsterdam, police occasionally engage in reactive policing of complaints about open use or sale of other drugs, but they do not proactively patrol in search of these offenses. We required not merely a random sample of cannabis users but a random sample of users who had enough experience defined as at least 25 episodes of use during their lifetimes to answer questions about career use patterns. In Amsterdam, recruitment of users began as part of a drug-use prevalence survey of the general population. The overall response rate was Comparisons of responders with nonresponders and with known city demographic data indicated no need for weighting. Of these experienced users, This modest response rate necessitated a check of representativeness. We compared the users who responded with the who did not on 12 demographic and drug-use prevalence variables. Respondents had slightly higher levels of formal education and slightly higher past-year prevalence of cannabis use, 26, 27 but otherwise, they showed no differences compared with nonrespondents and thus were reasonably representative of experienced cannabis users in the general population. Homeless and institutionalized persons were not interviewed for either survey. Beginning in , the Amsterdam survey of experienced cannabis users was replicated in San Francisco, where there is no population registry. To remain consistent with Amsterdam, we first drew an area probability sample by randomly selecting census tracts, blocks, buildings, households, and adults within households. We administered a brief prevalence survey containing demographic and drug-use prevalence questions. Unlike the Amsterdam prevalence survey, which was an extensive study in its own right, the brief prevalence survey in San Francisco was principally designed to generate a random representative sample of experienced cannabis users. The overall response rate of the San Francisco prevalence survey was As a check on their representativeness, respondents were compared with nonrespondents on 10 demographic and drug-use prevalence variables. No statistically significant differences were found. The Dutch questionnaire was translated for use in San Francisco. Non-English-speaking Asian Americans were excluded because of the prohibitive costs of translating instruments and training interviewers in the many Chinese and other Asian languages found in San Francisco. This exclusion was not consequential, because national prevalence studies show that illicit drug use among Asian Americans is the lowest of any ethnic group. However, the instruments were translated into Spanish, and bilingual interviewers conducted interviews when necessary. Homeless and institutionalized persons were not interviewed. The mean age at onset of cannabis use was nearly identical in both cities: The mean age at which respondents in both cities began their periods of maximum use was about 2 years after they began regular use: Clear majorities in both cities reported periods of maximum use of 3 years or less. We asked about the frequency and the quantity of use and the intensity and the duration of intoxication. During first year of regular use, strong majorities reported use of cannabis once per week or less, whereas small percentages reported daily use. Frequency increased during the period of maximum use but declined sharply thereafter. This decline was even greater for the past 3 months. The basic trajectory of frequency of use across careers was parallel in both cities. Most users reported a maximum-use period of 2 to 3 years, after which the vast majority sharply reduced their frequency of use or stopped altogether. Roughly three fourths of the respondents in each city reported that they had used cannabis less than once per week or not at all in the year before the interview. Amsterdam respondents used significantly smaller quantities than did San Francisco respondents during this period. Quantities consumed during maximum-use periods were larger and very similar across the cities. During the year before the interview, consumption among those who still used cannabis declined sharply. About 1 in 3 respondents in each city reported no use. Some recalled this occurence with greater consistency than did others, but all of them were able to make basic ordinal distinctions between more- and less-intense highs. Amsterdam respondents were significantly more likely than San Francisco respondents to report milder intoxication during the first year of regular use and during maximum-use periods: mean scores for the first year were 3. The same pattern was found for the more recent periods, although the mean scores declined. For the pastmonth periods, majorities in both cities reported milder highs of 1 to 3 on the 6-point scale. In short, respondents in both cities reported less intoxication with use over the course of their careers. Reported durations were correlated with frequency and with quantity but were not a function of frequency and quantity alone. One reviewer noted a divergence between San Francisco respondents, who reported more intense highs during 3 of the 4 periods, and Amsterdam respondents, who reported highs of longer duration during 1 period. Because we found no reason to suspect that either sample played up or played down their responses to any of the questions, this divergence may indicate culture-specific consumption styles or cultural grammars of intoxication. Substantial minorities in each city reported being high for 4 or more hours during maximum-use periods, but these proportions dropped sharply after those periods. We also asked respondents to characterize their overall career use patterns. Pattern names listed as shown to respondents. Two career use patterns were dominant in both cities. Pattern 4—gradual increased use followed by sustained decline—was the most common The second most common was Pattern 6—wide variation over time Pattern 3—stable use from the beginning onward—was selected significantly more often by Amsterdam respondents These findings are consistent with findings on frequency and quantity of use and intensity and duration of intoxication, and they have important public health implications. Claims that cannabis produces addiction or dependence 13— 15 lead one to expect that many experienced users would report Pattern 2—escalation of use over time. Another important question about the effects of drug policies concerns the use of other illicit drugs. Users who had ingested cannabis 25 times or more during their lifetimes were far more prevalent in San Francisco than in Amsterdam, and the same was true for users of other illicit drugs. During the 3 months before the interview, prevalence of crack and opiate use also were significantly higher in San Francisco, but cocaine, amphetamine, and ecstasy use were not significantly different. Proponents of criminalization attribute to their preferred drug-control regime a special power to affect user behavior. Our findings cast doubt on such attributions. Despite widespread lawful availability of cannabis in Amsterdam, there were no differences between the 2 cities in age at onset of use, age at first regular use, or age at the start of maximum use. Either availability in San Francisco is equivalent to that in Amsterdam despite policy differences, or availability per se does not strongly influence onset or other career phases. We also found consistent similarities in patterns of career use across the different policy contexts. Although a few significant differences were found in some dimensions of use during some career phases, the basic trajectory was the same in both cities on all dimensions of use: increasing use until a limited period of maximum use, followed by a sustained decrease in use over time or by cessation. It is significant, from a public health perspective, that clear majorities of experienced users in both cities never used daily or used large amounts even during their peak periods, and that use declined after those peak periods. Furthermore, both samples reported similar steady declines in degree and duration of intoxication. We expected differences in drug policies to affect the duration of cannabis-use careers and the rates of cessation. Criminalization is designed to decrease availability, discourage use, and provide incentives to quit. Decriminalization is said to increase availability, encourage use, and provide disincentives to quit. Thus, we expected longer careers and fewer quitters in Amsterdam, but our findings did not support these expectations. The mean career length was slightly greater in San Francisco 15 years than in Amsterdam 12 years , but this finding was mostly because of the somewhat higher mean age in the San Francisco sample 34 years vs 31 years. Similarly, nearly identical proportions of respondents in each city had quit by the time they were interviewed— If drug policies are a potent influence on user behavior, there should not be such strong similarities across such different drug control regimes. Our findings do not support claims that criminalization reduces cannabis use and that decriminalization increases cannabis use. Moreover, Dutch decriminalization does not appear to be associated with greater use of other illicit drugs relative to drug use in San Francisco, nor does criminalization in San Francisco appear to be associated with less use of other illicit drugs relative to their use in Amsterdam. Indeed, to judge from the lifetime prevalence of other illicit drug use, the reverse may be the case. Our study has limitations and should be replicated in other cities over longer periods. While our findings share the limitations of all self-report studies e. Further studies that examine prevalence before and after policy shifts would be illuminating, although previous studies of the impact of marijuana decriminalization among 11 US states during the s found no increases. One hypothesis for future research is that with a widely used drug like cannabis, the informal social controls that users develop as part of their culture 30, 31, 37— 39 have more powerful regulatory effects on their behavior than do formal social controls such as drug policies. This possibility emerged from responses to questions about the circumstances respondents found appropriate for cannabis use. In both cities, relaxation was the most common purpose of use, and majorities from both cities reported that they typically used cannabis with friends and at social gatherings. Majorities in both cities most often mentioned work or study as situations in which use was inappropriate. These data suggest that most experienced users organize their use according to their own subcultural etiquette—norms and rules about when, where, why, with whom, and how to use—and less to laws or policies. When experienced users abide by such etiquette, they appear to regulate their cannabis use so as to minimize the risk that it will interfere with normal social functioning. This pattern suggests that if formal drug policies are based on the folk informal drug policies users themselves already practice, drug policies may achieve greater relevance. An earlier version of this article was presented at the 97th Annual Meeting of the American Sociological Association, Chicago, Ill, August 15—19, Reinarman assisted in conceiving the study and analyzing the data. Kaal composed the figures and the tables that form the core of the data analysis. Cohen proposed the study, led its conceptualization, designed and supervised the data analysis, and assisted with writing the article. As a library, NLM provides access to scientific literature. Am J Public Health. Peter D. Cohen and Hendrien L. Find articles by Craig Reinarman. Find articles by Peter D A Cohen. Find articles by Hendrien L Kaal. Accepted Jun 7. Open in a new tab. Pattern Amsterdam, No. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.