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Snowball sampling: Theoretical and practical considerations
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SNOWBALL SAMPLING:
A PILOT STUDY ON COCAINE USE
VINCENT M. HENDRIKS, PHD.

PETER BLANKEN, PHC.
NICO F.P. ADRIAANS
This study was supported by a grant from the Commission of the European Community.
CIP-GEGEVENS KONINKLIJKE BIBLIOTHEEK, DEN HAAG
Hendriks, Vincent M., Blanken, Peter, & Adriaans, Nico F.P.
Snowball sampling: A pilot study on cocaine use / Vincent M. Hendriks, Peter Blanken, Nico
F.P. Adriaans - Rotterdam: Instituut voor Verslavingsonderzoek (IVO), Erasmus Universiteit.
Met lit. opg. - Met index.
ISBN
SISO
Trefw.: snowball sampling; verslaving
© 1992 IVO
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SNOWBALL SAMPLING:
A PILOT STUDY ON COCAINE USE
VINCENT M. HENDRIKS, PHD., PETER BLANKEN, PHC.,

& NICO F.P. ADRIAANS
FROM THE ADDICTION RESEARCH INSTITUTE (IVO), MEDICAL AND HEALTH SCIENCES
FACULTY, ERASMUS UNIVERSITY ROTTERDAM, THE NETHERLANDS
ANTONIA DOMINGO, PHD., & RICHARD HARTNOLL, PHD.

FROM THE INSTITUT MUNICIPAL D'INVESTIGACIÓ MÈDICA (IMIM), BARCELONA, SPAIN
RODOLPHE INGOLD, PHD., MOHAMED TOUSSIRT, PHC.,

THIERRY PLISSON, & VINCENT RAGOT
FROM THE INSTITUT DE RECHERCHE EN EPIDÉMIOLOGIE DE LA PHARMACODÉPENDANCE
(IREP), PARIS, FRANCE
DIETER KORCZAK, PHD.

FROM THE G.P. FORSCHUNGSGRUPPE, MUNICH, GERMANY
CONTENTS
Chapter 1. Introduction ....................................................................................................... 9
§ 1.1 Context of the study ................................................................................................... 9

§ 1.2 Theoretical background ............................................................................................. 10
§ 1.2.1 Historical developments .............................................................................. 10
§ 1.2.2 Recent trends .............................................................................................. 11
§ 1.2.3 Drug use epidemiology ............................................................................... 13
§ 1.3Research questions and methodology ................................................................................... 15
Chapter 2. Snowball-sampling: .................................................................................... 17

Theoretical and practical considerations
§ 2.1 Theory on snowball sampling ................................................................................... 17

§ 2.1.1 Overview ...................................................................................................... 17
§ 2.1.2 Discussion .................................................................................................... 21
§ 2.2 The practice of snowball sampling ........................................................................... 28
§ 2.2.1 The "pre-zero" stage .................................................................................... 28
§ 2.2.2 The zero-stage and snowball sampling stages .......................................... 32
Chapter 3. Description of cities and samples .................................................... 37
§ 3.1 Barcelona ................................................................................................................... 37

§ 3.1.1 Population and other parameters ............................................................... 37
§ 3.1.2 Drug use in Barcelona ................................................................................. 38
§ 3.1.3 Description of cocaine use patterns in Barcelona ...................................... 49
§ 3.2 Description of Barcelona sample .............................................................................. 50
§ 3.3 Paris ........................................................................................................................... 51
§ 3.3.1 Introduction .................................................................................................. 51
§ 3.3.2 Description of the city .................................................................................. 51
§ 3.3.3 Methodology ................................................................................................ 54
§ 3.4 Description of Paris sample ...................................................................................... 57
§ 3.5 Cologne ...................................................................................................................... 58
§ 3.5.1 Description of Cologne's city situation,
scenes, and backgrounds ........................................................................... 58
§ 3.5.2 City quarters with special drug abuse tendencies ..................................... 60
§ 3.5.3 Drug use patterns ........................................................................................ 60
§ 3.5.4 The fieldwork ................................................................................................ 60
§ 3.6 Description of Cologne sample ................................................................................. 61
§ 3.7 Comparison of the samples from Barcelona, Paris,
and Cologne .............................................................................................................. 62
EUROPEAN ADDICTION RESEARCH INSTITUTE (IVO)
v
Chapter 4. Cocaine use: Data analysis ................................................................. 65
§ 4.1 History of cocaine use ............................................................................................... 65

§ 4.1.1 Initial cocaine use ........................................................................................ 65
§ 4.1.2 Initiation circumstances ............................................................................... 68
§ 4.1.3 Length of cocaine use career ...................................................................... 68
§ 4.1.3 Pattern of cocaine use ................................................................................. 69
§ 4.2 Current cocaine use. ................................................................................................. 71
§ 4.2.1 Magnitude of current cocaine use ............................................................... 71
§ 4.2.2 Correlates of current cocaine use ............................................................... 76
§ 4.2.2.1 Circumstances of current cocaine use ..................................................... 76
§ 4.2.2.2 Mode of administration ............................................................................. 76
§ 4.2.2.3 Source of cocaine ..................................................................................... 78
§ 4.2.2.4 Other psychoactive substances ............................................................... 78
§ 4.2.2.5 Problems related to cocaine use .............................................................. 81
Chapter 5. Snowball sampling: Methodological analysis ......................... 85
§ 5.1 The lengths of the snowball chains .......................................................................... 86

§ 5.2 Similarity bias, or: Nominating look-a-likes ............................................................... 88
§ 5.3 Nominator effects on nominee-characteristics ......................................................... 94
§ 5.4 Selected nominees versus all nominees .................................................................. 96
§ 5.5 Conclusion ................................................................................................................. 96
Chapter 6. Conclusions ...................................................................................................... 99
Literature ............................................................................................................. 104
Appendices ....................................................................................................... 106
Index ...................................................................................................................... 113
EUROPEAN ADDICTION RESEARCH INSTITUTE (IVO)
vi
CHAPTER 1
INTRODUCTION
BY VINCENT M. HENDRIKS, PHD.
ADDICTION RESEARCH INSTITUTE (IVO)
§ 1.1 CONTEXT OF THE STUDY

In the mid 1980's, an international team of research scientists conducted a pilot study using a
snowball methodology on the incidence and prevalence of cocaine use in three European
Community cities: Munich, Rotterdam, and Rome. This exploratory pilot study involved the
collection of multiple snowball samples in each of the participating cities through intensive
fieldwork, and subsequent quantitative and qualitative data analysis.
The research team that conducted this pilot study operated under the responsibility and
coordination of prof. dr. Ch.D. Kaplan from the Addiction Research Institute (IVO) in
Rotterdam, The Netherlands, and involved dr. U. Avico from the Instituto Superiore di Sanita in
Rome, Italy, dr. D. Korczak from the Grundlagen- und Programmforschung Forschungsgruppe
in Munich, Republic of Germany, and dr. K.M. van Meter from the Laboratoire d'Informatique
pour les Sciences de l'Hommes, CNRS in Paris, France. In 1988, this team published the report
"Cocaine epidemiology in three European Community cities: A pilot study using a snowball
sampling methodology", which gives an overview of the theoretical background, the screening
and training procedures used, and the main substantial and methodological results of the project.
The above mentioned report has been the starting point of the present study on cocaine use
epidemiology in European Community cities. This second pilot initially involved the cities of
Paris, Barcelona, Cologne and Bilbao. During the development-phase of the study however, the
latter city, Bilbao, decided not to participate in the project. Also during the development-phase,
the coordinator of the first pilot and initial coordinator of the second pilot study, prof. dr. Kaplan,
left as director of the Addiction Research Institute. Given this change, the supervision and
coordination of the project was given to dr. V.M. Hendriks from the IVO. Other IVO members
who have been involved in this study are drs. P. Blanken, N.F.P. Adriaans, and mr. I.A. van
Leeuwen-Huijsman (organization and financial matters). Scientists who have been principally
involved from the three participating cities are dr. R. Hartnoll and dr. A. Domingo from the
Institut Municipal d'Investigació Mèdica in Barcelona, Spain, dr. R. Ingold from the Institut de
Recherche en Epidémiologie de la Pharmacodépendance (IREP) in Paris, France, and dr. D.
Korczak from the Grundlagen- und Programmforschung Forschungsgruppe in Munich, Republic
of Germany, the latter person being the only scientist in the present research team who had also
been involved in the first pilot project.
In december 1989, the Commission of the European Communities provided a grant for the
present study to the Addiction Research Institute in Rotterdam. This grant involved the
coordination of the pilot projects in the three above mentioned cities, and some basic financial
support for the data collection in the cities. In december 1990, a workshop - chaired by prof. dr.
Kaplan - was organized in Paris, to discuss and clarify the progress in the development of the
project. It was shortly after this workshop that prof. dr. Kaplan ceased his function at the
Addiction Research Institute, and - consequently - ceased his coordinatorship of the present pilot
9
study. Due to the subsequent shifts, it took until the summer of 1991 before the actual fieldwork
started.
In the data collection phase, the three cities each used a different questionnaire. The
questionnaire used in Barcelona was the result of discussion with the IVO; the instruments used
in Cologne and Paris were independently developed by these cities' investigators. In addition, the
snowball sampling procedures suggested by the IVO (see § 1.3) were followed in Barcelona; in
Cologne none of the respondents nominated other persons, while in Paris all nominees
mentioned by a person, were interviewed.
§ 1.2 THEORETICAL BACKGROUND

§ 1.2.1 HISTORICAL DEVELOPMENTS
The problem of drug use and misuse has been an issue of socio-political concern throughout
this century. It has touched the highest levels of international diplomacy and occupied the
administrations of local communities. Most recently, cocaine has been singled out as the "drug of
choice" for concern and debate. It sometimes appears as if cocaine use is an entirely new
phenomenon in the Western world, requiring entirely novel responses. This however, is not at all
the case. A short overview:
Until the mid 19th century, coca was rarely seen outside of South America. In the 1860's,
German scientists isolated the coca alkaloid, which they named cocaine. This formed the
starting-point of interest in medical applications of the drug in both the United States and Europe.
This early medical interest is perhaps most clearly reflected in the work of Freud, who
considered cocaine an effective drug for treating numerous physical and psychological
complaints, including asthma, digestive disorders, nervousness, depression, and morphine- and
alcohol dependence. Parallelling this medical interest, cocaine became increasingly popular as an
enjoyable, pleasure-providing substance, both in the United States and - starting in the years
preceding World war I - in Europe. Cocaine was found in numerous products, including tea,
chewing gum, "love-potions", tonics and soft drinks, the most famous of which was Coca Cola,
which contained a mixture of coca and caffeine until the year of 1903. Appreciation of one of the
coca-elixirs, "Vin Mariani", rang from Pope Leo XIII, Alexander Dumas, Thomas Edison, and
Jules Verne.
In the late 19th century, the first reports on cocaine's hazardous side effects, including severe
psychosis, anxiety, compulsive use, convulsions and death, appeared in the literature. It took
until 1914 before the nonmedical use of cocaine was prohibited in the United States under the
Harrison Narcotic Act, which labeled cocaine as a narcotic together with the opiates. In the same
decades, the European countries brought the use of cocaine under legal control. Despite these
legal measures, the "epidemic" use of cocaine continued until the end of the 1920's, the years
known as "les années folles". Since the 1930's, the use of cocaine gradually decreased, probably
as a combined result of the growing negative publicity around cocaine and the introduction of the
much cheaper, synthetically manufactured amphetamines.
For several decades, the use of cocaine remained at a relatively low level, the drug being
mainly used in specific segments of the general population, such as people in the entertainment-
business. Following the dramatic increase in heroin and marijuana use and misuse in the 1960's
and early 1970's, the prevalence of cocaine use increased considerably in the mid and late 1970's.
In the United States, a fourfold increase from 5.4 million in 1974 to 21.6 million in 1982 was
10
reported in the number of people who had used cocaine at least once in their life (Adams and
Durell, 1984). According to data from the National Household Survey on Drug Abuse (1974-
1984), the lifetime prevalence of cocaine use continued to increase into the early 1980's, whereas
the number of current (past thirty days) users remained stable between 1979 and 1982. In
Europe, a similar increasing trend could be observed, although the patterns of use and the exact
period over which the increase in cocaine use occurred, varied widely between countries.
Illustrating this trend in Europe, cocaine seizures in the Netherlands increased from 2 kg in 1976
to 46 kg in 1980 and 58 kg in 1983 (C.R.I., 1983).
§ 1.2.2 RECENT TRENDS
In the United States, the 1980's have again shown a dramatic increase of cocaine use. This
increase parallelled a decrease of the price of cocaine to all time lows, and a shift in both
dose/purity and route of administration. Specifically, American data from clinical populations
indicate an increased use of more dangerous routes of administration: intrave-nous
administration and - in particular - the smoking of cocaine freebase, the latter initially being
prepared from cocaine hydrochloride by users themselves, later in the 1980's increasingly found
on the market as a ready-made, pre-"based" product called "crack" (or in some areas of the
country: "rock", or "readyrock"). For example, early 1980's data from the National Institute on
Drug Abuse on routes of administration among primary cocaine clients show an increase in the
injection of cocaine from 918 in 1979 to 3.365 in 1984 (an increase of 267 %), whereas the
freebasing of cocaine increased with 4.970 % from 50 in 1979 to 2.535 in 1984 (NIDA, 1987).
Illustrating the continued increase of the use of freebase cocaine in the United States, in 1987
more than 60 % of all cocaine admissions to treatment in New York City were reported to
indicate smoking as the route of administration (Frank, Hopkins, and Lipton, 1987). In
Philadelphia, during the first quarter of 1985, 32 % of the cocaine admissions to treatment
programs reported smoking as their primary route of administration. By the fourth quarter of
1986, this percentage had increased to 55 % (Kozel, 1987).
Although the time reference varies across countries and the prevalence of cocaine use in
Europe has been far below that of the United States, Europe has largely followed the same
historical pattern of cocaine use as the United States, cocaine in the mid 70's primarily being
associated with style and wealth, in the late '70's and in the '80's more widely used. In most
European countries cocaine has usually been sniffed. Freebasing of cocaine has been relatively
rare. For example, although paraphernalia for making and smoking freebase cocaine were openly
on sale in parts of London around 1980-1981, the practice of freebasing has remained
uncommon (Hartnoll, 1987). The use of ready-made crack cocaine has been incidentally reported
in various countries, including the United Kingdom and the Netherlands (Grund, Adriaans, &
Kaplan, 1991), but has until now not become established. There is however, great concern
among policy makers that the cocaine epidemic in the United States will spread to the European
countries, assuming that now the American market seems to be saturated, the cocaine dealers
will focus their attention on Europe. This in turn could lead to an "americanization" of the
problems (see for example: Henman et al., 1985; European Parliament, 1986; Hewett, 1987;
Lewis, 1989). Whereas the European drug market is currently still seen as secondary to that of
the United States, there is growing concern that the unification-process of Europe after 1992 may
also result in a unification of illegal European drug markets, which in turn may stimulate the
drug-enterprise on the supply-side.
11
Parallelling the increased use of cocaine, current events in the Americas also show that
cocaine has taken on huge political proportions, calling for a "war on drugs" that stretches what
had seemed to be a metaphor into a stark reality. In Europe, the apparent incidence of cocaine
has received a much more restricted and sober attention. Although in most European countries
cocaine seizures have increased greatly over the past decade, it is not at all clear in what groups
in society the cocaine arrives, and what function cocaine represents for these different groups. In
the Netherlands for example, research has shown that cocaine is increasingly used in the
"classical" opiate (heroin) scene, and that cocaine use is increasingly associated with serious
social, psychological and medical problems in this group. These problems seem to result largely
from the specific psychopharmacological action of cocaine combined with the utilization of
similar routes of administration for cocaine as for heroin in this group (injecting, basing, and
"chinesing" ("chasing the dragon"))(Grund, Adriaans, & Kaplan, 1991). Whether the increased
consumption of cocaine can only be attributed to marginalized heroin users however, remains an
open question. Although there are indications that cocaine is increasingly used among youngsters
in certain ethnic minority groups from the Carribean and the Northern African regions, the
general impression is that outside the socially deviant groups cocaine has not yet emerged as a
serious social, psychological or medical problem (Cohen, 1990). Epidemiological data are
however insufficiently available.
Given these potential developments, it has become very important to critically monitor the
strengths and weaknesses of existing prevalence and incidence data on cocaine use in Europe,
and to apply alternative-, sometimes "optimum-feasibility" methodologies in cocaine use
epidemiology. This will be the focus of the next paragraph.
12
§ 1.2.3 DRUG USE EPIDEMIOLOGY
Traditionally, epidemiological research in the field of drug abuse has been confronted with
two major problems: the sociocultural sensitivities surrounding the behavior under study, and -
partly as a consequence - the low social visibility of the target group. Whereas at first sight, the
latter problem could ideally be dealt with through randomized sampling in the general
population, there are several difficulties that prohibit this approach:
First, given the societal view on addiction as deviant behavior and - consequently the
potential legal and social sanctions imposed on the behavior in question, respondents may be
hesitant to cooperate or tend to avoid morally or socially undesirable answers.
Second, although drug abuse is commonly thought of as a widespread phenomenon, a closer
examination of the available data indicates that, moving our focus of attention from lifetime drug
abuse prevalence through recent drug abuse prevalence to the prevalence of the current abuse of
a particular substance, there is a sharp decrease in prevalence rates. If we are studying last
month prevalence of a specific type of drug use in the general population, we are studying a
statistically very rare event, with rates being far below 1 percent. To achieve sufficient data for
an accurate estimation of current prevalence and of correlates of current drug abuse, randomized
sampling in the general population would require a very large sample; due to organizational or
financial constraints, this is often not feasible.
Third, whereas in other - less sensitive - research areas the approach has been to identify the
relevant sub-population, then sample from that population to study the extent and correlates of
the behavior, in the addiction field - given the "hidden" or "low visibility" nature of non-
institutionalized drug users - it has been found extremely difficult to identify and specify the
correct universe to be studied. Both household and school surveys as well as monitoring systems
that focus on specific target groups (drug abuse treatment admissions, hospital emergency
intakes, drug-related police arrests, etc.) seem to miss important segments of the drug-using
population. In surveys, specific groups of (non-institutionalized) drug users may be
underrepresented, because they are not living stable, easy to locate lives (Clayton & Voss, 1982).
Surveillance systems are limited to specific groups that may or may not compare to the total
population of drug users. For example, treatment-based surveillance systems "by definition"
incorporate only drug users who have experienced (physical, employment, legal, social, or
psychological) problems in relation to their drug use, thus missing the non-problematic or
controlled drug user.
Some authors have argued that the hidden nature of segments of drug users can best be
described by a concept of "floating populations". According to Kaplan et al. (1990) the hidden
population, or at least a significant subgroup, has the distinctive quality of sociogeographic
mobility, both horizontally and vertically. Because of both dimensions of mobility, the existing
surveillance systems that are grounded in fixed community-based institutions (health care or
social assistance programs) do not account for drug users who do not present themselves (Kaplan
et al., 1990). Concerning cocaine use, the concept of "floating populations" may be limited to the
more or less marginal groups of cocaine users, who lack a stable living or employment situation,
or to cocaine users who are involved in trading cocaine. Both the liberalization process in
Eastern European countries and the unification process in Western Europe, involving the
opening of borders in and between both regions, may make the issue of floating populations of
particular relevance in the near future.
Fourth, and perhaps most fundamental, survey studies in the general population are
inherently limited by the nature of the data obtained. As argued before, the survey methodology
13
has to rely on answers on closed questions, which may yield little understanding of the
phenomenon under study. Most clearly this is the case when we are exploring a new field or
phenomenon, of which we do not sufficiently know which questions are relevant; new insights
are unlikely to occur, since we will only obtain answers on questions we thought of as important.
A related and evenly fundamental critique on survey studies is their heavy reliance on
statistically significant relations, which can lend a false understanding of causality and may not
at all reflect the phenomenological reality of every day life. Summarizing common criticisms on
quantitative versus qualitative methodologies in the drug abuse field, McBride and Clayton
(1985) state: "It often seems that survey research gives us the appearance of mathematical
precision with causal models (...) but at times without a validity of context; whereas ethnographic
techniques provide a descriptive process that is directly relevant to the experiences of the drug
abusing subjects and their own perception of cause, but that does not give a sense of variance or
generalizability within that description" (pp. 516).
Given the above mentioned limitations of - and critiques on - large scale drug abuse survey
studies, another line of epidemiological research emerged in the European countries. In contrast
with the American approach of nationwide, general population- or high school-oriented studies,
European drug abuse epidemiology has been mainly risk group oriented, focussing on the local
level (the city as the unit of analysis), and intensive rather than extensive in approach.
Community-based, small scale studies have some important advantages. Because of the more
specific existing knowledge of the local situation it becomes less difficult to identify and localize
the target group(s); those who are most at risk are less likely to be missed. Consequently,
community-based studies provide a more direct link between actual situation and policy
decisions, thus reducing the chance of developing policies that "strike out at the wrong target".
Given the smaller scale, research findings can be presented relatively fast, and it becomes more
feasible to conduct several studies over time, providing insight in the temporal dynamics (short-
term changes in incidence and prevalence; new trends in patterns or types of drug use) of local
drug use. In addition, it is more feasible to incorporate - often time-consuming -
ethnomethodological techniques in the study design, providing a deeper understanding of the
subjects' perceptions of meaning and the role of contextual influences.
The European emphasis on city-level epidemiology is reflected by generally close ties
between epidemiological research and the existing local social or medical care systems; research
has been mainly policy-oriented, with a strong basis in local community problem definition and
problem solving. Partly as a result, research findings have mainly found their way to local
administrations; dissemination in the scientific press has been relatively rare.
The primary pragmatic, "ad hoc", and locally-specific research tradition has at the same time
led to a growing recognition that more knowledge is needed of wider trends and patterns of drug
abuse at the national or European level. This, in turn, has called into question the compatibility of
data-systems in the various local communities. Given this perceived need of higher levels of
generality, instead of investing in centralized national or international monitoring systems, the
European approach has been one of comparing community-based direct and indirect drug
indicators used, and attempting to integrate the knowledge produced by existing local
epidemiology networks.
A good example of this approach has been the work in the context of the Multi-City Study of
the Epidemiological Working Group of the Council of Europe's Pompidou Group, in which
several key European cities (among others Amsterdam, London, Paris, and Rome) have been
involved (see Hartnoll, 1986). In addition, the Commission of the European Communities has
14
supported several initiatives to develop or broaden new or alternative methodologies to study
epidemiological issues in the drug abuse field. One of these initiatives has been a first pilot study
on the application of snowball sampling to cocaine epidemiology. The current study further
explores this sampling method and the problems entailed in its use.
§ 1.3 RESEARCH QUESTIONS AND METHODOLOGY

Research questions
Given the limitations of the present state-of-the-art drug epidemiology, and given the
widespread political concern for a massive cocaine epidemic in Europe, the purpose of this study
is both methodological and substantive: (1) to investigate the feasibility of the snowball sampling
method for estimating (cocaine) prevalence, (2) to test the usefulness of snowball sampling for
estimating city parameters of cocaine incidence, and (3) to substantiate our existing knowledge
of cocaine use in European cities.
To investigate these issues, the present study addresses the following topics: (1) what are the
basic assumptions underlying snowball sampling and how do these relate to other methods of
sampling?, (2) what are - in practical terms - the strengths and limitations of snowball sampling?,
and (3) to give a description of rates, patterns, correlates and consequences of cocaine use in
three European cities.
Methodology
To investigate these research questions, data have been collected through the use of the
snowball sampling technique among a total of 98 cocaine users in the cities of Barcelona (41
subjects), Cologne (17 subjects), and Paris (40 subjects). To be included in the study, subjects
had to meet the criterion of at least four times of cocaine use in the preceding month, or at least
ten times of cocaine use in the last six months. The Paris team decided to use a different
criterion: "a subject who has been and still is a regular (at least one or more times a week) user of
cocaine" (see § 3.3.3). Data collection took place in 1991, and involved the assessment of a semi-
structured questionnaire that informed about demographic variables, initial cocaine use (age of
onset, initiation circumstance, co-use of other drugs, etc.), consume history patterns, current
cocaine use (amount of use, route of administration, cocaine use patterns, current cocaine use
circumstances, co-use of other drugs, etc.), and the presence of cocaine-related problems in other
(medical, psychological, legal, social, employment, financial) life areas. In addition, some basic
variables (age, gender, occupational milieu, and area of residence) were collected on the
nominees mentioned by the respondent (see appendix 1 for a detailed description of one of the
questionnaires).
In the data collection phase of the study, the three cities each used a different questionnaire.
Therefore, the data were initially coded and stored in a SPSS system file (SPSSx, 1983, 1988) for
each city separately. These three files were subsequently matched, involving the recoding of
those variables that were compatible. On the city level, the data were analyzed using the separate
system files; on the between-city level, the matched system file was used where appropriate.
There are many ways to construct a snowball or chain referral sample. The technique used in
15
the present study is described and discussed in full detail in chapter 2. To summarize here, the
technique involved the recruitment and training of fieldworkers who had some knowledge
beforehand about cocaine use, city-sites where cocaine is used, specific "argot" used in the
cocaine-scenes, about "what is going on" in the cocaine scenes in the city, etc. Based on this pre-
knowledge and on a tentative model on cocaine use milieus in the city, the fieldworkers selected
a first ("zero stage") respondent whose status was checked against the inclusion criterion of the
study. This person was administered the interview and was asked to assist in the selection and
contacting of other respondents by nominating cocaine users who would also qualify for the
study. At each stage of the snowball a single individual was selected through randomization from
the set of nominated subjects. Within each snowball sample, this procedure took place until the
snowball "extincted", i.e. (1) the selected individual could not nominate other cocaine users or
(2) both the selected nominee and a reserve nominee (also selected through randomization if the
first selected nominee did not cooperate) refused participating in the study.
The approach in Paris differed from the procedure described above. Because of difficulties in
finding and contacting respondents, the Paris team decided to omit the randomization in the
selection of nominees, and instead to interview each person who had been nominated (see §
3.3.3). In Cologne, none of the respondents nominated other persons, resulting in a (N = 17)
sample without nominees. For these reasons, the Barcelona data have been the main focus of
analyses in the present study.
16
CHAPTER 2
SNOWBALL SAMPLING:
THEORETICAL AND PRACTICAL CONSIDERATIONS
BY VINCENT M. HENDRIKS, PHD., & PETER BLANKEN, PHC.
§ 2.1 THEORY ON SNOWBALL SAMPLING

§ 2.1.1 OVERVIEW
A basic conceptual starting point in snowball sampling is that the behavior or "trait" under
study (in this case illicit drug use) can be conceived as a social activity. Although drug use may
in some cases lead to isolation in several important life areas, the drugs must inevitably be
obtained from another person, either directly from a dealer, or through an intermediate (partner,
friend, acquaintance, colleague). In addition, in contrast with the stereotype view on addicts as
only being directed toward satisfaction of their own craving, several studies have suggested that
mutual help and support in the areas of housing, clothes, money, and drugs, are common among
drug users. For example, according to Grund et al. (1989), these practices are imbedded in a set
of interpersonal relations and exchanges, that find their function in coping with craving, human
contacts, and survival in the margin of society.
Not only does the presence of either minimal contacts (e.g. a dealer), or of some form of
social support, open the way to directly study social and contextual (setting-) variables in the life
of drug users, it may also provide a mode of selecting and contacting subjects for study in
otherwise very difficult to target populations. Thus viewed, social ties may provide a basis for
sampling. The main questions then concern the extent of bias and the main sources of bias in
such samples.
The issue of bias has been the general problem in all epidemiological sampling designs.
Random sampling designs have the advantage of being grounded in a probabilistic theory, which
provides us with a formal model of selection and selection bias, and with the practical tools to
infer from sample to population. Although we can never be sure that a random sample is
"perfect", i.e. truly representative of the population from which it is drawn, we can at least apply
the "laws of chance" to estimate bias parameters. Non-random sampling designs do not have the
advantage of such a theory nor such tools. Most importantly, unknown or unknowable bias
parameters that are subject to the laws of chance in random models, cannot be assumed to be
corrected by such laws in non-random models.
If - as argued before - we can consider drug use to a certain degree as a social phenomenon,
and groups of drug users as populations consisting of subjects who are somehow connected, we
may borrow from the theoretical and mathematical advances in the field of social network
research on connectedness, "axon density", and epidemic processes. Given the current absence of
a systematic theory on bias in non-random sampling that parallels the probabilistic theory on
randomness however, these advances must be considered as analytical and basic, rather than
directly applicable in the substantive situation.
17
Goodman (1961) has been the first who attempted to describe snowball sampling and its
nominating-procedures in mathematical terms. On the formal level, he showed that data obtained
through an s stage k name snowball sampling procedure can be utilized to make statistical
inferences about aspects of the relationships in the population, if the requirement of a random (in
Goodman's paper a binomial-) initial ("zero stage") sample is met. In the special case of s=0 and
k=1 this would simply mean estimation of population parameters from a probability sample. If
s=k=1 and the snowball started from a binomial sample, an unbiased estimation can be given of
the number of pairs of individuals in the population who would name each other. In the case of
s=k=1 or in any other case with specified integer values for s and k, Goodman showed that the
maximum expected number of individuals interviewed in a snowball sample is a function of p,
the sampling fraction of the initial binomial sample (or: the expected ratio between binomial
sample size n and population size N (Goodman, 1961: 162). In contrast with other, more usual
random sampling models, in which either the sample size or the ratio between sample size and
population size is fixed in advance, in binomial sampling the sampling fraction itself is a random
variable with an expected value of p.
Goodman's fundamental work on snowball sampling parallelled the work of Rapoport (1957,
1979) who gave a more extensive treatment to the issue of bias parameters in networks. Rapoport
investigated the influence of selection bias in the context of a model of contagion processes, and
showed that contagion processes in a very large random "net" can be represented by a
mathematical model, which expresses the probability that upon completion of the contagion
process every individual in the net will be infected, and the ultimate degree of infection in the
population as a function of the average number of contacts that an infected individual makes. For
example, according to this model 80% of the population will ultimately be infected if each
infected individual randomly contacts two other persons.
Although extremely useful on the conceptual level, the model has two strong requirements
that limit its usefulness in practice: (1) the contagion process has to start with a randomly
selected individual, and (2) all of the targets of any contact along the contagion process are
assumed to be equiprobable. These limitations are clearly relevant to the issue of bias in
snowball sampling procedures, if we consider the nomination of other individuals (as in snowball
sampling) as a special case of "contagion". We know of course, that the naming of other people
who share a certain characteristic, is not a random process, and that the first ("zero stage")
respondent who is contacted to start the snowball, is usually not randomly selected. Instead,
naming others may be heavily influenced by the social (or geographical) distance between the
namer and the named, and by other factors.
In an attempt to formalize the issue of factors that influence events associated with tracing
(read: "nomination") procedures, Rapoport (1957) distinguished the following formal sources of
bias that can be expected to operate in social "nets":
1.The social distance between pairs of individuals: clearly, the probability of one individual
being connected to another is some function of the social distance between the individuals.
2.The "island model": several subsets of individuals may exist within which the connection
probabilities are random, but between which the connections have finite probabilities.
3.Overlapping acquaintance circles: although several subsets of individuals exist without any
connections between the subsets, the entire population can be connected due to individuals
being member of more than one subset.
4.Reflexive bias: a connection from an original individuals to a target individual enhances the
likelihood of a connection from the target person back to the original person.
5.Force field bias: some individuals, because of certain characteristics (for example popularity)
18
have a greater likelihood of being targeted than others.
In a later paper, Rapoport (1979) exemplified the operation of two kinds of bias, reciproke (or
reflexive) bias and "sibling" bias (if A names B and C, than B and C are likely to name each
other), in an experiment on the spread of friendship relations among high school students.
Assuming that both types of bias should "slow down" the growth in contacts (friendship
relations, contaminations, etc.) in comparison to the growth in a random net, the slowing down
effect of bias should be greatest in a very tight (little social distance) net. In terms of the
experiment, the growth should be slowest among "best friends", next slowest among "second
best friends", etc. Thus the curve that represents the fraction of individuals being named as "best
friend" along the successive steps in the nomination process, should be below the curve of
"second best friend", which in turn should be below the one of "third best friend", etc. In
addition, the curve derived from a randomized model (e.g. no friendship relations) should be
above all other curves. Not only did the investigators find exactly these results, they also found
that the plot of the "fifth or sixth friend" was already close to that of the randomized model.
However, although the above example suggests that the "speed" of spread and the seize of
the final fraction infected is a direct inverse function of the tightness of the population, this
appears to be not always the case. Rapoport (1979) also showed an example in which in a
completely structured ("tight", with much distance bias) population, the infection proceeds until
the whole population is infected. Apparently, distance bias can result in both a reduction and an
increase of the probability of connectedness, depending on the influence of other sources of bias.
Illustrating the enormous complexities involved in modelling these processes in mathematical
terms, Rapoport (1957) showed that from the "simple" case of single axon tracings (e.g. only the
best friend) to the case of multiple axon tracings (e.g. naming best friend, second best friend,
third best friend, etc.) different sources of bias seem to be operating at each step, the individual
and combined effect of which result in different sensitivities to departures from a random model.
In an attempt to synthesize the fundamental work of Goodman on snowball sampling and

Rapoport's work on random and biased nets, TenHouten et al. (1971) investigated the usefulness
of combining two sampling methodologies, site sampling and snowball sampling, for analyzing
community's informal leadership structures. In short, site sampling can be described as a
sampling procedure in which the target population is divided with regard to variables pertaining
to place ("where are the subjects?") and time ("when are the subjects there?"). For example, if
persons are not associated with a residential area, they may be associated with a commercial
area. This however, may be the case during the day but not at night. Importantly, site sampling -
under restrictions - can be subjected to the rules of randomization, and can thus be utilized in the
first step of a snowball sampling procedure, i.e. the zero stage snowball sample.
If the site sample can be considered as a probability sample, statistical inferences can be
made to the population from both the zero stage sample and the zero through s stages snowball
sample. In the latter case this would mean an inference from the sample matrix of relationships to
the matrix of relationships for the population. According to TenHouten et al. (1971), the sample
matrix can be used to estimate without bias the chance expectancy for the following parameters:
(a) the total sample size, given k (names) and s (stages);

(b) the distribution of sociometric status (choices received) in the matrix;
(c) the distribution of personal influence in the matrix (an individual's personal influence is
defined as the total number of individuals who name him, or who name individuals who, in
19
turn, name him, and so on, until all steps are considered);
(d) the number of reciprocated choices;
(e) the number of "cycles" of a given length;
(f) the number of s + k person, s-step, k-direction relations.
By comparing the chance expectancy for these parameters with the observed values in the
sample, it is possible to make a decision about the existence of structure (bias) in the sample.
Thus considered, snowball sampling can be applied as a screening technique, to test "the null
hypothesis for the theory of snowball sampling" (TenHouten, 1971: 247), i.e. there is no
structure in the sample; the population matrix of relations can be considered a random net.
To test this hypothesis, TenHouten et al. applied the methodologies used in Goodman's work
and Rapoport's theory on random and biased nets. In summary, since - as Goodman showed - the
expected total size of the snowball sample is a function of the ratio n0 /N (in which n0 is the size
of the zero stage sample) and of the distribution of personal influence scores (see under (c) on the
previous page), the expected number of persons entering the snowball sample from stages 1
through s can be compared against the observed number of persons entering the snowball
sample at each stage, provided if we know the population size. The observed number of
persons at each stage can differ from the expected number for two reasons: (1) there is structural
bias in the population, in which case - as Rapoport empirically demonstrated - the snowball
sample is expected to "funnel" (the number of persons entering each new stage of the sample is
smaller than expected by chance), and (2) persons chosen into the snowball sample may provide
no names for which interviews can be obtained (which also reduces the number of persons
entering the snowball sample in each subsequent stage). Whereas TenHouten et al. dealt with the
second problem by developing a procedure that adjusts for such "missing data" by adding the
number of persons who did not nominate anybody in previous stages of the snowball sampling to
the actual number of persons interviewed at each subsequent stage, the resulting "adjusted
observed number of persons" at each stage can then be compared against the expected
distribution in a random net, using a simple chi2-statistic.
§ 2.1.2 DISCUSSION
Given these advances in theory, what can be learned about the applicability of snowball
sampling in the actual research situation? As stated earlier, the focus of the work outlined above
has been mainly analytical and basic. Commenting on the usefulness of random graph models,
Rapoport states:
"Mathematical modeling is a vehicle for absolutely rigorous reasoning and therein lies its
advantage. A disadvantage of mathematical modeling is that it necessitates drastic
paring down of the details of the phenomena modeled. Outside the realm of physical
phenomena, these simplifications and abstractions can impair or altogether destroy the
model's pragmatic relevance. Because of its abstractness, a model may not lead to
testable predictions in specific contexts, but it may generate new concepts or sharpen
established ones and so contribute to clearer formulations of problems or theories"
(Rapoport, 1979: 130).
Although we have to be extremely conservative in interpreting the relevance of these models

for specific purposes, we can draw some more general conclusions about their applicability. The
20
most obvious limitation of the concepts described, is their reliance on randomness of contacts
between elements in a population. In real life, people make contacts in their social vicinity
(Rapoport, 1979). At the same time, the model based on random contacts provides a vehicle to
investigate nets of relations in terms of their departures from random nets, much like the
"screening"-technique used in TenHouten's study. In doing so however, we have to be very
cautious in rejecting the "null hypothesis" of no structure, given the evidence that structure
(compared to randomness) may both inhibit or enhance the fraction of elements ultimately
reached, depending on the topology of the (social) space between the elements. This discrepancy
may be partly accounted for by the occurrence of a "trade-off" process between speed and
efficiency of the spread of something by contact (Rapoport, 1979). The full problem however
remains to be solved.
A related - more practical - limitation refers to the finding that the expected total size of a
snowball sample (and thus the expected number of persons entering the snowball sample at each
stage) is determined by the initial zero stage sample fraction. Although true in the mathematical
sense, this finding does not include the contribution of fieldwork aspects to the "error variance"
found. In the actual research situation there are numerous confounding factors that co-determine
the "speed" and "efficiency" of a snowball sampling procedure. Many of these reflect field
procedures used by the interviewers to locate and contact respondents, and field circumstances
that may vary from one day to the other.
Given the pitfalls that are currently still present on the theoretical level, it seems that - in
order to make optimal use of the advances in theory (in terms of the possibility of using
inferential statistics, and to extrapolate from sample to population) - we have to take a pragmatic
standpoint, in the sense of attempting to implement as much rigor in the sampling design and -
procedures as possible. Discussing the utility of snowball sampling in the context of drug abuse
research, Biernacki and Waldorf (1981: 144) identified the following problem areas:
-finding respondents and starting referral chains;

-verifying the eligibility of potential respondents;
-engaging respondents as research assistants;
-controlling the types of chains and number of cases in any chain;
-pacing and monitoring referral chains and data quality.
Whereas each of these problems refer to basic processes in constructing a snowball sample that
should be dealt with, the degree of rigor of course depends on the purpose of the use of snowball
sampling in a study. If the aim of a study is primarily explorative, qualitative and descriptive,
snowball sampling offers clear practical advantages in obtaining information on difficult-to-
observe phenomena, in particular in areas that involve sensitive, illegal or deviant issues. It
provides an efficient and economical way of finding cases, that may otherwise be difficult or
even impossible to locate or to contact. In exploring a statistically rare event (such as illicit drug
use), snowball sampling has the potential of producing a rapidly growing database, that would
require enormous samples in household or other population surveys. For example, a 1 %
prevalence rate would require a sample of 10.000 subjects to yield 100 subjects who possess the
trait under study. More fundamentally, through the technique of snowball sampling we are able
to study a phenomenon in its ecological or social context. As such, it has been used extensively
in qualitative sociological research, among others on opiate addiction (Lindesmith, 1968) and
marijuana smoking (Becker, 1966). Through the course of a snowball at subsequent stages we
21
may gain initial insight into the social ties between people.
Since the focus of explorative research is primarily on the description of new or unknown
phenomena or on generating hypotheses about these phenomena, the generalizability of - and the
variance in - the findings is of a lesser concern. It is clear then, that less stringent criteria are
needed in the snowball sampling procedure. If the main purpose of a study is to provide "within-
group" or "between-group" descriptions in quantitative terms (percentages, means, distributions,
etc.), in the sense of generating more accurately "grounded" hypotheses about the population and
initial (tentative) testing of (these) hypotheses, snowball sampling should be subjected to more
rigorous procedures. In the case of formal extrapolation from sample to population, the highest
possible degree of rigor is needed to allow the types of statistical inferences that are suggested by
the theory on snowball sampling and on random and biased nets. In the following section, the
procedures required in the zero stage sampling and the snowball sampling process are discussed
in more detail in the context of (a) explorative research, (b) descriptive statistical inference, and
(c) statistical inference from sample to population.
The zero stage sample
According to theory, the requirement of a random zero stage sample is very strong. Whether
this requirement is corroborated by actual snowball sampling data however, remains to be shown
(in chapter 5 we will address this issue). The focus of this paragraph is limited to what theory
suggests.
For descriptive purposes, the zero stage sample should at least be grounded in a tentative
model or "map" of the distribution of the phenomenon under study over types of individuals,
places, and time. For example, the phenomenon may be more likely to occur among certain
age/gender/ethnic groups, in specific areas or sites of the city, or at specific times. This model
should have acceptable face validity with regard to already existing knowledge about the
phenomenon, and serves as a framework from which the snowball procedure can be started. For
descriptive purposes, the a-priori model can replace the random model for the zero stage sample.
In the case of descriptive statistical inferences, the initial model of the subgroups targeted for
study should be corroborated against existing theory, available statistics and "insider
knowledge". To ensure that the zero stage sample is a fairly accurate representation of the broad
model, some randomization procedures should be applied within each subgroup. For example, if
three "starter points" are desired for each subgroup, these can be randomly selected from an
initial pool of ten starter points. The total sample size should be sufficiently large, to ensure
reasonable representativity. On the basis of theory, this can better be done by starting with a
relatively large zero stage sample then by requiring a larger number of nominees per person. The
number of starter points per subgroup of course depends on the specificity of the subgroup in the
broad model. As a minimum in the case of specific subgroups, at least three starter points are
recommended. In order to infer statistically from sample to population, the requirement of a
random zero stage sample seems to be very strong. Thus, much effort should be directed toward
randomization procedures at this stage. To allow the "laws of chance" to correct for bias, the zero
stage sample size should be fairly large. If the full random model can not be used (as is often the
case), other kinds of probability sampling schemes should be adopted, such as stratified random
sampling, cluster sampling and randomized site sampling.
22
The snowball sampling process
For descriptive purposes, it seems unnecessary and inefficient to fix the number of nominees
(k) or the number of stages (s) in advance. When a larger sample is needed in a short time, it is
more efficient to let the nomination process proceed without these restrictions, until sufficient
data are gathered, or until the snowball stops by itself (no further nominees). To avoid a
restricted database in terms of relevant variables however, the characteristics of the respondents
reached, should be checked ad hoc against the broad description of the desired target group, and -
if necessary - the snowball procedure should be adapted accordingly. In any case, the number of
nominees for each respondent, and the number of stages of each snowball-chain should be
registered. In the case of a study involving tentative statistical inferences, or in the case of
estimating population parameters, it is not at all clear what the theoretical consequences are of
different ways of treating k and s. For the selection of nominees, the options - beside the simple
case of nomination of the desired number of persons plus one or more reserves - are basically: (a)
proportional random selection out of a larger "pool" of nominees (x % of the nominees
mentioned by a respondent are selected at random), (b) fixed random selection out of a larger
pool of nominees (x nominees are selected at random from the nominees mentioned by a
respondent), (c) "hierarchical forward selection" (for example "first best friend", "second best
friend", etc.) out of a larger pool of nominees, and (d) "hierarchical backward selection" (from
those mentioned in hierarchical order, the person(s) at the bottom of the list is (are) approached
first). Given the currently still unclear theoretical meaning of these alternatives, the choice seems
to depend on the goal of a study. For different purposes, each of these alternatives has advantages
and disadvantages in terms of rate of growth of the sample, the risks of a restricted (biased)
sample, etc. Tentatively, the following guidelines are suggested:
If the study is directed toward finding and analyzing structure (friendship, leadership, etc.)
in a group or network, it may be advisable to opt for alternative (c), since this method will trace
along the lines of closest ties between nominators and nominees. Under the condition of a
random zero stage sample, the resulting total snowball sample is likely to represent what
Rapoport (1979) has called a "randomly constructed biased" network or sample. If, on the other
hand, the purpose of "snowballing" is to obtain a snowball sample that is closest to a random
sample (in terms of the equiprobability of subjects selected from a defined population), then
option (b) or (d) may be good choices. Option (b) introduces a strong randomization factor in
each nomination step, and still has the advantage of employing a fixed k number of nominees,
necessary for the application of Goodman's and Rapoport's formulas for estimating population
parameters. Option (d) may also produce a relatively unbiased sample, given Rapoport's
observation that a tracing through "loose ties" ("8th best friend") between nominators and
nominees will yield a sample that is very similar to that derived from the completely randomized
model. In both option (b) and (d), the number of selected nominees should be relatively low in
comparison with the total number of nominees mentioned by a respondent. If the necessity of
obtaining a "random" snowball sample is not too strong, for example in the case of a sample
from which "within-group" or "between-group" descriptive statistical inferences are made,
option (a) may have certain advantages, in that it allows for a rapidly growing sample size if
respondents mention a large number of nominees, while maintaining a (constant) randomization
factor in each nomination step.
Parallel to the reasoning for different ways of treating the k number of nominees, the s
number of stages may vary. That is, for descriptive purposes, the best option is probably to let the
nomination process continue until the snowball "extincts" by itself. In the case of descriptive
23
statistical inferences, the number of stages can be either fixed in advance (and similar for every
snowball chain!) or determined by the actual snowball process itself, dependent on other factors,
most importantly those related to the importance of making inferences from sample to population
in a study. If a study is directed toward formal estimation of population parameters from the
sample, the s number of stages should have a specified value in order to be able to apply the
relevant formulas of estimating chance expectancy. This can be done by either fixing s in
advance, or - alternatively - by determining s ad hoc, and comparing the observed values for each
s with the expected values.
Beside these different ways of treating k and s from exploration to estimation of population
values, there should be a stepwise increase of rigor implemented in other aspects of the study,
including fieldwork-procedures, assessment-methods, and the handling of data. For example, the
fieldwork should be very carefully planned and monitored if the data are used for formal
estimation purposes. Much qualitative (and quantitative!) research has been plagued by vague
descriptions of the study sample, leaving the reader to wonder about the typicality of the group
studied. In any case, inclusion- and exclusion criteria should be formulated, and potential
respondents should be verified accordingly, both in the zero stage and in the subsequent 1
through s stages. In addition, to obtain information about the relation between the group studied
and the broader population that the group is a part of, data assessment should go beyond the
variables that are directly linked to the (individual, social, contextual) phenomenon under study.
For descriptive purposes this may be limited to the registration of some basic variables (age,
gender, ethnicity, etc.). For the estimation of population parameters however, a more extensive
database is needed on the background characteristics of the subjects, and standardized
measurement instruments should be included. Specifically, regardless which procedure has been
chosen for the selection of nominees (option a to d, see above), basic "identification"-data
(initials, gender, age, occupational background, etc.) should be obtained on all nominated
persons (selected and non-selected nominees), both to avoid "doubles", and to gain insight into
the specific course of a snowball-chain, and into the social structures in the group(s) studied.
In the context of snowball sampling, the estimation of a population prevalence parameter

should be regarded as a special case. If the initial zero stage sample is (randomly) selected on the
basis of the characteristic or trait (for example: cocaine use) that is also object of the prevalence
estimation (e.g. the rate of cocaine use in "the" population), than snowball sampling by itself
(1)
cannot yield a prevalence estimate of this characteristic. However, snowball sampling can be
combined with other techniques to arrive at a prevalence estimate of this characteristic. Among
various methods that have been proposed for indirectly estimating the prevalence of a certain
trait in hidden groups (including intensive case-finding, nomination techniques, extrapolations
from registered deaths, and capture-recapture techniques), both the nomination technique and the
capture-recapture technique seem to be most suitable for application in snowball sampling. In the
following section, the use of these techniques for estimating the prevalence of cocaine use in a
city are exemplified (see also: Hartnoll et al., 1985; Intraval, 1992).
(1)
The prevalence of other characteristics in the population that possesses the trait, such as the rate of
men and women among cocaine users or the rate of intravenous users among cocaine users, can be
estimated if the requirement of a random total snowball sample is met. As argued before, the
randomness of the sample can be investigated by testing the null hypothesis of snowball sampling. If no
structure (bias) is found, the sample can be considered a random net, and statistical inferences can be
made from sample to population.
24
The nomination technique
As a standard procedure in snowball sampling, each cocaine user selected into the zero stage
sample is asked to nominate other cocaine users that meet the inclusion-criteria. He is also asked
to indicate which/how many of these nominees have or have not attended a drug abuse treatment
program (within the specified region and time-period). For each nominating respondent, both in
the zero stage sample and in the subsequent s stages snowball sample, the ratio of "yes/no" drug
abuse treatment is calculated and the ratio is averaged across all respondents. This ratio can then
be used to extrapolate the number of non-treatment cocaine users from the registered number of
cocaine users who had attended a treatment program according to the specified criteria.
When the nomination technique is applied as described above, the method can only provide a
rough estimate of cocaine use prevalence. Since respondents may be unaware of whether the
nominees have attended a treatment program, or whether they have actually been admitted, the
ratio of "yes/no" drug abuse treatment can only be approximate. In addition, the method is based
on the assumption that the treatment registration of cocaine use is correct and similar across
treatments. Problems arrive, for example, if the same person is registered as a client in different
treatment programs within the time reference, which - if not screened - would result in an over-
estimation of the prevalence rate. On the other hand, an advantage of the method is that the
double counting of nominees (the same person is nominated by more than one respondent) does
not influence the total ratio of "yes/no" treatment, since this ratio is calculated for each
respondent individually and then averaged across all respondents (Hartnoll et al., 1985).
The accuracy of the estimation of prevalence through the nomination technique may be
improved by including different measures of "institutionalization" that may be available on the
city level. For example, in addition to the question of how many of the nominated persons have
attended a treatment program, the respondent may be asked to indicate the number of arrested (or
imprisoned) nominees. At the minimum, the variance in prevalence estimates resulting from each
measure, provides an indication of the robustness of the method.
Another way of improving the estimate-accuracy may be to restrict the number of nominees
to those who are "fairly well-known" to the respondent (in terms of such demographics as
gender, age, etc.) and to divide this group into:
- group a:those certainly known by the respondent to have/have not been in treatment, and
- group b:those not certainly known by the respondent to have/have not been in treatment.
For each respondent a lower, middle, and upper ratio of "yes/no" treatment is calculated as
follows. The lower ratio represents the number of nominees in group a who have been in
treatment, divided by all "fairly well-known" nominees (assuming that none of the nominees in
group b have been in treatment). The middle ratio represents the number of nominees in group a
who have been in treatment, divided by the total number of nominees in group a (only the
nominees in group a are used for the calculation). The upper ratio represents the number of
nominees in group a who have been in treatment plus all nominees in group b, divided by all
"fairly well-known nominees (assuming that all nominees in group b have been in treatment).
The following exemplifies these calculations. Suppose a respondent knows 30 cocaine users
fairly well, divided into 20 cocaine users in group a, and 10 cocaine users in group b. Of the 20
cocaine users in group a, 15 persons have been in treatment, and 5 persons have not been in
treatment. The lower ratio would be: 15/30 (0.5); the middle ratio would be 15/20 (0.75), and the
25
(2)
upper ratio would be 25/30 (0.8). These ratios can then be added separately and averaged
across all respondents to calculate a lower, middle and upper limit of the prevalence rate.
The capture-recapture technique
The capture-recapture technique was originally applied in the area of field ecology, to
estimate the size of animal populations (N): a first random sample of animals (ni) is caught,
tagged and released, and a second random sample (nj) is captured, and the number of tagged
animals (nij) is counted. The proportion of previously tagged animals in the second sample is
assumed to reflect the ratio of tagged animals to the total population (N=ni ⋅ nj / nij), under the
condition of independence between the samples (and given a sufficiently large sample size).
Several variants of this method have been developed to estimate population size in human
studies (Bloor et al., 1991; Drucker & Vermund, 1989). Recently, a Dutch study on the
prevalence of cocaine use applied the capture-recapture technique in the context of the snowball
sampling methodology (Intraval, 1992), reasoning that if the zero stage sample of respondents
and the 1st stage sample of nominees can be considered as independent, the degree of overlap
between the two samples is indicative for the population size. "Doubles" are counted both within
the 1st stage sample and between the zero stage and 1st stage sample to arrive at a "corrected"
estimate of prevalence. Besides questions around the randomness and independence of the two
samples - which are inherent to any capture-recapture application to hidden populations - the size
of the initial sample may heavily influence the accuracy of the population estimate. If this sample
size is small, the possibility of finding "doubles" in the second sample may be greatly reduced,
and the risk of bias due to specific network-structures (see p. 21) within the initial sample
increases. These potential error sources, in turn, will result in a large confidence interval of the
estimated prevalence.
§ 2.2 THE PRACTICE OF SNOWBALL SAMPLING(3)

BY NICO F.P. ADRIAANS
§ 2.2.1 THE "PRE-ZERO" STAGE
The initial model
Discussing the fields of application of snowball sampling in research, Biernacki and Waldorf
state:
"The method is well suited for a number of research purposes and is particularly applicable
when the focus of study is on a sensitive issue, possibly concerning a relative private
(2)
The difference between lower and upper ratio for each respondent is off course directly related to the
degree of certainty about the nominees' treatment-admissions.
(3)
In the grey-toned frames the different aspects of snowball sampling described in this paragraph are
illustrated by the procedures followed in Barcelona.
26
matter, and thus requires the knowledge of insiders to locate people for study" (Biernacki
& Waldorf, 1981: 141).
Given its illegal status and - consequently - the active prosecution by law enforcement
agencies, cocaine use can clearly be considered "a relative private matter". To prevent discovery
and prosecution, cocaine users have to hide their activities related to cocaine use. This points to
the value of insiders and insiders' knowledge to locate and contact cocaine users for study. The
qualities of the fieldworkers are therefore of critical importance to successfully apply snowball
sampling.
Similar to all sampling models, snowball sampling starts with describing and identifying the
target groups for study. In the practice of targeting hidden populations of cocaine users, this often
implies the development of a provisional "map" of the occurrence of cocaine use in a city. This
first "version" of the map may be based on earlier research on cocaine use in the city, on
registered data from the city's (police, hospital, drug abuse treatment, and other) institutions, and
on the already existing knowledge in the research team. For example, an initial categorization of
cocaine use in a metropolitan area may be as follows (see: Avico et al., 1988):
1.the movie-, art-, TV-, press-, and theater-milieu,

2.the prostitute-milieu,
3.the bank-, brokers-, advertisement-, and top managers-milieu,
4.the school-, and university- milieu,
5.the young criminals-, subcultural-, bar-, and disco-milieu, and
6.the foreign-, and ethnic milieu.
Based on pre-knowledge on social groups in Barcelona in general and on cocaine use and users
in the city specifically, the initial map of the Barcelonian research team was as follows:
1.the artists/actors milieu,

2.the musicians milieu,
3.the media milieu,
4.the marginal/unemployed milieu,
5.the white collar milieu,
6.the blue collar milieu,
7.the campus milieu,
8.the restaurant/bar milieu.
It is important to emphasize that the map at this stage is indeed a general and provisional one,
given that it is at least partly based on assumptions that may be incorrect. The map should
therefore be regarded mainly as a vehicle to "get the study started".
The selection and training of fieldworkers
If the initial map is considered to have sufficient face validity, the next step involves the
selection of the fieldworkers, based on the groups, types, or milieux described. Fieldworkers
27
should be recruited on the basis of either "membership" of one of the milieux described, or
having access to one or more of the milieux were cocaine use is expected to occur. At the
minimum, it is necessary to recruit more than one fieldworker, since one person can not be
expected to relate to the different milieux. Sometimes, more than one fieldworker is needed to
gain access in one milieu. Clearly, these milieux do not always represent discrete entities, but
often overlap each other. The complete team of fieldworkers should be able to cover the total
range of milieux described. The degree of success of the fieldwork-team, i.e. obtaining sufficient
relevant data, depends almost entirely on the caliber of the fieldworkers. The fieldwork-team
should include males and females, persons from different age groups, and - most importantly -
persons who "know what they are talking about". They need not be academics, but if they are,
they should be able or "freaky" enough to let go of their professional university-background. An
actor or actress who can adapt different roles may be suitable as well. They must be honest,
accurate and reliable as well as having the right status to gain access into a sensitive - sometimes
hostile - environment. They must be curious, easy in making contact, and skilled. They must be
physically able to work under difficult circumstances during the day and at night on the street, in
bars, at parties, in disco's, etc. Psychologically, they must be balanced enough to avoid "going
native", and if they already were, they should be able to maintain a minimum degree of stability
in their functioning.
Through the information described in the report on the first snowball sampling pilot study (Avico et
al., 1988) concerning the organization of the fieldwork, and through meetings between the
coordinators of the IVO and the project leaders in Barcelona, the Barcelonian team became
familiar with the guidelines, criteria and procedures to find and select potential fieldworkers. The
Barcelonian research team produced an initial list of names of persons who could qualify for the
job. This list contained students with whom they (had) work(ed), acquaintances, and colleagues
who were in some way connected to the specific field of study, and persons who were known to
have contacts with cocaine users, among others through the treatment system. These potential
candidates were invited and were informed about the project's goals and methods. On the basis of
the above mentioned criteria and qualities, five persons were selected:
1.Female; 24 years old; psychologist; became interested in drug addiction during study; currently
working in a drug abuse treatment program, mainly with heroin addicts and some cocaine
users.
2.Female; 26 years old; psychologist; acquired her Master's degree on the subject of drug
addiction; formerly worked in a drug abuse prevention program at schools; currently working at
IMIM; has contacts with friends, students and artists who use cocaine.
3.Female; 34 years old; musician and teacher; currently unemployed; has contacts with various
groups of cocaine users and artists; has been using cocaine herself.
4.Male; 30 years old; study background of sociology; used to live in South America and is in Spain
for one year; currently working in bars in Barcelona; has contacts with cocaine users through
his work and through friends.
5.Female; age approximately 30 years; acquired her Master's degree on the subject of drug
addiction; formerly worked in the field of drug abuse prevention; has recently worked with drug
addicts in the south of Spain.
Of these selected persons, one person (male fieldworker # 4) ceased his participation in the
project, mainly due to "role confusion" and the impossibility to combine his work in the bar and at
the same time interview cocaine users.
28
The combined qualities outlined above are not easy to find in one person. To find a group of
persons with these qualities is even more difficult. The selection of the fieldworkers should
therefore be regarded as one of the most critical and important stages of a study that involves
snowball sampling. Although it may be tempting to proceed fast with the recruitment of
fieldworkers, a careful (and sometimes time-costly) selection procedure at this phase may
prevent many difficulties at a later stage.
When the fieldworkers have been selected, an intensive training has to follow. This training
includes both a formal two- or three day training seminar with all members from the research
team (project leaders, researchers, secretarial workers, and fieldworkers) present, and a "training
on the job". The training seminar should address issues as the background of the researchers and
the selected fieldworkers, the background and goals of the study, the method of snowball
sampling, the role of the fieldworkers during the different phases of the study, the organization
and coordination of the fieldwork, and (if applicable) interviewing techniques. In the "training on
the job" the researchers and fieldworkers should get some experience with the everyday context
in which they will be collecting data in the field. This includes observing cocaine users, "hanging
around", talking with cocaine users, and more in general experiencing the atmosphere.
The training seminar in Barcelona was given by the coordinator and the community fieldworker
from the Addiction Research Institute (IVO) of Rotterdam, and was held at the Institut Municipal
d'Investigació Mèdica (IMIM). The seminar was attended by the two researchers who coordinated
the Barcelonian part of the study and by the five selected fieldworkers mentioned earlier. On the
first day of the seminar the members of the research team gave an outline of their backgrounds
and their motivation to participate in the study. Each participant was informed about the
background of the study (main results of the first snowball sampling pilot study; goals, design, and
methods of the current study), and about general and specific aspects of the fieldwork involved
(the role of the fieldworker; how to locate cocaine users; how to get cooperation from cocaine
users and/ or key informants; how to establish trust; the task of the fieldworker in the zero-, first,
second, etc. stage of snowball sampling; how to make fieldnotes and reports; cocaine prices;
cocaine use places, times, and -argot; how to handle problems in the fieldwork). The second day of
the training seminar focused on the content of the interview and the technique of interviewing. In
Barcelona, a semi-structured interview was used in which various "areas of interest" served as a
guideline. These areas of interest included: demographic background, initial cocaine use, consume
history patterns, current cocaine use, and the presence of cocaine related problems in other life
areas (see appendix 1).
Preparation of the field
Following the training, the fieldworkers should start exploring (key-) individuals and groups
of cocaine users in the city as soon as possible, and inform them about the study. Basic
information should be given on the goal of the study, the executing organization(s) and
person(s), the methods and organization of the study, the role of the fieldworker, and the role of
the respondent (what is expected from him and why is his cooperation needed). It may be
advisable to write out an information-sheet as a reminder for the fieldworker; this information-
sheet should at this phase only be given to key informants who ask for additional information.
The information should be given in a clear, but unobtrusive, low key manner. If there are any
29
questions, they should be answered as fully as possible. It should be particularly stressed that
there is absolutely no relationship between the fieldworker and law enforcement agencies. Any
suspicion that the fieldworker will share his information with the police will render him useless,
and may well put him in danger of physical harm. The most important object of this phase of the
study is to establish a research alliance between the research team, the fieldworkers, and key-
individuals and groups of cocaine users. To prepare the data collection, a network of (key-)
informants should be gradually built up in various groups, both with the purpose of having easier
access to the groups in the subsequent data collection phase, and for the fieldworker to become
known by the group(s).
Discretion is the key word; the relative safety within a cocaine use milieu should not be
disturbed. Functioning within the framework of illegality, potential prosecution and social
unacceptability, cocaine users have often developed a delicate balance - involving a variety of
behaviors and rituals, rules and languages (argots) - in their everyday lives, with the main
purposes of maintaining access to cocaine, protection of identity, and maintaining control over
cocaine or its undesired side-effects (harm reduction). To gain and to keep access to this "world",
none of the fieldworkers' activities should be threatening to this delicate balance. This means that
the fieldworkers have to accept the rules set by the cocaine use environment. Only if these
conditions are met, the fieldworker can be expected to be trustworthy and insider enough for the
respondent to cooperate in the study.
As an additional part of the pre-zero stage, it is often necessary to refine or adapt the initial
map made on cocaine use in the city, based on the fieldworkers' pre-knowledge and on their
initial exploration of the field (specific places/times where/when cocaine users meet; specific
groups of cocaine users; most recent developments concerning cocaine use in the city, etc.). It
may sometimes even be desirable to attract an additional fieldworker, if a cocaine using group
that was previously undetected needs to be covered in the study.
§ 2.2.2 THE ZERO STAGE AND SNOWBALL SAMPLING STAGES
Based on the (initial or adapted) map of cocaine use in the city, and making use of the
network of contacts with key-informants and groups established in the pre-zero stage, the
fieldworkers can now start to approach subjects in the various milieux as "starters" of the
snowball chains. Depending on the required total snowball sample size, the zero stage sample
should minimally contain three starter-points for each milieu that needs to be covered. The
selection of places, times and starter-respondents may be subjected to randomization. For
example, each xth person entering a location during a certain time interval may be selected for an
interview.
Each subject that is approached for an interview should first be informed about the study,
much in the manner described above. At this stage, it may be necessary for the fieldworker to
have an identification-card and an information paper available. After verifying the inclusion
criteria, the subject should be informed about the areas of interest and the duration of the
interview, and (if applicable) about the payment for the interview. In addition, he should be
asked to assist in finding other study respondents. Sometimes the respondent is not unwilling to
cooperate, but wants to have some time to think it over. In those situations it is very important to
make an appointment about how and when to contact the subject again.
In any case, the actual interview should take place in an atmosphere in which the subject
feels relaxed, at a location where the interview is not easily disturbed, and - within certain limits -
30
under conditions that are preferred by the respondent. For example, it is not advisable to
interview the subject in the presence of his friends, partner or acquaintances, since this may
obviously influence his answers. Introducing the interview, the fieldworker should make clear
that he is interested in everything that the respondent tells concerning the areas of interest of the
interview, and that he also wants to obtain certain specific information. The fieldworker should
listen very carefully, ask for additional information when necessary, and should have the role of
a "beginner" rather than that of a professional expert. The role of a scholar or student who is
being taught by the respondent is probably ideal, given the ego-busting properties of cocaine
intoxication. The fieldworker should try to check the answers within the context of answers on
other questions. Doing so, he should avoid to confront the respondent with inconsistencies
("How is that possible; you just told me..."), but instead should ask for additional information
("can you tell me...").
After having completed the interview, the subject should be asked to name or identify other
subjects who are expected to meet the study criteria. If he is hesitant to do so, it may be helpful to
show the subject ways to nominate other cocaine users without revealing their identity. For
example, the subject may describe the nominees in terms of their type of car or the first three
digits of their telephone number, or any other unpersonal characteristic that is only known to the
subject. However, basic (but non-identifiable) information should be obtained on the nominees'
age, gender, and occupation. If the nominee should be chosen at random, each nominee
mentioned can be assigned a number, and selected for instance by throwing dice or by using
numbered slips of paper. If the subject is still hesitant to name other cocaine users, he may be
asked to make the first contact with the selected nominee himself; in this case the nominee can
only be contacted by the fieldworker after he has already agreed to the nominator to cooperate in
the study. In the following grey-toned section, one of the Barcelonian fieldworkers, Ms.
Catherine Perez, describes the fieldwork-procedures followed in Barcelona, and the problems
encountered.
When the training sessions were finished, the zero-stages were selected on the basis of a review
of the possible cocaine milieux in Barcelona of which the interviewers had some knowledge or
contacts. These included two starter points at treatment centers in order to include heroin users.
31
Process of the fieldwork
1.We contacted the zero stage person by telephone, and explained briefly:
-the goals of the study and the institution were it was based;
-why we were contacting him or her;
-the importance of his/her knowledge and experience in cocaine use, and the relevance of his/her
collaboration with the study;
- what information we would expect he/she could give us;
-the absolute confidentiality and anonymity.
If the person was willing to take part, then we made an appointment at is/her convenience.
2.The meeting generally took place in a bar or at his/her home. We introduced ourselves, and
explained again in more detail the information given by telephone. Any questions were
answered as fully as possible. We also handed the person a letter containing all this
information, the telephone number of the institute, and the name of the study coordinator.
3.The interview was conducted informally, allowing areas to be covered naturally as they arose. If
particular questions were not raised throughout the interview, then the interviewer prompted
the subject. We did not fill in the protocol during the interview but only took some notes in a
notebook.
4.In the last part of the interview we asked the subject to provide his/her sociodemographic
characteristics (age, sex, nationality, years of school, job, and district of residence.
5.We asked the subject to describe the sociodemographic characteristics (age, sex, job, and
district of residence) of the cocaine users whom he/she knew.
6.Using numbered slips of paper, we randomly selected two nominees, and asked the subject to
introduce us to the first one. If he/she refused, we tried the second one.
7.Finally, we thanked the person for his/her collaboration and finished the interview.
8.The person for the following stage was contacted as follows. The person interviewed asked
his/her friend if he/she wished to participate in the study. If they agreed, the person in the zero
stage gave us his/her phone number and we contacted them. In a few cases we waited for the
person to phone us. Once contacted, we made an appointment.
If the interviewee refused to introduce anyone or the selected persons refused to be interviewed,
then we ended the chain and started a new one.
Problems in the fieldwork
In general, once the contacted person had agreed to be interviewed, it was easy to conduct the
interview. People were happy to talk openly about drug use. However, there were many chains that
we were unable to continue because a person refused to be interviewed or because the last
person interviewed wasunwilling to approach another person. We only have their
sociodemographic characteristics. It might not have been so easy to talk with them; people who
refused to be interviewed may have been more likely to perceive cocaine use as a problem. The
more difficult part at the interview was the nomination technique. Some people refused to describe
their friends, even when we explained that it was
32
impossible to identify any person from the few characteristics we asked for. They felt as if they were informing
on their friends. Some people who nominated other persons found it difficult to introduce us to the person
randomly selected or to other cocaine users. Frequently they refused, and only agreed to contact someone
whom they knew well. In those cases, that person became the zero-stage for a new snowball.
We consider it important that the fieldworker is an "insider" or has many contacts, otherwise it is possible,
after some refusals, to loose contact with the cocaine world and find it difficult to start and to continue new
chains. Another possibility would be to adopt more direct tactics and approach strangers who, for example,
are observed buying or using cocaine in a bar. This would need bold fieldworkers who felt at ease in cocaine
using milieux.
Organization of the fieldwork
During the zero stage and the subsequent snowball stages it is very important to closely
monitor the types and lengths of the snowball chains in relation to the milieux and groups
covered. In addition, problems that may arise on various levels of the fieldwork need to be
discussed without delay. During the snowball sampling procedure, fieldworkers may follow
"blind alleys", may have breakdowns, may loose their motivation, may produce huge expenses,
or may fail in doing their job, being unable to track a snowflake, let alone a snowball.
When case-finding and data collection has started, it is therefore of critical importance that
the fieldworkers and research staff operate in close contact with each other. There should be
clear lines of communication that are easily available. Sometimes the project leader needs to take
immediate decisions; a "hot-line" between a project office and the fieldworkers may then prove
valuable. Collective team meetings should be held regularly (for example weekly) to avoid bad
surprises, to update the datafiles, to discuss the results (interview material, fieldnotes, memo's,
etc.), the procedures followed, and the problems occurring in the fieldwork, to make necessary
adjustments, to keep control over the expenses, and to plan the next steps. In addition, frequent
and intensive contact between all members provides the fieldworkers with a feeling of being part
of a collective project, which is essential in keeping their motivation to continue participating. At
this stage it should become clear that the fieldworkers are more than "just" interviewers who are
also able to track difficult-to-find subjects. They are experts in the field, whose insider's
knowledge is not only indispensable to obtain data, but also to meaningfully interpret specific
information.
33
CHAPTER 3
DESCRIPTION OF CITIES AND SAMPLES
§ 3.1 BARCELONA
BY ANTONIA DOMINGO, PHD. & RICHARD HARTNOLL, PHD.
INSTITUT MUNICIPAL D'INVESTIGACIÓ MÈDICA
§ 3.1.1 POPULATION AND OTHER PARAMETERS
Barcelona, situated on the Mediterranean coast of northeast Spain, is the second largest city
in Spain and the capital of Catalunya, one of 17 Spanish Autonomous Communities. Barcelona-
city covers an area of 9907.41 Km2 with 1,734,501 inhabitants (Census revised for December
1988) and a density of 17,504 inh/Km2. The city is surrounded by several other municipalities
which constitute the metropolitan area with 1,381,541 inhabitants (1986 census). Barcelona
expanded until 1980. Since then the population has been slowly decreasing, both because of a
decline in birth rates and a gradual ageing of population, and because of migration. The age and
gender distribution is shown in table 1.
Table 1. Population by Age Group and Gender, Barcelona 1988
male female total
< 15 years 140 652 132 561 273 213

15 - 24 138 991 132 112 271 103
25 - 34 124 447 124 649 249 096
35 - 44 109 264 116 855 226 119
45 - 54 98 526 105 945 204 471
55 - 64 103 488 120 711 224 199
> 64 years 107 183 179 117 286 300
Total 822 551 911 950 1734 501
Source: Anuari Estadistic de la Ciutat de Barcelona, 1989.
Barcelona has a major harbour, which together with its airport, road and rail com-
munications, handle a large volume of international trade. The "Fira de Barcelona" is an
important site for international commercial exhibitions, with foreign companies accounting for
over 80% of the participants.
At present being renovated for the 1992 Olympics, Barcelona is also famous for architecture,
cultural activities and tourism. The lifestyle of professionals and of many young people gives to
Barcelona the atmosphere of a modern european city with a diversity of cultural activities and
lively night-life.
37
The city is divided into 10 districts, the first "Ciutat Vella" (Old City) is the original nucleus
of the city. The second, "Eixample", built at the turn of the century links the Old City to seven
other districts which originally were separate towns. "Nou Barris" (district 8) is more recent.
Barcelona-city and other municipalities constituting the metropolitan area appear as a continuous
urban entity. Most of the metropolitan area is served by a single public transport system. For the
snowball sample, we considered inhabitants in the metropolitan area covered by the Barcelona
bus and metro network.
§ 3.1.2 DRUG USE IN BARCELONA
It is only possible to give a descriptive overview of the situation in Barcelona, since few
reliable data are available concerning the incidence, prevalence and characteristics of drug use in
the general population of the city. There is more information on serious, problematic patterns of
drug use (primarily heroin addiction), mostly derived from indirect indicators such as the
demand for treatment, drug-related emergencies, deaths, HIV and AIDS. Data from Catalunya
and from Spain are included where relevant.
Overall drug policy in Spain is coordinated by the National Plan on Drugs in the Ministry of
Health. In Barcelona, coordination is provided by the municipal action plan on drug addiction.
Treatment is provided by a variety of public and non-profit-making associations. There are 14
nonresidential specialized treatment centers for drug addicts, four detoxification units in hospitals
(20 beds altogether), and ten rehabilitation centers. Methadone programmes expanded during
1991.
Sources of Information
A number of surveys have been carried out in Spain since the mid-1970's, mostly at local or
regional level, though some national population surveys have been conducted during the 1980's.
It is not possible to make direct comparisons between these surveys, since sampling frames and
methods varied. In the city of Barcelona, a survey of drug use in the general population aged 15-
64 was conducted in 1982. In Catalunya, surveys were carried out in 1982, 1986 and 1990
regarding drug use in the general population (aged 15-64), youth (aged 15-29) and school
children (varying age groups between 11 and 15). The rates obtained in these surveys tend to be
lower than those reported in other Spanish surveys. Whether this reflects differences in
prevalence or in methodology is not certain. Our guess would be the latter more than the former.
In particular, the sample sizes were small and few methodological details are provided.
Data on national and regional trends in addiction involving opiates and/or cocaine have been
available since 1987 through the Spanish Information System on Drug Addiction (SEIT). This is
a nationwide system, coordinated by the National Plan on Drugs in the Ministry of Health, in
which health data on opiates and cocaine are routinely collated by centers in each of the 17
autonomous (regional) communities. The three components of SEIT are: (1) a relatively
comprehensive system of reporting treatment demands from outpatient centers (medical and
nonmedical); (2) a less comprehensive system for collating data on opiate and cocaine-related
episodes reported by selected hospital emergency rooms; and (3) in certain major cities only, the
collection of data on drug-related deaths which are directly associated with the acute effects of
opiates or cocaine.
Other sources of information include data on infectious diseases associated with injecting
drug use (HIV; AIDS, hepatitis etc.), law enforcement data on seizures of illicit drugs and
38
arrests, and data on drug use by military conscripts.
In addition to these routine data, local reporting systems and research studies provide
additional information on particular aspects of drug use. In Barcelona, a research register of
toxicological emergencies seen at Hospital del Mar since 1979 has provided valuable
information on trends (this hospital covers the districts with the highest levels of addiction in the
city). Other recent investigations conducted include a retrospective survey of all opiate- and
cocaine-related emergencies seen in the four main hospitals of Barcelona, a three-year follow-up
study of addicts admitted to hospital, analysis of street samples of confiscated drugs, an in-depth
study of drug-related deaths between 1979 and 1990, studies of HIV seropositivity amongst
various samples of addicts (hospital, outpatient treatment, prison), and various studies of
treatment populations.
Overview of Drug Use in Barcelona
The broad picture of drug use in Barcelona can be described in terms of two populations. The
first consists of a larger, rather diffuse population of drug users who consume cannabis and, in
somewhat smaller numbers, other drugs such as cocaine, amphetamines, LSD, ecstasy and
possibly heroin. Although a minority may use one or more of these drugs intensively, sporadic or
recreationally-oriented patterns of drug consumption are more common. This population is
drawn from a wide spectrum of the general population aged 15 to 45 years, and is spread across
different areas and social groups in the city. In general, they cannot be characterized in terms of
any particular attribute such as social marginalization, occupation, or area of residence, though
there are likely to be socio-demographic variations and subgroup differences within this loosely
defined population. However, there are few recent data on which to base any reliable analysis.
The 1982 survey of drug use in the city of Barcelona found that "illicit drug users" (mainly of
cannabis) were more likely to be males aged 18-24, of higher educational level, living in middle
or high income districts of the city. The 1986 surveys in Catalunya gave similar results, though
with a somewhat wider age range (under 35). It is not known how far this pattern remains true in
1991, though it is likely that the age range has further broadened.
The second population consists of a smaller, more marginalized group of heavy drug users,
mostly heroin addicts and multiple drug injectors, who are concentrated in the more deprived
areas of the city. They are likely to be disproportionately represented in the indirect indicators
described above, and underrepresented in population surveys. It is this population which is
popularly seen as "the drug problem" in Barcelona (as else-where) for reasons that include their
visibility and their association with crime and AIDS.
'Ciutat Vella', the inner city district near the port, is seen as the area with the highest levels of
drug use, addiction, and drug dealing. This is especially true for heroin - for example, the rates
for heroin addicts from this district attending emergency rooms is seven times higher than for the
rest of the city. Other city districts probably have more similar rates of drug use. However an
inverse relationship with socio-economic indicators is observed for opiate addiction. Cocaine use
does not seem to follow the same pattern, although it is difficult to tell, since related medical
problems are less frequent and/or show up differently than for heroin.
Attempts have been made in recent years to move street drug use and trafficking away from
the city center, especially Ciutat Vella. The result has been a redistribution to other districts and
to municipalities within the metropolitan area. The areas most affected tend to be those with
lower socio-economic indicators on the outskirts of Barcelona.
39
Specific Drugs
Cannabis
As in many European cities, the most commonly used drug in Barcelona is cannabis (mostly
resin from North Africa). The use of cannabis as a popular, recreational drug, primarily amongst
young people, increased markedly during the latter 1970's, some years later than in many other
european countries. This pattern was observed in many parts of Spain. The survey data suggest a
relatively stable prevalence of cannabis use throughout the 1980's. The Catalunya surveys show
lifetime prevalence rates of 20-25% for the 15-29 year group, and 10-12% for the adult
population aged 15 years or more. The rates for the past 12 months were 10-11% and 5-6%
respectively, and for the past 30 days, 7-8% and 3-4%. Cannabis-related problems are rarely seen
in treatment or other medical services, and attitudes towards its consumption are relatively
relaxed.
Amphetamines
During the 1970's, the use of amphetamines, which were easily available without
prescription, was relatively common, at least amongst some groups such as students. For
example, surveys of Barcelona medical students in the 1970's showed lifetime prevalence rates
of 20-25%. In 1973/4, this was considerably higher than their use of cannabis. After availability
was reduced in 1982/83, prevalence fell sharply (e.g. to under 10% in Barcelona medical
students). The surveys of the population of Catalunya also show significant decreases in
amphetamine use between 1982 and 1990, especially in the 15-29 age range. Thus the 1990
survey gave a last 12 months prevalence figure of 1,2% in the 15-29 year old group, compared to
over 8% in 1982.
Heroin
At the end of the 1970's and during the early 1980's, the availability and use of heroin
increased. From 1982 to 1985, the number of heroin addicts entering treatment or attending
hospital emergency rooms in Barcelona also rose sharply. From 1986, most indicators suggested
that the prevalence of heroin addiction stabilized. In the past four years, the average age of
addicts has been rising. It appears that the availability of heroin has not diminished, however, and
there has been a steady incidence of new cases over the past few years. This pattern appears to be
common to many parts of Spain.
Unlike most other drug use, heroin addiction is concentrated in the more socio-economically
deprived areas of the city, notably, though not only, in Ciutat Vella (the old city). It also appears
that there are local concentrations of heroin addiction in some of the poorer areas of the
municipalities adjacent to Barcelona. A "guesstimate" of total prevalence might be in the order of
15,000 heroin addicts in the Barcelona metropolitan area (population 3.1 million) of whom
10,000 are residents of Barcelona city (population 1.7 million). If true, this would imply a rate of
about 6 per 1,000 population in the city of Barcelona, and of about 3.5 per 1,000 in the adjacent
municipalities within the Barcelona metropolitan area. The primary route of administration is
injection, at least amongst addicts entering treatment, is by injection, though a minority sniff the
drug. Up to June 1991, 767 cases of AIDS amongst drug injectors had been reported in the city,
accounting for 55% of all reported cases.
LSD and Ecstasy

LSD started to be used at the end of the 1970's and in the early 1980's, mainly in association
40
with cannabis, though prevalence rates were considerably lower than for cannabis. Survey data
suggests some decline in use since 1982, especially when measured in terms of recent or current
use (last 12 months or last 30 days). For example, the Catalunya surveys of youth indicate a fall
from 6.3% (last 12 months) in 1982 to 1.5% in 1990. Ecstasy has reportedly become more
widely available in the past two years, but there are no data on prevalence.
Cocaine
From the mid 1980's, as in many other european countries, the quantities of cocaine seized in
Spain started to increase dramatically (figure 1). In 1990, over 5 tons were seized, one third of
the total seized in Europe during that year. However, in common with other countries, indicators
of demand (or rather of the problematic consequences of consumption) do not show changes of
this order of magnitude. This is especially true of health indicators.
Indirect indicators of cocaine
National indicators (figures 2, 3, 4)

Nationally, the proportion of all treatment demands involving cocaine as a primary drug
increased from 1.9% in 1987 to 2.4% in 1990. The number of cocaine treatment demands rose
more than this (1987: 188, 1988: 278, 1989: 417, 1990: 600) but the raw figures are misleading
since the coverage of the reporting system increased during the initial years, and reporting
patterns may have changed as the system became established.
41
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Over the same period, the proportion of hospital emergency-room episodes in which cocaine
was the primary drug increased from 0.8% to 3.3% (The raw numbers were: 1987:19, 1988:
141, 1989: 264, 1990: 278. However the coverage for this indicator has expanded even more
than for treatment demand.) Data from drug-related mortalities in selected major cities indicate
that the proportion of cases in which the presence of cocaine was confirmed through toxicology
rose from 18-19% in 1987 and 1988, to 30% in 1989 and 25% in 1990. In almost all cases,
heroin/morphine was also present, and often other drugs as well.
Heroin continues to account for the great majority of treatment demands, emergencies and
drug-related deaths. It is apparent, however, that many heroin addicts use cocaine as well as
heroin. Thus between 1987 and 1990, almost half of the heroin addicts entering treatment were
reported to be using cocaine as a secondary drug. Conversely, about 40% of people starting
treatment for cocaine as a primary drug were reported to be using heroin as well. Since it is likely
that secondary drugs are underreported, the association between heroin addiction and cocaine use
within the treatment population is higher than suggested by these figures.
Data on the year of first use of cocaine for people entering treatment for cocaine as a primary
drug indicate that a minority started to use cocaine in the early 1970's, and that incidence of first
cocaine use steadily increased throughout the latter 1970's and 1980's (figures 5 & 6).
Fig. 5
44
Fig. 6
45
However, although the growth in cocaine use, within the treatment populations concerned,
started over ten years ago, it is apparent that the majority began to use cocaine from the mid
1980's on.
Police data show an increase in the number of arrests for illicit trafficking in cocaine, from
694 in 1984, to 2,559 in 1987 and 3,348 in 1990. Similarly, the number of seizures of cocaine
rose from 606 in 1984, to 2,019 in 1987 and 2,925 in 1990 (figure 7). It is not known how to
what extent these increases relate to cocaine availability within Spain, or to the wider european
cocaine market, or to changes in police activity concerning cocaine.
Catalunya and Barcelona indicators
In the SEIT data for Catalunya, cocaine is slightly more likely to be reported as a primary
drug for addicts starting treatment than in Spain as a whole (e.g 3.2% of treatment demands in
1990, compared to 2,4% for Spain). The raw numbers follow a similar pattern to those for all
Spain (42, 66, 79, 124) but coverage also expanded between 1987 and 1989. However, in
Catalunya, cocaine is less frequently reported (in SEIT) as a secondary drug amongst heroin
addicts (28%) than in all of Spain (48%).
Fig. 7
46
Similar differences for both primary and secondary drug can be noted in each of the previous
three years. Whether this reflects differences in drug use or in reporting practices is not clear.
Over half of the cases come from Barcelona city or its' metropolitan area.
SEIT emergency room data for Catalunya were not available before 1990. The register at
Hospital del Mar in Barcelona indicated a sudden rise in cocaine-related episodes from October
1986 (from 1 per month to 7 per month). This represented about 3% of all opiate/cocaine
emergencies. This rate of increase did not continue, and cocaine emergencies remained a small
proportion of all episodes. In 1990 and the first half of 1991, there were about 9 episodes per
month, 5% of all opiate/cocaine emergencies.
Similarly, data from the 1989 survey of four Barcelona hospital emergency rooms found that
5% of all opiate/cocaine episodes involved cocaine only, and a further 6% cocaine in
combination with opiates. Data on drug-related emergencies for the first three trimesters of 1990,
collected from these four hospitals by the Municipal Department of Health (but including a wider
range of drugs) reports that only 1% of episodes were cocaine-only, and 11% heroin and cocaine,
compared to 53% for opiates only. However, the 1990 SEIT report, which draws on the same
data set, gives a higher proportion of cocaine-related emergencies (14.8%, compared to 3.3% for
all of Spain). This figure can only be reconciled with other local data sources if it includes most
of the heroin and cocaine episodes as cocaine episodes (SEIT only allows the reporting of one
drug).
The data from the 1989 survey of Barcelona emergency rooms was analyzed in terms of
persons as well as episodes. This indicated that people who were involved in cocaine-with-opiate
emergency episodes were similar to people involved in opiate-only episodes. By contrast,
individuals involved in cocaine-only episodes were older (mean 27.9 compared to 25,9 for
opiates only, and 25,7 for cocaine-with-opiates). For all categories, residents of Ciutat Vella were
overrepresented. However, in terms of rates per 100,000 population aged 15-44, residents of the
more middle-class districts of Les Corts, Sarria and Gracia were more likely to attend for
cocaine-only episodes, whereas the opposite was true for the poorer districts of Ciutat Vella,
Horta-Guinardó and Nou Barris.
Survey data on cocaine in the general population
Data on cocaine prevalence taken from surveys of drug use in Catalunya from 1982 to 1990
are presented in table 2.
Table 2. Prevalence of Cocaine Use in Catalunya, 1982-90
lifetime last 12 last 30

year months days n
General population
(15-64) 1982 1,9 1,6 0,3 ?
(15-64) 1986 1,6 1,2 0,1 1.500
(15-64) 1990 3,3 1,7 0,7 1.560
47
Table 2. Prevalence of Cocaine Use in Catalunya, 1982-90 (Continued)
lifetime last 12 last 30

year months days n
Youth
(15-24) 1982 7,4 4,6 1,3 ?
(15-29) 1986 4,7 3,2 0,2 1.220
(15-29) 1990 5,7 3,1 1,5 3.117
School population
(12-15) 1982 1 - - ?
(11-16) 1986 0,4 - - 802
(12-14) 1990 0,8 0,2 0,0 904
Source: Organ Tècnic de Drogodependències, Departament de Santitat i Seguretat Social
It is important to emphasize the methodological limitations of these data.

(1)The sample sizes are small, especially for the general population.
(2)The low figures for last 30 day prevalence may be particularly unreliable. Confidence
intervals are not given, but are likely to be relatively large.
(3)No information is given about the sampling frame, the representativeness of the samples, or
the nonresponse rate.
(4)The surveys refer to Catalunya as a whole, rather than to Barcelona alone.
Direct extrapolations from the general population and youth surveys in Catalunya suggest the
following cocaine use prevalence rates for 1990 in the age-group 15-44 years: lifetime, 6-8%;
last 12 months, 3-4%; last 30 days, 1,5-2%.
It is likely that these estimates understate cocaine prevalence in Barcelona for three reasons:
(1)Barcelona rates are probably higher than for Catalunya as a whole.
(2)Survey methods tend to underestimate behavior such as cocaine use (partly because of
concealment, partly because the population with a higher probability of cocaine use -
under 45 years, no young children, and leading an active, sociable lifestyle - are much
less likely to be at home and thus less accessible to survey sampling).
(3)The estimates largely exclude cocaine use by heroin addicts (the majority of whom use
cocaine, more or less often).
Speculative estimates of the possible upper limits of cocaine prevalence in 1990 for the 15-
44 year age group, based on "informed guesses" as to the degree of underestimation, give a last
12 month prevalence figure of up to 12-13%, and last 30 day figure of up to 6%. It is likely that
the "true" figure lies somewhere between the lower rates given by the survey data, and the higher
rates obtained by speculative inference. Trends in the survey data suggest some increase since
1986, but smaller differences compared to 1982.
48
§ 3.1.3 DESCRIPTION OF COCAINE USE PATTERNS IN BARCELONA
Drug scenes in Barcelona probably differ according to the drugs involved. There are no other
sociological studies on which to draw, either for cocaine or other drugs, so the available
information based on information obtained through the present study.
Cocaine is usually used in social contexts such as parties, discotheques or going out at night
("de marcha"). Sometimes it is taken at home before going out, at other times in a car or in toilets
of bars or other places of entertainment. On some occasions consumption takes place in work
situations, and less frequently at home, apart from a few "binge" users. A few people also use
alone when working. Younger users tend to consume the drug as part of a drug cocktail that can
change depending on availability.
Cocaine use seems either to be sporadic (special events, opportunity, etc) or more than 3
days/week. Frequency of use appears related to availability and money. Typically, people use
about a quarter of a gramme on those days when they use it. It is almost always sniffed, except
by injecting heroin addicts. Freebase cocaine, or "crack" is rare. Some users also report smoking
cocaine hydrochloride in cigarettes.
Reasons given for using cocaine are mainly related either to changes in subjective state
("feeling good") or to sociability. Some refer to being able to drink more alcohol without getting
drunk as part of this pattern. Others relate cocaine use to work situations. Few people appear to
perceive their cocaine use in terms of problem solving.
Initial use normally occurs in social contexts (friends, partners, parties) or sometimes with
work colleagues. Dealers are very rarely the source at the time of first cocaine use. Later, the
source varies, some people continuing to obtain cocaine through friends, others buying it from a
dealer. Sometimes a group of friends pool their money to buy cocaine.
The price of cocaine is about 12-15,000 pesetas per gramme. The purity of 46 street samples
of cocaine seized in 1988 was 36%, though it is not known whether this was representative of the
whole city, nor if purity has changed over the past three years. Cocaine has been available in
Barcelona since the 1970's, though probably not on a widespread basis. The extent to which
availability has expanded recently is hard to assess. Some users report that in the past three years,
cocaine has been "everywhere".
Cocaine users are drawn from many cultural backgrounds and milieus. There appears to be
wide availability and use not only in entertainment, artistic and media milieus, but also, for
example, in some groups of administrative workers and market truck unloaders. Amongst opiate
users in more marginal neighborhoods, cocaine dealing is an important source of income. Apart
from youthful heroin addicts, there is little evidence that young adolescents are extensively
involved with cocaine.
Although cocaine is a "social drug" it seems to be shared in a rather restrictive fashion, often
in small, closed groups (camarillas). There sometimes appears to be tension between the
sociability associated with cocaine, and more secretive and possessive attitudes towards sharing
the drug or to openly admitting to having or using it. This was important as some people were
unwilling to contact other users to continue the snowball. In other cases, they appeared reluctant
to give full information on the extent of their use. Reasons may have included illegality, price,
ambivalence towards the extent or cost of their use, or anticipated disapproval from others. This
is less noticeable among younger groups of cocaine users. One curious though repeated
observation is that too many people seem to consume more cocaine than they buy. Attitudes
towards consumption and traffic of small quantities appear relatively permissive, even amongst
49
police and political circles.
§ 3.2 DESCRIPTION OF BARCELONA SAMPLE

BY ANTONIA DOMINGO, PHD. & RICHARD HARTNOLL, PHD.
INSTITUT MUNICIPAL D'INVESTIGACIÓ MÈDICA
Forty one cocaine users were interviewed (22 male, 19 female). They were aged 22 to 40
years (mean 30,7). Women were more likely to be in their late 20's, and men in their early 30's
(mean ages: men 31,5; women 29,8).
Only two were unemployed, and one person was a student. The others were drawn from
managerial/lower professional (37%), skilled nonmanual (22%), and skilled or semi-skilled
manual (27%) occupations. Only one person was in the higher professional group, and only two
were from unskilled manual occupations. In terms of occupational milieu, one third were
classified as "white collar" (34%), and one in six as "blue collar"(17%). One quarter were either
musicians (12%) or artists or actors (12%). Other occupational milieu were "restaurant/bar",
"media" and "campus". The white collar group covered a variety of occupations, including
hairdressers and beauticians, secretaries, business people, shop assistants, paramedical personnel
and computer programmers. Only one person was considered "marginal" (a prostitute).
The great majority were of Spanish nationality (but usually identifying themselves culturally
as Catalan). Just over half were single, and just under one quarter were either married or
divorced/separated. Only one in ten lived alone. Over half were living with a partner, and over
one quarter with their parents or other family. One third were living with their own children.
In terms of area of residence, subjects were spread fairly widely across most of the city.
When expressed in terms of the rate per 100,000 population aged 15-44, they were most likely to
live in Gracia, a district of Barcelona close to the center of the city which retains the atmosphere
of a village with a lively night-life and contains a mixed population of older, traditional working-
class and younger professionals who have moved in more recently. The educational level of the
sample was higher than that for the general population of Barcelona.
50
§ 3.3 PARIS
PARIS INDIVIDUAL REPORT ON COCAINE: NOTES AND OBSERVATIONS
BY RODOLPHE INGOLD, PHD.; MOHAMED TOUSSIRT, PHC.;
THIERRY PLISSON & VINCENT RAGOT
INSTITUT DE RECHERCHE EN EPIDÉMIOLOGIE DE LA PHARMACODÉPENDANCE (IREP)
§ 3.3.1 INTRODUCTION
In the next sections we are describing the methodology we have been using for this study on
cocaine in Paris, the way we have used the snowball sampling method, specific data op Paris and
qualitative data. Data collection began in March 1991 and was completed in january 1992.
From an historical point of view cocaine use has remained limited to small and limited
groups during the seventies. Among heroin users life time prevalence was low (2 to 7%)
according to different surveys. Cocaine use became more prevalent during the 80' and lifetime
prevalence rose to at least 40% in different studies. (See Ingold, Ingold, & Toussirt, 1990 for
more details). The important point is that cocaine began to be found at the street level in 1982
and began to be sold by ex heroin and ex cannabis dealers. Today the trend of cocaine use is up:
there are specialized crack and cocaine dealers who are found at the street level, in squatts and
night places in addition to private networks. First crack use at the street level has been
significantly identified in early 1989.
§ 3.3.2 DESCRIPTION OF THE CITY
Four departments in Paris: 75 is Paris intra muros; 92, 93 and 94 are the three departments
just outside of Paris.
Table 3.
Department Population
75 - Paris Centre 2.152.329

92 - Hauts de Seine 1.391.546
93 - Seine Saint Denis 1.381.329
94 - Val de Marne 1.215.398
Together: 6.140.602
51
Table 4. Population of 15 - 39 years old
Age Population by departments Population Paris

- 75 - - 92 - - 93 - - 94 - and Suburb
15 - 19 108.270 84.542 99.978 81.509 374.299

20 - 24 183.952 106.500 110.492 95.109 496.053
25 - 29 230.207 131.994 125.954 111.765 599.920
30 - 34 191.274 119.908 119.392 103.663 534.237
35 - 39 166.813 107.445 111.797 95.564 481.619
TOTAL 880.516 550.389 567.613 487.610 2,486.128
Table 5. 15 -19 Years old in Paris
Age Total % Males Females
15 - 19 108.270 5.0 54.299 53.971

20 - 24 183.952 8.5 84.821 99.131
25 - 29 230.207 10.7 111.140 119.067
30 - 34 191.274 8.9 94.942 96.332
35 - 39 166.813 7.8 81.670 85.143
Together 15-39 880.516 40.9 426.872 453.644
Table 6. Drug related deaths
Paris = P
France = F 1985 1986 1987 1988 1989
Heroine P 2164 2048 2378 2104

F 10693 9107 9189 9632 9525
Cocaine P 77 83 139 183

F 384 508 505 707 677
Cannabis P 3486 3100 2638 3078

F 13989 16014 16862 16257 18544
52
Table 7. Seizures: Paris intra-Muros 1986 - 1989
Paris = P
France = F 1985 1986 1987 1988 1989
Heroine P 46 66
(kg) F 277 219 213 221 295
Cocaine P 7 56
(kg) F 95 257 754 592 938
Cannabis P 372 255

(kg) F 8233 13259 12601 24407 17832
LSD P
(Unités) F 11088 11258 13766 7350 12124
Table 8. Number of seizures: Paris intra-Muros 1986 -1989
Years 1986 1987 1988 1989
Herbe 707 440 226 135

Resine 2467 2553 2240 2787
Huile 15 11 10 5
Heroine 1023 1620 1953 1810
Cocaine 71 118 147 192
Table 9.Survey of SESI (ministry of social affairs) related to

treated drug addicts in France in November of 87 and 89
Main Drug Abuse November 1987 November 1989
Héroïne, morphine, opium 4.997 5.804

Cocaïne 134 227
Cannabis et dérivés 1.352 1.905
LSD et autres dysleptiques 42 40
Other 1.972 2.226
Non réponse 307 402
Total 8.804 10.604
53
Table 10.Main drug of use (dependence) Study of SESI (ministry
of social affairs): Paris intra-Muros
Drug Abuse 1988 1989
N % N %
Héroïne 1.184 69,89 1.146 60,06
Cocaïne31 1,83 39 2,04
Cannabis 186 10,98 279 14,62
Autres produits 252 14,88 365 19,14
Sans réponse 41 2,42 79 4,14
Total 1.694 100,00 1.908 100,00
In Paris heroin is most commonly used by addicts. Cocain is also used as a "main drug of
use" but in a much smaller proportion. However, in our last study (IREP, 1992) cocain use is
used more or less by 45% of addicts, at least as a secondary drug (55% in Paris). In the same
study (IREP) 40% of these cocain users do inject the drug. In 50% of the cases cocain use
happens once a week or more.
§ 3.3.3 METHODOLOGY
The snowball methodology
We have found very quickly that it was extremely difficult to ask fieldworkers to randomly
choose subjects among those who were known by a given cocaïne user. Given this difficulty -
which is also related to the study in itself (cocaine use as a hidden and rare event) - we choose to
explore completely every referral chain. Field workers have been asked to describe precisely
every snowball, how they were introduced to a subject and by whom. (See figure 8, Diagramm
of the "Snowball" Contact).
In our study the definition of a cocain user is the following one: a subject who has been and
still is a regular (at least one or more times a week) user of cocain (snorting, smoking and/or
injecting) even if cocaine use is not a strictly daily use. We have excluded subjects who had only
experimented cocain and those who had given up cocain for a long time. But we have included
subjects who were using crack and subjects who were using cocain in addition to other drugs,
including alcohol.
The questionnaire
We have built a specific questionnaire for this study (see Appendix 2) in order to improve the
original questionnaire which had been suggested at the beginning of the study. This
questionnaire was filled in by the field worker during the interview. Subjects were informed of
the study and gave their consent to data collection.
54
Fig. 8
Diagramm of the "snowball" contact

The selection and training of fieldworkers
One fieldworker has been hired for this study after a long selection process. He is a musician
who has been a heroin user in the past and who gave up heroin use. However he also uses
cocaine on a episodic basis. He has been choosen because he knew many cocaine users in his
milieu ( musicians, Festivals, dealers, bikers) and could be trusted by them. He had no
experience in data collection and has been trained by us during a few days. During the first
weeks we had frequent meeting in order to supervise his work and check with him data
collection. In addition to data collection with the questionnaire, one of us gathered qualitative
information during the same time, with or without the fieldworker.
The first forty questionnaires have been filled by him only. His research has been conducted
in different social and geographic places: The flea market of Porte de Saint-Ouen ( where drugs
are available on week ends and sold to many different social groups: antic dealers, tourists,
musicians etc...); Night clubs and especially the ones where rock music is played; public
concerts; a motorbike club; "rave parties". In addition to this we could have access to isolated
persons who usually purchase cocaine in this milieu but do not belong to it (white collar).
The evaluation of trends (see NIDA article - Ingold, Ingold, & Toussirt, 1990)
In our last study (IREP 1992) we found that first cocaine use occurred mainly in 1980 and
after. Among 161 heroin users who also use cocaine we find: 31 subjects who used cocaine for
the first time before 1980; 88 subjects between 1980 and 1985; 42 subjects between 1986 and
1990. In terms of HIV seroprevalence: 27% of them are seropositive (no significant difference
with heroin users); 34% have not been tested or have been tested more than a year ago; 39% are
seronegative In terms of needle sharing there is no difference with the other groups, the majority
of them do not share syringes.
Analysis of qualitative data
Qualitative data have been gathered by direct observation of cocain users and interviews. The
main groups of interest have been the following ones: musicians (rock), workers in the field of
music and concerts, motorbike fans, prostitutes.
The networks of cocain dealing: 1) at the street level, cocain is available in the following
places: some selected places (les Halles...) where cocain may be found at street corners and at
specific times of day or night. For instance, at les Halles, cocain may be found from 2 am to 6 am
at a street corner. 2) In some public places such as clubs and bars. In some squatts, including
"artists squatts", cocain is frequently available and distributed, especially in the form of crack
cocain. 3) In private appartments: networks of friends, dealers making deliveries. 4) work places
(music technicians, journalists...).
Despite the large diversity of situations where cocain may be available, it has to be said that
cocain use remains a very discrete activity. It is more difficult to reach a cocain user than heroin
or, of course, cannabis users. This explains the difficulty of using a strict snowball methodology
where subjects would be randomly choosen.
Dealing and buying: some buy cocain in grams. However cocain may be sold (at the street
level) like heroin, that is to say by small quantities (1/10 of a gram for instance). We have also
found heroin dealers who were selling both drugs (heroin and cocain at a time: this has probably
56
contributed to the success of cocain among heroin users. Some heroin users give up heroin
during days or weeks and use exclusively cocain during that time). Crack is also sold in small
quantities, on or a few rocks ("caillou"). Crack is smoked in a pipe (usually a can of coke, coca
cola, or beer).
§ 3.4 DESCRIPTION OF PARIS SAMPLE

One out of four cocaine users interviewed in Paris (n=40) is female. The age of the Parisian
(4)
cocaine users varies from 18 up to 44. Female cocaine users are - on average - over three years
older than male cocaine users interviewed: 28.9 versus 25.2 years respectively.
Fig. 10
(4)
Mean=26.1 years; median=24 years; stddev=5.8
57
Most of the cocaine users interviewed in Paris are French (92.5%), the others come from
other European countries. 12.5% Of the Parisian cocaine users are married or living together.
Two of the interviewees are separated or divorced and the majority is single (82.5%). Five of the
cocaine users interviewed have children. Half of the sample lived alone (47.5%) and over one
third lived with friends (37.5%). The others lived with their parents (12.5%) or in some other
living arrangement (2.5%). The data available on the occupational milieu of the cocaine users
interviewed in Paris are of a somewhat different format compared to those provided by cocaine
users interviewed in Barcelona and Cologne, and are graphically displayed in figure 10.
§ 3.5 COLOGNE
BY DIETER KORCZAK, PHD
GP FORSCHUNGSGRUPPE
§ 3.5.1 DESCRIPTION OF COLOGNE'S CITY SITUATION, SCENES AND BACKGROUNDS
Cologne with approximately 1 Mill. (per 1.1.1991) habitants is situated in a highly

industrialized area in Nordrhein-Westfalia. Most important industry branches are steel and
pharmaceutical companies. Cologne's share of foreign habitants (163.014) is pretty high
compared to other german cities of the same size. Especially Turks (70.852), Italians (19.995)
and Jugoslawians (10.565) are located in city quarers with lower rents, such as Chorweiler.
During the last 3 years, a significant change took place concerning Cologne's drugscene.
Local small dealers used to buy daily low amounts of drugs in the borderclose Netherlands. This
procedure covered 80 -90% of the inquiry. Since 1989 local big dealers took over the field.
Those big dealers are in most cases Turkish or Italian citizens. They belong to overregional and
international drugorganizations with a background of organized crime. Italian gangs control the
import and business of cocaine, Turkish gangs organize and control the heroine-business.
At present the market is inundated with drugs. Prices are falling steadily and the drug quality
is improving (purity). The purity-content of heroine in street sales 1989, used to be 10 -15%, at
present it changed to 40%, in some cases even over 70%, as a matter of fact, this is the reason for
more drug deads.
Even small dealers started to organize themselves in small gangs (2 -3 persons) and work
together in a combination of dealer, mediator and depot holder. The minor drug business
changed from appartment-deals to more or less open deals on the streets and places. This follows
the same pattern like other capitals, f.i. Zurich. The opened scene is established in quarters of the
inner city like the main station and Neumarkt. The estimate of Cologne's drugaid center amounts
to 4.000- 6.000 consumers of hard drugs at present. In spring/summer 91 a police action of
intensified research (3 weeks, commission of 35 persons) took place. The seizures and arrests
calmed the scene down, but did not destroy the open street scene.
Cocaine use patterns are different from the other described scenes. Dealers operate in closed
and more private circles. The cocaine business is strictly organized, the commercial volume
outstandingly high.
58
Cologne's disco scene has a new trend
Young people tend to consume more "speed"(amphetamine), which is produced to a high

degree locally in Cologne. Both scenes, cocaine and speed have a high degree on dark figure
criminal action.
In 1989 the figure of drugdeads was 21, in 1990 it was 20, which is clearly less compared to
other German capitals. This year the figure of 52 drugdeads (per 31.10.'91) shows a serious
exacerbation of the situation mainly caused by the purity - content of drugs, 40% of those
drugdeads have never been in contact with the police concerning their drug - consumerism. The
average age of the deads did not ascend. The share of first consumers amounts to 19,58% in
1989 and 26,14% in 1990.
Table 11. Statistics 1989 - 91
1989 1990 1991
Consumers/dealer 1023/316 1050/254

* heroine 382/151 425/132
* cocaine 71/39 46/27
* cannabis 532/111 520/85
* amphetamine 35/11 52/7
* others 7/- 7/3
Drugdeads 21 20 52
Arrests
* previously
arrested persons 543 666 650
* warrants of arrests 85 78 93
Drugseizures in kg
* heroine 0.378 4.398
* cocaine 11.382 8.840
* amphetamine 0.392 1.554
* opium 0.862
* cannabis 31.612 16.428
§ 3.5.2 CITY QUARTERS WITH SPECIAL DRUG ABUSE TENDENCIES
Apart from the open street scene in the inner city two other hot points do exist. One is the
scene in Chorweiler which is established since years. Chorweiler is one of the typical fast built
cities of the 70ies, consisting of anonymous concrete-skyscrapers. Chorweiler is a typical social
burning point. Drugconsumers as well as small dealers live there, the scene is pretty much closed
up.
The other burning point is Köln-Kalk traditionally inhabited by social "week" people. The
share of foreign habitants, especially Turks, is very high. Fixed scene meeting-points like in
59
Chorweiler are missing, which makes it very difficult to watch and to control the scene.
§ 3.5.3 DRUG USE PATTERNS
First of all, drugs like Crack and LSD are of lower or no interest in Cologne. All police-
known heroine-consumers used Marihuana resp. Haschisch before they started with heroine. A
lot of heroine consumers are multiple consumers. They take also cocaine, haschisch and typical
drug compensation substances like Remedacen, Rohypnol, Medinox and with less share Codein.
Most of the heroine-consumers start off with blowing heroine, but with amounting
dependence degree and caused by more effect with less amount of heroine they easily start
fixing. Cocaine follows the same Cannabis-start pattern. Cocaine users tend to take amphetamine
before they consume cocaine. Sometimes the cocaine use is accompanied by the use of
amphetamines.
§ 3.5.4 THE FIELDWORK
For the conduction of the interviews, two interviewers have been selected: a 31 year old
female from the movie - and music- business and a 28-year old psychologist. Both were trained.
Fieldwork started in February 1991. The reason for the choice of these two people has been their
close contact to the cocaine scene. However the conduction of the interviews proved to be
difficult. The cocaine users showed a quite paranoic behaviour. They were suspicious and did not
even trust the interviewers which they personally knew. Their main concern was to get known to
the drug police.The Cologne police was regarded as very active and tried hard to get control of
the cocaine usage. Everybody of the interviewed users was very eager to hide his real identity. In
some cases, The interview was only given by the confirmation that the real profession was
covered by terms like "businessman". For the same reason, everybody denied to give nominees.
The interviews were finished in May 1991. No real snowball effect could be realized because of
the missing nominees. On the other hand, the access resources of the two interviewers have been
exploited. The supervisor tried - limited by time and financial resources - to engage new
interviewers. The general interest to participate for the studies was very low. Students from the
university who tried to contact the cocaine scene for interviews failed because they were not
accepted in that scene. Thus, the conduction of the Cologne part of the study causes quite
different results and conclusions than the former Munich cocaine study because a scene (like
Cologne) is very much under pressure. The snowball method seems to be only possible if the
research budget allows two fulltime fieldworkers and an extended time span.
§ 3.6 DESCRIPTION OF COLOGNE SAMPLE

In Cologne, only 17 cocaine users were interviewed. Almost three out of four interviewees
(5)
were male (71%). Their age ranges from 24 to 42 years. There is no difference in age between
female and male cocaine users (34 and 33 years on average).
None of the Cologne cocaine users were unemployed. In terms of occupational milieu (figure
11) the majority of them were classified as actors & artists (41%) or white collar (23%). The
(5)
Mean = 33.3 years; median = 34 years; stddev = 5.4
60
occupational milieu of the other cocaine users interviewed could be classified as: restaurant &
cafe (12%), campus (12%), blue collar (6%), or independent (6%). Four respondents did not
have the German nationality; they were either Italian, Ungarian, Turkish, or American. Except
for one, all cocaine users interviewed lived in Cologne.
Fig. 11
61
§ 3.7 COMPARISON OF THE SAMPLES FROM
BARCELONA, PARIS, AND COLOGNE
BY PETER BLANKEN, PHC.
In contrast to Paris and Cologne, the sample of cocaine users interviewed in Barcelona is
more evenly distributed as far as gender is concerned (see figure 12), although this difference is
(6)
not statistically significant. As can also be seen from figure 12, the cocaine users interviewed
in Paris are significantly younger (26.1 years on average) than those interviewed in Barcelona
(7)
(30.7 years on average) and Cologne (33.3 years on average).
One other striking difference is between the marital status and living arrangements of cocaine
( 8)
users interviewed in Barcelona and Paris. From figure 13 it can be seen that, while the
majority in Paris is single (82%) and either living alone (47%) or with friends (37%), in
Barcelona a substantial portion of interviewees is married (22%), or divorced, separated or
widowed (24%). Only a minority is living alone (10%) or with friends (5%), while a majority of
the sample is living with either a partner (56%) or parents or other family members (29%). In
addition, more cocaine users interviewed in Barcelona report to be living with their own children
(34%) than cocaine users in Paris do (12%).
There are, however, also similarities to be noted. For instance, in Barcelona as well as in
Paris the education level of the cocaine users interviewed seems to be higher than that for the
general population.
However, it can not be concluded that these differences reflect real differences between
cocaine users in the three cities, since different sampling strategies may have confounded these
results.
(6)
Chi² = 4.3; df = 2; p = .11
(7)
F-ratio = 13.8; p < .001 - Scheffe/Student-Newman-Keuls
(8)
For the cocaine users interviewed in Cologne no data have been reported on such factors as civil status,
living condition, children, and educational level.
62
Fig. 12
Fig. 13
CHAPTER 4
COCAINE USE: DATA ANALYSIS
BY PETER BLANKEN, PHC., VINCENT M. HENDRIKS, PHD & NICO F.P. ADRIAANS
In this chapter results will be presented on the rates, patterns, correlates and consequences of
cocaine use, as described by the cocaine users interviewed in Barcelona (n=41), Paris (n=40),
and Cologne (n=17). Whenever possible, comparisons are made between cocaine users from
these three cities. This, however, depends on the extent to which the data-files gathered in
Barcelona, Paris and Cologne can be reliably matched.
§ 4.1 HISTORY OF COCAINE USE

§ 4.1.1 INITIAL COCAINE USE.
Age at initial cocaine use
For the cocaine users interviewed in Barcelona the age at which they first used cocaine varies
(9)
from 14 to 35 years, with a mean age of 22.9 years. For the Cologne cocaine users
(10)
interviewed, the distribution of age at first cocaine use is quite comparable, ranging from 15
(11)
to 32 years, with a mean of 24.6 years. In Paris, the cocaine users interviewed seem to have
(12)
started cocaine use at an earlier age: 18.7 years on average, ranging from 11 to 26 years.
Figure 1 gives an overview of the age at which the interviewees in the three cities had their first
cocaine experiences. Statistically, it can be concluded that the Parisian cocaine users had their
(13)
first cocaine earlier in their life histories than cocaine users in Cologne and Barcelona.
Incidence of cocaine use
In figure 2 an overview is given of the cocaine use incidence rates for the three cities. Year of
cocaine use onset varies from the late '60s to the late '80s and early '90s. More specifically, in
Barcelona the interviewees first used cocaine from 1974 to the year prior
(9)
Median=22 years; mode=19 years
(10)
Since age at cocaine use onset was not registered in Cologne, nor in Paris, this has been computed,
based on their age and the year of first cocaine use.
(11)
(12)
(13)
F-ratio=14.9; p < .001 - Scheffe/Student-Newman-Keuls
Fig. 1
Fig. 2
66
to data collection, 1990. Almost half of the cocaine users interviewed had their first cocaine
experience in the years before 1983, while about one third used cocaine for the first time in the
period from 1987 to 1990. From figure 3 it can be seen there is some indication that cocaine use
incidence somewhat accelerates both in the years around 1980 as well as in the late '80s.
Fig. 3
First cocaine use among the interviewees from Paris dates back as far as the late '60s, also
stretching out into the '90s (the year prior to data collection). Over half of the sample first used
cocaine in 1985 or the years before (57%), while one out of four started as late as 1989 or 1990.
Thus, for cocaine users interviewed in Paris the acceleration in incidence rate appears to be later
than in Barcelona (see figure 3). In Paris first cocaine use rates center around 1984 and 1985 on
the one hand and around 1989 and 1990 on the other hand.
For Cologne, first cocaine use varies from 1978 to 1988. Although the Cologne sample is
very small, FIGURE 3 suggests that, cocaine incidence rates are also characterized by two waves,
the first taking place in the years prior to 1980, and the second in 1986.
§ 4.1.2 INITIATION CIRCUMSTANCES
As far as the circumstances in which initiation into cocaine use took place are concerned,
only from Barcelona - and less so from Cologne - relevant and reliable data are available.
Therefore the next paragraph is mainly restricted to cocaine users interviewed in Barcelona.
In contrast to some popular beliefs of aggressively pushing dealers, only one cocaine user
67
interviewed in Barcelona was introduced to cocaine by a dealer. Three out of four interviewees
(n=35) were introduced to cocaine by their partner (11%) or by friends (64%). The places and
situations characterizing this initiation are very diverse: home (13%); friend's house (22%); work
(17%); bar (13%); public place (4%); car (13%); travelling (17%) - although it should be noted
18 out of 41 cocaine users interviewed in Barcelona did not mention this topic (n=23). For half
of those mentioning their life circumstances at the time of their first cocaine use (only 15
respondents) these can be characterized as a period of change in either work or relationship. For
one user interviewed, cocaine consumption was embedded in a situation of (heroin) addiction,
while the others were in a period of drug-experimenting.
It should be stressed again, however, that -except for the topic of the person introducing the
interviewees to cocaine- less than half of the cocaine users interviewed mentioned the other
aspects related to their initiation into cocaine use.
Similarly, for cocaine users interviewed in Cologne introduction into cocaine generally took
place through friends or acquaintances (8 out of 17) and/or at parties (6 out of 16). One out of
four cocaine users interviewed in Cologne mentioned curiosity as the reason for trying cocaine.
§ 4.1.3 LENGTH OF COCAINE USE CAREER
In figure 4 the cocaine use career lengths for the interviewees in the three cities are
graphically displayed. These figures are only an approximation of the real career lengths, since
they have been computed on the basis of interview date and year of first cocaine use, thus
ignoring potential periods of abstinence. Given this limitation, it can be seen that there are no
large, statistically significant differences between length of cocaine use careers for the
(14)
interviewees from Barcelona, Paris, and Cologne, respectively: 7.7, 7.4, and 8.7 years.
Nevertheless, some differences can be observed between the three cities. While in Barcelona the
career lengths seem most evenly distributed [approaching a normal curve], in Paris the career
lengths of the cocaine users interviewed seem to be better represented by a trinomial distribution,
with peaks on 1 year, 4 to 6 years, and 15 years or more. This difference between Barcelona and
Paris is reflected in the median value of the cocaine career length, which almost equals the
average length for cocaine users interviewed in Barcelona (8.0 and 7.7 years respectively), while
in Paris the median value falls well below the average (6.0 versus 7.4 years). The Cologne
sample is too small to mention anything on its distribution form. However, again it should be
stressed that due to differences in sampling strategies, it is unknown whether these differences
reflect real differences between Barcelona and Paris.
(14)
F-ratio=0.4; p=N.S.
68
Fig. 4
§ 4.1.4 PATTERN OF COCAINE USE
For cocaine users interviewed in Barcelona and Paris some information on cocaine use
patterns has been gathered. One out of three cocaine users interviewed in Barcelona reported a
cocaine use pattern of fairly consistent increase over the years (34%). Next mentioned (17%)
were a stable pattern of cocaine use over the years and a pattern of starting and stopping over the
years (12%). The two other patterns reported were: increased use up till reaching a peak,
followed by a decrease (10%), and an extremely varied pattern (7%). Almost one out of five
cocaine users interviewed in Barcelona reported another or no pattern. Noteworthy is the fact
that no cocaine user reported using large amounts immediately.
As can be seen from figure 5 these patterns are slightly, though not significantly, related to
(15)
the cocaine use career length. For instance, cocaine users reporting a stable cocaine use
pattern had the highest career length, both on average and as maximum (9 and 17 years,
respectively), suggesting that a long history of cocaine can be characterized by a stable pattern of
consumption.
(15)
F-ratio=0.38; p=N.S.
69
Fig. 5
Half of the cocaine users interviewed in Cologne (53%) uses cocaine on a regular basis, and
almost 30% reported irregular use, characterized by discrete phases. The others mentioned a very
irregular pattern, an occasional pattern, or a pattern of initial increase, followed by a decrease.
The groups are, however, too small to contrast them by the length of their cocaine use careers.
70
§ 4.2 CURRENT COCAINE USE
§ 4.2.1 MAGNITUDE OF CURRENT COCAINE USE
Current cocaine use in Barcelona
Two out of three cocaine users interviewed in Barcelona used the substance less than ten
times in the month preceding the interview. Only 14% used cocaine on an [almost] daily (i.e., 20
days or more in the month preceding the interview). In accord with this observation is the self-
reported classification as sporadic user (44%) or regular weekend user (5%) by half of them.
Nevertheless, another 41% described themselves as regular users (i.e., more than regular
weekend user) or binge and regular user (10%).
Fig. 6
(16)
The average quantity of cocaine used is less than half a gram. Over two-thirds reported to
use one quarter of a gram cocaine or less on the days cocaine was used (71%), while less than
10% used one gram or more.
The amount of money spend on cocaine per week varies from zero to 45.000 pts., equalling
367 ecus, while the average for the cocaine users interviewed in Barcelona is 55 ecus per week
(stddev=67.4; mode=median=32 ecus). Of course, the extent of this amount is significantly
related to the number of days cocaine had been used, and -though to a lesser extent- to the
(16)
0.38 gr; stddev=0.42 gr.
71
(17)
quantity of cocaine used. Also, noteworthy is the fact that there is a positive relationship
between on the one hand the price paid per gram cocaine and on the other hand the number of
days cocaine had been used in the month preceding the interview, indicating that more frequent
(18)
cocaine is slightly associated with paying a higher price.
Fig. 7
As could have been expected, the sporadic cocaine users reported an average of 3.6 days,
which is significantly lower than the average frequency of cocaine consumption reported by
(19)
regular and binge users, respectively 13.2 and 15.1 days (see figure 6). There are no
significant differences between the sporadic, regular and binge users as far as the amount of
(20)
cocaine consumed is concerned, although some trend of increasing amounts of cocaine used
can be noticed (see figure 7) from sporadic (0.31 gr), through regular (0.42 gr) to binge users
(0.55 gr). As can be seen from figure 8 large differences exist between the three groups of
(21)
cocaine users with respect to the amount of money spend on cocaine, although these results
should be interpreted cautiously given the small number of binge users. Nevertheless, it can be
concluded quite confidentially that regular users spent more money on cocaine (63 ± 9.1 ecus)
(17)
r=0.68; p < .001 and r=.37; p < .05, respectively
(18)
r=.35; p=.012
(19)
F-ratio=15.2; p < .001 - Scheffe/Student-Newman-Keuls
(20)
F-ratio=0.6; p=0.54
(21)
F-ratio=15.7; p < .001
72
than sporadic users (26 ± 5.7 ecus), and that binge users -by the nature of binging- spent clearly
the most money. Finally, in figure 9 it is shown that some difference exist between the three
types of cocaine users with respect to the price paid per gram cocaine: cocaine bingers paid least
for a gram, although this difference is not significant - due to the relatively small group of binge
(22)
users (n=4).
Fig. 8
(22)
F-ratio=3.2; p=.053
73
Fig. 9
Fig. 10
In order to make cocaine use frequencies during the month preceding the interview
comparable, the answers of the cocaine users interviewed in Barcelona, Paris and Cologne were
recoded into none, seldom, intermediate, or [almost] daily. As can be seen from figure 10 the
highest frequency of cocaine use is reported in Cologne: 38% used cocaine on an (almost) daily
basis. Among the cocaine users interviewed in Paris cocaine use is least frequent: 57% used
seldom in the month preceding the interview, while only 7% used (almost) daily during that
period. In Barcelona the frequency of cocaine use seems most evenly distributed among the four
categories.
Another aspect on which the cocaine users interviewed in three cities can be reliably
(23)
contrasted is the price paid for one gram of cocaine. The price paid per gram cocaine in
(24)
Barcelona ranges from 57 to 147 ecus. In Paris, the price paid for a gram of
Fig. 11
(25)
cocaine varies between 75 and 151 ecus. Finally, for cocaine users interviewed in Cologne
(23)
The local prices paid per gram have been transformed to prices in ecus by the following multipliers:
 100 Pesetas = 0,82 ecus;
 100 Marken = 49,35 ecus;
 100 Francs = 15,15 ecus.
(24)
Mean=108.4 ecus; median=114 ecus; mode=97 ecus
(25)
Mean=107.8 ecus; median=105 ecus; mode=121 ecus
75
(26)
the price paid per gram cocaine ranges from 58 to 135 ecus. Although, as can be seen from
figure 11 some difference exist between the prices paid for cocaine in Barcelona, Paris and
(27)
Cologne, these differences are statistically non-significant.
§ 4.2.2 CORRELATES OF CURRENT COCAINE USE
§ 4.2.2.1 CIRCUMSTANCES OF CURRENT COCAINE USE
In general, cocaine use can be considered to be a social phenomenon. As reported by cocaine

users interviewed in Barcelona, cocaine is rarely used alone (7%), and mostly with friends or
colleagues (66%) and/or with a partner (37%). Quite related to this, are the places in which
cocaine is used - at home (29%), while going out (46%), or at work (39%) - and the motivation
underlying cocaine use - increased sociability while going out (41%), to feel good (44%) -, while
two other drives to use cocaine are less likely to be reported: to enhance work performance (7%),
or to enhance alcohol tolerance (i.e., being able to consume more alcoholic drinks, without
getting drunk) (12%).
More specifically, the social aspect of cocaine use can be seen in the clustering of some of
the above mentioned circumstances and motivations of current cocaine use. For instance, those
cocaine users interviewed in Barcelona reporting on cocaine use while going out, never
mentioned to use cocaine alone, and all reported to be with friends or colleagues and/or their
partner (44%). Evidently, using cocaine at work is highly related to the company of friends or,
more specifically, colleagues (85%) and the few cocaine users mentioning work enhancement as
(one of) the motivations for cocaine use all used cocaine at work. Nevertheless, even among the
group that uses cocaine at work other motivations are related to cocaine use as well: 44%
mentions to feel good, or like it as a motivation to use cocaine. Finally, those interviewees using
cocaine while they are going out mention increased sociability (63%), and to feel good, or like it
(42%) as main drives to consume the substance, while another 26% of them (in addition) use
cocaine to increase their alcohol consumption without getting drunk.
§ 4.2.2.2 MODE OF ADMINISTRATION
As can be seen from figure 12 in all three cities sniffing is the most common mode of
administration for the cocaine users interviewed, although some reported other administration
rituals in addition. Compared to cocaine users interviewed in Barcelona and Cologne, intranasal
(28)
cocaine use is lower in Paris: 93%, 94% and 72% respectively.
(26)
Mean=101.5 ecus; median=mode=98 ecus
(27)
F-ratio=0.76; p=0.47
(28)
Statistically, there is only a difference between Paris and Barcelona [F-ratio=4.1; p=.02 - Scheffe/
Student-Newman-Keuls]
76
Fig. 12
Fig. 13
77
(29)
Cocaine smoking is reported most frequently in Barcelona (24%) and hardly in Paris (5%).
Injection of cocaine is even less frequently reported, with a highest prevalence in Cologne
(12%). Whether the reported routes of administration are representative for the population of
cocaine users in the three cities, or whether they are due to sampling strategies is an open
question.
§ 4.2.2.3 SOURCE OF COCAINE
In all three cities some information has been solicited with regard to the source supplying the
cocaine used. For cocaine users interviewed in Barcelona the main sources supplying cocaine
were friends and/or partner (49%) or a dealer (49%). In Paris, similar sources were mentioned:
dealer (32%) or intermediates (65%). The cocaine users interviewed in Cologne reported in a
different way on their cocaine suppliers. Almost three out of four cocaine users got their cocaine
from a first hand (35%), second hand (35%), or third hand (18%) source. The other sources
(30)
mentioned were partners, friends or colleagues (12%, 18% and 6% respectively).
It is interesting to see that there is some association between on the hand the source
supplying cocaine, and, on the other hand, the frequency and quantity of cocaine consumption.
Cocaine users interviewed in Barcelona who got cocaine through friends or partners used
cocaine less frequently in the mont preceding the interview (7.1 days on average) and used less
grams of cocaine per day (0.23 gram), than users that bought their cocaine at a dealer (11.8 days,
( 31)
and 0.48 grams). These differences, displayed in figure 13, approach statistical significance.
However, there is no difference in price paid per gram cocaine for those users buying from a
dealer (108.4 ecus on average) and those getting cocaine via their partner or friends (108.3 ecus
(32)
on average).
§ 4.2.2.4 OTHER PSYCHOACTIVE SUBSTANCES
In Paris, the cocaine users interviewed also have lifetime or current (i.e., last month)
experience with a number of other illegal psychoactive substances. In addition to cannabis
(90%), about half of the sample ever used heroin (52%), while over one third report current
heroin use (37%). Another substance that many interviewees (55%) had ever used are
hallucinogens (mushrooms and/or LSD), though current use is much less prevalent (27%). As
can be seen from figure 14 both lifetime and current use of other substances (i.c., amphetamines,
alcohol and solvents) is low, although the validity of the alcohol prevalence figures is doubtful.
(29)
Statistically, there is only a difference between Paris and Barcelona [F-ratio=3.1; p=.05 - Student-
Newman-Keuls]
(30)
The percentages do not add up to 100%, since cocaine users interviewed were free to mention more
than one source.
(31)
Respectively: t-value=-1.78; df=27.5; p=0.085; and t-value=-1.94; df=19.6; p=0.068
(32)
t-value=-0.02; df=36.1; p=0.98
78
Fig. 14
Fig. 15
79
Lifetime experience with heroin, hallucinogens, and cannabis among cocaine users
interviewed in Barcelona is comparable to the experiences of Parisian users interviewed. (see
figure 15). With respect to current use the cocaine users from Barcelona seem to have different
patterns. 85% Did not use heroin in the month preceding the interview, and the last month
prevalence of hallucinogens and amphetamines is zero and 5% respectively. Likewise, recent
cannabis use is -compared to life time prevalence- low: 58% versus 85%. In contrast to the data
obtained from Paris, the numbers representing alcohol consumption seem to be more realistic: at
least one out of four cocaine users mentioned alcohol use in the month preceding the interview.
As far as concurrent substance use in the Cologne cocaine users interviewed is concerned, no
lifetime or last month prevalence figures are at hand.
Statistical comparisons between cocaine users interviewed in Barcelona and Paris yield
(33)
significant differences with respect to current cannabis use; lifetime - but not current -
(34) (35)
prevalence of amphetamine use; and current heroin use.
Fig. 16
(33)
t-value=-3.06; df=79; p < .01
(34)
t-value=3.06; df=79; p < .01
(35)
t-value=-2.40; df=79; p=.02
80
§ 4.2.2.5 PROBLEMS RELATED TO COCAINE USE
All cocaine users interviewed in the three cities have reported on problems they have
experienced in relation to their cocaine use. Some of these results can be seen in figure 16. Most
extensively this has been done in Barcelona. Medical problems have been commented upon in all
three cities. Highest prevalence of medical problems was registered among Parisian cocaine
users (42%), while these problems were reported to a lesser extent in Barcelona (27%) and
(36)
Cologne (18%). These differences were, however, statistically non-significant. Legal
problems are another aspect related to cocaine use and are mentioned especially by cocaine users
interviewed in Paris (50%) and hardly reported by cocaine users interviewed in Barcelona (2%)
or Cologne (6%). As far as financial and psychological problems are concerned, a comparison
can be made between cocaine users interviewed in Barcelona and Cologne. As can be seen from
figure 16 psychological problems appear to be more prevalent in Cologne (47% compared to
(37)
20% in Barcelona), while financial problems are, though not significantly, more often
(38)
reported in Barcelona: 29% versus 6% in Cologne.
(36)
F-ratio=2.11; p=0.13
(37)
Chi²=3.29; df=1; p=0.69
(38)
Chi²=2.55; df=1; p=0.11
81
CHAPTER 5
SNOWBALL SAMPLING: METHODOLOGICAL ANALYSIS
BY PETER BLANKEN, PHC., VINCENT M. HENDRIKS, PHD & NICO F.P. ADRIAANS
As outlined in chapter 2, snowball sampling methodology can, depending on the goal of the
study, be utilized in various ways employing different degrees of rigor and randomization in
selecting both zero stage respondents and nominees. In going beyond the pure explorative and
qualitative description of phenomena under study, snowball sampling, ideally, will give access to
a sample - meeting some referral criteria - which is statistically representative of the population
possessing a specific trait (e.g., "at least four times cocaine use in the preceding month, or at least
ten times of cocaine use in the last six months").
This chapter addresses the central issue of representativeness of the finally obtained snowball
sample. Basically, as the theory outlined in chapter 2 states, two sources of bias determine this
representativeness: (1) bias in the composition of the zero stage sample, and (2) bias in the
subsequent snowball sampling nomination process.
According to theory, inferences from sample to population can only be made if the zero stage
sample can be considered as a probability sample. In research in hidden populations however, the
application of the full random model or other types of probability sampling is often not possible
or feasible. Concerning the zero stage sample, the researcher often has no better option than to
rely on the "face validity" of a tentative map to judge its representativeness (see § 2.2). With
respect to the nomination process, there are several ways to "screen" the snowball sampling data
on the occurrence of bias, that provide the researcher with cumulative insight into the nature of
(39)
the snowball sampling process that occurred. The following methods are discussed:
(1) investigating the lengths of the snowball-chains,

(2)comparing nominator-characteristics to nominee-characteristics in terms of "look-a-likes",
(3)investigating the occurrence of nominator effects on the distribution of nominee-
characteristics,
(4)comparing the selected 1-sth stage nominees to the total pool of nominees.
§ 5.1 THE LENGTHS OF THE SNOWBALL CHAINS

The 41 Barcelonian cocaine users interviewed can be grouped in 26 different snowball
chains. More than half of these chains were limited in length to the "starter", i.e., consisted only
of zero stage respondents (65.4%). The longest chain consisted of six persons (including the zero
stage respondent). The average length of the snowball chains equaled 1.6 cocaine users (see
figure 2 on next page).
(40)
Interviewers differed substantially in average lengths of "their" snowball chains. For
example, one interviewer had an average chain-length of 2.4, whereas another interviewer's
(39)
The discussion of these methods is based on the results from Barcelona
(40)
F-ratio=4.3; df=35; p < .05
chains were limited to the zero stage (see figure 1).
Fig. 1
86
Fig. 2
87
Although most of the snowball chains extincted prematurely, 36 out of the 41 cocaine users
(41)
interviewed in Barcelona nominated 229 other cocaine users in total, for whom they provided
basic sociodemographic data on age (N=229), gender (N=229), occupational milieu (N=224), and
district of residence (N=224). The number of nominees varied from zero to fourteen, with an
(42)
average of 5.6 nominees. No difference was found between the number of nominees referred
(43)
to by zero stage respondents and by 1-sth stage respondents, neither did the sociodemographic
th
characteristics differ between zero stage and 1-s stage respondents.
§ 5.2 SIMILARITY BIAS, OR: NOMINATING LOOK-A-LIKES

Some factors that potentially influence the nomination process have earlier been discussed in
the second chapter. The island model, for example, points out that within the population of
cocaine users several subgroups of users may exist within which the likelihood to be nominated
may be random, but the limited connections between different subgroups may result in a finite,
and rather small, nomination probability across subgroups. For example, it could be that cocaine
users form rather connected, or closed subgroups that can be described by, e.g., area of residence.
If this would be the case, then the nominees are quite likely to live in the same area as the
nominator, and the probability within a snowball chain to cross from cocaine users of one city
area to cocaine users in another city area will be rather small. The implicit consequence of this
kind of bias is that - unless the selection of zero stage respondents is carefully weighed and
reflexive of the factual residence distribution - cocaine users from other city areas have a much
smaller probability to be included in the 1-sth stages of the snowball sample than cocaine users
living in the same area as the (zero stage) nominator. The final sample will then be biased, at
least with respect to the area of residence of the nominated and interviewed sample. In general,
the snowball sampling procedure has the inherent risk of recruiting respondents that are - in
unknown but systematic ways - similar to the person that nominated them, which in turn may
result in a biased, non-representative sample.
One way to investigate similarity bias in the nomination process is to relate some specific
characteristic of the nominator to the corresponding - available - characteristic of the persons
(s)he nominated:
(1)to what extent did subjects nominate persons who are similar to themselves in terms of basic
demographics ("look-a-likes")?, and
(2)did subjects with different characteristics - in terms of basic demographics - differ in tendency
to nominate look-a-likes?
(41)
It is estimated that within snowballs, and between snowballs starting from related zero-stages, approxi-
mately 10% of the nominations are duplications, due to social network relationships. As far as could be
estimated from the sociodemographic characteristics from the nominees belonging to non-related zero
stages (thus, different snowballs) there were no duplications amongst them. For the remaining part of
this chapter all nominees, including the doubles, will be used for the analyses.
(42)
Median=mode=5; Stddev=3.87
(43)
On average 5.7 and 5.4 nominees, respectively: t-value=.23; df=39; p=N.S.
88
Ad 1. For each respondent the ratio of nominees with the same gender can be computed. Clearly,
if all males nominate only men, or all females nominate only women, the similarity bias in the
nomination process is maximal. Conversely, if all males nominate only women and vice versa,
similarity bias is completely absent. In both cases however, the gender distribution of the
interviewed sample is completely determined by the female/ male ratio in the selected zero stage
group (assuming a fixed number of selected nominees per nominator and equal non-response).
Since similarity, social distance, geographic distance, etc. are integral aspects of relations
between people, there are no absolute criteria for determining whether or not these aspects
unacceptably influenced the characteristics of the total snowball sample. Notwithstanding this
lack of "cut-off points", investigation of the data may provide some clues in this matter. For
example, as can be seen from table 1, male cocaine users did not restrict their nominations to
(other) male cocaine users, nor did females only nominate other females.
Table 1. Respondent's sex and sex of nominees
Respondent [N] Nominees

Male Female All
Male [20] 89 44 133

Female [16] 61 35 96
(44)
All [36] 150 79 229
Perhaps of greater methodological importance are the results on occupational milieu and area
of residence in the nomination process (tables 2 and 3). In general, over one third of nominees
comes from the same occupational milieu as the nominator (37%), implying that almost two out
of three cocaine users nominated come from a different occupational milieu than the nominator.
Reading across each row of table 2 gives a picture of how respondents from each occupational
milieu nominated other cocaine users in terms of occupational milieu. Reading down each
column it is depictured how nominees from different occupational milieux were nominated
according to the occupational milieu of the cocaine user interviewed. For instance, of the twelve
nominations made by cocaine users from the media world, only two are in the same occupational
milieu (17%). Another way the table can be read, is by inferring that from all blue collar cocaine
users nominated, only a small percentage is nominated by other blue collar cocaine users (13%).
The most connected group seems to be formed by the white collar cocaine users, nominating
other white collar users in over 50% of their nominations, while exactly half of the white collar
cocaine users nominated are referred to by white collar cocaine users interviewed. It seems a
tenable conclusions that, perhaps with the exception of the white collar users, the nomination
process is not restricted with respect to occupational milieu. Excluding the densely connected
white collars, the overall percentage of nominations within the same milieu drops to 27%.
(44)
Five respondents did not nominate any other cocaine user and are therefore excluded from the
analysis.
89
Table 2. Respondent's occupational milieu and occupational milieu of nominees

media music artist restaurant campus white c blue c margin unempl all
media [2] 2 - 3 - - 6 - 1 - 12
musician [5] 2 14 3 6 2 7 1 - - 35
artist [5] 3 3 16 2 1 7 - 3 - 35
restaurant [2] - - 2 3 - 2 - - - 7
campus [2] - - - 5 - 3 1 - - 9
white [13] 3 1 4 2 3 44 16 4 3 80
blue [5] 2 1 3 4 - 17 3 7 2 39
marginal [0] - - - - - - - - - 0
unempl [2] - 2 - - - 2 2 - 1 7
total [36] 12 21 31 22 6 88 23 15 6 224
In a similar way, table 3 provides detailed analysis of the pattern of nominees' district of
residence, linked to the district of residence of the interviewed sample who provided the
nominations. Only 28% of the nominees live in the same area of Barcelona as the nominator,
implying that the nomination-process is not restricted to geographical areas. For example, half of
the nominees from cocaine users living in Eixample reside in the same area (50%), and almost
half of the nominees living in Eixample are referred to by nominators from Eixample (46%), thus
forming a rather connected group of cocaine users. In contrast, only one out of five cocaine users
nominated by interviewees from Gràcia comes from that area as well (21%), while only one out
of three nominees living in Gràcia are nominated by cocaine users from Gràcia (33%).
Ad 2. Further insight into the mechanisms by which the nomination process operated can be
obtained by investigating the second question. For each female nominator the ratio of female
nominations among all (her) nominees, and for each male nominator the ratio of male
nominations among all (his) nominees is computed, resulting in a percentage of look-a-like
nominees for each gender. By means of a simple T-test it can then be analyzed whether men and
women differed in tendency to nominate gender-a-likes. If they do (and this is not a reflection of
population parameters), the implication is that the outcome of the nomination process with
respect to gender distribution in the total snowball sample
90
Table 3. Respondent's area of residence and area of residence of nominees

CVella Eixam SMont LCorts Sarria Gràcia HGuin NBarr SAnd SMartí Metro Other Total
Ciutat Vella [3] 4 1 3 - 1 3 1 - - - - - 13

Eixample [8] 5 24 1 - 1 9 2 2 - 2 2 - 48
S-Montjuic [3] - 1 1 1 - 1 - - - - 1 - 5
Les Corts [0] - - - - - - - - - - - - -
Sarria [5] 4 6 3 - 8 9 1 1 - 3 - - 35
Gràcia [9] - 9 3 7 16 14 4 1 1 3 2 6 66
H-Guinardó [4] 3 3 - - - 1 4 - 1 3 1 - 16
Nou Barris [1] - 1 - - - - 3 - 1 3 - - 8
Sant Andreu [1] 1 - 1 - - - 3 - - 1 - - 6
Sant Martí [5] 1 6 2 1 - 5 1 - - 6 - - 22
Metropolitana [2] - 1 2 - - - - - - - 2 - 5
Total [36] 18 52 16 9 26 42 19 4 3 21 8 6 224
(again assuming a fixed number of selected nominees per nominator and equal non-response) is
influenced by the composition of the zero stage sample.
Analyses of the Barcelonian data showed that:

- female cocaine users are less likely to nominate same gender cocaine users, than male cocaine
(45)
users, as can be seen in figure 3. Among the nominees of female cocaine users 36% are also
female, while among the nominees of male cocaine users 64% are other male cocaine users;
- cocaine users in the middle age ranges of 26-30 years and 31-35 years are more likely to
nominate cocaine users that are of the same age ± 5 years than the group of younger (21-25
years) or older (36-40 years) cocaine users, although this difference is not significant (same
( 46)
figure);
- cocaine users from various areas of residence do not significantly differ with respect to
( 47)
nominating cocaine users from the same area, as shown in fig. 4; and, finally,
- cocaine users from different occupational milieux do differ significantly with respect to the
ratio of nominating other cocaine users from the same occupational milieu. From fig. 5 it can be
seen that cocaine users from the artist/actor, the music, and the white collar milieux are most
( 48)
likely to nominate other cocaine users within the same occupational milieu.
(45)
t-value=-4.12; df=34; p < .001
(46)
F-ratio=1.57; p=.216
(47)
F-ratio=1.02; p=.451
(48)
F-ratio=4.55; p < .01
91
Fig. 3
In sum, although there is some tendency to nominate other cocaine users that are in some
way similar to the nominator (especially for male cocaine users and for cocaine users from the
artist/actor, music, and white collar occupational milieux), in general the nomination procedure
seems to be unbiased, resulting in a varied and diverse pool of cocaine users.
92
Fig. 4
Fig. 5
§ 5.3 NOMINATOR EFFECTS ON NOMINEE-CHARACTERISTICS
Whereas the previous paragraph focused on the extent to which (differences in) look-a-like
nominations occurred, the present paragraph discusses the broader issue of (differences in) the
overall distribution of nominee-characteristics across nominator-categories.
Bias occurs if the distribution of basic sociodemographic variables among nominees
substantially differs across the sociodemographic categories of their nominators. Conversely, if
this distribution among nominees is independent from the (sociodemographic) characteristics of
their nominators, this suggests an unbiased nomination process: nominators with different
background characteristics have equal access to a comparable and larger group of nominees -
again, with respect to the distribution of basic sociodemographics.
Again, gender can best be used to illustrate this. If female and male cocaine users are
(49)
nominating other cocaine users with a similar female/male ratio - as in this study - then the
nomination process is likely to have been unbiased. Moreover, since the pool of nominees is not
affected by the selection of zero stage respondents, the distribution of the nominee-characteristics
in question might well be a valid indicator of the population parameter. Thus, the finding that
both female and male cocaine users in Barcelona nominate 36% female and 64% male cocaine
users suggests a 1:2 female/male ratio in the population.
Similarly, the distribution of the other basic demographic characteristics of the nominees can
be investigated. However, since the sample of cocaine users interviewed in Barcelona is
relatively small, it is not feasible to do this analysis with respect to area of residence and
occupational milieu. With respect to age a positive relation was found between the age of the
( 50)
nominator and the average age of the nominees (s)he referred to (see FIG. 6). Moreover, there
is a general tendency for cocaine users interviewed from differing age groups to regress to the
mean with respect to the average age of the cocaine users nominated: the youngest group of
cocaine users interviewed (21-25 years old) on average refer to older cocaine users (28.6 years),
while the older cocaine users interviewed (36-40 years old) on average nominate younger
cocaine users (33.3 years). Nevertheless, the average age of cocaine users nominated is 31.0
years, a negligible fraction above the average age of the cocaine users interviewed (30.7
(51)
years).
(49)
Both female and male cocaine users nominate approximately a 1:2 female/male ratio (36% female and
64% male cocaine users among the nominees of both female and male respondents; t-value=0.03;
df=34; p=.974)
(50)
F-ratio=4.39; df=32; p < .05
(51)
Since nominators showed a tendency to report the nominee's age in round numbers (as can be seen
from - Domingo and Hartnoll's - figure 7, peaking around 30 compared to 29 or 31, and similarly
at 35, 40 and 45 compared to one year younger or older) the ages of the nominees should be
taken as approximate, and the small age difference with the interviewed sample considered as all
the more unimportant.
94
Fig. 6
Fig. 7
95
§ 5.4 SELECTED NOMINEES VERSUS ALL NOMINEES
If some form of randomization was used in selecting the nominees from all nominees
mentioned by each nominator, then the resulting 1-sth stage respondents should form a
representative sample of the total pool of nominees (assuming that the non-response was
unsystematic). For this to be true, the non-response (or refusal) among selected nominees should
be unsystematic, and the 1-sth stage sample should be sufficiently large. By means of simple
univariate comparisons it can be evaluated whether the randomization indeed resulted in a
statistically representative 1-sth stage sample.
In the Barcelona snowball sampling process, for instance, the 1:2 female/male ratio in the
total pool of nominees was not reflected by the 1-sth stage respondents, in which an approximate
1:1 gender distribution was found. This difference is probably attributable to (a) the somewhat
higher refusal rate among selected males than among selected females (12 versus 8), (b) the fact
that some respondents refused to contact the selected nominee, and, instead, contacted someone
(52)
else, and (c) the small size of the 1-sth sample, which inhibited the randomization process to
work at full power (for the other sociodemographic variables, the comparison of selected
nominees versus the total pool of nominees is all the more hampered by the small size of the 1-sth
stage sample).
§ 5.5 CONCLUSION
As stated in the introduction of this chapter, the researcher is inevitably left with the
uncertainty as to whether the total snowball sample is truly representative of the population from
which it is drawn. This is particularly true for the composition of the zero stage sample.
Concerning the nomination process however, the researcher has several methods to screen for
bias. The line of reasoning followed in this chapter is that if these screening-analyses indicate
substantial bias in the nomination process, the researcher should be very cautious in inferring
from the snowball sample obtained. Conversely, if the analyses show no substantial bias in the
snowball sampling process, the researcher has cumulative support for considering the total
snowball sample as representative. Specifically, the researcher can be fairly sure about the
snowball sample if:
(1)the snowball chains are of sufficient length, ánd

(2)there was no tendency to only nominate "look-a-likes", nor did the ratio of "look-a-like"
nominations substantially differ across the nominator-categories, ánd
(3)the distributions of the variables among the nominees did not substantially differ across the
nominator-categories, ánd
(4)the selected nominees did not substantially differ from the total pool of nominees.
If - as was the case with respect to gender in the Barcelona sample (see table 4) the selected
nominees did differ from the total pool of nominees, this pool of nominees can nevertheless be
(52)
These persons were then interviewed and registered as a new chain, in which they became a zero stage respondent.
However, the female/male distribution among the six cases was exactly 1:2, and, therefore, does not explain the
discrepancy in gender distribution between the 1-sth stage sample and the nominees.
96
considered as providing "best estimates" for the distribution of population parameters. This,
however, is necessarily limited to those nominee characteristics that were provided by the
nominators.
Finally, the researcher can investigate to what extent zero stage respondents and selected
nominees (i.e.: 1-sth stage respondents) are similar or different - with respect to basic
sociodemographics and other (non- or cocaine-) related variables. If the zero stage stage sample
differs substantially from the 1-sth stage sample, the researcher may consider to remove the zero
stage sample from further analysis, since they were selected on the basis of a tentative map
constructed by the (possibly biased) research staff, while the 1-sth sample was randomly selected
out of an unbiased sample of nominees. The resulting (1-sth stage) snowball sample may well be
the best approximation of a representative sample that is feasible in studies in "hidden
populations" from which valid inferences can be made.
Table 4. Basic sociodemographic characteristics of cocaine users interviewed

(zero plus 1-sth stages) and their nominees (in %)
Gender: Sample Nominees Age: Sample Nominees

N=41 N=229 N=41 N=229
Female 46,3 34,5 Average 30,7 31,0
Male 53,7 65,5
Area of Residence: Sample Nominees Occupational mil.: Sample Nominees

N=41 N=224 N=41 N=224
Ciutat Vella 7,3 8,0 Media 4,9 5,3
Eixample 19,5 23,2 Musician 12,2 9,4
Sans-Montjuic 7,3 7,1 Artist/Actor 12,2 13,8
Les Corts 4,0 Restaurant/Bar 7,3 9,8
Sarria 12,2 11,6 Campus 4,9 2,7
Gràcia 22,0 18,7 White Collar 34,1 34,8
Horta-Guinardó 9,8 8,5 Blue Collar 17,1 10,3
Nou Barris 2,4 1,8 Marginal 2,4 6,6
Sant Andreu 2,4 1,3 Unemployed 4,9 2,7
Sant Martí 12,2 9,4
Area Metropol 4,9 3,6
Other 2,7
97
CHAPTER 6
CONCLUSIONS
BY VINCENT M. HENDRIKS, PHD., PETER BLANKEN, PHC., & NICO F.P. ADRIAANS
In the past decade, social scientists have become increasingly aware of the limitations of traditional
survey sampling methods in certain research fields. Among its major weaknesses are its heavy reliance of
quantitative, "thin" descriptions, its high costs, and its low "inclusion-rates" of certain hidden segments of
the population. As these weaknesses have become more apparent in the study of socially or culturally
sensitive topics, the need for alternative sampling schemes has been particularly high in the field of drug
abuse epidemiology.
The object of this study has been to investigate the usefulness of one of these alternative sampling
schemes - snowball sampling - in drug abuse epidemiology. The investigations on the snowball sampling
methodology presented in this report have been both theoretical and practical in intent. Given the still
preliminary nature of the existing "knowledge-base" on both these levels, the link between theory and
practice has been of major interest. In this chapter, the major conclusions concerning snowball sampling's
theory, practical procedures, and data analyses are summarized, and recommendations are given for
future research.
Theory of snowball sampling
On the theoretical level, much progress has been made in the field of social network research, which
has provided some important analytical viewpoints on bias in non-random samples. The current state-of-
the-art conceptual and mathematical models however, are not consistently corroborated by the actual
influence of bias parameters in experiments on "connectedness" and contagion processes. Most
importantly, a systematic theory on bias in non-random sampling that parallels the probabilistic theory on
randomness, is still lacking.
Current theory on connectedness is built on two strong requirements: the individuals who start the
connections should be selected at random, and the targets of the nominator should be equiprobable. In
terms of snowball sampling this means that the zero stage sample should be a random sample, and the
connections between people should be random connections. The question arises how important these
requirements are in practice. In the study of hidden populations, it is very difficult - if not impossible - to
obtain a random zero stage sample. In addition, in real life, connections between people are obviously not
random, but are instead influenced by the social, (sub-) cultural and geographical distance between the
nominator and the nominee. While the influence of these bias parameters is still unclear on the theoretical
level, it is even more puzzling how and to what extent each of these parameters bias a sample in actual
social research situations. The ultimate question as to whether a sample is truly representative of the
population from which it is drawn, cannot be answered. Whereas probabilistic theory provides us with
useful tools to quantitatively estimate bias, with snowball sampling we have to rely on more crude
indications of representativeness.
In the present study, the zero stage sample was not a random sample of the population of cocaine
users, but was instead based on a tentative map of the occurrence of cocaine use in a city. According to
theory, this might result in a restricted (biased) total snowball sample. Data analyses however indicated
that, if the snowball-chains are of sufficient length, the bias in the non-random zero stage sample is
somehow "corrected" for by the nomination process. Consequently, whereas theory suggests that it
is better to start with a large zero stage sample in order to ensure a representative total snowball sample,
the present data suggest that this can better be done by obtaining long snowball chains (i.e., a large 1-sth
stage sample), since this would allow the nomination process to sufficiently correct for the initial bias in the
zero stage sample. If this preliminary conclusion holds true in future research, one of the most limiting
requirements in snowball sampling, that of a random zero stage sample, would be greatly relaxed. At the
same time, this would place even greater emphasis on the quality of the nomination procedures and the
fieldwork involved.
Regarding the fields of application of snowball sampling, it is important to note that the estimation of
population parameters by means of snowball sampling is limited to those characteristics that are obtained
within the sample. Most importantly, if the zero stage and subsequent snowball sampling respondents are
recruited on the basis of the main characteristic under study (in the present study: cocaine use), snowball
sampling cannot yield an estimation of the prevalence of that characteristic (cocaine use) in the
general population, unless it is combined with other techniques. Of these, the nomination technique
and the capture-recapture technique have been discussed. The reliability of estimates produced by the
nomination technique seems to be limited mainly by (a) the fact that respondents have only limited
knowledge about "their" nominees, and (b) its dependence on the accuracy of (treatment, legal, etc.)
registration systems. The major limitation of the capture-recapture technique is its heavy reliance on the
size, independence and representativeness of the two samples involved.
Notwithstanding this limitation, the mere size of a snowball sample consisting of persons who all
possess the same trait of using cocaine, combined with the average number of cocaine users named and
the occurrence of "doubles" (persons who have already been named by others) among the named
persons at each snowball stage, can provide a rough indication of the prevalence of cocaine use in a city.
If for example, the fourth snowball stage already largely consists of doubles, then the size of the total
snowball sample may approach the prevalence in the population. If on the other hand, there are only few
doubles, the prevalence in the population is probably much higher than the snowball sample size.
Snowball sampling procedures
In the study of hidden populations, snowball sampling should be regarded as an "optimal-feasibility"

alternative to non-applicable random sampling schemes. Whereas probabilistic theory provides us with
various standard procedures for randomization, there are no such standards for snowball sampling. Given
this limitation, "good" snowball sampling procedures can only be defined in pragmatic terms: the rigor,
consistency and controllability (or: explicitness) of the sampling procedures followed.
In this study we have presented some guidelines for implementing rigor in the various stages of the
snowball sampling process, depending on the purpose of the use of snowball sampling in a study. First, in
the stage prior to the actual sampling, the "pre-zero" stage, much effort should be directed toward
"mapping" the target populations in the study area, both geographically, subculturally and socially.
Insiders' knowledge is a sine qua non in this stage, as professionals often lack the specific information
and the trust to locate and enter drug users' scenes. The selection and subsequent training of the
fieldworkers is therefore of critical importance. The "field" should be informed about the study, and a
research-alliance should be established with key informants through careful networking.
Second, in the zero stage, the selection of places, times and respondents should be subjected to
randomization if possible. If randomization is used, the sampling fraction should be registered, based on
for example the ratio of number of individuals selected versus the total number of persons entering a
location during a certain time interval.
Third, randomization should also be used in the nomination procedure (again registering the sampling
fraction), unless the study is directed to finding and analyzing structure (friendship, leadership, etc.) in a
group or network. In the latter case it may be advisable to select a nominee on the basis of a hierarchy in
the total list of nominees ("best friend", "second best friend", etc.). If the purpose of "snowballing" is to
obtain a sample that is closest to a random sample, the best choice seems to be to randomly select a
fixed, small number of nominees from all nominees mentioned by a respondent.
Fourth, the organization of the fieldwork is of critical importance for the success of a snowball
100
sampling study. The types and lengths of the snowball chains should be closely monitored in relation to
the milieus and groups covered, and the fieldworkers and research staff should operate in close contact
with each other.
Snowball sampling data analyses
In this study, we have attempted to go beyond the exploratory and descriptive level by providing
various guidelines to quantitatively "screen" for bias in the snowball sampling process that are easily
applicable in future studies. In addition, if substantial differences are found between the characteristics of
the zero stage respondents and the subsequent snowball stages' respondents, removal of the zero stage
group is suggested to enhance the sample's representativeness. Although these methods are necessarily
limited by their ad hoc character and by the basic nature of the variables involved, it minimally provides
the researcher with an indication of the representativeness of the snowball sample.
Given the pilot character of this study and its primary focus on methodology, the substantial results on
cocaine use in the three participating cities should be regarded as tentative; their status is that of
generating hypotheses - as with any small sample study. For example, the Barcelona dataset - which is
regarded as the most reliable in this study - contained only one "marginal" cocaine user, whereas in
Cologne no marginal users were found. Interpretations of the cocaine use data of Barcelona, Paris and
Cologne should therefore be limited to the sample interviewed.
Issues for future research
This pilot study has yielded various interesting insights, practical guidelines, and analyses-strategies
relevant to snowball sampling, but has also raised important questions and hypotheses about its
applicability.
The most central issue clearly refers to the representativeness of a snowball sample. To investigate
this issue in greater detail, future methodology-studies should incorporate both (stratified) random
samples and snowball samples in the same study, allowing for direct comparisons of the distributions of
variables between both methods. An issue that deserves special attention in future research, is the
estimation of population parameters within the context of snowball sampling. Particularly, studies should
focus on the occurrence of "doubles" - both within one snowball-stage sample, and between subsequent
snowball-stage samples - to further analyze the usefulness of "capture-recapture"-like techniques for
estimating prevalence in the population. Regarding the use of the nomination technique for estimating
prevalence, the accuracy of different forms of extrapolations from yes/no treatment ratios should be
further investigated.
Other topics for future research include (a) longitudinal application of snowball sampling within the
same geographical area, using similar inclusion criteria and nomination procedures, and (b) direct
comparisons between (proportional or fixed) random nominee selection, hierarchical nominee selection
("xth person listed") and a condition without any nominee selection (all listed nominees are traced).
Finally, to avoid the problem of empty cells in cross-tabulations (and to minimize bias), much effort
should be directed toward obtaining sufficiently large samples; sample-size is probably an even more
important factor in snowball sampling than in probabilistic sampling methods. As a rough indication, a
snowball sample size of N = 100 in a study as described in this report, would have allowed for much more
in-depth analyses of the data, and would have produced more powerful results.
101
102
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104
APPENDICES
1. Barcelona:
Snowball sampling of cocaine use: Description of minimal information within areas of interest
2. Paris:
Questionnaire cocaine (IREP)
105
APPENDIX 1
SNOWBALL SAMPLING OF COCAINE USE:
DESCRIPTION OF MINIMAL INFORMATION WITHIN AREAS OF INTEREST
Number of the interview:
Number of snowball:
Wave:
Position on the list:
How many on the list:
Name of the fieldworker:
1. Sex:
2. Age:
3. Year of birth:
4. Occupation:Note the respondent's current profession as specific as

possible (e.g.: "Clerk in bank" rather than
"works in bank"). If currently more than one
job, describe the different jobs as specific
as possible. Also note prostitution, dealer,
pimp, etc., if applicable.
5. Nationality:
6. Ethnicity:
7. Marital status:Note whether the respondent is currently married, has

never been married, is divorced, etc.
8. Living situation:Note whether the respondent is living alone, with

partner, with partner and children, with
parents, is homeless, etc.
9. Living area:Note the area (neighbourhood) in the city where the

repondent is currently living.
10. Education:Note the respondent's level of education reached.
11. Initial cocaine use:Note (1) the age of first cocaine use and (2) the
year of first cocaine use.
12. Initiation circumstance:Ask how it came about the first use of cocaine
106
(e.g. who, where, use of other drugs,
personal circumstances at the time, etc.).
13. History of cocaine use:Ask the respondent what happened with cocaine
use since the beginning (e.g.: has there been
a general increase, when was the period of
heaviest use, first increase, then decrease,
use of other drugs, etc.)
14. Current cocaine use:Ask the respondent (1) number of days of cocaine
use in last month, (2) route of
administration, (3) quantity on days that
cocaine was used.
15. Broad pattern of use:Ask wheter the respondent currently, typically

uses cocaine in binges, steady or
occassionally.
16. Current circumstance:Ask about the circumstances in which cocaine is

currently used (e.g.: who, where, personal
current circumstances, etc.).
17. Other substances:Ask for (1) what other drugs the respondent has used
during the past month, and (2) in what
frequency, and (3) route of administration of
currently used other drugs, and whether the
repondent is currently addicted to heroin.
18. Motivation:Ask if respondent thinks that reasons for using cocaine have
changed since they first used.
19. Money on cocaine(1) money spent on cocaine per week, and (2) what price
normally paid for cocaine per gram.
20. Source of cocaine:Ask the respondent where did he get his cocaine
during the last month (e.g.: from a friend,
from a dealer, from a friend of a friend,
etc.).
21. Problems:Any serious problems they have experienced associated with

cocaine use. Prompt for physical, employment,
financial, family, legal, social,
psychological.
22. No. cocaine users known:Prompt for social milieus & professions.
107
APPENDIX 2
109
INDEX
INDEX
1st stage 28
1-sth stage 83, 86, 94-95, 98 Data analysis 9, 65, 97-99
Data collection 10, 16, 32, 35, 51, 54, 56, 67
Analyzing structure 24, 99 Distribution 20-21, 23, 37, 65, 68-69, 83
Approximation 68, 95 86-88, 92, 94-95
Axon density 18
Axon tracings 19 Epidemiology 9, 12-15, 97, 102-103
Error 22, 28
Between snowballs 86 Exploration 25, 32
Bias 17-21, 23, 26, 28, 83, 86-87, 92, 94 explorative 22-23, 83
97-100 qualitative 9, 14, 22, 25, 51, 56, 83
bias parameters 17-18, 97 quantitative 9, 14, 22, 25, 97
distance 18-19, 87, 97 Extrapolations 26, 48, 100
error 22, 28
force field bias 19 Fieldnotes 31, 35
island model 19, 86 Fieldwork 9-10, 22, 25, 30-31, 33-35, 60
nominator effects 83, 92 98-99
overlapping acquaintance circles 19 fieldwork-procedures 25, 33
reciproke 19 fieldwork-team 30
reflexive bias 19 insider knowledge 23
screen for bias 94 organization of the fieldwork 30, 35, 99
sibling 19 preparation of the field 31
similarity bias 86-87 recruitment 16, 31
sources of bias 17, 19, 83 selection and training 29, 56
structural bias 21 training 9, 16, 29, 31, 33, 56, 99
systematic 18, 86, 97 Fieldworker(s) 16, 29-33, 35, 54, 56, 61
tendency 87-88, 90, 92, 94 99, 105
unbiased 18, 24, 90, 92, 95 Fixed random selection 24
unsystematic 94 Future research 97-98, 100
Capture-recapture 26-28, 98, 100 General population 11, 13-14, 38-39, 47-48
Case-finding 26, 35 50, 62, 98
intensive case-finding 26
Chain 16, 22, 24-25, 34, 54, 84, 86, 94 Hidden populations 28-29, 83, 95, 97, 99
chain-length 84 floating populations 13-14
chain referral 16 hidden 13, 26, 28-29, 54, 83, 95, 97
City-level epidemiology 14 99, 102
Cocaine seizures 11-12 hidden groups 26
Cocaine users interviewed 57-58, 61-62, 65 hidden segments 97
67-72, 75-76, 78, 80-81, 84, 86, 88, 92, 95 segments 11, 13, 97
Contagion 18, 97 Hierarchical backward selection 24
Correlates 13, 15, 65, 76 Hierarchical forward selection 24
111
selected nominees 24-25, 87, 89, 94, 95
Incidence 9, 12, 14-15, 38, 41, 44, 65, 67 selected nominees 24-25
Inclusion-rates 97 Nomination techniques 26, 86-88, 92, 94
Inferences from sample to population 25, 83 Nominator 24, 33, 83, 86-90, 92, 94-95, 97
Inferring 87, 94 nominator effects 83, 92
Initial sample 28 nominator-characteristics 83
Insider knowledge 23 Nominees 10, 16, 23-28, 33-34, 60, 83
Interview(s) 16, 21, 30-35, 54, 56, 60, 68 86-89, 92, 94-95, 98-100
71-72, 75, 78, 80, 105 doubles 25, 28, 86, 98, 100
Interviewees 58, 61-62, 65, 67-68, 76, 78, 88 duplications 86
Island model 19, 86 group of nominees 92
look-a-likes 83, 86-88, 92, 94
Leadership 20, 24, 99, 103 nominee-characteristics 83, 92
Longitudinal 100 nominee selection 100
Look-a-like 83, 86-88, 92, 94 number of nominees 23-25, 27, 86, 99
similarity bias 86-87 pool of nominees 24, 83, 92, 94-95
selected nominees 24-25, 87, 89, 94-95
Monitoring systems 13, 15 Non-random 17-18, 97-98
Non-representative 86
Network 18, 24, 28, 32, 38, 86, 97, 99, 103 Non-response 48, 87, 89, 94
closed 14, 49, 59-60, 86 Null hypothesis 20-21, 26
connected 18-19, 30, 86, 88
connectedness 18-19, 97 Population 11, 13-14, 17-28, 37-41, 44
connections 19, 86, 97 47-48, 50-52, 62, 78, 83, 86, 88
densely connected 88 92, 94-95, 97-98, 100,
geographic distance 87 Population parameters 18, 24-25, 88, 92, 95
random net 19-21, 26 98, 100
social distance 19, 87 Pre-zero stage 32
social network 18, 86, 97, 103 (tentative) map 23, 29, 32, 83, 95, 98
social network relationships 86 pre-zero 28, 32, 99
Nomination procedures Prevalence 9, 11-15, 22, 25-28, 38, 40-41
fixed number 87, 89 47-48, 51, 78, 80-81, 98, 100, 102-103
fixed random selection 24 Prevalence estimation 25
hierarchical backward selection 24 capture-recapture 26-28, 98, 100
hierarchical forward selection 24 drug-related deaths 39, 44
nominate(d) 10, 16, 21, 25-27, 33, 35 extrapolations 26, 48, 100
86-90, 92, 94 household 11, 13, 22, 103
nominating 16, 18, 26, 86, 88-89, 92 indirect indicators 38-39, 41
nominating look-a-likes 86 monitoring systems 13, 15
nomination(s) 18-19, 24-26, 34, 83 national indicators 41
86-88, 90, 92, 94, 98-100 population parameters 18, 24-25, 88
nomination process 19, 24-25, 83 92, 95, 98, 100
86-88, 92, 94, 98 population prevalence 25, 102
nomination techniques 26, 86-88, 92, 94 Proportional random selection 24
nominee selection 100
number of nominees 23-25, 27, 86, 99 Random 17-21, 23-24, 26-27, 33, 83, 86
proportional random selection 24 97-100, 103
randomly selected 18, 23, 34-35, 95 random(ized) model 19-20, 23-24, 83
referral criteria 83 random net 19-21, 26
112
randomization 16, 20, 23-25, 32, 83 Snowball sample 16, 18, 20-22, 24, 26, 32
94, 99 38, 83, 86-88, 94-95, 98-100
randomized model 19, 24 composition of the zero stage sample
randomly selected 18, 23, 34-35, 95 83, 89, 94
randomness 18, 21, 26, 28, 97 initial sample 28
Ratio 18, 20, 26-27, 62, 65, 68, 70, 72-73 snowball sampling process 23-24, 83, 94
76, 78, 81, 84, 87-89, 92, 94, 99 99
Refer 22, 48-49, 86, 88, 92 total snowball sample 24, 26, 32, 87-88
Referral criteria 83 94, 98
Refusal rate 94 zero stage sample 20, 22-26, 28, 32, 83
Reliability 98 89, 94-95, 97-98
Reliable 30, 38-39, 68, 100 Snowball sampling 9, 10, 15, 17-18, 20-26
Reliably 65, 75 28-32, 35, 51, 83, 86, 94
Representative 17, 49, 78, 83, 86, 94-95, 98 97-100, 102, 104, 105
statistically representative 83, 94 theory on snowball sampling 17, 20, 23
Representativeness 48, 83, 98-100 97
utility of snowball sampling 22
Sample size 18, 20, 23, 25, 27-28, 32 Snowball stage 98
98, 100 1st stage 28
Sampling 9-10, 13, 15, 17-18, 20-26, 28-32 1-sth stage 83, 86, 94-95, 98
35, 38, 48, 51, 62, 69, 78, 83, 86 1-sth stage respondents 86, 94-95
94, 97-100, 102-105 composition of the zero stage sample
alternative sampling 97 83, 89, 94
equiprobable 18, 97 initial sample 28
probabilistic 17-18, 97-100, 103 snowball stages 35, 99
probability 18-20, 23, 48, 83, 86 zero stage 16, 18, 20, 22-26, 28, 32
probability sample 18, 20, 83 34-35, 83-84, 86-87, 89
probability sampling 23, 83 92, 94-95, 97-99
random(ized) model 19-20, 23-24, 83 Sociodemographics 34, 86, 92, 94-95
randomization 16, 20, 23-25, 32, 83 background characteristics 25, 92
94, 99 basic (socio)demographics 86-87, 92, 95
sampling fraction 18, 99 Statistical inference 23
school 13-14, 19-20, 23, 29, 34, 38, 48 Survey 11, 14, 38-41, 47-48, 53, 97
snowball sampling 9-10, 15, 17-18 102-103
20-26, 28-32, 35, 51, 83, 86
94, 97-100, 102, 104-105 Target group 13-14, 24
stratified (random sampling) 23, 100 target population 20
survey 11, 14, 38-41, 47-48, 53, 97
102-103 Valid inferences 95
Screening 9, 20-21, 94 Validity 14, 23, 29, 87, 83
screen (for bias) 94 face validity 23, 29, 83
Snowball chain 25, 86
chain 16, 22, 24-25, 34, 54, 84, 86, 94 Within snowballs 86
chain-length 84
chain referral 16 Zero stage 16, 18, 20, 22-26, 28, 32, 34-35
extincted 16, 86 83-84, 86-87, 89, 92, 94-95, 97-99
length 20, 35, 68-70, 83-84, 94, 98-99 composition of the zero stage sample
snowball chains 24-25, 32, 35, 83-84 83, 89, 94
86, 94, 98-99 initial sample 23, 28, 32-33
113
non-random zero stage 98
selected zero stage group 87
selection of zero stage respondents
86, 92
starter points 23, 33, 84
target group 13-14, 24
zero stage respondents 83-84, 86, 92
94-95, 99
zero stage sample 20, 22-26, 28, 32, 83
89, 94-95, 97-98
114
INDEX
1st stage 28
1-sth stage 83, 86, 94-95, 98 Data analysis 9, 65, 97-99
Data collection 10, 16, 32, 35, 51, 54, 56, 67
Analyzing structure 24, 99 Distribution 20-21, 23, 37, 65, 68-69, 83
Approximation 68, 95 86-88, 92, 94-95
Axon density 18
Axon tracings 19 Epidemiology 9, 12-15, 97, 102-103
Error 22, 28
Between snowballs 86 Exploration 25, 32
Bias 17-21, 23, 26, 28, 83, 86-87, 92, 94 explorative 22-23, 83
97-100 qualitative 9, 14, 22, 25, 51, 56, 83
bias parameters 17-18, 97 quantitative 9, 14, 22, 25, 97
distance 18-19, 87, 97 Extrapolations 26, 48, 100
error 22, 28
force field bias 19 Fieldnotes 31, 35
island model 19, 86 Fieldwork 9-10, 22, 25, 30-31, 33-35, 60
nominator effects 83, 92 98-99
overlapping acquaintance circles 19 fieldwork-procedures 25, 33
reciproke 19 fieldwork-team 30
reflexive bias 19 insider knowledge 23
screen for bias 94 organization of the fieldwork 30, 35, 99
sibling 19 preparation of the field 31
similarity bias 86-87 recruitment 16, 31
sources of bias 17, 19, 83 selection and training 29, 56
structural bias 21 training 9, 16, 29, 31, 33, 56, 99
systematic 18, 86, 97 Fieldworker(s) 16, 29-33, 35, 54, 56, 61
tendency 87-88, 90, 92, 94 99, 105
unbiased 18, 24, 90, 92, 95 Fixed random selection 24
unsystematic 94 Future research 97-98, 100
Capture-recapture 26-28, 98, 100 General population 11, 13-14, 38-39, 47-48
Case-finding 26, 35 50, 62, 98
intensive case-finding 26
Chain 16, 22, 24-25, 34, 54, 84, 86, 94 Hidden populations 28-29, 83, 95, 97, 99
chain-length 84 floating populations 13-14
chain referral 16 hidden 13, 26, 28-29, 54, 83, 95, 97
City-level epidemiology 14 99, 102
Cocaine seizures 11-12 hidden groups 26
Cocaine users interviewed 57-58, 61-62, 65 hidden segments 97
67-72, 75-76, 78, 80-81, 84, 86, 88, 92, 95 segments 11, 13, 97
Contagion 18, 97 Hierarchical backward selection 24
Correlates 13, 15, 65, 76 Hierarchical forward selection 24
112
number of nominees 23-25, 27, 86, 99
Incidence 9, 12, 14-15, 38, 41, 44, 65, 67 proportional random selection 24
Inclusion-rates 97 randomly selected 18, 23, 34-35, 95
Inferences from sample to population 25, 83 referral criteria 83
Inferring 87, 94 selected nominees 24-25, 87, 89, 94, 95
Initial sample 28 selected nominees 24-25
Insider knowledge 23 Nomination techniques 26, 86-88, 92, 94
Interview(s) 16, 21, 30-35, 54, 56, 60, 68 Nominator 24, 33, 83, 86-90, 92, 94-95, 97
71-72, 75, 78, 80, 105 nominator effects 83, 92
Interviewees 58, 61-62, 65, 67-68, 76, 78, 88 nominator-characteristics 83
Island model 19, 86 Nominees 10, 16, 23-28, 33-34, 60, 83
86-89, 92, 94-95, 98-100
Leadership 20, 24, 99, 103 doubles 25, 28, 86, 98, 100
Longitudinal 100 duplications 86
Look-a-like 83, 86-88, 92, 94 group of nominees 92
similarity bias 86-87 look-a-likes 83, 86-88, 92, 94
nominee-characteristics 83, 92
Monitoring systems 13, 15 nominee selection 100
number of nominees 23-25, 27, 86, 99
Network 18, 24, 28, 32, 38, 86, 97, 99, 103 pool of nominees 24, 83, 92, 94-95
closed 14, 49, 59-60, 86 selected nominees 24-25, 87, 89, 94-95
connected 18-19, 30, 86, 88 Non-random 17-18, 97-98
connectedness 18-19, 97 Non-representative 86
connections 19, 86, 97 Non-response 48, 87, 89, 94
densely connected 88 Null hypothesis 20-21, 26
geographic distance 87
random net 19-21, 26 Population 11, 13-14, 17-28, 37-41, 44
social distance 19, 87 47-48, 50-52, 62, 78, 83, 86, 88
social network 18, 86, 97, 103 92, 94-95, 97-98, 100,
social network relationships 86 Population parameters 18, 24-25, 88, 92, 95
Nomination procedures 98, 100
fixed number 87, 89 Pre-zero stage 32
fixed random selection 24 (tentative) map 23, 29, 32, 83, 95, 98
hierarchical backward selection 24 pre-zero 28, 32, 99
hierarchical forward selection 24 Prevalence 9, 11-15, 22, 25-28, 38, 40-41
nominate(d) 10, 16, 21, 25-27, 33, 35 47-48, 51, 78, 80-81, 98, 100, 102-103
86-90, 92, 94 Prevalence estimation 25
nominating 16, 18, 26, 86, 88-89, 92 capture-recapture 26-28, 98, 100
nominating look-a-likes 86 drug-related deaths 39, 44
nomination(s) 18-19, 24-26, 34, 83 extrapolations 26, 48, 100
86-88, 90, 92, 94, 98-100 household 11, 13, 22, 103
nomination process 19, 24-25, 83 indirect indicators 38-39, 41
86-88, 92, 94, 98 monitoring systems 13, 15
nomination techniques 26, 86-88, 92, 94 national indicators 41
nominee selection 100
113
population parameters 18, 24-25, 88 stratified (random sampling) 23, 100
92, 95, 98, 100 survey 11, 14, 38-41, 47-48, 53, 97
population prevalence 25, 102 102-103
Proportional random selection 24 Screening 9, 20-21, 94
screen (for bias) 94
Random 17-21, 23-24, 26-27, 33, 83, 86 Snowball chain 25, 86
97-100, 103 chain 16, 22, 24-25, 34, 54, 84, 86, 94
random(ized) model 19-20, 23-24, 83 chain-length 84
random net 19-21, 26 chain referral 16
randomization 16, 20, 23-25, 32, 83 extincted 16, 86
94, 99 length 20, 35, 68-70, 83-84, 94, 98-99
randomized model 19, 24 snowball chains 24-25, 32, 35, 83-84
randomly selected 18, 23, 34-35, 95 86, 94, 98-99
randomness 18, 21, 26, 28, 97 Snowball sample 16, 18, 20-22, 24, 26, 32
Ratio 18, 20, 26-27, 62, 65, 68, 70, 72-73 38, 83, 86-88, 94-95, 98-100
76, 78, 81, 84, 87-89, 92, 94, 99 composition of the zero stage sample
Refer 22, 48-49, 86, 88, 92 83, 89, 94
Referral criteria 83 initial sample 28
Refusal rate 94 snowball sampling process 23-24, 83, 94
Reliability 98 99
Reliable 30, 38-39, 68, 100 total snowball sample 24, 26, 32, 87-88
Reliably 65, 75 94, 98
Representative 17, 49, 78, 83, 86, 94-95, 98 zero stage sample 20, 22-26, 28, 32, 83
statistically representative 83, 94 89, 94-95, 97-98
Representativeness 48, 83, 98-100 Snowball sampling 9, 10, 15, 17-18, 20-26
28-32, 35, 51, 83, 86, 94
Sample size 18, 20, 23, 25, 27-28, 32 97-100, 102, 104, 105
98, 100 theory on snowball sampling 17, 20, 23
Sampling 9-10, 13, 15, 17-18, 20-26, 28-32 97
35, 38, 48, 51, 62, 69, 78, 83, 86 utility of snowball sampling 22
94, 97-100, 102-105 Snowball stage 98
st
alternative sampling 97 1 stage 28
equiprobable 18, 97 1-sth stage 83, 86, 94-95, 98
probabilistic 17-18, 97-100, 103 1-sth stage respondents 86, 94-95
probability 18-20, 23, 48, 83, 86 composition of the zero stage sample
probability sample 18, 20, 83 83, 89, 94
probability sampling 23, 83 initial sample 28
random(ized) model 19-20, 23-24, 83 snowball stages 35, 99
randomization 16, 20, 23-25, 32, 83 zero stage 16, 18, 20, 22-26, 28, 32
94, 99 34-35, 83-84, 86-87, 89
sampling fraction 18, 99 92, 94-95, 97-99
school 13-14, 19-20, 23, 29, 34, 38, 48 Sociodemographics 34, 86, 92, 94-95
snowball sampling 9-10, 15, 17-18 background characteristics 25, 92
20-26, 28-32, 35, 51, 83, 86 basic (socio)demographics 86-87, 92, 95
94, 97-100, 102, 104-105 Statistical inference 23
114
Survey 11, 14, 38-41, 47-48, 53, 97
102-103
Target group 13-14, 24

target population 20
Valid inferences 95
Validity 14, 23, 29, 87, 83
face validity 23, 29, 83
Within snowballs 86
Zero stage 16, 18, 20, 22-26, 28, 32, 34-35

83-84, 86-87, 89, 92, 94-95, 97-99
composition of the zero stage sample
83, 89, 94
initial sample 23, 28, 32-33
non-random zero stage 98
selected zero stage group 87
selection of zero stage respondents
86, 92
starter points 23, 33, 84
target group 13-14, 24
zero stage respondents 83-84, 86, 92
94-95, 99
zero stage sample 20, 22-26, 28, 32, 83
89, 94-95, 97-98
115
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Snowball sampling: Theoretical and practical considerations

Article · January 1992

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VINCENT M. HENDRIKS, PHD.

CIP-GEGEVENS KONINKLIJKE BIBLIOTHEEK, DEN HAAG

Hendriks, Vincent M., Blanken, Peter, & Adriaans, Nico F.P.

VINCENT M. HENDRIKS, PHD., PETER BLANKEN, PHC.,

ANTONIA DOMINGO, PHD., & RICHARD HARTNOLL, PHD.

RODOLPHE INGOLD, PHD., MOHAMED TOUSSIRT, PHC.,

DIETER KORCZAK, PHD.

Chapter 1. Introduction ....................................................................................................... 9

§ 1.1 Context of the study ................................................................................................... 9

Chapter 2. Snowball-sampling: .................................................................................... 17

§ 2.1 Theory on snowball sampling ................................................................................... 17

Chapter 3. Description of cities and samples .................................................... 37

§ 3.1 Barcelona ................................................................................................................... 37

EUROPEAN ADDICTION RESEARCH INSTITUTE (IVO)

§ 4.1 History of cocaine use ............................................................................................... 65

Chapter 5. Snowball sampling: Methodological analysis ......................... 85

§ 5.1 The lengths of the snowball chains .......................................................................... 86

Chapter 6. Conclusions ...................................................................................................... 99

Literature ............................................................................................................. 104

Appendices ....................................................................................................... 106

Index ...................................................................................................................... 113

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§ 1.1 CONTEXT OF THE STUDY

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§ 1.2 THEORETICAL BACKGROUND

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§ 1.2.2 RECENT TRENDS

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§ 1.3 RESEARCH QUESTIONS AND METHODOLOGY

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§ 2.1 THEORY ON SNOWBALL SAMPLING

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In an attempt to synthesize the fundamental work of Goodman on snowball sampling and

(a) the total sample size, given k (names) and s (stages);

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Although we have to be extremely conservative in interpreting the relevance of these models

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-finding respondents and starting referral chains;

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The zero stage sample

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In the context of snowball sampling, the estimation of a population prevalence parameter

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The capture-recapture technique

§ 2.2 THE PRACTICE OF SNOWBALL SAMPLING(3)

§ 2.2.1 THE "PRE-ZERO" STAGE

The initial model

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1.the movie-, art-, TV-, press-, and theater-milieu,

1.the artists/actors milieu,