I S

MT

80

Substance Use, Violence, and Unintentional Injuryin Young Holidaymakers Visiting Mediterranean Destinations

Karen Hughes, MPhil,∗ Mark A. Bellis, DSc,∗ Amador Calafat, MD,† Nicole Blay, BSc,†

Anna Kokkevi, PhD,‡ George Boyiadji, MA,§ Maria do Rosario Mendes, MPsych,‖and Lubomira Bajcarova, BSc¶

∗Centre for Public Health, Liverpool John Moores University, Liverpool, UK; †European Institute of Studies on Prevention(Irefrea), Palma de Mallorca, Spain; ‡Athens University Medical School and University Mental Health Research Institute,Athens, Greece; §Open Therapeutic Community of Addicted Persons ‘TOLMI,’ Larnaca, Cyprus; ‖European Instituteof Studies on Prevention, IREFREA Portugal, Coimbra, Portugal; ¶European Institute of Studies on Prevention,IREFREA Italia, Venice, Italy

DOI: 10.1111/j.1708-8305.2010.00489.x

Background. Young people’s alcohol and drug use increases during holidays. Despite strong associations between substance useand both violence and unintentional injury, little is known about this relationship in young people holidaying abroad. We examinehow risks of violence and unintentional injury abroad relate to substance use and the effects of nationality and holiday destinationon these relationships.Methods. A cross-sectional comparative survey of 6,502 British and German holidaymakers aged 16 to 35 years was undertakenin airports in Cyprus, Greece, Italy, Portugal, and Spain.Results. Overall, 3.8% of participants reported having been in a physical fight (violence) on holiday and 5.9% reportedunintentional injury. Two thirds reported having been drunk on holiday and over 10% using illicit drugs. Levels of drunkenness,drug use, violence, and unintentional injury all varied with nationality and holiday destination. Violence was independentlyassociated with being male, choosing the destination for its nightlife, staying 8 to 14 days, smoking and using drugs on holiday,frequent drunkenness, and visiting Majorca (both nationalities) or Crete (British only). Predictors of unintentional injury werebeing male, younger, using drugs other than just cannabis on holiday, frequent drunkenness, and visiting Crete (both nationalities).Conclusions. Violence and unintentional injury are substantial risks for patrons of international resorts offering a hedonisticnightlife. Understanding those characteristics of resorts and their visitors most closely associated with such risks should helpinform prevention initiatives that protect both the health of tourists and the economy of resorts marketed as safe and enjoyableplaces to visit.

Unintentional injuries and interpersonal violenceare the leading causes of mortality and morbidity

in young Europeans.1 Among 15- to 29-year-olds acrossEurope, they accounted for over 100,000 deaths and5 million disability-adjusted life years lost in 2004,around 85% of which were due to unintentionalinjury.2 Both unintentional injury and violence arestrongly associated with substance use. For example,

Selected results from this study were presented at the 6thInternational Conference on Substance Use, Nightlife andRelated Health Issues, Zurich, Switzerland, June 7 to 9, 2010,and at the 10th World Conference on Injury Prevention andSafety Promotion, London, UK, September 21 to 24, 2010.

Corresponding Author: Karen Hughes, MPhil, Centre forPublic Health, Liverpool John Moores University, HenryCotton Campus, 15-21 Webster Street, Liverpool L3 2ET,UK. E-mail: k.e.hughes@ljmu.ac.uk

alcohol and drug use can cause physical and cognitiveimpairment that can increase vulnerability to bothunintentional injury and violence.3,4 Alcohol has a dose-responsive relationship with injury with the amount ofalcohol consumed increasing risks;5 relationships appearstrongest for violent injuries and for unintentionalinjuries such as falls.5–7 Different types of illicitdrugs have different effects, and understanding of therelationships between drug use and both violent andunintentional injuries is less well established. However,illicit drugs are commonly detected in drug tests ofinjured subjects8,9 and use of drugs such as cocaine andamphetamines in particular has been associated withviolence.3,10,11

Most substance use among young Europeansoccurs at weekend nights in recreational nightlifeenvironments.12–14 As such, these can be peak times andlocations for violence and unintentional injury.15–18 InEngland and Wales, eg, one fifth of all violence occurs

© 2011 International Society of Travel Medicine, 1195-1982Journal of Travel Medicine 2011; Volume 18 (Issue 2): 80–89

Substance Use, Violence, and Injury in Holidaymakers 81

in and around nightlife premises19 and alcohol-relatedinjuries, both intentional and unintentional, place a largeburden on health services at weekend nights.20 Everysummer millions of young Europeans take vacationsin foreign holiday resorts, where they can partake innightlife and substance use on a nightly basis. Researchhas shown that young people’s alcohol and drug useincreases during holidays abroad, along with other formsof risk taking (eg, sexual behavior).21–26 Despite this,few studies have explored injury and violence amongyoung holidaymakers. One study calculated that, acrossall ages, injuries sustained by nondomestic tourists inEuropean Union countries accounted for an estimated3,800 deaths, 83,000 hospital admissions, and 280,000emergency department treatments annually.27 In theGreek island of Corfu, one in five injury patientsadmitted to hospital in the 1996 summer season weretourists,28 whereas in Crete, foreign visitors werefound to account for one in three road traffic injurypatients with around one in five attributed to alcoholuse.29

Health treatment data provide useful information onthe health issues faced by young tourists abroad andthe burden these place on local resources. However,they provide no indication of the prevalence of violenceor unintentional injury in holidaymakers, with only themost serious injuries resulting in hospital admission.30

A study in Spain found that almost 7% of youngEuropean holidaymakers surveyed in Ibiza and Majorcahad experienced unintentional injury during theirstay and over 4% had been involved in a fight.10

Levels of substance use, violence, and unintentionalinjury varied between both holiday destinations andnationalities surveyed.10,21,31 Spain is just one of theseveral Mediterranean countries with holiday resortspopular among young Europeans. To better understandthe risks of injury in different destinations and factorsassociated with violence and unintentional injury inholidaymakers, we conducted a cross-sectional study of6,502 British and German holidaymakers visiting fivedifferent Mediterranean destinations in the summer of2009: Greece, Cyprus, Italy, Portugal, and Spain.

Methods

A short anonymous questionnaire was developed basedon the established research tools.10 The questionnaireexplored holidaymakers’ characteristics; reasons forchoosing their holiday destination; substance use onholiday and normal use at home; frequency of barand nightclub use on holiday; and negative holidayexperiences, including whether they, personally, hadbeen injured in an accident (here, unintentional injury)or involved in a physical fight (here, violence). Priorto the question on physical fighting, separate questionsasked if participants had been physically or verballythreatened, or involved in an argument, to distinguishbetween physical fighting (violence) and other forms

of aggression (threats and arguments; not analyzedhere).

Experienced researchers were recruited in each studysite and trained to implement the surveys. The surveytook place in the departure areas of airports in Palmade Mallorca, Spain; Faro, Portugal; Venice (Trevisoand Marco Polo airports), Italy; Crete (Heraklionairport), Greece; and Larnaca, Cyprus. The Britishand German holidaymakers were selected as the targetpopulation as these two nationalities accounted forthe highest proportions of international visitors usingeach airport in the study. Despite serving severalbeach resorts, Venice may represent a different type ofholiday destination than the other locations. However,its inclusion allows a comparison of behaviors andoutcomes with those experienced by young touristsvisiting traditional beach destinations.

Data collection took place between July 10 andAugust 30, 2009, covering peak summer holiday periods.Researchers approached all individuals who appeared tobe aged 16 to 35 years and traveling without childrenor older relatives, who were waiting to check in forflights bound for the UK or Germany. On the basis ofprevious studies,10,22 a target sample of 700 individualsof each nationality was set for each location. Overall,11,417 individuals were approached and asked if theyhad time to complete a short survey. Of these, 35.3%(n = 4,026) declined before being provided with anysurvey details. Those stating they had time were givenan explanation of the survey, assured of its anonymityand confidentiality, and asked if they would be willing toparticipate. At this stage, compliance was 92.5% (6,834of 7,391). Those agreeing to participate were handed aquestionnaire, clip-board, pen, and envelope and askedto self-complete the questionnaire and seal it in theenvelope for collection by researchers.

Completed questionnaires were returned to theUK and entered into a database using SPSS v15.At this point, 332 questionnaires were excluded dueto participants being outside the target age range ornationality, or for questionnaires being incomplete ordefaced. The final sample was 6,502. Target sampleswere achieved in all locations with the exceptionof German holidaymakers in Crete and Portugal(Table 1). Analyses used chi-squared, with backwardconditional logistic regression used to identify factorsindependently associated with unintentional injury andviolence on holiday. To distinguish between types ofillicit drugs used at home and on holiday, individualswere categorized as nondrug users, users of cannabisonly, and users of other illicit drugs [ecstasy, cocaine,amphetamine, ketamine, and gammahydroxybutyrate(GHB)] in each location. Individuals who used cannabisas well as other drugs were included in the ‘‘other illicitdrugs’’ category only. Those who reported having usedalcohol or drugs during the last 12 months at homewere classified as current home users.

J Travel Med 2011; 18: 80–89

82 Hughes et al.

Tab

le1

Par

ticip

antd

emog

raph

icsa

ndsu

bsta

nce

use

atho

me

byna

tiona

lity

and

holid

aylo

catio

n

Bri

tish

holid

aym

aker

sG

erm

anho

liday

mak

ers

pbe

twee

nna

tiona

litie

sin

All

All

Maj

orca

Ital

yC

rete

Cyp

rus

Port

ugal

p†A

llM

ajor

caIt

aly

Cre

teC

ypru

sP

ortu

gal

p†A

llM

ajor

caIt

aly

Cre

teC

ypru

sP

ortu

gal

N65

0237

1370

276

477

773

673

4—

2789

715

720

301

764

289

——

——

——

—

Gen

der

Mal

e48

.545

.348

.438

.644

.751

.943

.5—

52.7

59.7

40.6

55.1

58.2

48.1

——

——

——

—Fe

mal

e51

.554

.751

.661

.455

.348

.156

.5**

*47

.340

.359

.444

.941

.851

.9**

***

*∗∗

∗0.

444

∗∗∗

0.17

9

Age

16–1

937

.544

.867

.439

.559

.618

.639

.5—

27.8

58.0

23.3

15.9

11.8

18.3

——

——

——

—20

–25

37.6

35.8

29.8

32.5

35.1

43.5

38.0

—39

.933

.731

.749

.846

.348

.8—

——

——

——

26–3

524

.919

.42.

828

.05.

337

.922

.5**

*32

.38.

345

.034

.241

.932

.9**

***

***

***

***

***

***

Fina

ncia

llev

elH

igh

5.0

6.7

4.1

14.9

6.6

0.5

6.9

—2.

75.

22.

23.

70.

32.

8—

——

——

——

Med

ium

high

14.4

16.4

18.8

22.4

14.2

4.5

22.1

—11

.813

.19.

723

.63.

523

.2—

——

——

——

Med

ium

46.2

41.4

36.5

38.9

39.4

54.6

37.9

—52

.654

.156

.552

.549

.547

.4—

——

——

——

Med

ium

low

19.5

18.3

18.2

10.7

14.8

34.4

13.6

—21

.111

.216

.39.

042

.513

.5—

——

——

——

Low

7.0

8.4

9.7

8.9

10.7

5.7

6.9

—5.

26.

37.

51.

34.

13.

5—

——

——

——

Not

stat

ed7.

98.

812

.74.

214

.40.

312

.5**

*6.

710

.17.

810

.00.

19.

7**

***

***

***

***

**

**

Hom

esu

bsta

nce

use‡

Alc

ohol

(%us

e)95

.395

.697

.492

.897

.099

.391

.6**

*94

.994

.790

.198

.310

0.0

89.8

***

0.17

4*

0.07

00.

217

*0.

371

Tob

acco

(%us

e)48

.045

.836

.452

.044

.260

.635

.0**

*50

.847

.833

.949

.568

.354

.2**

***

***

***

*0.

118

****

*Il

licit

drug

sus

edN

one

79.8

77.0

81.4

71.1

83.0

66.2

83.9

—83

.690

.391

.797

.067

.077

.1—

——

——

——

Can

nabi

sonl

y12

.113

.29.

725

.98.

210

.911

.2—

10.5

7.7

7.4

2.3

17.3

15.8

——

——

——

—O

ther

illic

itdr

ugs§

8.1

9.7

8.9

3.0

8.8

23.0

4.9

***

5.9

2.0

1.0

0.7

15.7

7.0

***

***

***

***

***

***

*

GH

B=

gam

mah

ydro

xybu

tyra

te.

† pbe

twee

nlo

catio

nsw

ithin

natio

nalit

ies.

‡ Hav

eus

edat

leas

tonc

ein

the

last

12m

onth

s.§ I

nclu

ding

ecst

asy,

coca

ine,

amph

etam

ines

,ket

amin

e,an

dG

HB

∗ p<

0.05

,∗∗p

<0.

01,∗∗

∗ p<

0.00

1.

J Travel Med 2011; 18: 80–89

Substance Use, Violence, and Injury in Holidaymakers 83

Results

Samples varied by gender, age, and self-defined financiallevel, with a greater proportion of females recruitedin Italy and a younger sample obtained in Majorca(Table 1). The vast majority of participants were currentalcohol users (used at home in the 12 months prior tothe holiday), with home alcohol use lowest among thosevisiting Italy or Portugal. Almost half of the participantswere current home smokers and one in five reportedillicit drug use at home. Overall, higher levels of homedrug use were seen in British holidaymakers and invisitors to Cyprus.

Across all participants, the most common reasons forchoice of holiday destination were weather (58.8%)and nightlife (51.5%) (Table 2; participants couldselect more than one option). However, reasons fordestination choice varied significantly across locationsand nationalities. Across all participants, mean lengthof stay was 8.9 days. Alcohol use on holiday wasreported by 95.0% of respondents. Over two thirdsof all participants reported having been drunk duringtheir holiday. Frequent drunkenness (defined as beingdrunk on at least half of the days of stay) wasmost commonly reported by British holidaymakersin Crete (75.9%) and Majorca (71.0%). Half of theparticipants smoked on holiday and over 1 in 10used illicit drugs. Among those who used illicit drugs,86.5% used cannabis, 31.9% ecstasy, 18.3% cocaine,5.8% ketamine, 5.7% amphetamines, and 3.8% GHB.Use of any drug on holiday was highest amongvisitors to Cyprus and German visitors to Portugal.Almost a quarter (23.6%) of participants reportedvisiting bars and nightclubs every night during theirholiday, increasing to 58.2% in British visitors to Crete(Table 2).

Overall, 3.8% of participants reported involvementin violence during their holiday and 5.9% reportedunintentional injury (Table 2). For each nationality,the proportion experiencing these problems variedacross locations. In Crete, involvement in violence washigher among British holidaymakers than their Germancounterparts, yet there were no differences betweennationalities elsewhere. Around 1 in 8 British visitors toMajorca and Crete and almost 1 in 10 German visitorsto Majorca reported unintentional injury during theirholiday.

Bivariate analyses show that violence and uninten-tional injury on holiday were significantly higher inmales and decreased with age (Table 3). Violence wasmost common among those staying 8 to 14 days. Amongthose who provided a self-defined financial level, thosestating this as high were more likely to report bothunintentional injury and violence (although the highestlevels of unintentional injury were in those who did notprovide a financial level). Drinking alcohol on holidaywas associated with violence, whereas frequent drunk-enness (on at least half of the days of stay) was associated

with both outcomes (eg, violence, 7.3% of those report-ing frequent drunkenness compared to 0.6% of thosewho never got drunk; p < 0.001). Using illicit drugs,particularly ‘‘other illicit drugs,’’ both at home and onholiday was strongly associated with violence and unin-tentional injury. Both outcomes were also significantlyassociated with frequent use of nightlife (visiting barsand nightclubs) on holiday (Table 3).

To identify independent relationships with violenceand unintentional injury, logistic regression analyseswere conducted using all variables significant in bivariateanalyses and a combined variable of nationality andlocation (Table 4). Here, odds of violence were highestin those visiting Majorca and in British visitors toCrete. Odds of unintentional injury were increasedin visitors of both nationalities to Crete. Being malewas associated with both outcomes, whereas youngerparticipants had increased odds of unintentional injury,but not violence. Participants who were attractedto their destination due to nightlife had increasedodds of violence; however, differences in violencebetween those with the lowest and highest levels ofnightlife participation on holiday were not significant.Frequent drunkenness was associated with both violenceand unintentional injury. Smoking and using anyillicit drugs on holiday were associated with violence,but not unintentional injury. However, individualswho reported using drugs other than just cannabisat home showed increased odds of unintentionalinjury.

Individuals who reported having been involved inviolence on holiday were asked whether they were underthe influence of alcohol or drugs at the time. Of thosewho provided this information (186 of 236), 91.6%reported being under the influence of alcohol. Of thoseinvolved in a fight who were drug users, 16.2% reportedbeing under the influence of drugs at the time of thefight. Over half (51.3%) of the violence occurred inbars or nightclubs, with the remainder largely (36.0%)occurring in streets.

Discussion

A growing body of research is identifying the risksyoung people take with their health during holidayperiods and the problems they face particularlywhile away abroad. To our knowledge, however,this is the first study that has explored youngholidaymakers’ substance use and experience ofviolence and unintentional injury across multipledestination countries and different nationalities. Aswith all surveys of risky and antisocial behaviors,our study may have been affected by complianceand underreporting or exaggeration of risk behaviorsand experiences on holiday. However, we used anestablished methodology that ensured participants wereinformed of the purpose of the study and the topicsit covered, assured of its confidentiality, and providedwith a clearly anonymous mechanism of participation.

J Travel Med 2011; 18: 80–89

84 Hughes et al.

Tab

le2

Hol

iday

feat

ures

,beh

avio

rs,a

ndou

tcom

esby

natio

nalit

yan

dho

liday

loca

tion

Bri

tish

holid

aym

aker

sG

erm

anho

liday

mak

ers

pbe

twee

nna

tiona

litie

sin

All

All

Maj

orca

Ital

yC

rete

Cyp

rus

Port

ugal

p†A

llM

ajor

caIt

aly

Cre

teC

ypru

sP

ortu

gal

p†A

llM

ajor

caIt

aly

Cre

teC

ypru

sP

ortu

gal

Rea

sons

for

dest

inat

ion

choi

ce(%

yes)

Cos

t20

.817

.222

.13.

010

.727

.523

.4**

*25

.927

.112

.342

.829

.131

.5**

***

*∗

***

∗∗∗

0.49

4∗∗

Nig

htlif

e51

.555

.879

.717

.387

.764

.030

.4**

*45

.776

.46.

142

.461

.729

.7**

***

*0.

137

***

***

0.35

30.

832

Cul

ture

19.3

18.0

7.9

51.2

7.0

7.5

15.5

***

21.0

7.0

43.7

23.2

12.9

18.2

***

**0.

545

****

***

0.30

6W

eath

er58

.854

.050

.134

.345

.776

.864

.1**

*65

.266

.638

.672

.783

.273

.4**

***

***

*0.

085

***

****

Wor

k2.

63.

01.

48.

32.

30.

81.

8**

*2.

10.

66.

00.

70.

32.

4**

**

0.10

00.

082

0.07

40.

142

0.49

7V

isiti

ngfa

mily

/fri

ends

14.3

14.8

7.7

15.2

4.1

23.6

23.5

***

13.7

3.4

29.1

3.7

12.1

15.4

***

0.22

5**

***

*0.

748

***

**

Len

gth

ofst

ay(%

)U

pto

7d

55.9

57.4

66.3

54.8

63.5

50.1

52.4

—54

.049

.259

.946

.564

.929

.9—

——

——

——

8–14

d38

.536

.632

.633

.931

.647

.437

.5—

41.0

49.6

32.0

49.8

33.8

52.1

——

——

——

—15

orm

ore

d5.

66.

01.

211

.34.

92.

410

.1**

*5.

11.

38.

13.

71.

318

.1**

***

***

0.05

7**

***

***

*

Hol

iday

subs

tanc

eus

eA

lcoh

ol(%

used

)95

.096

.098

.490

.399

.499

.592

.8**

*93

.796

.982

.598

.010

0.0

91.7

***

***

0.05

7**

**

*0.

542

Tob

acco

(%us

ed)

49.7

48.1

43.4

49.3

50.5

61.5

35.0

***

51.8

54.2

30.6

52.2

67.9

54.5

***

****

***

*0.

628

***

*

Illic

itdr

ugus

eN

one

89.1

89.1

91.1

87.9

96.0

81.1

89.1

—89

.192

.595

.789

.083

.479

.9—

——

——

——

Can

nabi

sonl

y6.

25.

72.

711

.21.

26.

46.

8—

6.9

4.1

3.9

9.0

9.7

11.8

——

——

——

—O

ther

illic

itdr

ugs‡

4.7

5.2

6.2

0.9

2.9

12.5

4.0

***

4.0

3.4

0.4

2.0

6.9

8.3

***

**

***

***

***

***

Freq

uenc

yof

drun

kenn

ess§

(%)

Nev

er(in

clud

ing

nond

rink

ers)

29.0

21.9

8.0

47.1

5.4

18.2

30.2

—38

.520

.475

.046

.417

.941

.0—

——

——

——

<ha

lfof

the

days

ofst

ay35

.133

.221

.028

.018

.761

.636

.6—

37.6

30.8

16.2

38.2

64.6

33.6

——

——

——

—≥h

alfo

fthe

days

ofst

ay35

.944

.971

.024

.875

.920

.233

.2**

*23

.948

.88.

915

.417

.425

.4**

***

***

***

***

*0.

348

**

Freq

uenc

yof

visi

ting

bars

/clu

bs<

half

ofth

eni

ghts

ofst

ay32

.324

.912

.134

.66.

926

.544

.4—

42.3

25.6

80.8

39.0

22.0

46.4

——

——

——

—A

tlea

stha

lfbu

tnot

alln

ight

s44

.444

.340

.946

.434

.961

.338

.3—

43.8

51.4

14.9

53.1

60.3

42.1

——

——

——

—E

very

nigh

t23

.630

.847

.018

.958

.212

.217

.3**

*13

.923

.04.

27.

917

.711

.5**

***

***

***

***

***

0.07

2

Hol

iday

outc

omes

(%)

Ina

phys

ical

fight

3.8

4.1

6.5

0.7

6.4

4.1

3.0

***

3.3

5.8

1.0

2.4

4.2

1.5

***

0.12

10.

632

0.47

7*

0.92

60.

194

Uni

nten

tiona

linj

ury

5.9

6.8

12.0

1.6

12.7

2.6

5.5

***

4.7

9.1

4.0

6.6

0.9

3.7

***

***

0.08

1**

***

0.25

4

GH

B=

gam

mah

ydro

xybu

tyra

te.

† pbe

twee

nlo

catio

nsw

ithin

natio

nalit

ies.

‡ Inc

ludi

ngec

stas

y,co

cain

e,am

phet

amin

es,k

etam

ine,

and

GH

B.

§ Abo

ut2%

ofdr

inke

rsdi

dno

tpro

vide

info

rmat

ion

ondr

unke

nnes

s.∗ p

<0.

05,∗

∗ p<

0.01

,∗∗∗

p<

0.00

1.

J Travel Med 2011; 18: 80–89

Substance Use, Violence, and Injury in Holidaymakers 85

Table 3 Unintentional injury and violence on holiday by demographics and substance use

Violence Unintentional injury

% p % p

All 3.8 — 5.9 —

Gender Male 6.0 — 8.1 —Female 1.7 *** 3.9 ***

Age 16–19 5.7 — 9.7 —20–25 3.1 — 4.8 —26–35 1.9 *** 1.9 ***

Length of stay Up to 7 d 3.1 — 5.7 —8–14 d 5.0 — 6.0 —

15 or more d 2.3 *** 6.6 0.776

Financial level High 8.2 — 8.8 —Medium high 3.2 — 6.8 —

Medium 2.7 — 5.1 —Medium low 5.0 — 5.0 —

Low 4.2 — 6.6 —Not stated 5.1 *** 10.8 ***

Substance use at home Alcohol No 3.3 — 7.0 —Yes 3.8 0.692 5.8 0.416

Tobacco No 2.7 — 5.7 —Yes 5.0 *** 6.1 0.525

Illicit drugs None 2.7 — 5.3 —Cannabis only 6.4 — 6.0 —

Other drugs 10.3 *** 10.8 ***

Substance use on holiday Alcohol No 1.0 — 4.7 —Yes 3.9 * 6.0 0.365

Tobacco No 2.0 — 5.0 —Yes 5.6 *** 6.7 **

Illicit drugs None 2.7 — 5.4 —Cannabis only 11.3 — 5.9 —

Other drugs 14.8 *** 14.7 ***

Frequency of drunkenness on holiday Never (including nondrinkers) 0.6 — 2.5 —Less than half of the stay 2.8 — 2.8 —Half or more of the stay 7.3 *** 11.4 ***

Frequency of nightlife use on holiday Less than half nights of stay 1.2 — 1.2 —At least half but not every night 3.4 — 3.4 —

Every night 7.7 *** 7.7 ***

Reason for destination choice Cost No 3.9 — 6.2 —Yes 3.2 0.211 4.7 *

Nightlife No 1.1 — 3.3 —Yes 6.2 *** 8.3 ***

Culture No 4.2 — 6.6 —Yes 2.2 ** 3.0 ***

Weather No 4.3 — 7.3 —Yes 3.4 0.090 4.9 ***

Work No 3.8 — 5.8 —Yes 1.8 0.189 7.3 0.428

Visiting No 4.1 — 5.8 —Family/friends Yes 1.7 *** 6.3 ***

The samples were intended to be broadly representativeof holidaymakers traveling to each destination, yetsample recruitment was opportunistic, conducted ona convenience basis, and focused only on holidaymakersusing air transport to return home. However, weachieved high compliance among those who were

informed of the survey’s nature, thus reducing thepotential for participant self-selection to affect ourfindings.

Our study found that the Mediterranean holidaydestinations attract young people with differentbehavioral characteristics for different purposes and

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86 Hughes et al.

Table 4 Adjusted odds ratios (AORs) for involvement in violence and unintentional injury on holiday

Violence Unintentional injury

AOR 95% CI p AOR 95% CI p

Nationality–location British–Majorca 5.09 1.47–17.64 * 1.98 0.91–4.30 nsBritish–Italy 0.64 0.14–2.83 ns 0.53 0.21–1.34 nsBritish–Crete 5.08 1.46–17.72 * 2.22 1.03–4.78 *British–Cyprus 3.25 0.93–11.33 ns 0.66 0.28–1.56 nsBritish–Portugal 3.45 0.97–12.26 ns 1.47 0.65–3.29 nsGerman–Majorca 3.92 1.13–13.57 * 1.84 0.84–4.03 nsGerman–Italy 2.78 0.66–11.60 ns 2.03 0.89–4.67 nsGerman–Crete 2.78 0.69–11.38 ns 2.59 1.07–6.25 ∗

German–Cyprus 3.36 1.35–2.46 ns 0.23 0.08–0.68 ∗∗

German–Portugal (Ref) — — * — — ∗∗∗

Sex Male 2.38 1.70–3.32 2.02 1.57–2.58 —Female (Ref) — — *** — — ***

Age 16–19 — — — 2.82 1.81–4.39 ***20–25 — — — 1.64 1.05–2.55 *26–35 (Ref) — — ns — — ***

Reason for destination choice Cost (Ref ‘‘No’’) — — nsNightlife (Ref ‘‘No’’) 2.03 1.26–3.29 ** — — nsCulture (Ref ‘‘No’’) — — ns — — nsWeather (Ref ‘‘No’’) — — nsVisiting family/friends (Ref ‘‘No’’) — — ns

Length of stay Up to 7 d (Ref) — — —8 to 14 d 1.82 1.35–2.56 ***15 or more d 1.00 0.38–2.61 ns

Financial level High (Ref) — — ** — — nsMedium high 0.36 0.19–0.65 ** — — —Medium 0.36 0.21–0.61 *** — — —Medium low 0.60 0.34–1.06 ns — — —Low 0.53 0.27–1.04 ns — — —Not stated 0.64 0.31–1.32 ns — — —

Home substance use Tobacco (Ref ‘‘No’’) — — nsNo drugs (Ref) — — ns — — ***Cannabis only — — — 1.03 0.71–1.48 nsOther illicit drugs — — — 2.31 1.60–3.33 ***

Holiday substance use Alcohol (Ref ‘‘No’’) — — nsTobacco (Ref ‘‘No’’) 1.79 1.26–2.53 ** — — nsNo drugs (Ref) — — *** — — —Cannabis only 3.75 2.45–5.73 *** — — —Other illicit drugs 3.10 2.01–4.78 *** — — ns

Drunk Never (Ref) — — — — — —<50% of nights of stay 1.71 0.84–3.45 ns 1.16 0.75–1.79 ns≥50% of nights of stay 2.43 1.19–4.99 * 2.56 1.70–3.84 ***

Night life Less than half of the nights of stay (Ref) — — ** — — nsAt least half but not every night 0.80 0.47–1.38 ns — — —Every night 1.45 0.82–2.56 ns — — —

Statistics use a stepwise backward conditional logistic regression analysis. Reference categories for each variable are identified with (Ref). Shaded cells indicate factorswere not entered into the model as associations were not significant in bivariate analyses.ns = not significant.∗p < 0.05, ∗∗p < 0.01, ∗∗∗p < 0.001.

that these are reflected in the behaviors they engage inwhile abroad (Tables 1 and 2). Such information shouldbe used by authorities in both holidaymakers’ homeand destination countries to implement appropriateaction to protect holidaymakers’ health and well-being. Specifically, nightlife is a major attraction for

young people visiting Majorca, Crete, and Cyprus,and holidays in these destinations are characterizedby frequent participation in nightlife and substance use.Regular drunkenness is the norm among British visitorsto Majorca and Crete and German holidaymakers inMajorca. Visitors to Cyprus get drunk less frequently,

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Substance Use, Violence, and Injury in Holidaymakers 87

yet report more drug use, with almost one in five visitorsof both nationalities using drugs during their holiday.For young people choosing to holiday in Portugal andItaly, weather and culture, respectively, are the largestattractions. Here, holidaymakers use nightlife and getdrunk less frequently. Despite this, the highest levels ofoverall drug use were reported by German visitors toPortugal.

Across all samples, almost 6% of young holiday-makers reported having suffered unintentional injuryduring their holiday and almost 4% had been involvedin violence (Table 3). Unintentional injury was inde-pendently associated with being male, younger, an illicitdrug user at home (but not on holiday), frequentlygetting drunk on holiday, and visiting Crete (Table 4).Involvement in violence was associated with being male,attracted to the destination due to its nightlife, staying8 to 14 days, visiting Majorca (both nationalities) orCrete (British), smoking, regularly getting drunk, andusing drugs on holiday. The relationship between druguse and violence abroad was largely not temporal; only16.2% of drug users who reported violence identifiedthemselves as being under the influence of drugs at thetime of the incident. Links between drugs and violenceare complex and include the exposure of drug usersto environments that can feature violence (eg, illicitdrug markets and nightclubs) and shared risk factors(eg, sensation seeking) which can make individuals vul-nerable to both.8 The same is true for links betweenalcohol and violence.32 However, over 90% of violentincidents reported in our study occurred when individ-uals were under the influence of alcohol, reflecting thestrong temporal links between alcohol use and violence.5Although we cannot establish the causal role of alco-hol in violent incidents reported by holidaymakers, thedose-responsive relationship between alcohol and vio-lence suggests that alcohol would have been a majorcontributor to such harm. Conversely, it is likely thatlinks between tobacco and violence reflect a predisposi-tion to risk-taking behavior in some individuals ratherthan a causal relationship.33

Even after controlling for participants’ demograph-ics, substance use, and holiday nightlife habits, individ-uals visiting Majorca and Crete showed greater risks ofviolence and unintentional injury (Table 4). This sug-gests that other aspects of the environment in thesedestinations, or the individuals that choose them, arecontributing to higher harm. Resorts such as Magalufand Arenal in Majorca and Malia in Crete are renownedparty destinations for young holidaymakers and oftenmarketed as such in tourists’ home countries. Theytypically feature large concentrations of bars and night-clubs catering specifically to heavy drinking tourists,offering promotional drinks and entertainment focusedaround drinking and promiscuity.34 Such features havebeen identified as key environmental risk factors for vio-lence and injury.35–37 Although the frequency of visitingbars and nightclubs was not independently associatedwith violence or unintentional injury in our study, both

outcomes increased in those who used nightlife morefrequently and over half of the violent incidents reportedoccurred in bars or nightclubs. Further investigation ofthe environmental features of nightlife settings in resortsmay help to understand why some destinations are morevulnerable to violence and unintentional injury. Furtherwork is also needed to understand differences betweennationalities within destinations. For example, Germanvisitors to Crete reported significantly lower levels ofdrunkenness, nightlife use, and negative outcomes thantheir British counterparts. Whether these differencesrelate to the types of resort visited by each nationality,the types of holidaymakers choosing Crete or otherfactors require further study.

For young people intent on partying, reducedresponsibilities during holiday periods can enable themto increase nightlife participation substantially. Twothirds of our sample visited bars and nightclubs on atleast half of the nights of their holiday, with a quarterdoing so every night (Table 2). For an individual whogoes out once a week at home38 but every night onholiday, a 2-week stay in a foreign holiday resort couldcontain up to one fifth of their annual nights out.The risks associated with nightlife substance use can beexacerbated by environmental factors in foreign holidayresorts,39 including larger alcohol measures, unknowndrug markets, hotter climates and unfamiliar geography,language, and legislation (eg drink-driving). Despitethis, interventions to protect young holidaymakers’health are scarce. In fact, holidaymakers can fallinto a health and safety policy vacuum while abroad.Thus, they are not residents (and therefore long-termconcerns) of the countries they visit and while away fromhome their behavior is largely beyond the jurisdictionof authorities in their home countries. Consequently,holiday resorts may operate on economic models thatpromote and provide hedonistic, high-alcohol risk-taking environments with relatively little considerationfor visitors’ health.

The drunken behaviors reported by holidaymakersabroad are not typical among young nationals ofcountries such as Spain and Greece, who generallyreport lower alcohol use and drunkenness than theirNorthern European counterparts.15,38 Even when onholiday, young Spaniards do not frequently drinkto intoxication.21 Thus, hedonistic resorts can act asenclaves for heavy drinking tourists set within domesticcultures where drunkenness can be rare, and excessivebehavior may be tolerated more in tourists than it wouldbe in local young people. Yet youth binge drinking isincreasing in many European countries, with concernsthat heavy drinking cultures are spreading.40–42 Thus,authorities in Mediterranean resorts should considerany demonstration effects tourists drinking may haveon local youth. Furthermore, nightlife-related violenceand injuries can place major burdens on servicesand communities in resorts, while their longer-termhealth impacts return home with the holidaymaker.The pressures that hedonistic tourism place on resort

J Travel Med 2011; 18: 80–89

88 Hughes et al.

communities and young people’s longer-term healthhave yet to be measured against the benefits ofthis model of tourism. Developing this understandingshould be a key research priority. Critically, a reputationfor drunken behavior and violence can also damage aresort’s tourism.43 Tourism plays a major economicrole in Europe, generating over 5% of the EuropeanUnion’s gross domestic product and providing around10 million jobs.44

Cheap international travel and open borders withinEurope have been commercially exploited to createnightlife resorts where risks to health, such as injuryand violence, frequently result from highly intoxigenicenvironments. However, as those at risk are abroad,behaviors which might typically elicit a public healthresponse in endemic populations are tolerated andsometimes even encouraged in tourists—often forcommercial gain. A broader interpretation of Europeancitizenship would be one that considers both commercialbenefits from nightlife tourism and public health risksto its customers. Although such a model may requirechanges to existing nightlife destinations, the benefitscould extend beyond tourists and help to reverse thegradual dissemination of binge drinking cultures acrossEurope.

Acknowledgments

The study was funded by the European CommissionDirectorate-General for Justice, Freedom and Security(JSL/2007/DAP-1/135 30-CE-0227672/00-87). Weacknowledge and thank all those who supportedthe development and implementation of this study,including M. Juan, F. Mendes, S. Tripodi, B. Cibin,T. Stamos, P. Lazarov, I. Siamou, and P. Cowan. Wewould also like to thank the airport authorities in eachcountry for their support with the project and all theyoung holidaymakers who voluntarily participated inthis research.

Declaration of Interests

The authors state that they have no conflicts of interestto declare.

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