Alcohol and Alcoholism Advance Access published online on May 24, 2008
Alcohol and Alcoholism, doi:10.1093/alcalc/agn039
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Patterns of Binge Drinking At An International Nightlife Resort
Centre for Alcohol and Drug Research, Aarhus University, Købmagergade 26E, 1150 Copenhagen C, Denmark
* Corresponding author: Centre for Alcohol and Drug Research, Aarhus University, Købmagergade 26E, 1150 Copenhagen C, Denmark. E-mail: sebastientutenges{at}gmail.com
Received 24 September 2007; first review notified 9 October 2007; in revised form 22 April 2008; accepted 23 April 2008
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ABSTRACT |
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Aims: The aim of this study was to compare the patterns of substance use in young Danes while holidaying in the Bulgarian holiday resort of Sunny Beach (SB) to their patterns of substance use in Denmark. Methods: Data were collected from visitors to SB in 2007 (n = 1011). Information on alcohol and drug use was surveyed using a short questionnaire. Findings: Most individuals surveyed were regular drinkers in Denmark, and the use of most illicit drugs was rare. Patterns of substance use in SB revealed heavy drinking was common, both in adolescents and young adults. Conclusions: International nightlife resorts provide a context for excess in drug use and alcohol use. Alcohol poses a potentially severe threat to the short- and long-term health of young tourists, but little attention has been paid to form interventions targeting binge drinking in nightlife resorts.
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Introduction |
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Binge drinking among youth is a growing concern throughout the western world. In Denmark, the problem seems particularly severe with both national and international studies showing that young Danes drink larger quantities of alcohol, more frequently and with a clearer focus on drunkenness than youth in most other European countries (Hibell et al., 2004
; Sabroe and Fonager, 2002; Settertobulte et al., 2001). The drinking pattern in Denmark resembles the British, with its propensity for occasional binge drinking (Plant and Plant, 2006). It is characterized by weekday abstinence and drinking sessions with peers during the weekend (Gundelach and Järvinen, 2006).
A number of adverse health consequences have been observed from substance use in nightlife, including fights, accidents and a range of other negative effects (Bellis et al., 2005). Binge drinking in particular may lead to negative consequences, such as blackouts, personal injuries and sudden death. Heavy drinking may also contribute to accidents, violence and rape (Dunn et al., 2003), be a risk factor for sexually transmitted diseases (Josiam et al., 1998) and contribute to the development of alcohol dependence (Grant et al., 2001).
Substance use undertaken in a foreign country has additional elements of risk. Language and geography is generally unfamiliar and this may obstruct access to health services. Additionally, individuals far away from home are not held back by the constraints of work and family that normally moderates substance use (Bellis et al., 2002). Accordingly, a range of studies have identified amplified substance use in people on holidays abroad (Bellis et al., 2003; Segev et al., 2005; Smeaton et al., 1998). Youth who come to destinations attracted by the ‘party reputation’ of a scene may consume even more drugs and alcohol than other youth (Josiam et al., 1998). In some instances, such as backpacking holidays, youth may increase their use of alcohol rather than illicit substances (Bellis et al., 2007).
Slanchev Bryag also known as ‘Sunny Beach’ (SB) has become one of the worlds’ most popular nightlife resorts in recent years. This Bulgarian resort is located on the Black Sea and in Northern Europe, it is renowned for its warm weather, long beach strip, low prices and wild parties. The resort is densely packed with bars, discotheques and restaurants, and many of these venues attract customers with happy hours, free first drinks and discounts on alcohol shots and whole bottles of strong spirits. Local and international operators offer a variety of party events such as ‘pub crawls’, ‘sailing party cruises’, ‘karaoke nights’, ‘Foam Parties’ and so on. These events have a clear focus on drunkenness, sex and fun. Trained guides participate in the party events and entertain with risqué shows, singing, dancing, competitions and drinking games. In case of emergency, the guides lend first aid or accompany casualties to the hospital. Tourists of all ages visit SB, but in the nighttime, especially in the month of July, the resort is dominated by boisterous youths from Northern Europe.
During the summer 2007, 
5100 Danes in the ages between 16 and 30 years went to SB with travel agencies specialized in young travellers. An equally large, but unknown, number travelled with other agencies.
In the later half of 2007, SB has received intensive media coverage in Denmark and Sweden. Before June 2007, SB was only mentioned a few times in the Danish press database Infomedia, which has full coverage of Danish printed and electronic mass media, but during July and August 2007, several hundred articles appeared. A number of events at SB have resulted in a substantial media reaction: a 17-year-old Danish man choked in his own vomit during a pub crawl, a 24-year-old Swedish man was beaten to death by security guards outside a discotheque and four cases of rape were reported by Danish women.
During this period, we had a team of researchers in SB conducting ethnographic field studies and two survey studies. In this article, we report the main findings from one of the surveys. The purpose of the analyses is to characterize the phenomenon of substance use among young travellers to SB, and identify gender and age characteristics of youth, who use substances heavily. Specifically, we will look at previous substance use patterns, types of substances used, heavy drinking and demographic factors that influence substance use patterns.
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Method |
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A cross-sectional survey was undertaken at Bourgas airport between 4 July and 21 July 2007. This airport is mainly used by tourists holidaying in SB. The procedure was highly similar to the procedure used in studies at Ibiza by Bellis and colleagues (2003
). Research assistants were instructed to target youth, mainly 16- to 24-year-olds, and approach such individuals while they were waiting to check in for their flights back to Denmark. However, as the assistants were unable to exactly determine people's age by just looking at them, we included all those who responded to the questionnaire, regardless of the age they reported.
In order to exclude other nationalities, only individuals returning to Denmark were asked to complete the short, anonymous questionnaire. Data collected included individuals’ basic demographics and levels of substance use (alcohol, tobacco, amphetamine, ketamine, cannabis, ecstasy, LSD, cocaine and GHB) in Denmark and during the current holiday in SB. The questionnaire was similar in layout to the questionnaire used in the Ibiza surveys (Bellis et al., 2003), but due to the different nature of the party scene in SB, specific questions about ecstasy use were replaced by questions about binge drinking. The questionnaire contained questions about the frequency of drinking broken into the following categories: drinking >6 units per day, drinking >12 units per day and drinking to intoxication. Note that due to time restrictions of youth waiting to check in on a flight, we had limited time and space to explain concepts such as ‘alcohol unit’. Therefore, the respondents’ understanding of a unit may have varied. Moreover, drink sizes and contents vary substantially in the venues of SB. Some venues serve drinks with large amounts of alcohol, others serve drinks with low amounts of alcohol—it is almost impossible to taste the difference. Therefore, there is some uncertainty about the actual amount consumed.
The question about intoxication was taken from the European School Survey Project on Alcohol and Other Drugs (ESPAD) (Hibell et al., 2004), but, due to restrictions on time and questionnaire length, amounts consumed per night were not collected for illicit drugs.
The intoxication question from the Danish part of the ESPAD survey was: ‘On how many occasions have you been DRUNK from drinking alcoholic beverages? For instance, not being able to speak clearly, had difficulty walking straight, thrown up, or had a hard time remembering what had happened?’ (Hibell et al., 2004). This question was asked both with regard to lifetime and with regard to the stay in SB. Individuals were also asked whether their parents were staying at SB.
We collected questionnaires on 13 different days at a total of 30 flights. We strived to approach as many as possible at each flight. Researchers approached potential participants and asked if they had time to fill in a short questionnaire for a research project under Aarhus University, and recorded the gender of those who refused. Those who indicated that they had time were then informed of the nature of the questionnaire, and if they refused at this stage, their gender was recorded again. We registered the gender of those who refused to participate after being approached first, and after being informed of the nature of the survey.
Analyses
The analysis utilized a combination of 
2, Mann–Whitney U, McNemar and Wilcoxon signed-rank tests, with ANOVA being used to assess age/gender interaction in terms of heavy drinking. As the main indicator of drinking, we used the proportion of total days in SB, where subjects reported drinking 12 or more units of alcohol. To assess the impact of heavy drinking on adverse outcomes, we used Spearman rank-order correlations.
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Results |
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Over the 13 days, we approached a total of 1238 subjects. A total of 87 women and 197 men refused (26%) (see Figure 1). Those who indicated that they had time were then informed of the nature of the questionnaire (n = 1068), and among these compliance was 95% (n = 1011). A total of 22 women and 35 men refused after being informed of the nature of the study. The refusers at any point were more likely to be male [
2(1) = 17.2, P < 0.0001]. The respondents were 55% male, and the mean age was 19.9 years [range: 13–34, standard deviation (SD) = 3.1]. The mean number of days spent in SB was 7.8 (range: 1–15, SD = 2.2). A total of 18.1% travelled with a long-term partner, 11.9% with their parents, 2.0% with both partner and parents and 71.6% with neither.
Substance use in Denmark
The pattern of substance use in Denmark is showed by gender in Table 1. Also shown in Table 1 is the proportion of respondents who are within each age group by gender. As can be seen, the single largest group of respondents are those aged 18–19 years for both genders.
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A total of 23.1% had a lifetime history of illicit substance use. Cannabis had been used by 17.0% in lifetime (11.0% past year), amphetamine by 14.2% (5.2% past year), cocaine by 11.5% (5.3% past year) and all other drugs <5% lifetime. Men used illicit substances more frequently than women (Mann–Whitney U-test, Z = –3.35, P = 0.0008).
A total of 27.7% were daily smokers, 19.0% were ex-smokers (not in past year), 22.4% were chippers (smoking past year but <5 days per week) and 31.0% had never smoked. No gender difference was found on tobacco use (Mann–Whitney U-test, Z = –0.02, P = 0.98).
Alcohol was used by nearly everyone: 97% had had alcohol in their lifetime, and 28.5% drank weekly or more. Males used alcohol more frequently than women (Mann–Whitney U-test, Z = –6.72, P < 0.0001). Using the ESPAD question, 4.8% reported never having been alcohol intoxicated, 20.9% reported being intoxicated 1–20 times in their lifetime and 74.3% reported having been drunk >20 times in their lifetime.
Substance use in Sunny Beach
As in Denmark, alcohol was by far the most commonly used substance in SB: 96.0% reported drinking and 72.5% reported drinking 5 or more days per week in SB. Only 5.0% reported using drugs, the most common being cannabis, which was reported by 3.2%.
A total of 86.7% reported drinking 6 or more units in at least 1 day, and 71.2% reported drinking 12 or more units in at least 1 day. More than a third (41.3%) reported drinking 12 or more units per day for 6 or more days. A total of 72.7% reported having been alcohol intoxicated, and 17.0% reported having been intoxicated every day.
We compared substance use patterns with Wilcoxon signed-rank tests. We recoded use in both Denmark and SB, so that 0 = ‘never’ or ‘not in past year’, 1 = ‘use weekly or less’, 2 = ‘use 1–3 days per week’, 3 = ‘use 2–4 days per week’ and 4 = ‘use 5 or more days per week’. The reason was that for use in Denmark, the use could be reported as less than monthly and 1–3 times per month. All illicit drugs were combined because the use of any individual substance was rare. Thus, if any illicit substances had been used, the frequency of illicit substance use was coded as the frequency of the most frequently used substance.
The use of illicit drugs was significantly more common in Denmark (Wilcoxon Z = 5.72, P < 0.00001). Of those who were not past-year users in Denmark (n = 625), 0.8% reported using illicit drugs in Bulgaria. The use of alcohol was not more common in SB [96% in both places, 2(1) = 0.0, P = 1.0], but the frequency of drinking was larger (Wilcoxon Z = 21.81, P < 0.00001). The use of tobacco was no more common in SB than in Denmark (McNemar 2 = 0.18, NS), and the use was not significantly more frequent.
Finally, we estimated the age/gender interaction. Subjects were coded for age (16–17, 18–19, 20–21, 22–23, or 24–25). We excluded the youngest and oldest groups from this analysis, as these groups were small and might have distorted results, leaving 804 subjects for the analysis. Then we estimated the proportion of days drinking 12 or more units per day. The results are shown in Fig. 2. Both age [F(4, 770) = 4.22, P = 0.002] and gender [F(1, 770) = 141.05, P < 0.0001] were significantly associated with drinking. There was a no interaction between the two [F(4, 770) = 1.80, P = 0.13].
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Underage drinking
Of those who were under the legal age in Denmark and Bulgaria (<18 years, n = 136), 91% had been drinking in Bulgaria. A total of 71% had drunk at least 6 drinks per day on at least 1 day, and 31.0% had drunk 12 or more units 6 or more days per week.
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Adverse events associated with drugs and alcohol
A total of 12 informants (1.2%) reported seeking medical treatment for an alcohol-related problem during their stay in SB. Twenty-five informants (2.5%) reported seeking treatment for other accidents. A total of 89 informants (8.8%) reported being in a fight during their stay.
Fights (Spearman rho = 0.20, P < 0.0001), seeking medical assistance for an alcohol-related problem (Spearman rho = 0.07, P = 0.03) and accidents (Spearman rho = 0.07, P = 0.04) were associated with the proportion of days drinking 12 or more units.
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Discussion |
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A substantial number of youth returning from holiday on SB reported very heavy drinking during their stay. Several adverse outcomes related to alcohol were observed, in particular fights and alcohol-related events that required some kind of medical treatment. Most of the youth who visited this resort were not drug users in Denmark, and illicit drug use was even more rare in Sunny Beach. These increases have also been shown in other studies, although some substances are used more frequently in some resorts than others (Bellis et al., 2003
; Segev et al., 2005).
In many ways, the risk and protective factors were similar in this study to those identified in a number of other studies. Male gender was a risk factor and being with a partner or parents was associated with decreased risk (Bellis et al., 2007; Smeaton et al., 1998). However, the pattern of substance use at SB also differed from other studies that investigated substance abuse patterns in backpackers (Bellis et al., 2007), travellers to Ibiza (Bellis et al., 2003) and students on spring break (Josiam et al., 1998), in that the youth holidaying at SB displayed no increase in the use of illicit substances, and illicit substance use was quite rare.
Drinking was very common among those under the legal age, with very heavy drinking occurring in boys and girls aged 15–16 years. While we did not specifically ask youth about whether they had bought the alcohol in bars, based on our observations on the location, we believe that a substantial proportion of under-age drinking did occur in bars and nightclubs.
We observed a significant age by gender interaction on alcohol drinking. Specifically, for both genders, alcohol use increased with age during late adolescence, but the consumption of males increased more, and male drinking remained at a higher level, whereas women's drinking showed a decreasing trend after the age of 16–17 years. Prospective studies have shown that among young heavy drinkers, both drinking quantity and drinking problems usually decline during early adulthood (Baer et al., 2001), but also that early onset of alcohol use predicts later development of alcohol dependence (Grant et al., 2001). A ‘binge-drinking holiday’ may be one event in a young person's life that introduces the person to practices of heavy drinking.
Prevention measures should probably differ between various groups. For those who are under the legal drinking age of 18, several options are available that are not feasible with adults. Legal measures can be taken in Bulgaria, and parents can be alerted to the characteristics of the scene to take preventive action against drinking in the youngest groups.
For both adults and adolescents, preventive measures could focus on preventing fights and information about symptoms that can be triggered by drinking heavily, to encourage reduced drinking when symptoms occur.
Findings such as these stress that alcohol is in many ways just another substance, not unlike cannabis, cocaine or synthetic drugs (Cook and Reuter, 2007). Alcohol is used as an intoxicant with a binge use pattern and leads to adverse consequences. An important difference between alcohol and illicit substances, however, is that due to the legal status of alcohol, the alcohol and party industry are free to market alcohol and to set up scenes such as SB, where heavy drinking becomes the norm.
A limitation to our study is that we did not have time to define the term ‘alcohol unit’ as discussed above. Consequently, respondents cannot assess the exact number of units that they consumed during drinking sessions.
Future research should look into the short-term and long-term consequences of such heavy drinking. This includes adverse health events associated with a drinking holiday, as well as potential precursors of alcohol dependence, to address the degree to which binge drinking holidays may contribute to the development of alcohol problems.
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ACKNOWLEDGEMENTS |
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The study was paid for in whole by the Centre for Alcohol and Drug Research, a research centre under Aarhus University, funded by the Danish Government. No ethical approval was sought, as Danish research ethics committees do not approve or disapprove of research studies that do not involve invasive procedures or medication. We thank Karen Hughes and Mark Bellis for making the questionnaire from their original studies available to us.
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