Substance Use, Violence, and Unintentional Injury in Young Holidaymakers Visiting Mediterranean Destinations

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1 I S T M 80 Substance Use, Violence, and Unintentional Injury in 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 Bajcàrova, 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 Institute of Studies on Prevention, IREFREA Portugal, Coimbra, Portugal; European Institute of Studies on Prevention, IREFREA Italia, Venice, Italy DOI: /j x Background. Young people s alcohol and drug use increases during holidays. Despite strong associations between substance use and both violence and unintentional injury, little is known about this relationship in young people holidaying abroad.we examine how risks of violence and unintentional injury abroad relate to substance use and the effects of nationality and holiday destination on these relationships. Methods. A cross-sectional comparative survey of 6,502 British and German holidaymakers aged 16 to 35 years was undertaken in 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% reported unintentional 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 independently associated 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 were being 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 hedonistic nightlife. Understanding those characteristics of resorts and their visitors most closely associated with such risks should help inform prevention initiatives that protect both the health of tourists and the economy of resorts marketed as safe and enjoyable places to visit. Unintentional injuries and interpersonal violence are the leading causes of mortality and morbidity in young Europeans. 1 Among 15- to 29-year-olds across Europe, they accounted for over 100,000 deaths and 5 million disability-adjusted life years lost in 2004, around 85% of which were due to unintentional injury. 2 Both unintentional injury and violence are strongly associated with substance use. For example, Selected results from this study were presented at the 6th International Conference on Substance Use, Nightlife and Related Health Issues, Zurich, Switzerland, June 7 to 9, 2010, and at the 10th World Conference on Injury Prevention and Safety Promotion, London, UK, September 21 to 24, Corresponding Author: Karen Hughes, MPhil, Centre for Public Health, Liverpool John Moores University, Henry Cotton Campus, Webster Street, Liverpool L3 2ET, UK. k.e.hughes@ljmu.ac.uk alcohol and drug use can cause physical and cognitive impairment that can increase vulnerability to both unintentional injury and violence. 3,4 Alcohol has a doseresponsive relationship with injury with the amount of alcohol consumed increasing risks; 5 relationships appear strongest for violent injuries and for unintentional injuries such as falls. 5 7 Different types of illicit drugs have different effects, and understanding of the relationships between drug use and both violent and unintentional injuries is less well established. However, illicit drugs are commonly detected in drug tests of injured subjects 8,9 and use of drugs such as cocaine and amphetamines in particular has been associated with violence. 3,10,11 Most substance use among young Europeans occurs at weekend nights in recreational nightlife environments As such, these can be peak times and locations for violence and unintentional injury In England and Wales, eg, one fifth of all violence occurs 2011 International Society of Travel Medicine, Journal of Travel Medicine 2011; Volume 18 (Issue 2): 80 89

2 Substance Use, Violence, and Injury in Holidaymakers 81 in and around nightlife premises 19 and alcohol-related injuries, both intentional and unintentional, place a large burden on health services at weekend nights. 20 Every summer millions of young Europeans take vacations in foreign holiday resorts, where they can partake in nightlife and substance use on a nightly basis. Research has shown that young people s alcohol and drug use increases during holidays abroad, along with other forms of risk taking (eg, sexual behavior) Despite this, few studies have explored injury and violence among young holidaymakers. One study calculated that, across all ages, injuries sustained by nondomestic tourists in European Union countries accounted for an estimated 3,800 deaths, 83,000 hospital admissions, and 280,000 emergency department treatments annually. 27 In the Greek island of Corfu, one in five injury patients admitted to hospital in the 1996 summer season were tourists, 28 whereas in Crete, foreign visitors were found to account for one in three road traffic injury patients with around one in five attributed to alcohol use. 29 Health treatment data provide useful information on the health issues faced by young tourists abroad and the burden these place on local resources. However, they provide no indication of the prevalence of violence or unintentional injury in holidaymakers, with only the most serious injuries resulting in hospital admission. 30 A study in Spain found that almost 7% of young European holidaymakers surveyed in Ibiza and Majorca had experienced unintentional injury during their stay and over 4% had been involved in a fight. 10 Levels of substance use, violence, and unintentional injury varied between both holiday destinations and nationalities surveyed. 10,21,31 Spain is just one of the several Mediterranean countries with holiday resorts popular among young Europeans. To better understand the risks of injury in different destinations and factors associated with violence and unintentional injury in holidaymakers, we conducted a cross-sectional study of 6,502 British and German holidaymakers visiting five different Mediterranean destinations in the summer of 2009: Greece, Cyprus, Italy, Portugal, and Spain. Methods A short anonymous questionnaire was developed based on the established research tools. 10 The questionnaire explored holidaymakers characteristics; reasons for choosing their holiday destination; substance use on holiday and normal use at home; frequency of bar and nightclub use on holiday; and negative holiday experiences, including whether they, personally, had been injured in an accident (here, unintentional injury) or involved in a physical fight (here, violence). Prior to the question on physical fighting, separate questions asked if participants had been physically or verbally threatened, or involved in an argument, to distinguish between physical fighting (violence) and other forms of aggression (threats and arguments; not analyzed here). Experienced researchers were recruited in each study site and trained to implement the surveys. The survey took place in the departure areas of airports in Palma de Mallorca, Spain; Faro, Portugal; Venice (Treviso and Marco Polo airports), Italy; Crete (Heraklion airport), Greece; and Larnaca, Cyprus. The British and German holidaymakers were selected as the target population as these two nationalities accounted for the highest proportions of international visitors using each airport in the study. Despite serving several beach resorts, Venice may represent a different type of holiday destination than the other locations. However, its inclusion allows a comparison of behaviors and outcomes with those experienced by young tourists visiting traditional beach destinations. Data collection took place between July 10 and August 30, 2009, covering peak summer holiday periods. Researchers approached all individuals who appeared to be aged 16 to 35 years and traveling without children or older relatives, who were waiting to check in for flights bound for the UK or Germany. On the basis of previous studies, 10,22 a target sample of 700 individuals of each nationality was set for each location. Overall, 11,417 individuals were approached and asked if they had time to complete a short survey. Of these, 35.3% (n = 4,026) declined before being provided with any survey details. Those stating they had time were given an explanation of the survey, assured of its anonymity and confidentiality, and asked if they would be willing to participate. At this stage, compliance was 92.5% (6,834 of 7,391). Those agreeing to participate were handed a questionnaire, clip-board, pen, and envelope and asked to self-complete the questionnaire and seal it in the envelope for collection by researchers. Completed questionnaires were returned to the UK and entered into a database using SPSS v15. At this point, 332 questionnaires were excluded due to participants being outside the target age range or nationality, or for questionnaires being incomplete or defaced. The final sample was 6,502. Target samples were achieved in all locations with the exception of German holidaymakers in Crete and Portugal (Table 1). Analyses used chi-squared, with backward conditional logistic regression used to identify factors independently associated with unintentional injury and violence on holiday. To distinguish between types of illicit drugs used at home and on holiday, individuals were categorized as nondrug users, users of cannabis only, and users of other illicit drugs [ecstasy, cocaine, amphetamine, ketamine, and gammahydroxybutyrate (GHB)] in each location. Individuals who used cannabis as well as other drugs were included in the other illicit drugs category only. Those who reported having used alcohol or drugs during the last 12 months at home were classified as current home users.

3 82 Hughes et al. Table 1 Participant demographics and substance use at home by nationality and holiday location British holidaymakers German holidaymakers p between nationalities in All All Majorca Italy Crete Cyprus Portugal p All Majorca Italy Crete Cyprus Portugal p All Majorca Italy Crete Cyprus Portugal N Gender Male Female *** *** *** Age *** *** *** *** *** *** ** *** Financial level High Medium high Medium Medium low Low Not stated *** *** *** *** *** *** * ** Home substance use Alcohol (% use) *** *** * * Tobacco (% use) *** *** *** *** *** ** *** Illicit drugs used None Cannabis only Other illicit drugs *** *** *** *** *** *** *** * GHB = gammahydroxybutyrate. p between locations within nationalities. Have used at least once in the last 12 months. Including ecstasy, cocaine, amphetamines, ketamine, and GHB p < 0.05, p < 0.01, p <

4 Substance Use, Violence, and Injury in Holidaymakers 83 Results Samples varied by gender, age, and self-defined financial level, with a greater proportion of females recruited in Italy and a younger sample obtained in Majorca (Table 1). The vast majority of participants were current alcohol users (used at home in the 12 months prior to the holiday), with home alcohol use lowest among those visiting Italy or Portugal. Almost half of the participants were current home smokers and one in five reported illicit drug use at home. Overall, higher levels of home drug use were seen in British holidaymakers and in visitors to Cyprus. Across all participants, the most common reasons for choice of holiday destination were weather (58.8%) and nightlife (51.5%) (Table 2; participants could select more than one option). However, reasons for destination choice varied significantly across locations and nationalities. Across all participants, mean length of stay was 8.9 days. Alcohol use on holiday was reported by 95.0% of respondents. Over two thirds of all participants reported having been drunk during their holiday. Frequent drunkenness (defined as being drunk on at least half of the days of stay) was most commonly reported by British holidaymakers in Crete (75.9%) and Majorca (71.0%). Half of the participants smoked on holiday and over 1 in 10 used 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 among visitors to Cyprus and German visitors to Portugal. Almost a quarter (23.6%) of participants reported visiting bars and nightclubs every night during their holiday, increasing to 58.2% in British visitors to Crete (Table 2). Overall, 3.8% of participants reported involvement in violence during their holiday and 5.9% reported unintentional injury (Table 2). For each nationality, the proportion experiencing these problems varied across locations. In Crete, involvement in violence was higher among British holidaymakers than their German counterparts, yet there were no differences between nationalities elsewhere. Around 1 in 8 British visitors to Majorca and Crete and almost 1 in 10 German visitors to Majorca reported unintentional injury during their holiday. Bivariate analyses show that violence and unintentional injury on holiday were significantly higher in males and decreased with age (Table 3). Violence was most common among those staying 8 to 14 days. Among those who provided a self-defined financial level, those stating this as high were more likely to report both unintentional injury and violence (although the highest levels of unintentional injury were in those who did not provide a financial level). Drinking alcohol on holiday was associated with violence, whereas frequent drunkenness (on at least half of the days of stay) was associated with both outcomes (eg, violence, 7.3% of those reporting frequent drunkenness compared to 0.6% of those who never got drunk; p < 0.001). Using illicit drugs, particularly other illicit drugs, both at home and on holiday was strongly associated with violence and unintentional injury. Both outcomes were also significantly associated with frequent use of nightlife (visiting bars and nightclubs) on holiday (Table 3). To identify independent relationships with violence and unintentional injury, logistic regression analyses were conducted using all variables significant in bivariate analyses and a combined variable of nationality and location (Table 4). Here, odds of violence were highest in those visiting Majorca and in British visitors to Crete. Odds of unintentional injury were increased in visitors of both nationalities to Crete. Being male was associated with both outcomes, whereas younger participants had increased odds of unintentional injury, but not violence. Participants who were attracted to their destination due to nightlife had increased odds of violence; however, differences in violence between those with the lowest and highest levels of nightlife participation on holiday were not significant. Frequent drunkenness was associated with both violence and unintentional injury. Smoking and using any illicit drugs on holiday were associated with violence, but not unintentional injury. However, individuals who reported using drugs other than just cannabis at home showed increased odds of unintentional injury. Individuals who reported having been involved in violence on holiday were asked whether they were under the influence of alcohol or drugs at the time. Of those who provided this information (186 of 236), 91.6% reported being under the influence of alcohol. Of those involved in a fight who were drug users, 16.2% reported being under the influence of drugs at the time of the fight. Over half (51.3%) of the violence occurred in bars or nightclubs, with the remainder largely (36.0%) occurring in streets. Discussion A growing body of research is identifying the risks young people take with their health during holiday periods and the problems they face particularly while away abroad. To our knowledge, however, this is the first study that has explored young holidaymakers substance use and experience of violence and unintentional injury across multiple destination countries and different nationalities. As with all surveys of risky and antisocial behaviors, our study may have been affected by compliance and underreporting or exaggeration of risk behaviors and experiences on holiday. However, we used an established methodology that ensured participants were informed of the purpose of the study and the topics it covered, assured of its confidentiality, and provided with a clearly anonymous mechanism of participation.

5 84 Hughes et al. Table 2 Holiday features, behaviors, and outcomes by nationality and holiday location British holidaymakers German holidaymakers p between nationalities in All All Majorca Italy Crete Cyprus Portugal p All Majorca Italy Crete Cyprus Portugal p All Majorca Italy Crete Cyprus Portugal Reasons for destination choice (% yes) Cost *** *** *** *** Nightlife *** *** *** *** *** Culture *** *** ** ** *** ** Weather *** *** *** *** *** ** ** Work *** *** * Visiting family/friends *** *** *** *** *** ** Length of stay (%) Up to 7 d d or more d *** *** ** *** *** *** *** Holiday substance use Alcohol (% used) *** *** *** *** * * Tobacco (% used) *** *** ** *** *** * *** Illicit drug use None Cannabis only Other illicit drugs *** *** * * *** *** *** *** Frequency of drunkenness (%) Never (including nondrinkers) <half of the days of stay half of the days of stay *** *** *** *** *** *** ** Frequency of visiting bars/clubs <half of the nights of stay At least half but not all nights Every night *** *** *** *** *** *** ** Holiday outcomes (%) In a physical fight *** *** * Unintentional injury *** *** *** ** ** * GHB = gammahydroxybutyrate. p between locations within nationalities. Including ecstasy, cocaine, amphetamines, ketamine, and GHB. About 2% of drinkers did not provide information on drunkenness. p < 0.05, p < 0.01, p <

6 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 Gender Male Female 1.7 *** 3.9 *** Age *** 1.9 *** Length of stay Up to 7 d d or more d 2.3 *** Financial level High Medium high Medium Medium low Low Not stated 5.1 *** 10.8 *** Substance use at home Alcohol No Yes Tobacco No Yes 5.0 *** Illicit drugs None Cannabis only Other drugs 10.3 *** 10.8 *** Substance use on holiday Alcohol No Yes 3.9 * Tobacco No Yes 5.6 *** 6.7 ** Illicit drugs None Cannabis only Other drugs 14.8 *** 14.7 *** Frequency of drunkenness on holiday Never (including nondrinkers) Less than half of the stay Half or more of the stay 7.3 *** 11.4 *** Frequency of nightlife use on holiday Less than half nights of stay At least half but not every night Every night 7.7 *** 7.7 *** Reason for destination choice Cost No Yes * Nightlife No Yes 6.2 *** 8.3 *** Culture No Yes 2.2 ** 3.0 *** Weather No Yes *** Work No Yes Visiting No Family/friends Yes 1.7 *** 6.3 *** The samples were intended to be broadly representative of holidaymakers traveling to each destination, yet sample recruitment was opportunistic, conducted on a convenience basis, and focused only on holidaymakers using air transport to return home. However, we achieved high compliance among those who were informed of the survey s nature, thus reducing the potential for participant self-selection to affect our findings. Our study found that the Mediterranean holiday destinations attract young people with different behavioral characteristics for different purposes and

7 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 * ns British Italy ns ns British Crete * * British Cyprus ns ns British Portugal ns ns German Majorca * ns German Italy ns ns German Crete ns German Cyprus ns German Portugal (Ref) * Sex Male Female (Ref) *** *** Age *** * (Ref) ns *** Reason for destination choice Cost (Ref No ) ns Nightlife (Ref No ) ** ns Culture (Ref No ) ns ns Weather (Ref No ) ns Visiting family/friends (Ref No ) ns Length of stay Up to 7 d (Ref) 8 to 14 d *** 15 or more d ns Financial level High (Ref) ** ns Medium high ** Medium *** Medium low ns Low ns Not stated ns Home substance use Tobacco (Ref No ) ns No drugs (Ref) ns *** Cannabis only ns Other illicit drugs *** Holiday substance use Alcohol (Ref No ) ns Tobacco (Ref No ) ** ns No drugs (Ref) *** Cannabis only *** Other illicit drugs *** ns Drunk Never (Ref) <50% of nights of stay ns ns 50% of nights of stay * *** Night life Less than half of the nights of stay (Ref) ** ns At least half but not every night ns Every night ns Statistics use a stepwise backward conditional logistic regression analysis. Reference categories for each variable are identified with (Ref). Shaded cells indicate factors were not entered into the model as associations were not significant in bivariate analyses. ns = not significant. p < 0.05, p < 0.01, p < that these are reflected in the behaviors they engage in while abroad (Tables 1 and 2). Such information should be used by authorities in both holidaymakers home and destination countries to implement appropriate action to protect holidaymakers health and wellbeing. Specifically, nightlife is a major attraction for young people visiting Majorca, Crete, and Cyprus, and holidays in these destinations are characterized by frequent participation in nightlife and substance use. Regular drunkenness is the norm among British visitors to Majorca and Crete and German holidaymakers in Majorca. Visitors to Cyprus get drunk less frequently,

8 Substance Use, Violence, and Injury in Holidaymakers 87 yet report more drug use, with almost one in five visitors of both nationalities using drugs during their holiday. For young people choosing to holiday in Portugal and Italy, weather and culture, respectively, are the largest attractions. Here, holidaymakers use nightlife and get drunk less frequently. Despite this, the highest levels of overall drug use were reported by German visitors to Portugal. Across all samples, almost 6% of young holidaymakers reported having suffered unintentional injury during their holiday and almost 4% had been involved in violence (Table 3). Unintentional injury was independently associated with being male, younger, an illicit drug user at home (but not on holiday), frequently getting drunk on holiday, and visiting Crete (Table 4). Involvement in violence was associated with being male, attracted to the destination due to its nightlife, staying 8 to 14 days, visiting Majorca (both nationalities) or Crete (British), smoking, regularly getting drunk, and using drugs on holiday. The relationship between drug use and violence abroad was largely not temporal; only 16.2% of drug users who reported violence identified themselves as being under the influence of drugs at the time of the incident. Links between drugs and violence are complex and include the exposure of drug users to environments that can feature violence (eg, illicit drug markets and nightclubs) and shared risk factors (eg, sensation seeking) which can make individuals vulnerable to both. 8 The same is true for links between alcohol and violence. 32 However, over 90% of violent incidents reported in our study occurred when individuals were under the influence of alcohol, reflecting the strong temporal links between alcohol use and violence. 5 Although we cannot establish the causal role of alcohol in violent incidents reported by holidaymakers, the dose-responsive relationship between alcohol and violence suggests that alcohol would have been a major contributor to such harm. Conversely, it is likely that links between tobacco and violence reflect a predisposition to risk-taking behavior in some individuals rather than a causal relationship. 33 Even after controlling for participants demographics, substance use, and holiday nightlife habits, individuals visiting Majorca and Crete showed greater risks of violence and unintentional injury (Table 4). This suggests that other aspects of the environment in these destinations, or the individuals that choose them, are contributing to higher harm. Resorts such as Magaluf and Arenal in Majorca and Malia in Crete are renowned party destinations for young holidaymakers and often marketed as such in tourists home countries. They typically feature large concentrations of bars and nightclubs catering specifically to heavy drinking tourists, offering promotional drinks and entertainment focused around drinking and promiscuity. 34 Such features have been identified as key environmental risk factors for violence and injury Although the frequency of visiting bars and nightclubs was not independently associated with violence or unintentional injury in our study, both outcomes increased in those who used nightlife more frequently and over half of the violent incidents reported occurred in bars or nightclubs. Further investigation of the environmental features of nightlife settings in resorts may help to understand why some destinations are more vulnerable to violence and unintentional injury. Further work is also needed to understand differences between nationalities within destinations. For example, German visitors to Crete reported significantly lower levels of drunkenness, nightlife use, and negative outcomes than their British counterparts. Whether these differences relate to the types of resort visited by each nationality, the types of holidaymakers choosing Crete or other factors require further study. For young people intent on partying, reduced responsibilities during holiday periods can enable them to increase nightlife participation substantially. Two thirds of our sample visited bars and nightclubs on at least half of the nights of their holiday, with a quarter doing so every night (Table 2). For an individual who goes out once a week at home 38 but every night on holiday, a 2-week stay in a foreign holiday resort could contain up to one fifth of their annual nights out. The risks associated with nightlife substance use can be exacerbated by environmental factors in foreign holiday resorts, 39 including larger alcohol measures, unknown drug markets, hotter climates and unfamiliar geography, language, and legislation (eg drink-driving). Despite this, interventions to protect young holidaymakers health are scarce. In fact, holidaymakers can fall into a health and safety policy vacuum while abroad. Thus, they are not residents (and therefore long-term concerns) of the countries they visit and while away from home their behavior is largely beyond the jurisdiction of authorities in their home countries. Consequently, holiday resorts may operate on economic models that promote and provide hedonistic, high-alcohol risktaking environments with relatively little consideration for visitors health. The drunken behaviors reported by holidaymakers abroad are not typical among young nationals of countries such as Spain and Greece, who generally report lower alcohol use and drunkenness than their Northern European counterparts. 15,38 Even when on holiday, young Spaniards do not frequently drink to intoxication. 21 Thus, hedonistic resorts can act as enclaves for heavy drinking tourists set within domestic cultures where drunkenness can be rare, and excessive behavior may be tolerated more in tourists than it would be in local young people. Yet youth binge drinking is increasing in many European countries, with concerns that heavy drinking cultures are spreading Thus, authorities in Mediterranean resorts should consider any demonstration effects tourists drinking may have on local youth. Furthermore, nightlife-related violence and injuries can place major burdens on services and communities in resorts, while their longer-term health impacts return home with the holidaymaker. The pressures that hedonistic tourism place on resort

9 88 Hughes et al. communities and young people s longer-term health have yet to be measured against the benefits of this model of tourism. Developing this understanding should be a key research priority. Critically, a reputation for drunken behavior and violence can also damage a resort s tourism. 43 Tourism plays a major economic role in Europe, generating over 5% of the European Union s gross domestic product and providing around 10 million jobs. 44 Cheap international travel and open borders within Europe have been commercially exploited to create nightlife resorts where risks to health, such as injury and violence, frequently result from highly intoxigenic environments. However, as those at risk are abroad, behaviors which might typically elicit a public health response in endemic populations are tolerated and sometimes even encouraged in tourists often for commercial gain. A broader interpretation of European citizenship would be one that considers both commercial benefits from nightlife tourism and public health risks to its customers. Although such a model may require changes to existing nightlife destinations, the benefits could extend beyond tourists and help to reverse the gradual dissemination of binge drinking cultures across Europe. Acknowledgments The study was funded by the European Commission Directorate-General for Justice, Freedom and Security (JSL/2007/DAP-1/ CE /00-87). We acknowledge and thank all those who supported the development and implementation of this study, including M. Juan, F. Mendes, S. Tripodi, B. Cibin, T. Stamos, P. Lazarov, I. Siamou, and P. Cowan. We would also like to thank the airport authorities in each country for their support with the project and all the young holidaymakers who voluntarily participated in this research. Declaration of Interests The authors state that they have no conflicts of interest to declare. 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