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S U M M A R Y This review focuses on the impact of legislation, enforcement, and sanctions in increasing safety belt usage (SBU). It finds strong and consistent evidence of past and current legislative and enforcement efforts, as well as consistent evidence suggesting the importance of sanctions. All three measures must be publicized to maximize their potential for impact. The earliest SBU laws were associated with a median 32 percentage point increase in observed usage, from baselines of 16% to 18%. Increases were greater in states that allowed for stan- dard (primary) enforcement procedures and, in those states, they were greatest when enforce- ment and/or sanctions were present. In general, these early laws affected lower-risk groups (e.g., females, adults, urban and late-night motorists, etc.) to a greater extent than higher- risk groups (e.g. males, teens, rural and daytime motorists, etc.), thus increasing the usage gap between such groups. These laws resulted in median 7% to 9% reductions in fatalities and 13% reductions in injuries. These reductions were lower than expected, based on the magnitude of increases and the known effectiveness of safety belts against deaths. From January 1993 through February 2007, 18 jurisdictions upgraded their secondary enforcement laws to allow for primary enforcement. These upgrades were associated with a median 13 to 16 percentage point increase in observed SBU, from a median baseline of about 65% (range: 52% to 83%). Recent upgrades, those implemented since 1999, were associated with somewhat smaller gains (median = 11 points), compared with pre-2000 upgrades (median = 16 points). With regard to usage among occupants killed in crashes, these upgrades were associated with a median increase of 8 percentage points (range: â1 to +21), with recent upgrades associated with gains that were slightly larger than those of earlier upgrades (+10 versus +7 points, respectively). In contrast to results concerning initial laws, studies of primary law upgrades suggest that they affect higher risk groups to the same (or greater) extent as they affect lower risk groups, thus decreasing the usage gap between these two risk groups. There also is recent evidence that upgrades affect usage among drinking drivers and among occupants killed in late-night crashes. In some cases these increases have been greater than among nondrinking drivers and occupants killed in daytime crashes. Studies of the impact of primary law upgrades on fatalities have shown a median 7% to 8% decline in fatalities, greater than would be predicted based on the measured change in usage (observed or among crash victims). This finding is consistent with a relatively greater impact on high-risk occupants. Using changes in usage among crash victims (median = 9.7 points in recent upgrades), it is estimated that future upgrades would be associated with 4% to 5% fewer deaths and 6% fewer moderate-to-serious injuries. The average annual savings (per state) would be about $138 million. Of course, there is a large range associated with this estimate, with large and populous states experiencing greater savings than smaller, less populous, and usually rural states. The Impact of Legislation, Enforcement, and Sanctions on Safety Belt Use 1
2Most recent upgrades have been implemented in conjunction with high visibility enforce- ment (HVE) efforts, usually as part of national Click It or Ticket (CIOT) mobilizations. Thus, reported impact is often associated with a combination of legislative, enforcement, and pub- licity efforts. This combination of law upgrades and repeated HVE has provided some of the largest impacts in observed use and use among crash victims. Highly visible enforcement, usually in the form of periodic waves of intensified enforce- ment and publicity (blitzes), also has been consistently associated with large and significant increases in observed usage. At the local level, a review of more than 25 HVE programs resulted in a median increase of about 13 percentage points (range: â7 points to 41 points), usually from low-to-modest baseline rates. Benchmark programs provided increases as high as 41 points, from a median baseline of about 54% usage (range: 25% to 72%). The impact associated with HVE generally followed a ratcheting or saw-blade pattern, with large initial increases followed by modest declines, followed by additional increases and modest declines with each subsequent HVE effort. Generally, usage rates stabilized following repeated waves of HVE (e.g., in North Carolina). Based upon these studies of local HVE efforts, it appears that: a) sustained enforcement was as effective as blitz enforcement and it was usually associated with less abrupt decay in both enforcement and usage following program completion; b) publicity was essential for program impact, with paid ads associated with greater increases than other forms of media activity, but with earned media (i.e., efforts to generate local news stories) also essential for maximum impact; c) daytime enforcement generally affected daytime usage more than late- night usage, while nighttime enforcement affected late-night usage (sometimes among bar patrons) more than daytime usage; d) nonsanction approaches, where police attempted to increase usage by means of positive messages and gestures rather than with warnings or cita- tions, were generally ineffective; e) checkpoints and/or roadblocks were nearly always asso- ciated with large observed impacts; f) median intensity of enforcement was 54 citations per 10,000 residents (range: 20 to 140); g) median intensity of paid media efforts (where reported) was 36Â¢ per capita (range: 26Â¢ to 38Â¢); and h) median awareness of enforcement efforts (where reported) was 49% (range: 10% to 90%).1 At the state, regional, and national levels, a 1993 benchmark program implemented in North Carolina was associated with a 16 point increase in observed usage from a baseline of about 63%. Over two waves (7 weeks) of enforcement, this effort included more than 6,000 checkpoints, nearly 60,000 citations (81 per 10,000 residents), and about $600,000 for paid advertising (8Â¢ per capita). Telephone surveys indicated that 85% of the public were made aware of the enforcement effort. Associated with this program, an estimated 45 deaths and 320 serious injuries were avoided in the first 6 months. Based on this reported impact on deaths and injuries, the total cost savings associated with the program was as high as $115 mil- lion during that 6-month period. Few, if any, state or regional programs have been implemented with the intensity or coor- dination of this benchmark program, where checkpoints were coordinated and implemented in every county. However, several reasonably intense programs have achieved increases ave- raging 7 to 9 percentage points. States with higher baseline usage rates generally, but not always, experienced smaller impacts than those with lower baseline rates. This negative rela- tionship between baseline rates and impact partially explains why repeated program imple- mentations successively result in smaller increases in observed usage. Public adaptation to ongoing activity is likely another factor. 1These indices of enforcement and media intensity represent activity levels over the duration of the program, rather than per week or per wave of activity.
A longitudinal examination of observed and Fatality Analysis Reporting System (FARS) rates shows that it is important to view the impact of HVE (and upgrades) over the longer term. Most states that participated in early Selective Traffic Enforcement Program (STEP) demonstrations (i.e., from 2000 to 2002) continued to participate in national Operation ABC and CIOT mobilizations. As a result, these states experienced 5-to 6-year increases that averaged about 15 percentage points. Increases were generally greater in states that also upgraded their laws during this period (median increase of 19 points) than in secondary law states that did not upgrade their laws (median increase of 14 points). Longer-term trends in usage among crash victims (FARS use) suggest that outcomes in these STEP states resulted in substantial reductions in fatalities, injuries, and costs. A com- parison of pre-upgrade and post-upgrade FARS use in three Great Lakes Region states showed increases ranging from 8 points to 13 points. Each of these states implemented multiple waves of HVE and upgraded their SBU laws. These increases in FARS use translated to an estimated average annual impact of 70 fewer deaths, 1,000 fewer moderate-to-serious injuries, and cost savings of more than $200 million per year, per state. Each of these states is now focusing on higher-risk occupants. The effectiveness of sanctions is not as well documented as the effectiveness of laws and HVE. Clearly, initial laws were more effective when sanctions were in effect than when they were not in effect. In addition, early research showed a positive relationship between the magni- tude of a fine and usage among crash victims. There is consistent evidence that these relation- ships between sanctions and impact were greater in primary law states than in secondary law states. Impaired driving studies also suggest a positive relationship between sanctions and impact on fatalities. Thus, while insufficient research has been conducted with regard to the impact of sanctions on SBU, it is likely that publicized increases in sanctions would increase the impact of upgrades and HVE efforts. With current nationwide usage above 80% and with some states achieving observed rates above 90%, concern has been expressed about the potential for additional impact in such states. However, a comparison of observed and FARS rates suggests that there is capacity for additional gains in all states, particularly with regard to usage among high-risk occupants involved in potentially fatal crashes. These comparisons, along with documented low usage rates among high-risk groups (particularly in alcohol-related crashes), suggest that addi- tional emphasis should be placed on enforcement of safety belt laws during late-night hours and, wherever feasible, in conjunction with enforcement of alcohol-impaired driving laws. This suggestion was offered as early as 1986. 3