GETTING TO ZERO
A Comprehensive Approach
to a Persistent Problem
Steven M. Teutsch, Amy Geller, and Yamrot Negussie, Editors
Committee on Accelerating Progress to Reduce
Alcohol-Impaired Driving Fatalities
Board on Population Health and Public Health Practice
Health and Medicine Division
A Consensus Study Report of
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This project was supported by the National Highway Traffic Safety Administration (Contract No. 10002951). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Getting to zero alcohol-impaired driving fatalities: A comprehensive approach to a persistent problem. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24951.
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COMMITTEE ON ACCELERATING PROGRESS TO REDUCE ALCOHOL-IMPAIRED DRIVING FATALITIES
STEVEN M. TEUTSCH (Chair), Adjunct Professor, University of California, Los Angeles, Fielding School of Public Health; Senior Fellow, Public Health Institute; Senior Fellow, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California
JULIE A. BALDWIN, Professor, Department of Health Sciences, Director, Center for Health Equity Research, Northern Arizona University
LINDA C. DEGUTIS, Executive Director, Defense Health Horizons, Henry M. Jackson Foundation; Adjunct Professor, Rollins School of Public Health, Emory University
MUCIO KIT DELGADO, Assistant Professor of Emergency Medicine and Epidemiology, Perelman School of Medicine, University of Pennsylvania
DAVID H. JERNIGAN, Associate Professor, Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University
KATHERINE KEYES, Associate Professor of Epidemiology, Mailman School of Public Health, Columbia University
RICARDO MARTINEZ, Chief Medical Officer, Adeptus Health; Assistant Professor of Emergency Medicine, School of Medicine, Emory University
TIMOTHY S. NAIMI, Associate Professor of Medicine, School of Medicine, School of Public Health, Boston University; Clinician-Investigator, Section of General Internal Medicine, Boston Medical Center
JEFF NIEDERDEPPE, Associate Professor, Department of Communication, Cornell University
CHARLES P. O’BRIEN, Kenneth Appel Professor and Founding Director, Center for Studies of Addiction, University of Pennsylvania
JODY L. SINDELAR, Professor, Public Health (Policy) and Economics, School of Public Health, Yale University
JOANNE E. THOMKA, Program Counsel, National Association of Attorneys General
DOUGLAS WIEBE, Associate Professor of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
AMY GELLER, Study Director
YAMROT NEGUSSIE, Research Associate
AIMEE MEAD, Research Associate (from June 2017)
SOPHIE YANG, Research Assistant (from June 2017)
MARJORIE PICHON, Senior Program Assistant (until September 2017)
JENNIFER COHEN, Program Officer (July 2017–January 2018)
HOPE HARE, Administrative Assistant
MISRAK DABI, Financial Associate
BERNARDO KLEINER, Associate Division Director, Transportation Research Board
ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
KRISTINE M. GEBBIE, Torrens Resilience Institute, Flinders University
NORMAN GIESBRECHT, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health
RALPH HINGSON, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health
ANNE McCARTT, formerly with Insurance Institute for Highway Safety
SCOTT C. RATZAN, AB InBev Foundation
EDUARDO ROMANO, Pacific Institute for Research and Evaluation
RUTH SHULTS, Centers for Disease Control and Prevention
MICHAEL D. SLATER, The Ohio State University
FRANK A. SLOAN, Duke University
GORDON SMITH, West Virginia University
SRINIVASAN SUNDARARAJAN, Ford Motor Company
STEPHEN K. TALPINS, Rumberger Kirk & Caldwell and National Partnership on Alcohol Misuse and Crime
LAWRENCE WALLACK, Portland State University
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ROBERT B. WALLACE, The University of Iowa, and RICHARD J. BONNIE, University of Virginia. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
The Committee on Accelerating Progress to Reduce Alcohol-Impaired Driving Fatalities wishes to acknowledge the many people whose contributions and support made this report possible. The committee benefited from presentations made by a number of experts. The following individuals shared their research, experience, and perspectives with the committee: Nadia Anderson, Douglas Beirness, Nancy Bill, Jessica Cicchino, Phillip Cook, James C. Fell, Debra Furr-Holden, Jacqueline Gillan, Thomas Greenfield, J. T. Griffin, Frank Harris, Ralph Hingson, Tara Kelley-Baker, Bill Kerr, Russ Martin, Jim McDonnell, Jeff Michael, Keith Nothacker, M. J. Paschall, Francesca Polletta, Rebecca Ramirez, Craig Reinarman, Lawrence Robertson, Steve Schmidt, Clint Shrum, Brooke Stringer, Steve Taylor, Anne Teigen, Nick Van Dyke, Robert Voas, Diane Wigle, and Thomas Woodward.
The following individuals were important sources of information, generously giving their time and knowledge to further the committee’s efforts: Thomas F. Babor, Charles DiMaggio, Lori Dorfman, Deborah Fisher, Adnan Hyder, Jonathan Noel, Jamie Oliver, Katherine Robaina, Robert Strassburger, Andres Vecino-Ortiz, and Katherine Wheeler-Martin.
The committee is thankful to the study staff for their support of this study: Amy Geller, Yamrot Negussie, Aimee Mead, Sophie Yang, Marjorie Pichon, Jennifer Cohen, Bernardo Kleiner, and Rose Marie Martinez. The committee also acknowledges the support of other National Academies of Sciences, Engineering, and Medicine staff, especially Daniel Bearss, Clyde Behney, Misrak Dabi, Iliana Espinal, Chelsea Frakes, Greta Gorman,
Hope Hare, Nicole Joy, Sarah Kelley, Ellen Kimmel, Dana Korsen, Rebecca Morgan, Tina Ritter, Doris Romero, Barbara Schlein, Lauren Shern, Elizabeth Tyson, and Taryn Young.
The committee also benefited from past National Academies studies relevant to this report, particularly the 2004 report Reducing Underage Drinking: A Collective Responsibility.
Finally, funding for this project was provided by the National Highway Traffic Safety Administration. The committee extends special thanks for that support.
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American Association of State Highway and Transportation Officials
American Beverage Institute
alcohol by volume
American College of Emergency Physicians
Automotive Coalition for Traffic Safety
American Hospital Association
American Indian/Alaska Native
Abbreviated Injury Scale
administrative license revocation
administrative license suspension
Association for Medical Education and Research in Substance Abuse
Alcohol Policy Information System
American Stop Smoking Intervention Study
alcohol use disorder
blood alcohol concentration/content
breath alcohol concentration
Behavioral Risk Factor Surveillance System
Community Anti-Drug Coalitions of America
cognitive behavioral therapy
Centers for Disease Control and Prevention
Crash Injury Research and Engineering Network
Crash Outcome Data Evaluation System
Community Preventive Services Task Force
Driver Alcohol Detection System for Safety
Department of Motor Vehicles
Department of Transportation
driving under the influence
driving while impaired
emergency medical services
Enhanced Safety of Vehicles
Fatality Analysis Reporting System
Fixing America’s Surface Transportation
Federal Bureau of Investigation
Food and Drug Administration
Federal Highway Administration
Federal Motor Carrier Safety Administration
Governors Highway Safety Association
geographic information system
highway vehicle miles traveled
Insurance Institute for Highway Safety
Institute of Transportation Engineers
Mothers Against Drunk Driving
Moving Ahead for Progress in the 21st Century Act
minimum legal drinking age
National Center for Statistics and Analysis
National Conference of State Legislators
National Electronic Injury Surveillance System
National Epidemiologic Survey on Alcohol-Related Conditions
National Household Travel Survey
National Highway Traffic Safety Administration
National Institute on Alcohol Abuse and Alcoholism
National Incident-Based Reporting System
National Roadside Survey of Alcohol and Drug Use by Drivers
National Safety Council
National Survey on Drug Use and Health
National Trauma Data Bank
National Transportation Safety Board
Organisation for Economic Co-operation and Development
Pan American Health Organization
police accident report
passive alcohol sensor
preliminary breath test
place of last drink
responsible beverage service
Remove Intoxicated Drivers
Research of Alcohol Detection Systems for Stopping Alcohol-Related Fatalities Everywhere
Substance Abuse and Mental Health Services Administration
screening, brief intervention, and referral to treatment
Safe Communities Coalition
standard deviation of lane position
social determinants of health
State Data System
standard deviation of speed
standardized field sobriety test
sales to intoxicated persons
Swedish Traffic Accident Data Acquisition
transdermal alcohol content
Uniform Crime Reporting System
Uniform Accident and Sickness Policy Provision Law
vehicle to infrastructure
vehicle to vehicle
vehicle miles traveled
World Health Organization
Web-based Injury Statistics Query and Reporting System
Youth Risk Behavior Surveillance System
Alcohol-impaired driving crash/fatality—In all U.S. states1 drivers are considered legally impaired to drive when their blood alcohol concentration (BAC) is greater than or equal to 0.08 grams per deciliter (g/dL, often expressed as %, as in 0.08%).2 Thus, in the United States, any crash involving one or more drivers with a BAC of 0.08% or higher is typically referred to by the National Highway Traffic Safety Administration (NHTSA) as an alcohol-impaired driving crash, and fatalities stemming from those crashes are defined as being alcohol-impaired driving crash fatalities. Of note, however, is that impairment begins below 0.08%, so this is an underestimate relative to all crash fatalities in which impairment from alcohol may have contributed.3
Alcohol-related crash/fatality—A crash or a fatality from a crash that involves one or more drivers of a motor vehicle with any alcohol in their system (i.e., a BAC greater than 0.00%). This term also subsumes alcohol-impaired driving crashes. It is a useful umbrella term for all motor vehicle
1 Utah recently passed legislation to lower the BAC law to 0.05% beginning in December 2018.
2 States may have lower BAC laws for individuals under the minimum legal drinking age of 21 and for commercial drivers.
3 Of note, a crash involving a nonimpaired motor vehicle driver and an impaired pedestrian or cyclist is not counted as an alcohol-impaired motor vehicle crash by NHTSA’s Fatality Analysis Reporting System, which collects information about all motor vehicle crash fatalities occurring on U.S. public roadways.
crashes that involve any alcohol. Some have also used the term alcohol-involved to convey the same idea.
Alcohol use disorder (AUD)—The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) combines previously separate disorders (alcohol abuse and alcohol dependence) into one alcohol use disorder with a continuum of mild, moderate, and severe subclassifications. A patient is diagnosed with AUD if he or she displays 2 of the 11 symptoms during a 12-month period; the subclassifications are based on the number of symptoms the patient has (mild AUD = 2 or 3 of the symptoms, moderate AUD = 4 or 5 symptoms, and severe AUD = 6 or more symptoms).
Binge drinking—Used to connote drinking at or above levels during a drinking occasion/episode that typically results in impairment-level BAC (i.e., ≥0.08%) for most men and women drinking at typical drinking rates. This corresponds to drinking five or more drinks for men and four or more drinks for women in about 2 hours. Most public health and epidemiologic studies use five/four thresholds, and members of the general public interpret the term binge drinking to mean drinking to the point of impairment or intoxication.
Blood alcohol concentration/content (BAC)—The percentage (%) of ethanol in the blood, based on the mass of alcohol per mass of blood. For instance, a BAC of 0.10 (0.10%, or one-tenth of 1 percent) means that there are 0.10 grams of alcohol for every deciliter (100 ml) of blood. Blood alcohol concentrations can also be derived from breath tests or transcutaneous monitors. This is sometimes expressed in milligrams per deciliter, in which case a BAC of 0.1% is expressed as 100 mg/dL.
Driver—Refers to the operator of any motor vehicle, including a motorcycle or motorboat. For surveillance purposes (e.g., NHTSA), this is usually restricted to motor vehicles operating on land, meaning motor vehicles, including motorcycles and related vehicles, operating on public roadways.
Driving under the influence (DUI), driving while impaired (DWI)—These are legal terms that refer to operating a motor vehicle while one’s blood alcohol concentration is above the limit set by state law, or on the basis of field sobriety tests or observed behavior. Colloquial terms for DUI and DWI include
Drink-driving—Refers to driving or operating a motor vehicle while impaired or while one’s blood alcohol concentration is above the limit set by law (more commonly used in the United Kingdom).
Drunk driving crash/fatality—Widely used and recognized, and generally refers to driving or crashes or fatalities that are related to alcohol impairment (in most U.S. states based on BAC levels ≥ 0.08%; see footnote 1).
Impairment—Refers to the deterioration of an individual’s judgment and/or physical ability. Physiological and cognitive impairment begin at BAC levels below those that are associated with intoxication. As a legal standard, impairment and DWI laws are based on a person’s physical or mental impairment as judged on the basis of BAC level, performance in standardized field sobriety tests, or observed behavior. Although this report is focused on impairment from alcohol, impairment can result from other substance use, distracted driving, and other reasons.
Intoxication—Refers to the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs. This is usually based on a subjective determination (one feels the sensation, or observes a behavior in another person). Physiological impairment begins at BAC levels below those that are associated with intoxication. Intoxication is not a legal standard.
Motor vehicle crash fatality—NHTSA defines a motor vehicle crash fatality as one that (1) involves at least one motor vehicle (e.g., car, motorcycle); (2) results in the death of a driver, passenger, cyclist, pedestrian, or occupant of a vehicle in transit within 30 days of the crash; and (3) occurs on a public U.S. roadway.
Per se laws—Per se laws in DUI or DWI cases generally establish that once an individual is shown to have a BAC at or above a certain limit (e.g., 0.08%) that person will be considered impaired by law. In such circumstances, no further evidence of intoxication or impairment need be demonstrated for the purpose of a DUI case. Currently, all states have per se DUI laws.
U.S. standard drink—In the United States, a standard drink is 14 grams or 0.6 ounces of pure ethanol (a weight-based measure). This is the amount of ethanol in 12 ounces of 5 percent alcohol-by-volume (ABV) beer, 5 ounces of 12 percent ABV wine, or 1.5 ounces of 40 percent ABV distilled spirits (40 percent ABV, or 80 proof, is the concentration in most brands of whiskey, vodka, rum, gin, etc.).
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More than 10,000 people are killed in the United States each year from alcohol-impaired driving, and that number is on the rise. After decades of progress, the number of alcohol-impaired driving deaths first stagnated and is now actually increasing. Alcohol-impaired driving remains the greatest single cause of motor vehicle fatalities, significantly exceeding the number of deaths from distracted driving and drugged driving. Passengers, pedestrians, cyclists, and occupants of other vehicles—who make up almost 40 percent of alcohol-impaired driving fatalities1—are secondhand victims, and their fatalities are just as intolerable as those of the victims of cigarette secondhand smoke. For each death, hundreds more are injured or disabled.
Our apathy toward 29 alcohol-impaired driving deaths per day is unacceptable, particularly because these tragic events can be prevented. This report describes how this can be accomplished with the tools already at our disposal and on the near-term horizon. By marshalling real-time, comprehensive data and the collective action of all the relevant stakeholders, we can make step-by-step progress toward eliminating these needless deaths and injuries. Vision Zero—the framework for eliminating motor vehicle deaths—provides the road map. Policy makers can enact and implement evidence-based policies, the clinical care system can identify and manage those at risk, the enforcement and legal systems can
1 NCSA (National Center for Statistics and Analysis). 2016. Alcohol-impaired driving: 2015 data. DOT HS 812 350. Washington, DC: National Highway Traffic Safety Administration.
identify and manage offenders, the alcohol beverage industry can support and implement effective actions grounded in evidence and take steps to reduce harmful drinking, engineers and the private sector can partner to develop and incorporate effective technologies into vehicles and devices, government agencies can provide the leadership and research to enact and enforce policies to reinvigorate progress, and the public can advocate for effective actions. These collaborations can establish processes for the actions that need to be taken, determine the entities primarily responsible, assess progress toward implementation, and develop mechanisms to identify problems, investigate them, and take effective action. As some Organisation for Economic Co-operation and Development nations have demonstrated, alcohol-impaired driving deaths can be virtually eliminated. This report provides the science base to do so.
I want to extend my gratitude to the National Highway Traffic Safety Administration for stimulating and sponsoring this report. It is another step in its continued leadership in making our roadways safer. Thanks, too, to the committee, staff, and consultants for their creativity and energy in bringing this report to fruition.
Steven M. Teutsch, Chair
Committee on Accelerating Progress to Reduce
Alcohol-Impaired Driving Fatalities