7

Generating Action

INTRODUCTION

To initiate and sustain action that will bolster progress to reduce alcohol-impaired driving fatalities, the United States needs a strategic and comprehensive national effort. Such an effort requires the engagement of stakeholders across multiple sectors such as transportation, law enforcement, public health, the private sector, philanthropy, and others. Furthermore, it will entail garnering public will to address alcohol-impaired driving and allocating the resources needed to do so by creating and sustaining public discourse to underscore the magnitude of the problem and outline strategies to move these efforts forward. A multilevel ecological approach that targets individual beliefs and attitudes, community-level collaboration, institutional partnerships, and social norms (see Figure 1-6 for an illustration of these levels in the socioecological model) will be needed to catalyze a movement to achieve reductions in alcohol-impaired driving fatalities once again. This chapter highlights the key elements, approaches, innovations, and partnerships that could generate such action and overcome existing barriers. The chapter begins with a discussion of the role of historic and current social movements. This is followed by sections that explore the role of community-based approaches, the media environment and media advocacy, and discussions of stakeholder accountability and recommendations for action to reduce alcohol-impaired driving fatalities.

THE ROLE OF SOCIAL MOVEMENTS

Mothers Against Drunk Driving: A Historical Perspective

There is a significant and understandable tendency to look back at Mothers Against Drunk Driving (MADD) and credit that organization with much of the progress that has been made in reducing alcohol-impaired driving in the United States. Indeed, Fell and Voas (2006) do so, concluding that MADD made such a difference by contributing to the public view that alcohol-impaired driving is socially unacceptable, encouraging state legislatures and Congress to adopt laws and policies, and creating an unparalleled network of victims’ services.

MADD has a compelling history. Founded in 1980, it received early on more seed money from the federal government (National Highway Traffic Safety Administration [NHTSA]) than any other source (including alcohol manufacturers, who ultimately donated $50,000 but were no longer involved with MADD by the mid-1980s) (Fell and Voas, 2006). By 1985, MADD had 377 chapters, with at least one in every state except Montana (Wolfson, 1995), and a budget approaching $10 million (Reinarman, 1988). By 1990, it had annual revenues of almost $50 million (Fell and Voas, 2006).

Although not solely attributable to MADD, from 1981 to 1986 states passed 729 laws concerning drinking and driving, with an accompanying dramatic drop in deaths from alcohol-impaired driving (Fell and Voas, 2006). One analysis of MADD’s state-level activism concluded that MADD did this without reliance on conventional resources (Wolfson, 1995). Wolfson found that legitimacy, based in the fact that state chapter presidents were generally personally affected by alcohol-impaired driving and there were high levels of victim membership in state chapters, combined with lobbying and legislative activity were more important in explaining significant policy change at the state level (i.e., passage of 21 as the minimum purchase age for alcohol) than the age of members, the overall size of the membership, the revenues of the chapter, network cohesiveness, or the level of organization—all of which are more usual measures of a social movement’s magnitude and likely success (Wolfson, 1995).

The salience of alcohol-impaired driving in the media, and particularly the role of the Ad Council and NHTSA’s “Friends don’t let friends drive drunk” campaign, is worth noting during this time period as well. The campaign is often regarded as an integral contributing factor to the shifting social norms around alcohol-impaired driving (Ad Council, n.d.; Glascoff et al., 2013). While this campaign lacks rigorous evaluative studies, its airing being coincident with MADD’s activities could suggest the importance of coordinating media approaches with grassroots efforts to

maximize impact. (For more on media approaches, see the section in this chapter on The Media Environment and Media Advocacy.)

In historical review, MADD meets the five “core practices” Ganz posits for the development of a successful social movement in a 2013 Institute of Medicine (IOM) workshop (2014). In putting victims first—and particularly, as Reinarman (1988) points out, unequivocally innocent victims, such as the parents and relatives of children (nondrivers) who were in car crashes—MADD built a “people,” a network of relationships based in common experience and commitments. From these people, MADD built a narrative, a meta-story that every MADD president can tell of the progression from happy family to unjust tragedy to righteous and sympathetic activist. MADD then developed strategy, which for Ganz translates to “figuring out how to turn what people have—that is, resources—into what they need—power—in order to get what they want” (IOM, 2014, p. 12). Ganz also encourages viewing resources as political, economic, and cultural or moral. MADD used a moral stance, along with its compelling narrative, to attract significant media attention and create collective outrage, which in turn generated political pressure for change. It did this through action, from marching around the White House in 1980 to organizing a national summit of 435 youth from every congressional district in 2000 to encourage Congress to adopt a law requiring all states to set the maximum permissible blood alcohol concentration at 0.08%. Finally, MADD organized a national structure, which has endured, with a symbolic presidency rotating among victim members who can carry the organizational narrative with legitimacy, matched by a professional CEO and permanent staff that ensure continuity and focus.

This valuable historical perspective does not provide insights into why MADD arose when it did, what conditions facilitated its emergence, and if those conditions can be replicated today. Currently, a new or renewed social movement to end deaths from alcohol-impaired driving could emerge and carry the work forward. Sociologists generally view social movements as oppositional to the existing order. Thus, Polletta defines a social movement as “an organized effort to change laws, policies, or practices by people who do not have the power to effect change through conventional channels” (IOM, 2014, p. 6). To this extent, the conditions in which MADD arose certainly no longer exist. Alcohol-impaired driving is no longer seen as an acceptable behavior; it has already been stigmatized and more uniformly criminalized (Greenfield and Room, 1997). While Ross feared that it would become “a normal consequence of a society that accepts alcohol in recreation and provides no means of transportation other than private vehicles,” the fact that politicians arrested for driving while impaired (DWI) can expect news stories pillorying their behavior suggests otherwise (1997, p. 13). A 2017 content

analysis of print and television news media found that about 15 percent of news stories regarding an alcohol-impaired driving incident featured a local person of prominence in the community (e.g., local politician) as the perpetrator (Fisher, 2018).

Building on its success from the 1980s, MADD officially added “and prevent underage drinking” to its mission statement in the late 1990s (Fell and Voas, 2006). It has since worked in coalition with other organizations to implement the much broader public policy agenda foreshadowed in the 1989 report of the Surgeon General’s Workshop on Drunk Driving and laid out in the National Research Council and the IOM report Reducing Underage Drinking: A Collective Responsibility (NRC and IOM, 2004). This agenda includes increasing alcohol taxes and enhancing voluntary restrictions on alcohol advertising, an issue MADD did not address in its earlier history. The broadened mission has not led to the levels of success earlier achieved by MADD.

More recently, MADD’s activities have focused on advancing promising technological solutions to address alcohol-impaired driving. This includes advocating and lobbying for all-offender ignition interlock laws in every state (see Recommendation 5-3 in this report) as part of its Campaign to Eliminate Drunk Driving, which launched in 2006 (MADD, 2017). MADD was also instrumental in establishing the Driver Alcohol Detection System for Safety (DADSS) initiative (see Chapter 4 for more on DADSS) and testifies to legislative committees on the promise of new technologies such as autonomous vehicles (Sheehey-Church, 2017).

Creating a Social Movement in the Current Environment

It is worth examining the differences in the current environment and the environment during the era when MADD emerged. In addition to alcohol-impaired driving no longer being normative, media attention to the issue has waned. MADD’s competitor, Remove Intoxicated Drivers, received differential treatment for its advocacy of advertising restrictions, while MADD’s avoidance of that issue was key to the organization’s success in the news media, particularly television news, in the 1980s (Mosher and Jernigan, 1989). Reinarman (1988, p. 112) argued that “MADD did in some senses suit the interests of the alcohol, advertising, and broadcasting industries who were facing what they saw as a broader threat, and the movement both aided and was aided by broader conservative currents.” Yanovitzky found that media attention to alcohol-impaired driving, instigated largely by MADD’s efforts, played a key role in influencing state and federal legislative action, which in turn stimulated population-level behavior changes around alcohol-impaired driving (Yanovitzky, 2002a).

If MADD is to recover its earlier influence, or if some other organization or emerging movement is to pick up the torch of alcohol-impaired driving as a social issue, it will likely need to be able to capture media attention as MADD did in its early years. The role of funding from NHTSA in getting MADD off the ground and the lesson it offers as to the ability of well-aimed seed funding to sprout results need to be taken into consideration. As described below, support for media advocacy training, and updating that training to encompass social media, would also be a key ingredient for success (Dorfman et al., 2005). This is a critical role that foundations can play in the support of social movements (for guidance to philanthropy on how to support movement building, see Masters and Osborn, 2010).

The sociological literature on social movements has long focused on resource mobilization, meaning the “ability to organize, recruit adherents, deploy strategy, gain strength, and achieve their aims—within the limits of existing political opportunities” (Walder, 2009, pp. 397–398), as key to the success of those movements. What this focus neglects, however, as Walder points out, is the relationship between prevailing social structures and the political orientations taken by social movements. At the height of its success in the 1980s, MADD matched the political climate of the Reagan–George H. W. Bush years, charting a course in line with conservative values at the same time that it took an oppositional stance to the normative nature of drinking and driving. In his analysis of MADD, Reinarman (1988, p. 92) argues that MADD’s “foci and tactics succeeded when they did largely (although not merely) because they were in harmony with the morality, policy ideologies, and social-control strategies of the Reagan administration.” For example, MADD’s individualistic focus, lack of attention to structural factors, and limited retributive solutions could be thought of as aligning with the conservatism at the time (Reinarman, 1988). While multiple authors have pointed to protecting the public’s health as the frame most likely to succeed MADD in movements to reduce alcohol-impaired driving (Reinarman, 1988; Ross, 1997), that frame, even as it has been espoused by MADD itself, has yet to capture the public imagination or the media attention so critical to MADD’s earlier success.

Efforts to rekindle interest in these issues by stimulating action in other sectors are also currently at their historical nadir. The Enforcing Underage Drinking Laws program in the U.S. Department of Justice sent tens of millions of dollars to local law enforcement each year for more than a decade. As discussed in Chapter 2, while still authorized, that program’s funding fell from $25 million in 2009–2010 to $10 million in fiscal year 2013 and subsequently disappeared from the federal budget. Meanwhile, there has been a dramatic drop in federal funding for more

TABLE 7-1 Funding for Federal Substance Abuse Prevention Programs, 2009–2014

NOTES: Dollar amounts are presented in the millions unless otherwise noted and are not adjusted for inflation; *with sequester.

SOURCE: Personal communication with Sue Thau, December 12, 2017, Community Anti-Drug Coalitions of America. Available by request from the National Academies of Sciences, Engineering, and Medicine’s Public Access Records Office (PARO@nas.edu).

general work on substance abuse (see Table 7-1 for data on funding of federal substance abuse prevention programs from 2009 to 2014).

Meanwhile, led by craft brewers and their congressional representatives, efforts to roll back federal excise taxes on alcohol have achieved traction and may well succeed, with 218 cosponsors in the House as of June 2017.¹ This stands in stark contrast to the Reagan–Bush era, when (in 1991) federal beer and wine taxes were increased for the first time since 1951.

Polletta describes social movements as having three “essential ingredients”: political opportunities, mobilizing structures, and resonant frames (IOM, 2014). MADD’s frame on alcohol-impaired driving, while novel in 1981, is no longer capturing media attention and as such it is less resonant, at least in the media environment. MADD continues, largely because of its victim services, to possess a substantial mobilizing structure, matched in the alcohol and other drug space only by Community Anti-Drug Coalitions of America (CADCA), the other major national organizing effort with alcohol explicitly in its mission. Federal funding for the efforts of CADCA’s approximately 3,000 member coalitions has also shrunken substantially, while language added in Section 503 of the 2012 federal appropriations bill further restricted what federally funded coalitions can do regarding public policy. Political opportunities, unpredictable as they are, may present themselves in the future, providing an opening for alcohol-impaired driving to regain its place in the national agenda.

RECENT COMMUNITY-BASED APPROACHES

Community Coalitions

While the concept of coalitions has evolved over time, coalitions can be broadly defined as formal, long-term alliances among organizations that collaborate toward a common goal (Butterfoss, 2007). Community-based coalitions are a widely accepted tool for public health promotion and prevention efforts. They have also been identified as important elements of multicomponent initiatives to promote motor vehicle safety (Goodwin et al., 2015; Shults et al., 2009) and to prevent alcohol-related harms (D’Onofrio et al., 2005). Butterfoss et al. (1993) identify six attributes of coalitions that make them instrumental in generating action. The authors assert that coalitions:

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¹ At the time this report was being finalized in December 2017, Congress passed a tax bill (Tax Cuts and Jobs Act of 2017, H.R.1, 115th Cong., 1st sess.) that would decrease federal alcohol excise taxes by about 16 percent.

1. Allow organizations to confront new and broader issues without having to take on sole responsibility;
2. Develop and demonstrate public support for a particular issue;
3. Maximize the effect of individuals and groups through joint action;
4. Minimize duplication of efforts;
5. Mobilize more resources and strategies than any one actor could garner alone; and
6. Provide an opportunity to engage participants from various constituencies.

The characteristics of an effective coalition can be measured by the capacity of organizations to be effective coalition members,² the capacity of the coalition, and the outcomes and effects of the coalition activities (Raynor, 2011). Chavis argues that although community coalitions can be powerful catalysts for mobilizing and focusing resources, they have not traditionally been successful at developing and managing services and activities in the community. He also suggests that it may behoove coalitions to delegate those tasks to community organizations with the necessary capacity (Chavis, 2001). Cramer et al. (2006) offer a conceptual model for understanding effective coalitions in health promotion, titled the “Internal Coalition Outcome Hierarchy.” The authors posit that effective coalitions have two important features. The first is a diverse membership that collaborates well to achieve objectives within the following seven constructs: shared social vision, efficient practices, knowledge and training, relationships, participation, activities, and resources. The second is leadership that fosters a learning environment that is conducive to achieving the collectively desired outcomes (Cramer et al., 2006).

Lessons from Previous Community-Based Funding Efforts

There is a significant history of federal funding of community-based efforts in tobacco control from which efforts to reduce alcohol-impaired driving deaths can benefit. Two major community-level funding initiatives—the Community Intervention Trial for Smoking Cessation (COMMIT) and the American Stop Smoking Intervention Study for Cancer Prevention (ASSIST)—made significant contributions to national capacity

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²Raynor (2011) details the capacities of effective coalition members, which include but are not limited to skills/knowledge to work collaboratively; commitment to the coalition in action as well as its name; ability to articulate what they bring to the table; willingness to share resources; willingness to share power/credit; and strategic use of coalitions to fill critical gaps and leverage resources toward achieving the mission.

and success in reducing tobacco-related disease and death. Both have been carefully evaluated. COMMIT was a 4-year effort in 11 intervention communities; ASSIST was more policy focused, and ultimately sent $114 million to 17 states over 8 years—an average of $1.14 million per state per year. ASSIST benefited from the COMMIT experience, and focused on building state capacity to deliver comprehensive tobacco use prevention and control. ASSIST showed that implementation of effective policies would lead to concrete reductions in the problem “on the ground.” It demonstrated that states with greater capacity, such as high-functioning tobacco control staff and structures in the health department, staff with experience in tobacco use control and prevention, and strong collaboration between agencies and across the state, had better outcomes. It also showed that such an intervention was comparable in its cost-effectiveness to other public health preventive interventions (NCI, 2006).

The Robert Wood Johnson Foundation in the 1990s also made a significant investment in community-based prevention in alcohol control. In particular, its A Matter of Degree program that funded colleges to reduce excess drinking and related problems confirmed the finding from ASSIST that community-based efforts could produce policy and environmental change, and that those sites that focused more on environmental and policy change were the most likely to affect the problem (Weitzman et al., 2004).

The abovementioned and other previous efforts demonstrate that a substantial investment in community-level policy and environmental change can be a cost-effective approach to the improvement of health and safety in that community. Applying such an approach to alcohol-impaired driving at the community level would require a willingness to invest significant government and/or private philanthropic dollars in the effort. This willingness in and of itself may be a measure of the degree to which there is a general commitment to addressing and reducing alcohol-impaired driving fatalities.

Community Coalitions and Alcohol-Impaired Driving

Community coalitions with the goal of addressing alcohol-impaired driving exist around the country. For example, the Texas Impaired Driving Task Force began with an informal meeting of stakeholders and evolved into a coalition that meets to discuss progress to eliminate alcohol- and drug-related crashes through stakeholder work projects and to provide guidance and technical assistance to the Texas Department of Transportation. The coalition is a multisector group, including representatives from law enforcement, media development/communications, treatment, research, alcohol service, driver licensing, public health, and more (Texas

A&M Transportation Institute, 2016). Many states are forming coalitions to advance Vision Zero efforts to eliminate all traffic fatalities and serious injuries, including California, Colorado, and Massachusetts (see Chapter 1 for more information on Vision Zero). Box 7-1 describes a community coalition that developed a DWI taskforce in Louisiana.

Community-level collaboration has been identified as a key element of efforts to reduce alcohol-impaired driving fatalities. The Community Preventive Services Task Force conducted a systematic review of multicomponent interventions with community mobilization for reducing

alcohol-impaired driving,³ and found strong evidence that “carefully planned, well-executed multicomponent programs with community mobilization can reduce alcohol-related crashes” and produce cost savings (Shults et al., 2009, p. 368). One of the positive spillover effects of community mobilization identified in the review was the promotion of individual and community empowerment, as well as the development of problem-solving capacity. In addition, a synthesis of lessons learned from demonstration site projects to reduce impaired driving in rural communities cited the importance of allocating time and resources to build community support through a variety of strategies including coalition building (Cox and Fisher, 2009).

Aguilar and Delehanty (2009) documented the implementation and evaluation of a community-based social marketing initiative in Wisconsin that aimed to reduce alcohol-impaired driving among motorcyclists, a group that has high rates of impaired driving fatalities. One key aspect of the initiative was a coalition made up of tavern and restaurant owners, law enforcement officers, local business owners, members of the motorcycling community, and community activists. The authors reported encouraging outcomes, which included the assembly of a coalition of nontraditional partners and a reduction in the number of motorcycle crashes in which alcohol was a reported factor by 35 percent in the experimental counties, compared to 2 percent in other urban Wisconsin counties, but the reduction did not reach statistical significance (p = 0.07) (Aguilar and Delehanty, 2009).

Shults et al. (2009) identified some of the barriers faced by community coalitions in their review of multicomponent interventions to reduce alcohol-impaired driving. Among these challenges, the authors express particular concern for the tendency to engage in less effective interventions (e.g., public education) because they may be more palatable based on the community’s social and economic interests. Other challenges include gaining and sustaining consensus among group members, inefficiency in implementing decisions and interventions, ideological differences between member organizations, competition over resources, power imbalances, and existing sociocultural tensions among the various actors.

Alcohol tax coalitions Coalitions can also facilitate progress on alcohol-impaired driving fatalities by focusing their efforts on population-based preventive interventions such as increasing alcohol taxes

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³ Multicomponent programs here are defined as the implementation of interventions or policies in multiple settings (e.g., responsible beverage service in bars and sobriety checkpoints), or that modify the community environment to reduce alcohol-impaired driving (Shults et al., 2009).

(see Recommendation 3-1 in this report). As referenced in Chapter 3, one barrier to the implementation of alcohol tax increases is the lack of awareness of the efficacy of taxes to reduce harmful drinking and related consequences such as alcohol-impaired driving fatalities (Jernigan and Waters, 2009). Policy makers tend to view alcohol taxes primarily as revenue-raising measures, and to be unaware of the positive public health effects related to tax increases. Inserting a public health “voice” into public debates over alcohol taxes can be challenging (Ramirez and Jernigan, 2017). Broad-based coalitions are an important and promising tool for communities to employ to educate the public and policy makers about alcohol taxes.

Ramirez and Jernigan (2017) analyzed the ability of diverse coalitions in three states to pass laws increasing alcohol excise taxes. They found that strategic use of polling data, leveraging existing political champions, broad-based coalition building (beyond the alcohol and drug fields), past experience with legislative initiatives, allocating tax revenues strategically to build political and coalition support, and generating media coverage through intentional media advocacy were key elements of successful campaigns. The most successful grassroots effort occurred in Maryland, where the statewide coalition of more than 1,200 organizations generated 239 media articles mentioning the state sales tax increase on alcohol by 3 percent in significant print media outlets, and succeeded without a leading politician as champion in increasing the tax and generating more than $70 million in revenues, leading to a significant drop in alcohol-impaired drivers on Maryland roadways (Ramirez and Jernigan, 2017). One study found that the tax increase led to a 3.8 percent drop in alcohol consumption relative to what would have been expected given prior sales trends (Esser et al., 2016), while another found that the tax increase was associated with a decline in crashes involving drivers with alcohol in their system (12 percent for drivers 15–34 years old and 6 percent for all drivers) (Lavoie et al., 2017). The formation of such coalitions is an important tool to advance evidence and catalyze action on interventions that can be challenging to implement in the policy-making arena.

Effective Community-Based Approaches for Alcohol-Related Issues

Multicomponent, community-based approaches are a viable way to reduce alcohol-related harms at the local level, as they address the social and environmental conditions that shape the problems at hand (Aguirre-Molina and Gorman, 1996; Shults et al., 2009). In their review of the literature on community-based programs, Aguirre-Molina and Gorman (1994) found that the most promising community prevention efforts:

• Are grounded in models of community action for social change;
• Value community empowerment and have origins in community development;⁴
• Target multiple systems and employ multiple strategies;
• Recognize the importance of social policy;
• Use tools from a public health model (e.g., addressing social and environmental factors beyond individual behaviors); and
• Use the best available evidence to inform the interventions.

The authors also cite two examples of comprehensive community-based alcohol prevention programs, the Prevention Research Center and Communities Mobilizing for Change on Alcohol (CMCA), both of which targeted community-level policies, practices, and the alcohol environment to reduce alcohol-related harm.

CMCA was a 15-community randomized trial in which the intervention was a community organizing project that targeted policies, practices, and social norms to reduce underage persons’ access to alcohol. The project involved community organizers working with stakeholders such as public officials, enforcement agencies, alcohol merchants, the media, and schools to change community policies regarding youth drinking. The organizing effort led to institutional policy changes in all seven intervention communities including changes in retailer policies, media coverage, and law enforcement practices (Wagenaar et al., 1999). Wagenaar et al. (2000) evaluated the intervention’s effect on youth drinking and driving using arrest and crash data from state departments of public safety and transportation. The findings demonstrated a reduction in arrest and traffic crashes for 15- to 20-year-olds and a statistically significant reduction in DWI arrests among 18- to 20-year-olds.

Another effective community prevention model is Communities That Care (CTC),⁵ a coalition-based system that seeks to prevent adolescent problem behaviors (e.g., alcohol use, substance use, delinquency, and violence). A community-randomized trial assessing the system’s effects on adolescents 8 years after implementation found that students in the CTC communities were more likely than students in the control communities to have abstained from drinking alcohol (relative risk = 1.31; 95% confidence interval 1.09–1.58) (Hawkins et al., 2014). It is important to note that the program also showed sustained effects on tobacco use,

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⁴ Community empowerment is defined by Wallerstein and Bernstein as a “social-action process in which individuals and groups act to gain mastery over their lives in the context of changing their social and political environment” (1994, p. 142).

⁵ For more information, see http://www.communitiesthatcare.net (accessed September 5, 2017).

delinquency, and violence. The CTC model is unique in that it does not focus solely on alcohol use; it also addresses shared risk factors and trains local communities to select the evidence-based intervention(s) that best suit that community’s needs and assets.

Tools for Communities to Generate Action

There are a variety of publicly available tools and resources for communities that seek to take action on alcohol-impaired driving. For example, CADCA developed an Impaired Driving Prevention Toolkit for communities that seek to develop a comprehensive plan to address alcohol-impaired driving.⁶ The toolkit provides guidance on how to:

• Conduct a community assessment;
• Use a logic model to guide the planning process;
• Examine the research and evidence-based interventions that target the problem; and
• Design an intervention map for a defined local condition (CADCA, n.d.).

In 2011 NHTSA published A Guide for Local Impaired-Driving Task Forces, which features case studies of task forces around the country and discusses their histories, structures, and approaches (Fell et al., 2011). Other community resources exist to provide guidance on starting and maintaining coalitions for a broad range of issues, such as the Community Tool Box from the Center for Community Health and Development at the University of Kansas.⁷ In addition, the Pan American Health Organization offers a free online course in alcohol policy advocacy that walks through the elements of an alcohol policy change campaign.⁸

THE MEDIA ENVIRONMENT AND MEDIA ADVOCACY

Media discussions and framing of a problem are important influences on what is actually done about that problem (Iyengar, 1991). Content analyses of the current news media environment are essential to inform media advocacy efforts to reframe coverage of health-related issues in ways that advance public health goals (Dorfman, 2003). Fisher (2018) noted that

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⁶ For more information, see http://www.preventimpaireddriving.org (accessed August 21, 2017).

⁷ For more information, see http://ctb.ku.edu/en/table-of-contents/assessment/promotion-strategies/start-a-coaltion/main (accessed August 24, 2017).

⁸ For more information, see https://mooc.campusvirtualsp.org/enrol/index.php?id=40 (accessed August 24, 2017).

in the U.S. news media, alcohol-impaired driving stories mainly focus on victimization and punishment and show it as an individual problem and an individual responsibility. The stories overwhelmingly focus on the perpetrators. The most common voices in the stories are law enforcement, traffic safety advocates, prosecutors, and other attorneys. Strikingly missing from this list are victims themselves—the focus and key strength of MADD as a social movement in an earlier era and generally a voice often perceived as authentic in advocacy approaches. The presence of traffic safety advocates points to a potential for presenting broader solutions such as those described in this report; however, Fisher found little mention of such solutions, even among thematically framed stories which placed the problem in a broader societal context. These findings are indicative of a greater need for training and capacity in the use of mass media in support of community-based policy and environmental interventions—in other words, of a need for greater use of media advocacy. (See Appendix B for Fisher’s media content analysis.)

Media Advocacy

Definition and Theory

Decades of theory and research on agenda setting and framing emphasize that the news media both shape what the public and policy makers think about (see McCombs and Reynolds, 2009; McCombs and Shaw, 1972) and invite certain perspectives about how to think about them (see Iyengar, 1991, 1996). The default news media frame for social problems, including most health issues, is one that focuses on portrayals of people as villains and victims (termed “episodic” coverage, in contrast to “systemic” coverage of underlying causes and population-level consequences and solutions) and thus emphasizes individual responsibility for causing and solving social problems (Dorfman and Krasnow, 2014; Iyengar, 1991).

Media advocacy seeks to reframe public health issues in terms of broader, upstream causes that are best addressed through collective action (community mobilization) and local, state, or federal policy changes to create healthier physical, built, social, and economic environments (see Wallack et al., 1999). Media advocacy involves the strategic use of the news media in support of community organizing to increase public and policy-maker awareness of public health problems, identify effective systems and policy changes to address them, and support progress toward their passage and implementation (Wallack et al., 1993). The theory and practice of media advocacy combine insights from the fields of communication, political science, public health, and sociology, resting on the

assumptions that strategic efforts can influence the volume and nature of media coverage to emphasize upstream policy solutions to complex health problems, and that media coverage, in turn, influences the likelihood of policy debate, passage, and successful implementation (Chapman and Lupton, 1994; Dorfman and Krasnow, 2014).

Case Studies of Policy Success Involving Media Advocacy

Much like paid media campaigns, media advocacy interventions face major challenges in evaluation (see Stead et al., 2002). Media advocacy interventions are often conducted concurrently and intertwined with a variety of other intervention strategies, including paid media, community mobilization, and more direct forms of policy advocacy, such as direct contact with policy makers. In addition, the desired outcome for media advocacy is the passage of a particular policy; in a particular community, this amounts to a sample size of a single observation, making broader generalizations very difficult. As a result, many media advocacy evaluations have employed a case study approach, describing media advocacy efforts (along with other activities) and detailing the timeline of political action (or inaction) related to these efforts.

A variety of case studies have described the probable role of media advocacy in shaping policy debates and outcomes surrounding a variety of issues, including violence prevention (Wallack and Dorfman, 1996), tobacco (Jernigan and Wright, 1996; Lane and Carter, 2012; Wakefield et al., 2005), and health disparities and food insecurity (Rock et al., 2011). Several media advocacy case studies have also examined policy debates in the context of alcohol control and policy to limit alcohol-impaired driving. Various authors have credited media advocacy efforts with helping to shape policy debates surrounding a variety of policies to reduce violence against women via changes in messages conveyed in alcohol advertising (Woodruff, 1996), reduce the volume of alcohol-related marketing (Jernigan and Wright, 1996), and reduce rates of alcohol-impaired driving (Russell et al., 1995).

Evidence of Media Advocacy Effects in Shaping Favorable News Coverage

A few studies have moved beyond case study reports to describe systematic changes in the volume and nature of news media coverage in response to media advocacy intervention featuring multiple communities. These studies provide mixed evidence for the success of multisite media advocacy in shaping favorable news coverage. Schooler et al. (1996) compared tobacco-related media coverage between two intervention communities and two comparison sites as part of the Stanford Five-City Project

to reduce risk factors for cardiovascular disease. Schooler et al. (1996, p. 346) concluded that media advocacy efforts were highly successful in one treatment community but not the other. They attributed success in the successful intervention community to “frequent, regular, systematic contact with media professionals and provision of materials.” Stillman et al. (2001) evaluated changes in news coverage of tobacco control policy in response to ASSIST, a multistate intervention that featured media advocacy efforts as part of broader efforts to change policy and increase rates of smoking cessation. While the authors found that rates of tobacco control policy-related news coverage were greater in intervention states compared to nonintervention states, there were no differences in the rates of change between these groups. This indicates that preexisting differences in the states could account for the observed differences. The authors recommended caution in interpreting group differences as evidence of media advocacy effects.

The strongest evidence in support of media advocacy effects in promoting favorable news coverage comes from a community trial to reduce alcohol-related injury (largely focused on alcohol-impaired driving fatalities). The Community Trials Project sought to inform and mobilize three communities (compared to three matched control communities) to take individual and policy action to reduce alcohol-related injury and death through a variety of intervention strategies, including the strategic use of news media to promote alcohol control policy. Two evaluation studies concluded that media advocacy efforts as a part of this trial, over and above other trial activities, succeeded at increasing the volume of alcohol policy-related coverage, relative to both the comparison communities and larger state and national trends (Treno et al., 1996), and community awareness of alcohol control policies (Holder and Treno, 1997).

Combined, this work provides additional evidence that media advocacy can, under the right conditions, increase the volume and framing of news media coverage in ways that support proposed health policy changes, but more work is needed to parse out factors (at the community level) that shape the likelihood of success in promoting favorable coverage.

Evidence of Media Advocacy Effects on Policy Change

A few studies have used time series analysis and event history models to provide evidence that news coverage of health policy topics can increase policy debate and enactment in local communities. Asbridge (2004) concluded that print media coverage of the health effects of secondhand smoke, combined with direct advocacy efforts, contributed to an increase in the adoption of laws restricting public areas where people

could smoke in Canadian communities. Niederdeppe et al. (2007) argued that local newspaper coverage of youth antismoking advocacy activities contributed to increases in the passage of tobacco product placement ordinances targeting retail establishments. Yanovitzky (2002b) found that increased news media coverage of alcohol-impaired driving was associated with increased policy attention (measured by the number of congressional hearings about alcohol-impaired driving and the number of anti-alcohol-impaired driving bills introduced to Congress in a particular month) and policy action (measured by the number of anti-alcohol-impaired driving laws passed by U.S. states over time). These studies offer consistent evidence that strategic efforts to increase news coverage relevant to policy goals can generate policy debate and action favorable to improving public health.

Challenges for Media Advocacy in the New Media Environment

Despite some available evidence supporting media advocacy as an effective strategy to advance public health goals, a variety of caveats and cautions are in order. Several authors have identified a variety of potential unintended consequences and limitations of media advocacy. DeJong (1996) cautions that media advocacy can be a high-risk as well as a high-reward strategy for community coalitions. He cites a case in Massachusetts in which media advocacy brought to light significant internal debates about MADD’s mission, rendering it less effective thereafter than it might otherwise have been. Harwood et al. (2005) further warn that media advocacy efforts need to take into account the local political culture. They describe how while media advocacy regarding efforts at alcohol control policy change in Louisiana succeeded in placing the issue on the public agenda, continued attention once policy campaigns entered sensitive periods of negotiation and compromise in the state legislature inadvertently catalyzed the attention and opposition of powerful interests in that state. Gibson (2010) notes that media advocacy’s typical reliance on commercial, mainstream media may fundamentally constrain its ability to shape policy debates owing to inherent limitations of journalistic norms and practice. This concern is particularly noteworthy in light of recent changes in the news media landscape, including widespread declines in the number of local newspapers, newspaper circulation, and advertising revenues. This has contributed to smaller newsroom staff, limiting resources for nuanced coverage of health policy topics (Pew Research Center, 2017).

In response to these challenges, media advocacy efforts have increasingly moved toward the use of interactive, participatory, and social media. Clark and Marchi (2017) coined the term “connective journalism”

to describe the user-centric practices of information sharing that have emerged over the past decade among youth. Clark and Marchi (2017) assert that youth who engage in connective journalism use “social media to communicate their concerns to one another and to mobilize community members in response” (p. 13). Several studies describe cases where advocacy organizations have effectively used hashtags and other social network tactics to generate public discussion about health and social policy topics (Bail, 2016; Saxton et al., 2015). The Truth Initiative, a nonprofit formerly known as the American Legacy Foundation, extended its anti-tobacco countermarketing campaign to reach youth on social networking sites. This targeting of social networking sites was associated with prompting more than 800,000 visitors to the campaign’s website (Duke, 2007). There are reasons for caution in an overreliance on social media approaches, however. Tufekci (2017) studied use of social media to galvanize social protest movements in venues as disparate as the Arab Spring and the Occupy Movement, and concludes that while social media may make mobilization of large numbers of people easier, they may also make movements vulnerable to failure owing to “a lack of organizational depth and experience, of tools or culture for collective decision making, and strategic, long-term action” (p. xxvii).

Media advocacy efforts in the future will need to monitor and adapt to the changing media environment in an effort to shape the nature of public and policy-maker discussions of policy approaches to reduce alcohol-impaired driving fatalities, and exclusive reliance on traditional news media will likely be insufficient to change the national conversation on this issue. Community organizing and media advocacy, along with the use of paid media when feasible, are best viewed as complementary strategies to shape the broader media environment and help to accelerate progress toward further reductions in alcohol-related fatal crashes (Slater et al., 2000). The following sections will explore the roles of a number of stakeholders to take action on reducing alcohol-impaired driving fatalities.

STAKEHOLDER ACTION

Thus far, this chapter has discussed various strategies and tools to create awareness and capacity in addition to garnering support for activities to reduce alcohol-impaired driving. Much of this entails a grassroots approach that engages many stakeholders across sectors. Likewise, efforts to ensure that a sustainable infrastructure is in place to address this problem require a comprehensive, multisector approach that will create opportunities for action. There are a number of stakeholders that need to be engaged—some are traditional, and others are novel for the field of

alcohol-impaired driving. Some important stakeholders include, but are not limited to,

• Federal, state, and local governments (e.g., departments of health, transportation, and law enforcement);
• Legal sector (e.g., judges and attorneys);
• Health care sector (e.g., clinicians, hospitals, addiction treatment providers, and insurers);
• Alcohol industry (e.g., producers, wholesalers, and retailers);
• Hospitality sector;
• Automobile industry;
• News media/advertising (television, print, radio, and social media);
• General public;
• Community coalitions; and
• Alcohol consumers.

See Table 8-1 for a summary of stakeholders who are needed to ensure implementation of the evidence-based and promising interventions discussed throughout this report.

To begin, a revised approach to renew and further progress on alcohol-impaired driving would require a change in the status quo and the setting of ambitious goals, such as zero alcohol-impaired driving fatalities. One stakeholder that could spearhead such an effort would be the U.S. Department of Health and Human Services’ Healthy People decadal initiative. Healthy People has provided evidence-based benchmarks and monitored progress for improving the health of the nation for three decades.⁹ This includes objectives for reducing substance abuse and specifically alcohol-related driving fatalities. The Healthy People 2020 baseline and target objectives for alcohol-related deaths per 100 million vehicle miles traveled were 0.39 and 0.38, respectively (Healthy People, 2017). Based on the stagnation in progress to reduce alcohol-impaired driving fatalities and the growing movement toward zero deaths in the traffic safety community, the committee concludes:

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⁹ For more information, see https://www.healthypeople.gov (accessed October 3, 2017).

However, the most important factor in reducing deaths, injuries, and adverse socioeconomic effects of impaired driving is actually taking action to achieve stated targets.

Accountability

To achieve a more ambitious goal for reducing alcohol-impaired driving fatalities, it is important to have specific roles and accountabilities identified for each actor. When multiple sectors have a role to play to address a pressing and multifaceted problem, accountability can be difficult to operationalize. Accountability refers to “the principle that individuals, organizations, and the community are responsible for their actions and may be required to explain them to others” (Benjamin et al., 2006, p. 30) and can have different meanings to various fields (IOM, 2011). The U.S. Department of Transportation and law enforcement agencies are not the only actors accountable for or involved in accelerating progress toward zero deaths from alcohol-impaired driving. However, sharing accountability across sectors can be challenging. A 2011 IOM report provided a framework for accountability for improving health. That framework is applicable to alcohol-impaired driving as well. The report notes that the following four elements need to be in place to measure accountability:

1. An identified body with a clear charge to accomplish particular steps toward health goals;
2. Ensuring that the body has the capacity to undertake the required activities;
3. Measurement of what is accomplished against the identified body’s clear charge; and
4. The availability of tools to assess and improve effectiveness and quality (such as a feedback loop as part of a learning system, incentives, and technical assistance).

The following sections discuss the roles and accountabilities of stakeholders who play a role in reducing alcohol-impaired driving fatalities. In some cases, the committee makes recommendations to specific stakeholders to accelerate progress.

The Role of the Health Sector

The health sector (i.e., health care delivery systems and governmental public health agencies) is one of many that could take on an expanded role in preventing alcohol-impaired driving fatalities.

The Role of Health Care

Chapter 5 discusses a number of opportunities for the health sector to screen individuals for hazardous drinking, provide timely and adequate care for injured persons, and evaluate and treat those who engage in hazardous drinking. (For example, see Recommendation 5-2 to health care systems and health insurers regarding their role in facilitating effective evaluation and treatment strategies for those who need it.) This section will highlight the changing nature of the health care system and opportunities to leverage those changes.

The health care system is changing dramatically, transitioning from small independent hospitals into large complex health systems that encompass greater geographical areas to serve larger populations. New partnerships and access points such as urgent care and retail clinics are often integrated into a health system network to support provision of care across a spectrum of needs. These new health care systems are often incentivized not only to provide care but also to improve the health of the population they serve and to ensure that the system also provides community health benefits.¹⁰ This has created greater awareness of the diverse needs of the population, the effect of socioeconomic status on health, the need for accessible transportation, the effects of the built environment and local policies on health outcomes, and the locations of businesses such as grocery stores and pharmacies (Howard and Norris, 2015; NASEM, 2017). Health care systems are encouraged to collect more information about these varied determinants of health on patients and link data to identify high-risk and vulnerable populations and patients (Alley et al., 2016; Wyatt et al., 2016). Health care delivery systems can also do the following:

• Ensure that patients who are admitted for an alcohol-related injury are screened and treatment is offered.
• Share and link injury data with public health agencies to identify high-risk or vulnerable groups.
• Work with communities to identify sources of alcohol that contribute to alcohol impairment.
• Provide information on alcohol impairment for civic entities such as schools, employers, and churches so that they can increase awareness of community risks and take steps to intervene.

These are also opportunities for demonstrating community health benefits. Redelmeier and Detsky (2017) offer specific guidance for the role

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¹⁰ 26 CFR § 1.501 (r)-3.

of clinical providers to take action against alcohol-impaired driving. The authors assert that physicians are positioned to identify high-risk patients and to provide advice that will be taken seriously. See Box 7-2 for an adapted list of Redelmeier and Detsky’s physician strategies to prevent alcohol-impaired driving.

The Role of Public Health

Local and state public health departments could also engage in efforts to inform and facilitate initiatives to reduce alcohol-impaired driving. As discussed in Chapter 6, applying an epidemiological investigative approach to identify high-risk establishments (e.g., on-premise outlets that overserve patrons) and areas where crashes occur would be an activity for which local public health agencies could offer their technical expertise. Such an approach would require collaboration and sharing data with local departments of transportation and planning, law enforcement, researchers, the hospitality sector, and health care providers such as hospitals and emergency medical technicians. Public health agencies are also effective conveners for local issues that may necessitate the engagement of multiple stakeholders, often because of their use of population-based data and existing relationships in a given community (NASEM, 2017). As this report underscores the need for a comprehensive, public health (i.e., preventive) approach to alcohol-impaired driving, it is important to note that local and state public health agencies do not generally receive much funding to address alcohol-related harms in contrast to other health issues such as tobacco, which often has several dedicated funding streams.

Chapter 1 discusses the importance of applying a health equity lens to the issue of alcohol-impaired driving. With many local and state public health agencies already adopting a health equity focus in their activities, ensuring that inequities are not perpetuated is a natural role for public health agencies (NASEM, 2017). This is particularly relevant for the implementation of alcohol-impaired driving interventions that have the potential to exacerbate inequities in the criminal justice system, such as enforcement efforts (Horn et al., 2014) or plea bargains for DWI offenders (Rousseau and Pezzullo, 2013). Another strategy to ensure that equity issues are addressed at the local level is to engage community residents in the development of solutions (NASEM, 2017). As discussed earlier in the chapter, community coalitions are a powerful tool to ensure the needs of a community are being met.

In terms of national public health actors, the Surgeon General is particularly well positioned to highlight alcohol-impaired driving and evidence-based solutions as a public health priority. Creating high visibility for the topic in the public health arena can lead to sustained action among the public and policy makers. For example, the Surgeon General’s 1964 report on smoking and health had enormous impact on how the country moved forward with tobacco policy (CDC, 2006). With respect to alcohol-impaired driving specifically, the 1989 Surgeon General’s Workshop Proceedings on Drunk Driving very clearly outlines the interventions that are supported by the available research base. This included increasing alcohol taxes, which were a centerpiece of the Surgeon General’s recommendations on impaired driving (HHS, 1989). In summary, leveraging the influence of a public health figure such as the Surgeon General could raise awareness and support for proven and sometimes neglected interventions that could reduce alcohol-impaired driving injuries and fatalities.

The Role of the Alcohol Industry

As Babor et al. (2018) have summarized, alcohol companies have taken on an active role in traffic safety and alcohol-impaired driving. As alcoholic beverage producers are becoming increasingly concentrated in terms of ownership, both in the United States and globally, they have amassed significant resources with which to influence alcohol policies and problems (Jernigan, 2009; Jernigan and Babor, 2015). Some of this influence may be negative. Commercial activities that may contribute to alcohol-impaired driving include

• Increasing the overall availability or decreasing the real price of alcohol;

• Developing products that mix or marketing that encourages the mixing of alcohol and energy drinks, which may facilitate heavier drinking and risk taking (McKetin et al., 2015; Striley and Kahn, 2014);
• Juxtaposing alcohol marketing with motor vehicle speed through auto racing sponsorships (Babor et al., 2018; EuroCare Institute of Alcohol Studies and Monash University, 2015); and
• Heavy exposure of youth to alcohol marketing during a period in life when young people are particularly vulnerable to marketing regarding risky behaviors like alcohol-impaired driving (Pechmann et al., 2005).

Corporate political activities seek to create a favorable regulatory environment for their products through influencing decision makers, promoting ineffective over effective policies, and building partnerships with civil society and governmental organizations that weaken the ability of those organizations to pursue or implement effective policies (Getz, 1997; Hillman et al., 1999; Schuler, 1996). These are normal activities for corporations seeking to maximize revenues and profits; however, in the case of alcohol and alcohol-impaired driving, these activities can function as barriers to progress. A content analysis of 97 industry actions on alcohol-impaired driving concluded that nearly all (97.9 percent)¹¹ were either ineffective or of unknown effectiveness (Babor et al., 2018). See Appendix C for a content analysis by Babor and colleagues.

The pattern of alcohol companies or their corporate social responsibility organizations is to express concern about the problem of impaired driving and alcohol-related crashes and their resulting deaths, injuries, and economic costs. However, they generally promote ineffective or non-evidence-based policies and generally oppose effective population-based strategies to reduce binge drinking and impaired driving (Babor et al., 2018).

Guidance on the role of the alcohol industry in reducing the burden of harmful drinking is provided in the World Health Organization’s (2010) Global Strategy to Reduce the Harmful Use of Alcohol. This strategy, endorsed by the 63rd World Health Assembly, provides the following conclusion and recommendations to the industry:

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¹¹ This information was updated after the prepublication release.

To that end, based on the literature, documented practices of the alcohol industry, and the committee’s expertise, the committee concludes:

Actions by the alcohol industry to support efforts to reduce alcohol-impaired driving could also include

• At a minimum, adhering to and strengthening self-regulatory standards;
• Submitting needed data on alcohol sales and consumption (WHO, 2010); and
• Subjecting industry activities to reduce harmful use of alcohol to rigorous independent evaluations, free of conflict of interest (i.e., employing evaluation design methods as robust as those used to evaluate public health interventions) (Anderson and Rehm, 2016).

Model Legislation

As discussed throughout this report, policies that address alcohol and impaired driving vary substantially from state to state. In part, this is attributable to the decision to delegate alcohol control and regulation to the states after Prohibition. Many of the strategies outlined in this report require new legislation to be passed at the state level. Stakeholder groups such as community coalitions often lack the technical expertise to develop such legislation. While each state could design and implement the policies and laws that are tailored to its respective population, benchmarks for the states would provide guidance on which evidence-based strategies to adopt. As technology and practice at the state level move forward, there is a constant need to be able to learn from state experiences and not continually be faced with “reinventing the wheel” of model state legislation. To that end, and in an effort to improve uniformity and the adoption of effective policies nationwide, the committee recommends:

This would allow states that choose to adopt various policies or laws to reduce alcohol-impaired driving to do so based on the best available evidence, or to update policies or laws currently in place to ensure they are as effective as possible. States often adapt model laws to ensure they are consistent with state laws and community needs and resources and such model legislation has been developed for alcohol-impaired driving policies in the past. For example, model legislation published in 1984 was developed for administrative license suspension (NHTSA, 1986). The National Conference of State Legislatures could provide updated legislation for this law and new model legislation for a number of other laws, including policies regarding DWI look-back periods, limits on plea agreements and diversion programs, child endangerment laws, open container laws, and use of electronic warrants, among others.

Multisector Collaboration

Alcohol policy, and by extension policy approaches for reducing alcohol-impaired driving, is often not housed in one particular place in state or federal government because the responsibility for regulating alcohol is spread across government agencies. To address this, Congress mandated in the Sober Truth on Preventing Underage Drinking Act of 2006¹² the creation of an Interagency Coordinating Committee on the Prevention of Underage Drinking (ICCPUD), composed of the heads of 15 government agencies and others as needed. In the past, the creation of federally appointed committees to address alcohol-impaired driving has been a catalyst for action. For example, the Presidential Commission on Drunk Driving, convened in 1982, and its successor, the National Commission Against Drunk Driving, both contributed to public policy development around impaired driving (Fell and Voas, 2006) in the 1980s. A new, multisector group is needed to coordinate and reinvigorate progress to reduce alcohol-impaired driving fatalities. A comprehensive approach will require the cooperation and expertise of the U.S. Departments of the Treasury, Transportation, Health and Human Services, and Justice, and other federal agencies. In the case of underage drinking, Congress mandated in legislation the creation of the ICCPUD. Ideally, such a coordinating body on alcohol-impaired driving can be created without a congressional mandate. To this end, the committee recommends:

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¹² Public Law 109-422.

A federal interagency coordinating committee could include

• U.S. Department of Health and Human Services—Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration, Indian Health Service, National Institutes of Health;
• Alcohol and Tobacco Tax and Trade Bureau;
• U.S. Department of Transportation—National Highway Traffic Safety Administration, Federal Highway Administration;
• U.S. Department of Homeland Security (emergency services sector);
• U.S. Department of Justice;
• U.S. Department of Defense; and
• U.S. Department of Veterans Affairs.

The interagency committee could convene other stakeholders such as private philanthropy, schools, hospitals, public health, health care, the hospitality/restaurant industry, payers, medical insurers, and trial lawyers to further maintain accountability and transparency by sharing information.

Funding and Organizational Commitment

The majority of this chapter focuses on community action and the need for a renewed social movement. The history of MADD included critical investment by NHTSA early on in what at the time likely appeared as a promising but unproven community-based strategy. The history of tobacco control has demonstrated the importance of a demonstration project approach to build capacity within the field, establish the feasibility of effective approaches, and contribute to a paradigm shift both in social norms and in policy environments far beyond where the demonstration projects initially occurred. Based on extensive evidence and experience in the use of community coalitions both in the alcohol field and in other areas of public health, the committee recommends:

Such an approach should create an infrastructure for change. At a minimum, it would combine one or more coordinating centers providing training, technical assistance, and ongoing coaching with demonstration project sites in a diverse array of states and settings situated, for example, within state health or transportation departments with existing infrastructures that can promote sustainability when the funding expires. As was the case with the ASSIST project, there should also be funding for careful scientific evaluation of this effort, so lessons learned may be captured and translated into health and safety policies and practices across the country. Beyond this minimal approach, there is a great need for the funding of stronger advocacy organizations and of media infrastructures that can support the kind of countermarketing that has been so effective in promoting effective tobacco control. Dedicated funding streams for some of these activities could come from earmarked taxes on alcohol itself. However, the need for funding for effective advocacy and education of policy makers points to the importance of complementing public funding with initiatives from private philanthropy that are commensurate in size with the scale of the problem of alcohol-impaired driving in the United States.

Social movements can be powerful catalysts for change. MADD changed the landscape regarding alcohol-impaired driving in the 1980s. Their efforts led to decades of reductions in deaths on the nation’s roadways. The end of that decline should be a powerful motivation to generate a social movement that can “finish the job” that MADD so ably began. Such a movement should bring together an unprecedentedly broad array of stakeholders, build on the lessons of past efforts, integrate and take advantage of emerging technologies and practices, and engage states and the federal government in a new “race to the bottom”: a race to zero alcohol-related fatalities on our roadways by the year 2030.

CONCLUDING OBSERVATIONS

This chapter largely explores strategies and approaches that address the overarching social, economic, political, legal, and physical context that is identified in the committee’s conceptual framework (see Figure 1-5). As emphasized throughout the report, generating sustained action requires comprehensive approaches that target multiple levels, including communities and the media environment. Furthermore, traditional and novel stakeholders need to be engaged in efforts to reduce alcohol-impaired driving fatalities to fulfill their various accountabilities. With support for

and creation of innovative projects, multisector collaboration, benchmarks to guide states, and stakeholder engagement, the vision of zero deaths from alcohol-impaired driving fatalities will be attainable.

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