Traffic deaths remain a leading killer of Americans of all ages in the United States today. Injury and violence cause more deaths than noncommunicable and infectious diseases among people ages 1–44 (see Figure 1-1). Unintentional injury, including traffic fatalities (which make up 26 percent of unintentional injury deaths), is the fourth leading cause of death for all Americans (CDC, 2017d,e). Despite years of success, traffic deaths from all causes are on the rise in the United States for the third straight year. In 2016, 37,461 people died from traffic crashes, an increase in deaths of 5.6 percent from 2015 (NCSA, 2017a). For each death, there are many more injuries. The estimated number of people injured from traffic crashes increased in 20151 from 2.34 to 2.44 million (NCSA, 2016a).
Since 1982, alcohol-impaired driving has accounted for approximately one-third of all traffic deaths on average (34 percent from 1982 to 2016 and 31 percent in the last 10 years—2006 to 2016 [Michael, 2017; NCSA, 2016b, 2017a]). Furthermore, 29 people in the United States die each day from an alcohol-impaired driving crash—that is one person every 49 minutes (NCSA, 2017a). Alcohol-impaired driving is a growing public health and safety problem that transcends the transportation, law enforcement, and clinical systems. Despite this trend, the problem is not intractable. There
1 The 2016 fatal traffic crash data became available late in the study process (October 2017); however, in-depth analyses had not yet been completed during the writing of this report. When 2016 analyses were not available, 2015 (or most recent) data were used.
are many existing evidence-based and promising strategies to address alcohol-impaired driving; however, a coordinated, multilevel approach across multiple sectors will be required to accelerate change. This report presents these interventions and opportunities.
To accelerate progress to reduce alcohol-impaired driving fatalities, the National Highway Traffic Safety Administration (NHTSA) asked the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to identify promising interventions to reduce the fatalities caused by alcohol-impaired driving in the United States (the full charge to the committee is provided in Box 1-1). To respond to the charge, the Committee on Accelerating Progress to Reduce Alcohol-Impaired Driving Fatalities was formed.
At the first committee meeting, Jeff Michael, Associate Administrator for Research and Program Development at NHTSA, described the mission of the committee as twofold. First, the committee was tasked with identifying promising interventions that could be used to decrease alcohol-impaired driving fatalities in the United States, including interventions to be applied in the short and long term. NHTSA has been striving to reduce alcohol-impaired driving fatalities since it was founded in 1970 (Federal Register, n.d.). The committee’s task was to build on that work, identifying which interventions have been effective and which interventions need to be modified and how, and proposing new interventions that may emerge,
such as advances in technology. The committee was given discretion on whether to consider interventions implemented by other countries to inform their conclusions and recommendations. Second, Michael expressed the need to increase public and policy maker attention to the issue of alcohol-impaired driving. He explained that recently distracted driving and cannabis use and driving have overshadowed alcohol-impaired driving in the public and political spheres despite alcohol-impaired driving having higher fatality rates. There is a wide breadth of literature on the efficacy of different interventions to reduce alcohol-impaired driving fatalities. The challenge presented to the committee was not only to review that literature, but also to conceptualize new ways of approaching the problem and to revitalize old ones.
The data outlined above on alcohol-impaired driving present a growing sense of urgency to reverse the current trend and improve the safety of communities, decrease associated health care costs, and save lives. Alcohol-impaired driving is entirely preventable and accounts for the largest percentage of traffic deaths. Between 2009 and 2015 the number of alcohol-impaired driving traffic deaths plateaued at about 10,000 deaths per year (NCSA, 2016b) (see Figure 1-2). Now the number of deaths from alcohol-impaired driving fatalities is beginning to rise again (although as a proportion of all traffic fatalities, the percentage has stayed about the same for alcohol-impaired driving) (NCSA, 2016a, 2017a). In 2016, alcohol-impaired driving fatalities accounted for 28 percent of traffic deaths with
a total of 10,497 lives lost, a 1.7 percent increase from 2015 (NCSA, 2017a). In comparison, distracted driving accounted for 9 percent of traffic deaths in 2016, with a total of 3,450 deaths (NCSA, 2017a) (see Figure 1-3). In 2015, 48 percent of alcohol-impaired driving fatalities occurred in rural areas (NCSA, 2017b). Similar to smoking, there are secondhand effects of alcohol-impaired driving; in 2015, almost 40 percent of alcohol-impaired driving fatalities were victims other than the drinking driver (NCSA, 2016b). Comparatively, victim deaths from secondhand smoke exposure were responsible for about 8.5 percent of all smoking deaths in the same year (HHS, 2014). These consequences justify interventions to protect the public. Box 1-2 contains key statistics about alcohol-impaired driving.
Alcohol-impaired driving remains the most deadly yet preventable danger on U.S. roads. The United States has the highest number of alcohol-impaired traffic deaths per capita among 10 Organisation for Economic Co-operation and Development countries based on 2015 data (see Figure 1-4).2 In 2013, the United States had the second highest percentage of traffic fatalities attributed to alcohol-impaired driving (31 percent) when compared to 18 other high-income countries; other countries’
proportion of crash fatalities involving alcohol ranged from 3.2 (Israel) to 33.6 percent (Canada) (Sauber-Schatz et al., 2016). It is important to note that these studies did not use vehicle miles traveled in their analysis—doing so would likely make the U.S. less of an outlier.
Alcohol-impaired driving is an important health and social issue as it remains a major risk to Americans’ health today, surpassing deaths per year of certain cancers,3 HIV/AIDS,4 and drownings,5 among others (CDC, 2016b, 2017b,c,f), and contributing to long-term disabilities from head and spinal injuries from those injured in alcohol-impaired crashes.
Progress has been made over the past three decades, but that advancement has been incremental and has stagnated more recently. Importantly, social interest has lagged over time (Hedlund and McCartt, 2002; IIHS, n.d.; Redelmeier and Detsky, 2017; Williams, 2006), leading to missed opportunities for implementing effective countermeasures throughout society (e.g., a missed opportunity is the lack of changes to some policies based on the best available evidence). Without a concerted effort, the number of alcohol-impaired driving injuries and deaths could continue to increase.
Successful past efforts are well recognized. In the early 1980s alcohol-impaired driving rose to the forefront of the public’s attention (Fell and Voas, 2006). Attitudes toward drinking and driving shifted as groups like Mothers Against Drunk Driving (MADD), which was founded by a mother whose 13-year-old daughter was killed by an alcohol-impaired driver, began opening chapters across the country and sharing victims’ experiences with policy makers (Fell and Voas, 2006). Alcohol-impaired driving penetrated the media through campaigns such as the U.S. Department of Transportation and the Ad Council’s “Friends don’t let friends
drive drunk” public service announcements. Although this national campaign has not been rigorously evaluated, it is often credited with contributing to the shift in social norms around drinking and driving (Ad Council, n.d.; Glascoff et al., 2013). According to Voas and Lacey (2011) and Subramanian (2002), in 1982, which was the first year that alcohol-impaired driving was included in the current system for estimating the number of traffic fatalities in the United States, alcohol-impaired driving caused 26,173 deaths—the highest number recorded to date (Voas and Lacey, 2011). From the 1980s through the early 2000s, alcohol-impaired driving fatalities steadily decreased (Voas and Lacey, 2011). Numerous new laws were passed that helped decrease alcohol-impaired driving, including laws making it illegal to purchase alcohol under the age of 21 (minimum legal drinking age), or to drive with a blood alcohol concentration (BAC) of 0.10% or greater (Fell and Voas, 2006). Other laws increased law enforcement authority, allowing them to conduct sobriety checkpoints and to confiscate the licenses of driving while impaired (DWI) offenders (Fell and Voas, 2006). Fell and Voas (2006) and Voas and Lacey (2011) estimated that these actions saved more than 300,000 lives from 1982 to 2001.
Although much progress has been made as states passed and implemented policies, these heterogeneous policies lacked benchmarks and have been enforced with varying intensity. Progress has stagnated and
even reversed. It will likely worsen without renewed and innovative efforts, which are now possible. The plateauing fatality rates indicate that what has been done to decrease deaths from alcohol-impaired driving has been working but is no longer enough. Changes are needed to accelerate progress and save additional lives (see additional alcohol-impaired driving trends in Chapter 2 and Appendix A).
Social, technological, financial, and clinical changes provide a timely opportunity to reinvigorate successful efforts to reduce alcohol-impaired driving injuries and deaths. These changes present greater opportunities for individuals and community movements, greater insights into underlying causes, improved targeting of effective interventions, and enhanced data systems that offer a greater understanding of causes and contributing factors as well as more effective targeting of solutions and tracking progress. Every individual and stakeholder now has the opportunity to better recognize the problem, identify ways risks can be addressed, and work together to minimize or eliminate them.
At the societal level there is a greater understanding of how individual and population actions and the environment affect health. Clinical changes include hospital-based interventions that have transitioned to population- and community-based interventions, with a greater focus on early intervention, and with that framework there is a better understanding of how various segments of society can work together in innovative ways toward a common goal.
The transformation of technology includes interconnectivity of information; the growth of “big data” analytics provides new insights that help delineate cause and effect and better identify problem areas and target interventions (see Chapter 6 for additional discussion). Together, these trends provide the substrate for a dramatic shift in addressing alcohol-impaired driving and making significant gains. Technologically, the emergence of big data has provided organizations, policy makers, and stakeholders tremendous insight that allows them to have a data-driven approach for targeting high-risk individuals, geographic zones, and roadway hotspots for specific interventions, as well as more rapidly seeing the effects of directed countermeasures and the return-on-share investments (see Chapter 6 for additional discussion). In addition, technology has allowed new interventions like ignition interlock devices and ridesharing opportunities using smartphone technology that provide new potential countermeasures in ways never available before.
Given these advances and the current focus on reducing traffic fatalities, there are many opportunities to involve traditional and novel
stakeholders in innovative ways and to leverage newly available societal and technological infrastructure to break through the stagnation and accelerate progress on the path toward a new, comprehensive approach to confronting alcohol-impaired driving (see Chapters 7 and 8 for more on the roles of various stakeholders).
The Committee’s Approach
Though recognizing that alcohol-impaired driving is a crime, and that enforcement and criminal justice approaches are critically important, the committee takes a holistic public health approach. The committee’s approach is focused on population-level strategies aimed at providing the maximum benefit at the population level. This includes understanding the problem based on available data and surveillance, identifying risk and protective factors, reviewing the evidence for interventions, implementing interventions that will likely have the largest public health impact, and monitoring progress. A public health approach also uses a social determinants of health6 lens. The social determinants of health allow for exploration of the complex intersections of social, cultural, political, economic, legal, and systems-level influences on health and well-being. The social determinants of health framework considers access to health care, economic stability, education, neighborhood and built environment, and social and cultural contexts as influential on health and wellness outcomes. Such an approach enables key health issues to be considered in the context of the social and physical environments in which people live, enriching opportunities for cross-sector data analytics and collaborative solution development. Individual behaviors, physical and social environments, and access to services and information all play a role in facilitating or mitigating risky behavior and risky situations and the negative health outcomes associated with them (Stockwell et al., 2015). Social determinants of health can play a large role in advancing health equity as well. Health equity means that everyone has full and equal access to opportunities that allow them to lead healthy lives. To achieve health equity, people’s health and wellness ought not be compromised or disadvantaged because of race/ethnicity, sex, income, sexual orientation, education, neighborhood, rural residence, or any other social condition.
6 The World Health Organization describes the social determinants of health as “the conditions in which people are born, grow, live, work, and age . . . circumstances shaped by the distribution of money, power, and resources at global, national, and local levels” (WHO, n.d.).
These concepts are discussed in more detail in Chapter 2 as they relate to alcohol-impaired driving.
Conceptual Framework for Preventing Alcohol-Impaired Driving Fatalities
Traditional approaches to preventive countermeasures are categorized as being implemented before the event, during the event, or after the event—each point represents opportunities to intervene. One such approach is the use of the Haddon Matrix, which is commonly used in the injury field and looks at human, environmental, and vehicle factors before, during, and after a crash (Haddon, 1980). The Haddon Matrix paradigm provides an important organization to the many inputs that address alcohol-impaired driving crashes, and the committee’s conceptual model grows from that approach. There are many contextual factors that may affect alcohol use and driving, but for the purpose of this report the committee primarily discusses interventions directly related to the prevention of alcohol-impaired driving crash fatalities. This includes precrash interventions, such as alcohol policies that affect price and physical availability of alcohol and alcohol consumption, alternative transportation and ridesharing options that may affect whether an impaired person chooses to drive, and enforcement policies such as ignition interlocks for repeat offenders that may affect whether an impaired person drives once in his or her vehicle. Figure 1-5 (the committee’s conceptual framework) illustrates the sequence of behaviors leading to an alcohol-impaired driving fatality, the potential intervention opportunities, and the important factors that shape the outcomes.
The sequence of events in the framework begins with drinking alcohol, which can lead to drinking to the level of impairment, driving while impaired, being involved in an alcohol-impaired motor vehicle crash, and finally to crashes that result in serious injuries and fatalities. The injuries and fatalities can include the driver, occupants, pedestrians, bicyclists, or drivers and occupants of other vehicles. Within the phases, the additional layer around the perimeter of the shapes (e.g., one layer around “drink to impairment,” two around “drive impaired”) signifies increased likelihood or risk of a negative outcome among the behaviors (squares), and increased severity among the outcomes (diamonds). An individual can drop off of this sequence at any point; for example, a person may consume alcohol, but not to the level of impairment, or may plan an alternative mode of transportation. Furthermore, there are individual risk factors that affect the likelihood of drinking to impairment (e.g., being a binge drinker or having an alcohol use disorder) and driving while impaired (e.g., prior DWI, availability of a vehicle, or possession of a driver’s license). While
these are not reflected in the framework, they are important individual-level considerations and will be discussed in the report as they relate to alcohol-impaired driving and effective interventions.
In addition, driving while impaired does not always lead to a collision and an alcohol-impaired driving collision does not always result in an injury or fatality. These are potential outcomes of impaired driving, as indicated by the dashed lines leading up to them. However, the extensive literature on alcohol-impaired driving demonstrates a causal effect between impaired driving and increased risk for motor vehicle crashes and fatalities (Blomberg et al., 2005; Compton and Berning, 2015; Voas and Lacey, 2011). Thus, while the committee’s ultimate goal is to accelerate progress to reduce alcohol-impaired driving fatalities, the major task is to reduce alcohol-impaired driving.
Above the sequence of events, the figure highlights intervention opportunities that consist of effective or promising solutions to reduce alcohol-impaired driving. These opportunities include the sociocultural
environment; the alcohol environment; clinical treatment; behavior change; education; policies and laws; enforcement and arrest; the legal system; the physical environment and transportation; vehicle factors; and technologies. These areas of intervention opportunity interact with one another and target multiple levels (e.g., individual, interpersonal, institutional, community, and societal). The strategies, programs, policies, and systems within these intervention opportunities need to take into account the varied environmental contexts within which they will be implemented. These are the social, economic, political, legal, and physical contexts. The socioecological model (see Figure 1-6) is also a useful framework for understanding alcohol-impaired driving and how to prevent it, as the model reflects the interactions among individual, interpersonal, community, institutional, and societal levels, and it presents opportunities for potential interventions in each level.
Interventions for alcohol-impaired driving can target various points along the sequence at the bottom of the conceptual framework, and many
affect outcomes through complex pathways (see, for example, Figure 11 in Voas and Lacey, 2011). For instance, the legal consequences of driving while impaired can have a deterrent effect, preventing someone from drinking to the level of impairment (Voas and Lacey, 2011), and they can also deter someone who has been arrested for involvement in an alcohol-impaired driving crash from reoffending (Sloan et al., 2011).
For the purpose of this report, the committee applied a socioecological viewpoint while evaluating interventions and making recommendations (see Figure 1-6). Alcohol-impaired driving is a complex, multicomponent problem requiring a multifaceted set of synergistic interventions. The individual level consists of knowledge, attitudes, behavior, self-concept, and skills related to alcohol-impaired driving (such as drinking behavior or perceived risk of being pulled over and arrested by law enforcement for driving while impaired). These beliefs and attitudes could be linked to policies and interventions that are shown to affect them (e.g., minimum legal drinking age laws or mass media campaigns). The interpersonal level includes interpersonal processes and primary groups, such as formal and informal social networks, family, friends, treating physicians, and work groups. These groups could include bystanders who may or may not intervene when a person is making the decision to drive while impaired. At the institutional level (also sometimes called “organizational”), there are social institutions with organizational characteristics and rules for operation that affect alcohol-impaired driving (e.g., MADD, the alcohol industry, and law enforcement). The community level describes the relationships among organizations, institutions, and informal networks with specific boundaries (e.g., the alcohol environment and transportation alternatives). At the public policy and societal level, there are local, state, and national laws and policies that influence alcohol-impaired driving and the associated risk factors such as excessive drinking. This model illustrates the multiple levels at which a comprehensive approach to reducing alcohol-impaired driving could intervene, as well as the actors involved. There is substantial overlap across the levels of the model, and the interventions and actors within each level interact with one another. Interventions presented in this report range from the individual level to population-level approaches to reduce alcohol-impaired driving.
There are several effective and important interventions that can prevent fatalities that are not reflected in the conceptual framework or this report (e.g., the automobile manufacturing process and highway and road design). For example, the committee focused on postcrash interventions directly related to reducing DWI recidivism (e.g., legal consequences, brief interventions in emergency rooms, and continuing education) or those that are important for specific populations (e.g., rural communities).
In an effort to produce a report that focuses on what actions need to be taken over the next 30 to 40 years, the committee does not fully address many issues less directly related to alcohol-impaired driving crashes and fatalities, including postcrash survival interventions, highway and road design, and vehicle safety crash tests. Though each of these is important in its own right, they are not the focus of this report.
As noted in the committee’s statement of task, an intervention could be a program, system, or policy. The literature on the effectiveness and applicability of alternative interventions provides important information for assessing which interventions are most effective, cost-effective, and suitable for either a general or more specific population. Selection of interventions ought to be based on the extant literature; however, many interventions have not been adequately evaluated for general or specific effectiveness, or evaluated for effectiveness when brought to scale. In addition, comparisons of interventions are often incomplete and difficult to conduct because studies vary in dimensions such as the appropriateness of the study design and setting, outcomes measured, failure to consider other consequences (that is, externalities), quality of execution, interactions with other interventions, and inclusion of economic consequences. Furthermore, a lack of studies on an intervention does not equate to lack of effectiveness. Conversely, the presence of methodologically flawed studies that conclude an intervention is effective are of limited value.
With the above in mind, the committee examined the available literature on alcohol-impaired driving interventions that target alcohol consumption, drinking to impairment, driving while impaired, and the postcrash and/or postarrest phase. The committee was not charged with undertaking a systematic review of the evidence, but rather to identify which interventions are most promising to prevent alcohol-impaired driving injuries and fatalities given the current state of knowledge and environment. The committee did, however, conduct a comprehensive literature review to gather information on interventions and barriers to action from the peer-reviewed and grey literature. This entailed a systematic search of academic and governmental databases and websites for studies that evaluated or assessed the effects of interventions on any one of the following outcomes: alcohol consumption, binge drinking, alcohol-impaired driving, arrests, recidivism, and alcohol-impaired driving crashes, injuries, and fatalities.7 The sources of evidence spanned across
7 Search terms included alcohol terms (such as alcohol-impaired fatalities, alcohol-impaired driving, alcohol-related deaths, binge drinking, blood alcohol concentration/
multiple sectors, including transportation, the criminal justice system (e.g., law enforcement and courts), and public health (e.g., injury prevention and substance use). Each field has its own scientific methods and standards. In general, the committee’s assessment of individual studies and an overall body of literature followed the methodologic approach of the Community Preventive Services Task Force (Task Force on Community Preventive Services, 2000).8 For example, the Task Force evaluates the body of evidence around a specific intervention by factoring in the number of available studies, the strength of the study design and execution, and the size and consistency of observed effects. In assessing the evidence, the committee relied on existing systematic reviews and meta-analyses with strong methodologies from credible organizations with clear and established evidentiary standards and review processes such as the Centers for Disease Control and Prevention and the Cochrane Collaboration.9 In addition, the committee drew from existing, comprehensive reviews of the evidence, such as NHTSA’s Countermeasures That Work to inform its work. The following section describes some of the factors that the committee took into consideration when assessing the impact of interventions.
Considerations for Assessing Alcohol-Impaired Driving Interventions
When assessing specific interventions, the committee considered total population impact (how much alcohol-impaired driving would be reduced), cost-effectiveness, feasibility, and values and public acceptance. The committee considered the following factors when examining and comparing studies.
Suitability of study design and quality of execution Quality and sophistication vary across studies. Randomized controlled studies and randomized field studies can assess the causal effect, but they are often unsuitable for evaluation of population-based interventions. Other approaches use observational data and can capitalize on, for instance,
content, drunk driving) paired with traffic terms (such as accidents, traffic fatalities, traffic safety, crashes) and intervention terms, among others.
8 The Community Preventive Services Task Force was formerly known as the Task Force on Community Preventive Services. Task Force publications prior to 2012 are cited as the latter, and those published after 2012 are cited as the former.
9 Cochrane defines a systematic review as “a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review.” Relatedly, a meta-analysis involves “the use of statistical techniques in a systematic review to integrate the results of included studies” (http://community.cochrane.org/glossary [accessed November 29, 2017]).
variations in policies over time and across jurisdictions to assess the effect. The design and statistical approach, such as controlling for confounding factors, can affect the results and the confidence a decision maker has that the intervention is effective.
Real-world effect The applicability of the findings to the real world (effectiveness, studies with high external validity) often differs from the findings in a more controlled experiment (efficacy, studies with high internal validity). Similarly, the results of a project implemented on a small scale may differ from the results when the project is implemented nationally. In general, real-world implementation falls short of the results of studies conducted in ideal settings. The committee was most concerned about findings in real-world situations.
Examined outcomes and measurement of spillover effects Importantly, the outcomes measured (i.e., only considering alcohol-impaired driving crashes or fatalities, including only those in a car, not pedestrians) and how they are measured are critical, yet commonly differ from study to study. The extent to which benefits and harms (positive and negative spillovers) are measured matters because the total population effect (net benefit) is important in selecting interventions.
Heterogeneity in effect across populations The effectiveness of interventions can also vary among different populations. For example, some interventions may be more effective for young people and less effective for adults, and others, such as ignition interlock devices, will be effective only for drivers of vehicles that have them equipped. Among the numerous factors that lead to heterogeneity are location (e.g., rural versus urban), demographics (e.g., age, gender, and race/ethnicity), and drinking habits (e.g., heavy, light, or binge drinkers). Understanding these differences is important for comparing study results and for selecting interventions most suitable for target populations.
Scale, intensity, or focus of interventions The estimated effectiveness of interventions may depend on the scale or intensity with which they are implemented. For example, if a sobriety checkpoint is implemented only occasionally, it could have a small effect and a high cost per death averted. But, if it is scaled up, the marginal cost could decline and the marginal effect could increase.
Optimal set of interventions Alcohol-impaired driving results from a complex set of factors. Consequently, reducing alcohol-impaired driving requires a set of interventions. Because some interventions are already
in place, the key question to address is which additional approaches, or scaled-up approaches of current tactics, will reduce alcohol-impaired driving the most. Unfortunately, few studies assess the synergies among interventions.
Sets of interventions and synergies (positive or negative externalities) Adopting a set of interventions can modify the effectiveness of individual approaches, as interventions can have positive or negative synergies. For example, sobriety checkpoints may be enhanced by a media campaign and vice versa. By the same token, an intervention that reduces alcohol-impaired driving crashes might affect other alcohol-related outcomes in similar or different ways (such as consequences of alcohol on families) as well. If only alcohol-impaired driving fatalities are considered as the outcome, an intervention might not seem very effective, but if all the benefits (harms and costs) are included, then the intervention may be sufficiently effective to be worth implementing. This comprehensive approach of including negative and positive spillovers is the gold standard for analyses but demands more information than is generally available to inform published studies.
Match of intervention to population Some approaches might be most effective when they are aimed at high-risk groups. For example, alcohol treatment combined with ignition interlock devices may be most effective in reducing alcohol-impaired driving fatalities if they are aimed at repeat offenders or young drivers.
In sum, comparisons across studies are needed to better assess intervention opportunities; however, such comparisons are often not available or are difficult to interpret. The committee used the available evidence and balanced the concepts above in considering effective and promising interventions to reduce alcohol-impaired driving fatalities.
Cost-Effectiveness and Cost-Benefit
Interventions will also likely vary in the degree to which the costs of the intervention are a good use of governments’, or more broadly, society’s resources. In the literature the committee reviewed, value for use of resources is typically analyzed as being “cost-effective” or “cost-beneficial.” A cost-effectiveness analysis compares the effect (e.g., alcohol-impaired driving fatalities) of an intervention to the costs of implementing the intervention; other costs can be included as well, depending on the perspective of the study. In contrast, a complete cost-benefit analysis values all effects in dollar terms and sums them, and then compares this
value to the dollar costs of implementing the intervention. If the monetary benefits outweigh the dollar costs, the intervention is considered to be cost-beneficial. However, there are relatively few studies that provide consistent, empirical estimates of either of these measures for the interventions that the committee reviewed. Furthermore, not all interventions have been evaluated by a cost-effectiveness or cost-benefit study. Although the committee was not specifically asked to review cost-effectiveness of the interventions, where analyses were available that were robust enough to provide some insight, the committee included an overview.
In its statement of task the committee was asked to look at international examples addressing alcohol-impaired driving as appropriate. While looking at examples outside of the United States can be informative, certain caveats on applicability are important. For example, some differences in fatality rates or other measures of progress in the United States compared to other countries may be explained by differences in population density, availability of mass transit, and other factors. O’Neill and Kyrychenko (2006) note that comparisons of the United States and other countries can mask the vast differences across U.S. states, largely explained by population density and other non-highway safety factors, and fail to address the underlying differences that do not relate to highway safety policy. This is not to say that comparisons are not helpful, but these potential differences are important to consider. In terms of the acceptance and success of various interventions, differences in culture, laws, and implementation need to be considered as well. In this report the committee points to international examples and lessons learned when appropriate and notes what does (or does not) make these examples relevant to the U.S. context.
Tension Between Civil Liberties and Needed Interventions
There are often inherent ethical tensions that exist between control measures to protect the public’s health and civil/personal liberties—the tension between the good of the collective and rights of the individual. This tension has existed since the fight against infectious disease in the nineteenth and twentieth centuries and continues today in efforts to address chronic conditions (Bayer, 2007) and more recently with tobacco use, fluoridation, food regulations, and traffic safety laws. These trade-offs can be difficult to address but are important to consider. In relation to alcohol-impaired driving, for example, impairment can be measured in several ways by a law enforcement officer (and all 50 states
and the District of Columbia have implied consent laws),10 although drivers may refuse BAC testing (states vary on whether refusal is a criminal offense) and this can hinder the prosecution process. Another example is sobriety checkpoints—some states do not allow checkpoints as they believe they impinge on personal liberties. While mandatory BAC testing would be beneficial to arresting officers and prosecutors and the allowance of sobriety checkpoints is critically important, the committee did not make recommendations on whether these laws should be changed at the state level. The committee does recommend, for example, the use of sobriety checkpoints, but it will be up to the states which have laws against their use to weigh the potential benefits of using them for the health of their population against the need to uphold personal liberties in that instance. A balance inevitably needs to be struck based on the values of the community. Furthermore, reducing alcohol-impaired driving injuries and fatalities is difficult to separate from the broader public health rationale for reducing excessive alcohol consumption since drinking is the precursor for alcohol-impaired driving.
A Comprehensive Approach to Address Alcohol-Impaired Driving
There is no one-size-fits-all approach that will solve the problem of alcohol-impaired driving. For a problem this large and widespread, a systematic population approach is needed. In addition, each state is unique in terms of laws in place, population needs, transportation options, roadway conditions, and many other factors, so an intervention that is appropriate in one state or locality might not be as impactful in another (e.g., in an urban population versus a rural one). Therefore, the committee does not prioritize among its recommendations; while each state needs to take a comprehensive approach to addressing alcohol-impaired driving (see Figure 1-5), the exact combination of interventions for particular states will vary. While targeted interventions for important subpopulations would be beneficial, more data are needed to accurately implement these (see Chapter 6). Generally, alcohol-impaired driving studies do not focus on subpopulations.
When identifying conclusions and recommendations the committee focused on interventions that are evidence based, promising, and relevant in the current environment, or where improvements are needed to increase effectiveness. When the committee identified the need for a specific action and a specific actor, a recommendation was provided.
10 Meaning that drivers using state roads (or federally owned park roads) have “consented” to comply with sobriety testing if there is indication that they are driving while impaired. More detail is provided in Chapter 5.
Where the available evidence and the committee’s expertise led the committee to reach a conclusion about the state of the evidence or the need for a particular action, a conclusion was provided. While many of the strategies outlined in this report are not new, systematically implementing these policies, programs, and systems changes would renew progress and save lives.
Conventional behavior change models assume individuals consistently act in their own interest and form behavioral change intentions based on a rational assessment of the costs and benefits. Behavioral economics, for example, applies psychological insights to understand the many natural decisions people make that routinely deviate from their best interests. Along with several other fields, the behavioral economics literature demonstrates cases where rationality is limited by impulsiveness, social norms, and the context in which choices are made (Cohen et al., 2000; Matjasko et al., 2016; Rice, 2013; Thorgeirsson and Kawachi, 2013; Zimmerman, 2009). These insights help explain why many traditional health promotion efforts have limited success, such as simply increasing awareness of the risks of drinking and driving. Policies and interventions to improve public health can therefore be made more effective if designed with insights from behavioral economics. For example, individuals show status quo bias and tend not to deviate or opt out from default options (the events that will occur if no alternatives are selected). For example, many people do not deviate from default options for retirement savings, generic medications, and health insurance plans (Halpern et al., 2007, 2013). Therefore, changing environments to make the healthy or less risky option the default is highly likely to be successful (Frieden, 2010).
Research shows that those who repeatedly drink and drive compared to those who do not engage in such behavior actually know DWI laws better, but are poorer planners (i.e., in planning a transportation alternative), lack self-control, and are more impulsive with much higher temporal discounting rates,11 preferring short-term rewards over bigger, long-term rewards (Sloan et al., 2014). Because those who drive while impaired by alcohol have difficulty improving their behavior, a productive approach would be to implement policies and interventions that make the transportation and drinking environments safer. Furthermore, these insights suggest that stringent policies are needed to counter the impulsivity and lack of self-control especially among DWI offenders. Finally, the high personal discount rates among those who drive while impaired by alcohol
11 The rate at which individuals discount future costs and benefits.
suggest swiftness of punishment and increasing the perceived chances of getting caught are critical to deterrence. Accelerating progress to reduce alcohol-impaired driving fatalities thus will require a system designed to accommodate the shortfalls in decision making by those who drive while impaired by alcohol.
With these ideas and the conceptual model in mind, the committee recognizes the need for an overarching philosophy and process for improvement, tailored to local environments and involving a range of stakeholders motivated by a common goal to reduce alcohol-impaired driving fatalities.
NHTSA (the sponsor of this report), the Federal Motor Carrier Safety Administration (FMCSA), the Federal Highway Administration (FHWA), and the National Safety Council launched the Road to Zero coalition in 2016 with the bold goal to end all traffic fatalities within 30 years (NHTSA, 2016). With more than 360 partners nationwide, the coalition has pledged to focus on evidence-based strategies to reduce traffic fatalities, such as the use of seat belts, rumble strips, behavior change campaigns, and data-driven enforcement (NHTSA, 2016; NSC, 2017). The Road to Zero expands the discussion to include not only representatives of roadway, behavioral, and vehicle safety, but also nonprofit groups, public health officials, and technology companies—dozens of organizations working together to develop a coordinated approach (NSC, 2017). While the Road to Zero effort acknowledges that zero deaths is a “lofty” goal, it notes that it is attainable because traffic fatalities are preventable and no traffic fatality is acceptable; a future with zero traffic deaths is more certain than ever with the emergence of self-driving cars and the Safe Systems transportation approach; and a coordinated effort that brings together multiple stakeholders with the same goal can achieve more than individual organizations working independently.
The Road to Zero is consistent with Vision Zero—a philosophical approach to road safety that was crafted in the 1990s and adopted in Sweden in 1997 (see Box 1-3). Vision Zero, as a unifying philosophy, has expanded to the United States and other countries. While originally focused on road builders and design, Vision Zero continues to have an increasing breadth of participants. Its principal aim is to eliminate all serious traffic injuries and fatalities (Rosencrantz et al., 2007). Described as “audacious,” “bold” (Aboelata et al., 2017), and “radical” (Belin et al., 2012), this innovative approach transformed the traditional approach of
transportation design, in which the road builders simply expected road users to use the road as designed, and instead shifts responsibility to the transportation system and road designers to prevent injury and death. This brings in new stakeholders and creates innovative partnerships. Everyone has a role and an opportunity to contribute to the shared goals. Vision Zero is a starting point that can be expanded to address alcohol-impaired driving. Therefore, each alcohol-impaired driving fatality could be thought of as a system failure and understanding the reason for that failure facilitates interventions to prevent recurrence. Vision Zero continues to expand and has been adopted by more than two dozen U.S. cities.
Achieving Vision Zero in the United States
Other initiatives or programs aimed at achieving zero deaths from traffic fatalities in the United States include the Vision Zero Network, which is composed of U.S. cities that have made the pledge to pursue
continuous elimination of traffic fatalities and serious injuries within a designated time period (Vision Zero Network, 2017). Toward Zero Deaths: A National Strategy on Highway Safety is an initiative that was created in 2009 by a steering committee cooperative with the aim of eliminating traffic injuries and fatalities nationwide. It receives technical support from FHWA, FMCSA, and NHTSA and is promoted by many groups including the American Association of State Highway and Transportation Officials, the Governors Highway Safety Association, and numerous state departments of transportation (AASHTO, 2015; TZD, 2015). The Institute of Transportation Engineers also launched a Vision Zero Task Force in 2016 that supports Vision Zero efforts in U.S. cities through public–private partnerships, volunteerism, and raising awareness (ITE, 2017, n.d.).
The Vision Zero philosophy is spreading throughout the country but in a disjointed and fragmented fashion. Instead of working together, invested partners are creating their own, slightly different Vision Zero programs. Implementing a unified Vision Zero as a U.S. policy to reduce alcohol-impaired driving injuries and fatalities is an important step. To fulfill Vision Zero successfully, shared goals and continued progress toward reducing alcohol-impaired driving fatalities is essential. Vision Zero will need to include interventions to modify drinking as well as alcohol-impaired driving (see Chapter 2 for information on the relationship between drinking and impaired driving), in addition to more traditional engineering solutions. More data at the community level are also needed, as is the integration of data systems to better target where alcohol-impaired traffic fatalities occur and to make the appropriate changes (see Chapter 6 for more information on data system needs). To address this growing public health and safety problem, an integrated systems change requires many varied partners to join the transportation and transportation system design sector in recognizing that alcohol-impaired driving fatalities are preventable. These partners include government agencies, state and local public health departments, clinicians, health care systems, law enforcement, car manufacturers, auto insurers, advocacy organizations, technology companies, employers, alcohol retailers, wholesale distributors, alcohol producers, and the hospitality industry, among others (see Chapters 7 and 8 for further explanation of stakeholder accountability).
Vision Zero aspires to reach zero traffic fatalities. Reducing alcohol-impaired driving is, in part, a means to that end. A public health approach to injury prevention that encompasses the full array of contributing variables or causes for the target harm is needed. From this perspective, reducing excessive alcohol consumption and reducing alcohol-impaired driving are two of the logically available means. As discussed throughout the report, altering the alcohol and driving environments often entails
trade-offs, as described above. Vision Zero is an aspirational goal, not a policy prescription.
Bold goals are important and can be used to galvanize action, change social norms, and bring stakeholders together around a common vision and goal. The committee recognizes that in an economic sense, eliminating all roadway fatalities would require investments that have diminishing returns and that there are important alternate uses of those resources; however, Vision Zero is not primarily an economic goal. It is about establishing an aspirational goal that can rally stakeholders, provide focus, and make substantial progress toward achieving that goal.
If Vision Zero is further expanded to specifically address the largest killer on the road—alcohol-impaired driving—and the wide range of stakeholders were to unite behind one comprehensive, overarching approach to Vision Zero with clearly defined roles and responsibilities, they would be able to provide a stronger message, provide more targeted and effective interventions, and tackle alcohol-impaired driving more cohesively. Table 8-1 outlines the stakeholders who are needed to ensure implementation of the evidence-based and promising interventions discussed throughout this report.
Importantly, the public itself can also directly participate in preventing alcohol-impaired driving through Vision Zero. Introducing a goal of zero alcohol-impaired driving injuries or fatalities requires the country to adopt a new, multisector approach and system for improvement, driven by stakeholders motivated by a common goal. Throughout this report the Vision Zero philosophy is applied to alcohol-impaired driving with the aim of developing a comprehensive approach that involves stakeholders across sectors.
Conclusion 1-1: Alcohol-impaired driving is a complex preventable public health problem that requires a comprehensive and collaborative multisector approach.
Box 1-4 highlights key terms related to impairment used throughout the report. For the purpose of this report, the term alcohol-impaired driving is used. While impairment can be caused by other substances or conditions, and although it begins before reaching the BAC limit set by state law, this report generally uses the term to mean driving with a BAC of 0.08% or higher. The term applies to drivers of all vehicle types and does not include pedestrians or cyclists.
This report also uses DWI (instead of DUI or a similar state-specific phrase). DWI is a legal term; states vary in how they designate the violation of driving while impaired by alcohol. See the report glossary for definitions of other terms in this report. Discussion of what it means to be impaired follows.
Alcohol’s Physiological Effects and Influence on Driving
As noted in Box 1-4, the current legal definition of alcohol impairment in almost all 50 states is a BAC of 0.08%. Although this is the limit set by state law, impairment begins at lower levels; even small amounts of alcohol affect the brain.
Biologically, alcohol impairment occurs before reaching BAC of 0.08%, and impairment affects driving-related skills and behaviors. A standard drink in the United States has 14 grams of pure alcohol, which is the amount of alcohol in approximately 12 ounces of beer of 5 percent alcohol by volume (ABV), 5 ounces of wine of 12 percent ABV, or 1.5 ounces of distilled spirits of 40 percent ABV (NIAAA, n.d.-b) (see Figure 1-7). However, alcohol content varies by beverage type and serving size and therefore a “drink” may contain either more (or less) than the standard 14 grams of pure alcohol (Kerr et al., 2005, 2008, 2009).
Once consumed, alcohol is absorbed from the stomach and small intestine into the bloodstream. Most alcohol metabolism takes place in the liver, but the gastrointestinal tract, pancreas, and brain also metabolize alcohol. Most alcohol is chemically broken down by a process with two enzymes into acetaldehyde and acetate,12 which is further metabolized and eliminated as water and carbon dioxide (CDC, 2017a; NIAAA, 2007). Alcohol circulates in the bloodstream until the body can metabolize it.
Individuals differ in their degree of impairment at a given BAC. Several factors affect alcohol’s physiological influence, including weight, age, sex, race, and ability to metabolize alcohol. Women are often more sensitive to the effects of alcohol and have a higher BAC than men after drinking the same amount of alcohol, in part because women usually have a higher percentage of body fat than men (Cederbaum, 2012; Frezza et al., 1990). Additionally, genetic variations in enzymes affect the clearance of one of the by-products of alcohol metabolism, resulting in an intensified physiological reaction and altering the risk of developing alcohol dependence. Genetic differences interact with other individual
12 Alcohol dehydrogenase and aldehyde dehydrogenase. Other enzymes have similar roles but may only be active after consumption of large amounts of alcohol.
The amount and rate of alcohol an individual consumes, along with how often one drinks, and the use of drugs or prescription medications can also affect the body’s response to alcohol (CDC, 2017a; NIAAA, n.d.-a). For example, alcohol interacts with a variety of medications such as antibiotics, antidepressants, and opioids and other pain medicines, and can either heighten or hinder the medication’s effect (Weathermon and Crabb, 1999). Over-the-counter medications, herbal supplements, and cannabis also alter alcohol metabolism (Ronen et al., 2010; Weathermon and Crabb, 1999).
Alcohol is a central nervous system depressant (Dry et al., 2012). The effects of alcohol include psychomotor impairment, decreased inhibition, diminished alertness and sleepiness, confusion and problems with concentration, reduced visual focus, and slurred speech. At higher BAC levels, alcohol can induce vomiting, blackouts, disrupted breathing, seizures, coma, and death (NHTSA, n.d.; NIAAA, n.d.-a).
Driving requires several complex skills. A driver must maintain the correct speed and keep their vehicle within the appropriate lane while observing and processing their surroundings for safety information (such
as traffic signs, other vehicles, and pedestrians). Alcohol affects the capacity to drive safely by impairing information processing and reaction time and compromising judgment and coordination (CDC, 2017a), and the risk of crash increases with higher BAC levels (Hingson et al., 2000; Martin et al., 2013; Starkey and Charlton, 2014). Chapter 4 describes the effects of escalating BAC levels on driving abilities in more detail.
To address its charge, the committee gathered information through a variety of means. It held three information-gathering meetings that were webcast live. The first, held in February 2017, focused on obtaining information on the history of alcohol-impaired driving and interventions currently being used in the United States. The second meeting, held in March 2017, focused on obtaining information on the current alcohol environment, stakeholder activities, relevant surveillance systems, and social movements. The third meeting was held in May 2017; presentation topics included pertinent technological innovations, alcohol policy (such as taxes and warning labels), DWI arrests in tribal communities, and automobile and insurance industry perspectives (committee meeting agendas are listed in Appendix E). The committee also met in deliberative meetings throughout the study process. The committee received public submissions of materials for its consideration throughout the course of the study.13 The committee’s online activity page provided information to the public about the committee’s work and facilitated communication with the public.14
Throughout this report the committee provides conclusions and recommendations for short-, mid-, and long-term interventions. Chapter 2 provides an overview of the current alcohol and transportation environments. Chapters 3 through 5 target intervention points identified in the conceptual framework: Chapter 3 describes interventions to reduce drinking to impairment, Chapter 4 discusses interventions that affect an individual’s likelihood to drive once impaired, and Chapter 5 describes postcrash and postarrest interventions. Chapter 6 identifies data and surveillance needs and opportunities. Chapter 7 considers the importance of social movements and other approaches to generate stakeholder action, and Chapter 8 ties together the previous chapters’ recommendations and conclusions. The committee also commissioned four papers
13 Public access materials can be requested from http://www8.nationalacademies.org/cp/projectview.aspx?key=49848 (accessed April 26, 2017).
14 See http://nationalacademies.org/hmd/Activities/PublicHealth/ReduceAlcoholImpairedDrivingFatalities.aspx (accessed April 26, 2017).
to offer additional context and perspective on alcohol-impaired driving. These papers helped to fill gaps in the literature and were considered in conjunction with other literature on these topics. Appendix A describes data and surveillance systems that could better inform alcohol-impaired driving interventions in the United States. Appendix B presents a content analysis of how alcohol-impaired driving is framed in the news. Appendix C provides an overview of the role of the alcohol industry in alcohol-impaired driving interventions. Finally, Appendix D gives insight into international alcohol-impaired driving countermeasures.
To achieve zero alcohol-impaired crash fatalities—where every alcohol-impaired driving death could be thought of as a failure of the system—a systematic, multipronged approach with clear roles and accountabilities across sectors (including public health, transportation, law enforcement, and clinical care) is needed. Victims are dying each day, and fatality rates are rising—substantial progress has been made in the past, and that progress needs to be jump-started again. As a philosophy, Vision Zero offers a system for improvement and a way to rally stakeholders from many arenas around a common goal. No one intervention will solve the preventable deaths resulting from alcohol-impaired driving. This report lays out a comprehensive set of evidence-based and promising interventions and system improvements that when implemented together have the potential to eliminate these preventable deaths.
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