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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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3

Interventions to Reduce Drinking to Impairment

INTRODUCTION

Most interventions to reduce alcohol-impaired driving have focused on decreasing the likelihood that someone will drive after already being impaired by alcohol. Conversely, less attention has been focused on reducing drinking to impairment before driving. This has been demonstrated in policy activity; during the past two decades the implementation of driving-oriented policies has increased among states, while the implementation of effective drinking-oriented policies has remained virtually unchanged (Nelson et al., 2015). However, there are a number of effective interventions to reduce drinking to the point of impairment (i.e., binge drinking1), and some of these interventions have an independent effect on reducing impaired driving and alcohol-impaired driving crashes (Elder et al., 2010; Fell et al., 2009; Hingson et al., 2008; McCartt et al., 2010; Rammohan et al., 2011; Xuan et al., 2015a). Therefore, increasing adoption of interventions that have been proven to reduce excessive drinking is an important and underused strategy to reduce morbidity and mortality from alcohol-impaired driving.

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1 Binge drinking is defined as drinking at or above levels during a drinking occasion/episode that typically results in impairment-level BACs (i.e., ≥0.08%) for most men and women drinking at typical drinking rates. This corresponds to drinking five or more drinks for men and four or more drinks for women in about 2 hours. Most public health and epidemiologic studies use five/four thresholds, and members of the general public interpret the binge drinking term to mean drinking to the point of impairment or intoxication.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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As illustrated in the committee’s conceptual framework (see Figure 1-5), the first two behaviors that the committee identified as points of intervention for reducing alcohol-impaired driving fatalities are alcohol consumption and drinking to impairment. Chapter 2 underscores the proximal relationship between binge drinking and alcohol-impaired driving. This chapter will highlight the drinking-oriented interventions (i.e., policies, programs, systems, and strategies) that have a strong evidence base supporting their population-level effectiveness, while other interventions discussed may be promising but underevaluated, or relatively ineffective but commonly used or familiar. These interventions will be examined within the context of the concepts and considerations for comparing interventions that were discussed in Chapter 1, as well as barriers to implementation and strategies to overcome them, lessons learned from other countries, and key research needs. This chapter is organized by the most salient intervention opportunities identified in the conceptual framework that target alcohol consumption (particularly consumption stemming from illegal sales to underaged or intoxicated persons) and interventions designed to reduce binge drinking, including policies and laws, enforcement, educational interventions, and technological interventions.

The chapter presents discussions of policies and laws that target the alcohol environment (e.g., policies to maintain or increase price of alcohol, limit physical availability, reduce illegal alcohol sales, and restrict alcohol marketing) and shape drinking behaviors that reduce alcohol-related harms (e.g., alcohol-impaired driving crashes). The committee applied an upstream, preventive approach to reducing alcohol-impaired driving fatalities and used the best available evidence to inform the selection of these specific policies and laws from an array of options for states and localities. However, it is important to recognize that some upstream interventions and policies have a broader reach than others. Some (e.g., social host liability) are targeted directly at preventing impaired driving, while others (e.g., enforcing underage drinking laws) target unlawful consumption. However, some of these polices (e.g., raising the price and reducing the number of alcohol outlets) operate further upstream and affect all consumers. The policy-relevant effect is that these actions reduce choice overall while aiming to reduce excessive or harmful alcohol consumption. The committee acknowledges that population-level policies may be more controversial than polices that are more precisely targeted at high-risk consumers, excessive consumption, or risky behavior. While these interventions have been shown to reduce most types of alcohol-related harm at the population level and achieve the desired public health benefits, they also have the potential to reduce liberties of responsible adult consumers. However, there are health benefits to these population-level policies beyond only reducing alcohol-impaired driving, for example,

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

reducing violence and child abuse and neglect (Foran and O’Leary, 2008; Kuhns et al., 2014; Widom and Hiller-Sturmhofel, 2001). Ultimately, these considerations have to be balanced by policy makers in light of the values of their particular community. For purposes of this report, however, the committee believes the evidence shows that the trade-offs outweigh the potential reduction in individual choice.

Historically, the support for and enactment of effective policies and laws have been the impetus for reducing alcohol-impaired driving fatalities (Fell and Voas, 2006). Furthermore, these policies do not operate in siloes. As discussed in Chapter 1, progress in this area requires a comprehensive approach, which includes a set of complementary policies to reduce hazardous drinking, enhanced with enforcement. Throughout this chapter, the committee offers recommendations to all levels of government on which sets of policies and laws to adopt or improve to reduce alcohol-impaired driving. These are the policies and laws that the committee has determined will have the greatest effect on population health by reducing excessive drinking and ultimately, alcohol-impaired driving.

POLICIES TO MAINTAIN OR INCREASE PRICE

Raising Alcohol Taxes to Reduce Impaired Driving and Related Consequences

Overview

Alcohol taxes have perhaps the strongest and most consistent evidence base of any U.S. policy for reducing excessive drinking and related harms, and there is also strong evidence that higher alcohol taxes reduce alcohol-impaired driving and motor vehicle crash fatalities (Elder et al., 2010; Wagenaar et al., 2009, 2010). The 2016 Surgeon General’s Report on Alcohol, Drugs, and Health identifies price and tax policies as an evidence-based policy to reduce alcohol misuse and related problems (HHS, 2016). Despite this, alcohol taxes do not cover alcohol-related costs and have declined in inflation-adjusted terms at both federal and state levels (Naimi et al., 2017; Sacks et al., 2015).

In the United States, alcohol taxes may be applied as specific excise taxes, which are based on a fixed dollar amount per volume and are sometimes referred to as volume-based taxes. This is the most common type of tax, and it is the only form of federal taxation on alcohol. Some states also have ad valorem excise taxes, which are based on a percentage of price. Most but not all states apply the general sales tax to alcohol (APIS, 2016c).

Higher alcohol taxes, which are imposed on the producers of alcohol, are typically passed through to consumers as higher prices. While the

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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FIGURE 3-1 A conceptual model for the causal relationship between increased alcohol taxes and decreased excessive alcohol consumption and related harms.
SOURCE: Adapted from Elder et al., 2010.

industry could soften the effect of taxes by reducing their prices, alcohol taxes are typically passed on to consumers at an equal or even higher rate (Ally et al., 2014; Kenkel, 2005; Young and Bielinska-Kwapisz, 2002). Consequently, consumers face higher alcohol prices. The bulk of the evidence suggests that higher prices reduce both overall consumption and high-risk alcohol-related activities and adverse outcomes. The evidence base is strong, with consistent findings across a variety of study designs including quasi-experimental time series analyses and panel studies (see, for example, Elder et al., 2010; Wagenaar et al., 2009, 2010; Xuan et al., 2013). In addition, higher taxes are protective for a range of outcomes that are related to binge drinking, including interpersonal violence, sexually transmitted infections, and unintentional injuries including motor vehicle crashes (Wagenaar et al., 2010). See Figure 3-1 for a conceptual model that delineates the causal pathway by which an increase in alcohol taxes could reduce excessive alcohol consumption and harmful consequences.

Drinking, Binge Drinking, and Impaired Driving

Efforts to reduce the health, social, and economic costs of alcohol-impaired driving and alcohol-related crashes and crash fatalities depend on reducing the frequency and intensity of alcohol impairment in the

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

population and on reducing the likelihood that those who are impaired will drive a motor vehicle. Overall, approximately 5 percent of drinkers report having driven after “having had perhaps too much to drink” during the past 30 days (Flowers et al., 2008). Binge drinking, which typically results in a level of blood alcohol concentration (BAC) that produces impairment, is therefore a precursor to alcohol-impaired driving among those who subsequently drive a motor vehicle. In addition, 12 percent of binge drinkers report having driven a motor vehicle during or within 2 hours of their most recent binge drinking episode. Those who reported binge drinking and subsequent driving consumed an average of 8 drinks, and 26 percent of them consumed 10 or more drinks (Naimi et al., 2009). In cross-sectional surveys, 84 percent of those who report having driven “after having perhaps too much to drink” also report binge drinking; self-reported binge drinkers account for 88 percent all of impaired driving episodes (Flowers et al., 2008). Because survey respondents may drink and binge drink less than the population as a whole, and because survey respondents may underreport their own consumption or related activities such as driving after binge drinking, it is likely these estimates are conservative.

Higher Taxes Reduce Alcohol Consumption and Binge Drinking

Higher prices for alcohol are related to lower consumption and reduced binge drinking among adults and youths (Elder et al., 2010; Wagenaar et al., 2009; Xuan et al., 2013). One summary measure of the effect of taxes on consumption is the price elasticity of demand; this is a proxy for the tax elasticity of demand. Across multiple studies, the average price elasticity of demand for alcohol is –0.65, which means that every 10 percent increase in price is associated with a 6.5 percent reduction in consumption (Wagenaar et al., 2009). Even among heavy drinkers the price elasticity for alcohol is –0.28 (Wagenaar et al., 2009). Furthermore, there is a strong inverse relationship between taxes and binge drinking (Xuan et al., 2015b) and taxes and outcomes related to binge drinking, which demonstrates that taxes still have a strong effect on those who drink excessively (Elder et al., 2010; Wagenaar et al., 2010).

Higher Taxes Reduce Impaired Driving and Motor Vehicle Crash Fatalities

There is also strong and direct evidence that higher taxes reduce impaired driving and fatal motor vehicle crashes. A meta-analysis by Wagenaar et al. (2010) examined effect sizes in studies that assessed a diverse set of alcohol-related outcome measures, including traffic crashes and alcohol-related driving measures. The study combined independent estimates in random-effects models to calculate aggregate effect estimates

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

across 50 studies. Among the 21 studies that specifically examined effects of alcohol prices or taxes on traffic safety outcomes, all 34 independent estimates showed an inverse association, with 68 percent of those estimates reaching statistical significance. The average effect size for the 34 independent estimates was –0.112 (p<0.001). The authors concluded that doubling the alcohol tax would lead to an 11 percent reduction in traffic crash deaths (Wagenaar et al., 2010).

A systematic review by the Guide to Community Preventive Services convened by the Centers for Disease Control and Prevention (CDC) also found that alcohol-impaired driving was inversely related to the price of alcoholic beverages (Elder et al., 2010). The review included 11 studies that evaluated the effects of alcohol prices or taxes on motor vehicle crashes. Across the studies, the association between alcohol prices or taxes and motor vehicle injuries and fatalities was generally significant. Furthermore, the authors report that the magnitude was comparable to the relationship between alcohol prices or taxes and alcohol consumption. The elasticities reported in these studies were generally higher in the studies that examined outcomes more proximally related to alcohol consumption (e.g., alcohol-related crashes) when compared to those that are less directly related (e.g., overall crash fatalities). The authors also reviewed three studies that assessed the relationship between alcohol prices or taxes and price elasticities for self-reported alcohol-impaired driving. Price elasticities in samples from the United States and Canada (range of –0.50 to –0.81; all p<0.05) showed that there was consistent evidence of an inverse relationship between price and impaired driving.

A recent (2017) interrupted time series study investigated the effect of an increase in alcohol sales tax in Maryland on the rate of drivers involved in an injury crash who were “alcohol-positive” (i.e., drivers for which the investigating officer perceived any alcohol involvement or their BAC was above 0.00%). The authors found that the 2011 tax increase (from 6 percent to 9 percent) lead to a significant 12 percent reduction in alcohol-positive drivers aged 15–20 years (p<0.007) and 21–34 years (p<0.001). For drivers ages 55 and above, the rate of alcohol-positive drivers increased during the post-intervention period, which the authors posit could be related to this age group’s average socioeconomic status in the state of Maryland and thus, decreased price sensitivity. Overall, the study also showed a 6 percent reduction (p<0.03) in the population-based rate of alcohol-positive drivers after the increase was enacted. The effect was modeled using three denominators—per population of Maryland, licensed drivers in Maryland, and vehicle miles traveled in Maryland—which all found similar results. The authors controlled for a number of factors (e.g., monthly unemployment prevalence in Maryland and annual state per-capita personal income) and included a proxy, alcohol-negative crashes, to control

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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for external factors such as the economy, advancements in car safety, and highway design (Lavoie et al., 2017).

Cost-Effectiveness of Raising Alcohol Taxes

Raising taxes has been shown to reduce impaired driving and related consequences; these are important and valued benefits. Moreover, the additional, direct program costs of collecting the taxes are relatively small as the tax collecting infrastructure is already in place. Furthermore, the higher tax revenue raised by the government (i.e., federal or state) can more than offset these relatively small costs, depending on the size of the tax increase. Thus raising taxes is likely to generate government revenue. However, there may be a level of taxes beyond which taxes would no longer increase revenue; that is, if individuals reduced their consumption or price of alcohol consumed, or turned to untaxed black markets. Another potential cost would be the lost enjoyment (utility) to those drinkers who reduced their drinking levels. The committee considers that loss of utility to be small. Conversely, on a population level, this cost would be more than offset by reduced societal costs such as lost productivity and diminished utility (e.g., physical or emotional pain for victims or their friends and family) that result from excessive alcohol consumption and alcohol-impaired driving injuries and fatalities. In sum, considering all these costs leads the committee to the conclusion that raising taxes would be cost-beneficial.

Other Considerations in Raising Taxes, in Addition to Their Effectiveness

Despite evidence of effectiveness for reducing alcohol-impaired driving and alcohol-related crash fatalities, taxes are low and therefore represent an important “old” but neglected strategy that could be much more aggressively implemented. Thus, raising taxes represents an important public health opportunity. Currently, alcohol-specific excise taxes in states and at the federal level are low in absolute terms. Specifically, the federal tax on a standard drink (0.6 oz., or 14 grams of ethanol) of beer is $0.05, a standard drink of wine is $0.04, and a standard drink of distilled spirits is almost $0.13 (TTB, 2016). In 2015, the average state alcohol-specific excise tax per standard drink was $0.03 for beer, $0.03 for wine, and $0.05 for spirits. These taxes therefore account for a small percentage of the price of alcohol. Furthermore, federal and state taxes have eroded in inflation-adjusted terms relative to historical levels. Federal alcohol taxes have not been changed or adjusted for inflation since 1991. While alcohol taxes historically (late 1800s through early 1900s) accounted for more than one-third of federal government revenue, they now account for less than half

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

of 1 percent of federal government revenue (Cook, 2007). Among states from 1991 to 2015, the average inflation-adjusted (in 2015 dollars) specific excise tax rate declined 30 percent for beer, 27 percent for wine, and 32 percent for spirits (see Figure 3-2). Alcohol tax erosion is not a new phenomenon. Average declines in specific excise taxes since their inception (which varied by state following the repeal of Prohibition) are more than twice as large as those from 1991 to 2015 (Naimi et al., 2018).

Taxes can be levied to reduce alcohol consumption, and/or to cover costs related to the use of alcohol, particularly those costs that are borne by those other than the drinker or alcohol-related businesses. These costs are sometimes referred to as external (or secondhand or spillover costs). Currently, alcohol taxes are considerably lower than the external costs or harms related to a standard drink of alcohol. For example, the external cost per one standard drink of alcohol is approximately $2.00, of which approximately 40 percent is paid by federal and state government (Sacks et al., 2015). This cost estimate includes health care costs (e.g., hospitalization, ambulatory care, specialty care for alcohol use disorder), lost productivity (e.g., impaired productivity at work, absenteeism), and other costs such as criminal justice corrections and alcohol-related crimes. By comparison, after factoring in federal and state alcohol taxes, the average tax per standard drink is less than $0.20 (Naimi, 2011, 2018).

Preventing medical and social harms to others is generally an important justification for public health interventions, and taxation in particular. Many of the adverse health effects and social harms from alcohol also include secondhand effects. In the case of alcohol-impaired driving, this would include all the effects on those other than the drinking driver, as evidenced by fatality data from comprehensive national and state level data sources (e.g., data from the Fatality Analysis Reporting System [FARS] and state highway safety offices) (NCSA, 2016; Quinlan et al., 2014; Retting, 2017). Other types of alcohol-related secondhand health effects include alcohol-related violence victimization, as demonstrated by high-quality meta-analytic reviews (Foran and O’Leary, 2008; Kuhns et al., 2014), and child abuse and neglect, for which the evidence is not yet conclusive (Widom and Hiller-Sturmhofel, 2001). In the case of tobacco policy, for example, adverse health outcomes from secondhand (e.g., external) smoke harms were an important consideration for adopting indoor smoking bans and other tobacco control policies (WHO and Task Force Initiative, 2007). Because of the effect of higher taxes on a number of other alcohol-related health outcomes, social problems, and economic costs, spillover effects from raising alcohol taxes would result in additional benefits beyond their impact on alcohol-related motor vehicle crash fatalities (e.g., reduced underage drinking, reduced alcohol-related violence).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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FIGURE 3-2 Average inflation-adjusted specific alcohol excise taxes among U.S. states from 1991 to 2015.
NOTE: The figure includes all 50 U.S. states for beer, and 32 states for distilled spirits and wine (those 32 states without any state monopoly on wholesale distribution or retail sales of either distilled spirits or wine).
SOURCE: Naimi et al., 2018. Reprinted with permission from Alcohol Research Documentation, Inc., publisher of the Journal of Studies on Alcohol and Drugs.

There are some concerns, however, about how increasing alcohol taxes will affect some drinkers and some special populations. The same tax per drink is paid by all drinkers, and thus drinkers who impose no harm on others will pay taxes. Yet, this is an inevitable side effect, and those who drink the most will pay the majority of increased alcohol-related costs. Specifically, those drinking in excess of recommended federal drinking guidelines would pay approximately five times as much in additional costs from tax increases compared to nonexcessive drinkers,

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

and as a group heavy drinkers would pay at least 72 percent of aggregate additional costs. Furthermore, the total increase in alcohol-related costs (i.e., product plus tax) for most nonexcessive drinkers would be modest in absolute terms (Naimi et al., 2016).

There may be concern that increasing alcohol taxes could disproportionately burden disadvantaged or vulnerable populations. However, as a group, low-income persons tend to consume less alcohol than those with higher incomes—in part because low-income and minority groups are more likely to abstain from consuming alcohol (Esser et al., 2014). Therefore, additional costs from tax increases are actually higher for whites, for those with higher incomes, and for those who are employed (Naimi et al., 2016). A review that included nine studies assessing the relationship between price or taxes and drinking among young people found that alcohol taxes are also protective for underage drinking (Elder et al., 2010); this is important as underage drinkers constitute another important vulnerable population who are disproportionately likely to cause and incur harms from alcohol consumption.

Alcohol-related trade groups contend that alcohol taxes could adversely affect businesses that produce or sell alcohol (DISCUS, n.d.). However, research suggests that money diverted from alcohol production and consumption to other sectors of the economy could produce gains for those sectors. Additionally, the resulting reduction in excessive drinking could increase productivity. Economic modeling studies of the employment effects of alcohol taxes found that alcohol tax increases would actually lead to net increases in jobs at the state level, because of the transfer of jobs and spending from alcohol-related sectors to other, more labor-intensive sectors of the economy, such as government services or health care (Wada et al., 2017).

Increasing alcohol taxes raises revenue for whichever level of government imposes the taxes, such as state and federal governments. Raising alcohol taxes is thus a highly cost-effective policy intervention. Despite this, and the clear interest by government in additional revenue sources, taxes have been allowed to decline in inflation-adjusted terms over time. Increasing alcohol taxes is generally met with stiff opposition from alcohol-related trade groups and industries (Babor et al., 2018).

Public opinion polling has been used as a tool to measure support for alcohol taxes (Global Strategy Group, 2005; Gonzales Research & Marketing Strategies, 2009; Raabe, 2006; Richter et al., 2004). Jernigan et al. (2009, p. 13) assert that such “polling has consistently found substantial levels of support for increasing alcohol taxes, particularly if the proceeds or some portion thereof are dedicated to preventing and treating alcohol problems [e.g., increasing access to treatment] or expanding access to health care.” Prior evidence suggests that public awareness of the efficacy

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

of tax increases to reduce alcohol-related problems is low. Findings from a 1996 national survey showed that almost 80 percent of respondents did not believe alcohol tax increases would decrease injuries. Despite this, the respondents accurately assessed the role of alcohol in fatal falls, drowning, and poisoning, and overestimated its role in motor vehicle fatalities (Girasek et al., 2002). Interviews with policy makers in three states—Illinois, Maryland, and Massachusetts—that recently increased state alcohol taxes confirmed this finding: policy makers were both unaware and skeptical of the ability of alcohol tax increases to influence alcohol consumption or problems (Ramirez and Jernigan, 2017).

Increasing alcohol taxes is a highly effective strategy for reducing binge drinking and alcohol-related motor vehicle crash fatalities. In this section, the committee reviews a body of evidence including high-quality systematic reviews (e.g., Community Preventive Services Task Force2 review by Elder et al., 2010) and meta-analyses (e.g., Wagenaar et al., 2009, 2010) that shows a consistent inverse relationship between alcohol taxes and alcohol consumption and binge drinking (see Chapter 2 for a discussion of the proximal relationship between binge drinking and alcohol-impaired driving), as well as motor vehicle crash fatalities. In addition to the empirical evidence that indicates the efficacy of increased prices and taxes for reducing binge drinking and alcohol-related motor vehicle crash fatalities, there are practical considerations that support the need for increased taxes. As discussed in this chapter, the erosion of alcohol taxes over the years, the cost-effectiveness of taxes as a population-based intervention, and the potential for wide reach provide additional rationale for increasing alcohol taxes. In addition, current alcohol excise taxes are very low, represent a small fraction of the price of alcohol, and do not cover alcohol-related costs. Drawing from the empirical evidence and the aforementioned considerations, the committee recommends:

Recommendation 3-1: Federal and state governments should increase alcohol taxes significantly.

By significantly, the committee means that alcohol taxes should be increased enough so that they have a meaningful impact on price, thence reducing alcohol-related crash fatalities. Increases should comprise a meaningful percent of the net-of-tax price (e.g., 30 percent or more) of

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2 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.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

alcohol products, and cover the marginal external (i.e., secondhand) costs incurred by the sale of alcohol.3

These taxes can be levied as specific excise taxes (which in the United States are based on a fixed amount per unit volume of alcohol) or as ad valorem excise taxes (based on a percentage of price). Specific excise taxes may be preferred because it is the volume of ethanol that is associated with impaired driving. As a percentage of sale price-based taxes, ad valorem taxes are lower for less expensive alcohol products, which tend to be consumed by target groups, such as heavy drinkers and those who are more price sensitive (e.g., underage persons and young adults). However, volume-based excise taxes erode with inflation and therefore need to be indexed to inflation. Ideally, taxes would be based on ethanol content rather than beverage type. Taxes can be earmarked to support alcohol-related activities (e.g., funding sobriety checkpoints), which may enhance public support.

The Three-Tier System of Alcohol Distribution and Wholesale Pricing Policies

Since the end of Prohibition in 1933 most states have used a three-tier system to regulate the distribution of alcohol (Durkin, 2006). The first tier consists of producers and alcohol importers (NABCA, 2015; South Carolina Legislature, 2007). They sell directly to licensed wholesalers (tier two) who then sell to retailers who are licensed to sell alcohol to the public (tier three) (Durkin, 2006; South Carolina Legislature, 2007). Table 3-1 shows the distribution of the three tiers. The system was set up primarily to prevent organized crime from controlling alcohol sales as they did during Prohibition (Martin, 2001). In addition, the system was established to prevent alcohol producers from dominating community life, as they did during the period when saloons were the primary community institution and producers controlled the saloons (Aaron and Musto, 1981). To that end, each tier is regulated individually by the state, and no individual or company can invest in more than one tier (Martin, 2001). The system also helps to ensure orderly markets, prohibit the sales of alcohol to minors, and facilitate the collection of taxes (Martin, 2001).

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3 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. A recent analysis by the Urban-Brookings Tax Policy Center estimated the number of motor vehicle fatalities attributable to the reduction in alcohol taxes proposed by this legislation based on four empirical studies (Looney, 2017). The author concluded that the legislation would cause between 280 to 660 additional motor vehicle deaths and 1,550 total alcohol-related deaths from all causes per year.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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TABLE 3-1 The Three-Tier System of Alcohol Distribution

Tier Actors Role
1. Producers Wineries, breweries, distillers, and importers Produce and sell alcoholic products to wholesalers
2. Wholesalers Wine, beer, and distilled spirits distributors Distribute alcohol to retailers
3. Retailers On-premise (e.g., bars) and off-premise (e.g., package stores) retailers Sell alcohol to the public

SOURCE: Information from NABCA, 2015.

A report from the National Alcohol Beverage Control Association discusses the economic, regulatory, commercial, and public health benefits of the three-tier system and cautions against the deregulation of the system (NABCA, 2015). Of note, one benefit is that the three-tier system maintains higher prices of alcohol products. In addition, the report cites industry actors, from manufacturers to wholesalers and distributors, who have expressed support for the three-tier system. Findings from a 2015 survey conducted by the Center for Alcohol Policy show that the majority of the public (89 percent) agrees that it is very important to keep the alcohol industry regulated. The key findings from the survey also indicate that the public supports the current system of alcohol regulation at the state level (CAP, 2015). However, recent changes in the alcohol market, such as the rise of Web-based commerce and other outlets, pose challenges to maintaining the current three-tier system (Schmidt, 2017).

The wholesalers within tier two are subject to pricing restrictions that are intended to maintain higher prices, reduce competition, corruption, and crime (APIS, 2016b). These laws can regulate wholesalers’ ability to provide discounts based on the quantity of alcohol purchased, require them to establish a minimum markup or maximum discount for all products, require them to post their prices publicly and hold these prices for a set amount of time (i.e., post-and-hold laws), or restrict their ability to extend credit to retailers in the form of loans or deferred invoices (APIS, 2016b). These restrictions are implemented differently by state and by type of alcoholic beverage; for example, in Michigan the sale of beer and wine is regulated by the three-tier system and the sale of spirits is regulated by the state, while in Missouri all three types of alcohol are regulated by the tier system but volume discounts and post-and-hold laws only apply to wine and spirits (APIS, 2016b). Those states that did not set up a three-tier system for alcohol distribution after Prohibition chose to operate as monopolies, regulating the distribution and sales of alcohol themselves

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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(for more information see the section “Policies to Address Physical Availability”) (Foust, 1999; McGowan, 1997).

Retail Price Restrictions

Happy hours, two-for-one specials, unlimited drinks, and free drinks are examples of alcoholic drink specials that are available over a specified period of time, during which alcohol is sold at a discounted price and/or higher volume at an on-premises location such as a bar or restaurant. The laws restricting these kinds of drink specials vary by state. For example, in Alaska happy hours are prohibited but free beverage specials and unlimited beverages for a fixed price or period are allowed, while in South Carolina happy hours are permitted between 4:00 pm and 8:00 pm and specials that provide multiple servings for a single serving price are allowed (APIS, 2016a). Currently there are 18 states that have no laws placing restrictions on drink specials (APIS, 2016a).

Studies have found that these kinds of drink specials are associated with increased excessive alcohol consumption (Babor et al., 1978, 1980; Thombs et al., 2008, 2009), especially among young drinkers (Baldwin et al., 2014; Kuo et al., 2003; Van Hoof et al., 2008). Research also shows that about half of drinkers who drive impaired are coming from a licensed establishment (e.g., bars, restaurants, or clubs) (Naimi et al., 2009). One study assessed the relationship between banning drink specials and alcohol consumption in Ontario, Canada, but owing to study design limitations the results were inconclusive (Babor, 2010; NHTSA, 2005a; Smart, 1996; Smart and Adlaf, 1986). More research is needed to determine the effects of introducing these policies on alcohol consumption and alcohol-impaired driving specifically. Enforcement and adjudication of these laws are time-consuming, as they require observation, surveillance, and undercover operations, and tend to be a low priority for enforcement officials (NHTSA, 2005a). Collecting place of last drink (POLD) data from alcohol-impaired driving offenders could help target enforcement at problematic establishments, thereby increasing the effectiveness of policies restricting drink specials (NHTSA, 2005a).

Minimum Alcohol Pricing

Minimum alcohol pricing typically sets a minimum price per standard drink based on ethanol. In the event of a price increase (e.g., alcohol tax increase), drinkers can consume less, purchase cheaper products, or a combination thereof. Substituting lower price for quality can mitigate the effects of policies that increase alcohol prices (Gruenewald et al., 2006). Thus, the premise of minimum pricing is to limit substituting lower

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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priced alcohol for quality and excessive consumption by placing a limit on how low alcohol beverage prices can be. Minimum alcohol pricing has been shown to reduce hazardous alcohol consumption (Gruenewald et al., 2006; Holmes et al., 2014; Purshouse et al., 2010) and related harms (Stockwell et al., 2013; Zhao et al., 2013) in countries such as Canada and the United Kingdom. The available evidence indicates that less expensive products demonstrate higher price sensitivities than higher-priced products and that less expensive products are preferred by hazardous drinkers (Stockwell et al., 2015). Therefore, these policies have an effect on hazardous drinkers, including low-income drinkers (Holmes et al., 2014), and potentially underage persons, as they do not have a great deal of discretionary income and are relatively price sensitive.

POLICIES TO ADDRESS PHYSICAL AVAILABILITY

Regulating Outlet Density

Policies to address the physical availability of alcohol to reduce excessive alcohol consumption and related harms often target outlet density, the number of establishments within a given area where alcohol may be legally sold to be consumed on-premise (e.g., bars, clubs, restaurants) or off-premise (e.g., package stores) (Campbell et al., 2009). There is evidence that increased alcohol outlet density is associated with increased alcohol-related crashes (Scribner et al., 1994; Treno et al., 2007) and self-reported impaired driving (Gruenewald et al., 2002), including among underage persons (Reboussin et al., 2011; Treno et al., 2003). An ecological study conducted in New Mexico found that areas within the highest tertile of distilled spirits outlet density were associated with a 50 percent increase in alcohol-related crash rates and a two-fold increase in alcohol-related crash fatalities when compared with the lowest tertile of outlet density (Escobedo and Ortiz, 2002).4 While there is a body of literature that documents the positive relationship between outlet density and subsequent drinking and alcohol-impaired driving, there is less research examining reductions in alcohol outlet density.

The Community Preventive Services Task Force found that there is sufficient evidence to recommend the regulation of alcohol outlet density based on the positive association between outlet density and excessive alcohol consumption, as well as related harms (Task Force on Community Preventive Services, 2009). However, it is important to note that the authors concluded that the available studies specifically evaluating the

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4 Distilled spirits outlet density rates were calculated for each county, and counties were divided into three groups: low, middle, and high.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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relationship between alcohol outlet density and motor vehicle crashes have produced mixed results (Campbell et al., 2009).

More recently, Ponicki et al. (2013) conducted a spatial panel analysis of all California zip codes from 1999 to 2008, and the results showed that local bar density was positively associated with the likelihood that motor vehicle crashes were alcohol related. Other research points to traffic flow as a moderator of the relationship between outlet density and single-vehicle nighttime crashes; that is, crashes were more likely to occur in areas with higher on-premise outlet density and highway traffic flow (i.e., motor vehicles per day). These findings have implications for local transportation and planning decisions, and the authors suggest that the effects of alcohol outlets on crashes are context dependent (Gruenewald and Johnson, 2010).

There are a number of challenges to regulating alcohol outlet density. Similar to other alcohol policies, commercial and financial consequences can prompt the alcohol industry (manufacturers, distributers, and retailers) to actively oppose policies to limit or reduce outlet density (Campbell et al., 2009; Giesbrecht, 2000). In addition, state preemption laws can limit local governments’ ability to regulate outlet density (Mosher, 2001). Despite these barriers, there is evidence that employing tools such as health impact assessments can help drive policy changes to reduce outlet density (Thornton et al., 2013). Another potential challenge with addressing outlet density is the measurement of outlet density in a given state or community. CDC provides guidance on how to measure alcohol outlet density and identifies three main approaches: container-based, distance-based, and spatial access-based (CDC, 2017). Such public health surveillance approaches can identify high-risk areas and provide data to make the case for regulating outlet density in a given area.

Regulating Hours and Days of Sale

Policies that regulate when alcohol can be sold vary by state and retail setting (i.e., on- or off-premise) and can also vary within states that allow local jurisdictions to set their own restrictions (Hahn et al., 2010). On-premise alcohol outlets are allowed to operate for a median of 19 hours per day on weekdays and Saturdays and 17 hours per day on Sundays; nine states have no restrictions on limits of hours of sale (Hahn et al., 2010). All U.S. policies that limit days of off-premise sales target Sundays,5 but these policies vary from state to state. As of 2016, 12 states

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5 Sunday bans on alcohol sales originate from “blue” laws, some of which date back to pre-Revolution-era policies that prohibited working, shopping, or consuming alcohol on Sundays (APIS 2016d).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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had full bans or minor exceptions (e.g., selling at wineries or on special events); other states have reduced hours, bans on spirits, or no bans at all (APIS, 2016d).

In 2010 the Community Preventive Services Task Force (Task Force) reviewed the evidence on regulating hours and days of sale. Hahn et al. (2010) examined studies assessing the effects of increased hours of sale in on-premise settings on excessive alcohol consumption and related harms. The authors concluded that limiting hours of alcohol sales in on-premises settings was effective in reducing alcohol-related harms (no studies were found on the effects of sales in off-premises settings) (Hahn et al., 2010). The Task Force reviewed studies conducted in high-income countries, but no research was available on how limiting hours of sales would affect alcohol-impaired driving fatalities in the United States specifically. The Task Force also found that an increase in 2 or more hours of sale led to an increase in harm, while there was insufficient evidence to determine the effect of increasing hours of sale by less than 2 hours (Hahn et al., 2010).

The Task Force also synthesized the evidence on maintaining or reducing days of sale. The authors reported that maintaining existing limits on days of sale is effective at preventing alcohol-related harms, and increasing days of sale leads to increased alcohol-related harms and decreasing days of sale leads to decreased alcohol-related harms (Middleton et al., 2010). Another study on days of sale and alcohol-related crash fatalities used a quasi-experimental approach to assess the effect of repealing or scaling back bans on Sunday sales in 14 states (Stehr, 2010). The results demonstrated an effect in New Mexico only, where Sunday sales were associated with a 3.7 percent increase in alcohol-related traffic fatalities. Stehr (2010) posits that this finding is related to a corresponding increase in alcohol consumption in New Mexico (14.1 percent and 8 percent increases in the sale of beer and spirits, respectively—much higher than what was reported in the other states).

A 2017 systematic review of policies regulating hours and days of alcohol sales included studies that assessed the effect on motor vehicle crashes and fatalities from a number of countries including Australia, Canada, the United Kingdom, and the United States (Sanchez-Ramirez and Voaklander, 2017). The authors reported mixed results on the effect of extended hours of sale on motor vehicle crashes and fatalities. This included a study that found that the extension of bar hours in the United Kingdom was associated with a decrease in motor vehicle crashes (Green et al., 2014). The authors of the review conclude that the relationship between these policies and motor vehicle outcomes is complex, and more research is needed in this area.

There are a number of barriers to maintaining or imposing limits on hours and days of sale. This type of regulation could affect alcohol sales,

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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which would beget opposition from the alcohol manufacturing, distribution, and retail industry (DISCUS, 2017; Hahn et al., 2010; Middleton et al., 2010). According to the Community Preventive Services Task Force, state preemption laws could also undermine local efforts to regulate the sale of alcohol (Hahn et al., 2010), which has been a common barrier for local public health prevention efforts (IOM, 2011).

State Monopolization of Alcohol Sales

There are currently 17 states6 as well as several jurisdictions in Alaska, Maryland, Minnesota, and South Dakota in which government agencies control the sale of beer, wine, and/or spirits (NABCA, 2017). The government monopoly standardizes the price of alcohol throughout a state and the profits are kept by the state (Simon, 1966). Overall, privatization of alcohol sales is associated with an increase in the price of alcohol (Simon, 1966). However, Hahn et al. (2012) theorize that privatized systems may offer a wider array of low-priced products that could appeal to high-volume or high-risk drinkers. A study conducted in Iowa found that after privatization only 37.4 percent of those surveyed who purchased spirits in the past month noticed that sales prices had increased since privatization (Fitzgerald and Mulford, 1993). In its evidence review, the Community Preventive Services Task Force concluded that the privatization of alcohol sales increases per capita alcohol consumption, and by proxy, alcohol-related harm (Hahn et al., 2012). The review also found that remonopolization of alcohol sales is associated with decreased alcohol consumption (Hahn et al., 2012). The median increase in per capita sales of alcohol of the studies reviewed was 44.4 percent (Hahn et al., 2012). Trolldal (2005) evaluated the effects of the privatization of alcohol sales in Alberta, Canada, on fatal motor vehicle crashes and found a nonsignificant decrease. The author speculated that there may not have been a great effect because alcohol wholesales were still monopolized and that private alcohol sales were confined to distilled spirits stores. Another study conducted in Iowa after the privatization of wine and spirit sales also found no significant decrease in motor vehicle crashes (Fitzgerald and Mulford, 1992). The privatization of alcohol sales, however, does result in higher alcohol outlet density, which may account for some of the harmful effects (Hahn et al., 2012).

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6 These states are Alabama, Idaho, Iowa, Maine, Michigan, Mississippi, Montana, New Hampshire, North Carolina, Ohio, Oregon, Pennsylvania, Utah, Vermont, Virginia, West Virginia, and Wyoming.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Alcohol Sales Concurrent with Driving

One important yet understudied feature of the alcohol environment is the sale of alcohol that is concurrent with or very proximal to driving. This includes the concurrent sale of alcohol and gasoline, the sale of consumption-ready single-serving drinks, drive-through package stores, and the sale of alcohol in fast-food establishments. In many cases this also includes the marketing of alcohol, such as beer, with the sale of gasoline. While there is not a substantial evidence base to draw from in this area, it is important to address because the nature of these sales often involve driving shortly after purchase.

There is some limited evidence on the relationship between drive-through package stores and alcohol-related motor vehicle crashes. One study explored alcohol purchase locations among convicted impaired drivers in New Mexico. For offenders who bought the alcohol they drank prior to their arrest, drive-through stores were the preferred outlet of purchase. The authors found a statistically significant relationship between purchase at drive-through package stores and screening as high-risk problem drinkers (p<0.01) and drinking in the vehicle prior to arrest (p<0.01) (Lewis et al., 1998). Another study conducted in New Mexico examined the spatial relationship between drive-through package store locations and alcohol-related crashes before and after the state banned drive-through alcohol sales using cross-sectional and longitudinal regression analyses. The authors found an increasing trend of alcohol-related crashes relative to total crashes prior to the ban and a decreasing trend after the ban. However, there was no statistically significant relationship between the number of drive-through outlets and the rate of alcohol-related crashes (Lapham et al., 2004).

Some states have implemented restrictions on the sale of alcohol concurrent with or proximal to driving, such as bans on drive-through package stores. These are often presented as common sense measures to reduce alcohol-related harm. More research is needed to determine the effects of the sale of alcohol concurrent with driving on alcohol-impaired driving.

Open Container Laws

Related to alcohol sales concurrent with driving are open container laws, which were designed to reduce alcohol-impaired driving by prohibiting the possession or consumption of open alcoholic beverage containers in a motor vehicle.7 As part of the 1998 Transportation Equity Act for the

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7 An open container is defined as “any bottle, can, or other receptacle that contains any amount of alcoholic beverage, and that is open or has a broken seal, or the contents of which are partially removed” (APIS, 2016e).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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21st Century, Congress stipulated that states enact open container laws that meet six specific criteria or have a portion of their federal highway funds allocated to alcohol-impaired driving countermeasure programs, law enforcement, and/or hazard elimination (APIS, 2016f).8 These criteria require that state law prohibit possession of alcoholic beverage containers and consumption of alcohol in motor vehicles; cover the entire passenger area; apply to all types of alcoholic beverages; apply to all vehicle occupants; apply to all vehicles on public highways; and provide for primary enforcement of the law. While the parameters of the law vary by state, 40 states and the District of Columbia are in compliance with federal requirements (Advocates for Highway and Auto Safety, 2017). As of 2016, six states had no form of open container law. In addition to the open container laws that have been passed by most states, as of 2013, 39 states currently have laws that allow on-premise establishments to re-seal an opened, but unfinished bottle of wine so that it can be transported in a vehicle without violating the open container law (NCSL, 2013).

There is a limited body of evidence that examines the relationship between open container laws and drinking while driving or alcohol-impaired driving (Goodwin et al., 2015). Stuster et al. (2002) conducted pre- and post-analyses of four states (Iowa, Maine, Rhode Island, and South Dakota) that passed open container laws in 1999. The authors found a decline in alcohol-related crashes among the states that passed the law over the 6-month period following enforcement when compared to the same 6-month period of the prior year. The decline was not statistically significant. However, the findings also showed that states with no open container laws had significantly greater proportions of alcohol-related fatal crashes than states with partially or fully compliant laws. Furthermore, the states that had enacted fully compliant laws had the lowest proportions of alcohol-related crashes among the four states examined. Two other studies have also found a relationship between open container laws and reduced alcohol-related fatalities (Benson et al., 2000; Eisenberg, 2003), while one multivariate regression analysis found no significant effect (Chang et al., 2012). More recent research suggests that while having an open container law is not related to alcohol-impaired driving, enforcement of open container prohibitions is associated with reduced self-reported alcohol-impaired driving (Lenk et al., 2016). Given the limited available evidence and the high number of states that have open container laws, there is an opportunity to further investigate the effects of these laws and their levels of enforcement.

This chapter discusses how the alcohol environment can shape alcohol-related outcomes such as excessive drinking (a precursor to impaired

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8 23 U.S.C. § 154.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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driving) and alcohol-impaired driving. One important feature of this environment is the physical availability of alcohol (e.g., outlet density and hours and days of sale), which can vary by community or state. In this section, the committee presents an overview of the recent literature on outlet density and hours and days of sale from high-quality systematic reviews by the Community Preventive Services Task Force (e.g., Campbell et al., 2009; Hahn et al., 2010; Middleton et al., 2010) and individual studies with a variety of methodologies and outcome data sources (e.g., telephone surveys, hospital discharge data, state forensic data, and state highway and transportation department data) (Escobedo and Ortiz, 2002; Gruenewald et al., 2002; Treno et al., 2003, 2007). Collectively, this body of evidence suggests a strong, positive association between physical availability of excessive alcohol consumption and alcohol-related harms. Although this relationship is more clearly demonstrated by the evidence for other alcohol-related harms, alcohol-impaired driving and crashes are also affected by physical availability and have a strong link to excessive consumption (Flowers et al., 2008). This evidence indicates a need to limit physical availability in areas that have not already done so. It is important to note that more research is needed to determine optimal physical availability policies to reduce alcohol-impaired driving specifically. Furthermore, each state and locality will have different concentrations of physical availability and existing policies, thus requiring a tailored approach based on that area’s needs and available policy levers. Therefore, the committee recommends:

Recommendation 3-2: State and local governments should take appropriate steps to limit or reduce alcohol availability, including restrictions on the number of on- and off-premises alcohol outlets, and the days and hours of alcohol sales.

In addition, states should consider restricting or eliminating alcohol sales in locations in which the customer is driving or may drive shortly after purchasing alcohol (i.e., potentially high-risk outlets with respect to drinking and driving), such as at drive-through windows at package stores, gasoline stations, and fast-food restaurants.

POLICIES TO REDUCE ILLEGAL ALCOHOL SALES

Minimum Legal Drinking Age Laws and Enforcement

Federal legislation encouraging a minimum legal drinking age (MLDA) of 21 was passed in 1984, and by 1988 all states and the District of Columbia had enacted a minimum legal age of 21 for the purchase and

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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possession of alcohol (Fell et al., 2008). Most states enforce laws against the sale of alcohol to minors through local law enforcement agencies and alcohol beverage control agencies (Elder et al., 2007). Both types of agencies often lack resources to effectively carry out their enforcement duties. The federal Enforcement of Underage Drinking Laws Program aimed to help alleviate such resource constraints, allocating $25 million in federal block grants to all states and the District of Columbia. Since 2010, funding for this program decreased and eventually dissipated (see Table 7-1 for funding of this and other federal substance abuse prevention programs).

MLDA Laws

There is a robust evidence base that supports the passage and maintenance of MLDA laws based on the effects they have had on decreasing alcohol-related harm in persons under age 21. Based on strong evidence for the effectiveness of MLDA laws of 21 in decreasing alcohol-related vehicle crashes and injuries among 18- to 20-year-olds, the Community Preventive Services Task Force recommended maintaining current MLDA laws (Shults et al., 2001). A systematic review of 49 studies examining the effects of raising and lowering the MLDA indicated 10 to 16 percent decreases in alcohol-related crashes when the MLDA was raised and increases of similar magnitude when it was lowered (Shults et al., 2001). Wagenaar and Toomey (2002) published a review of the effects of MLDA laws based on 79 studies published from 1960 to 2000. Among the studies, 58 percent found an inverse relationship between the age 21 MLDA and traffic crashes; none found an opposite association (Wagenaar and Toomey, 2002). DeJong and Blanchette (2014) conducted a review of the evidence on the age 21 MLDA from 2006 to 2013 and concluded that this research has reinforced the finding that the federal MLDA law has led to a reduction in alcohol-related crashes and consumption among youth, with other positive effects for this population in the long term.

Enforcement of MLDA Laws

While MLDA laws have been found to be effective (HHS, 2016), strict and consistent enforcement is needed to optimize the effect of these laws. Elder et al. (2007) reviewed eight studies analyzing the effects of programs implemented by local law enforcement or alcohol beverage control agencies that aimed to increase compliance checks in community retailers. When enhanced enforcement programs were in place, including high intensity and publicity, successful purchases of alcohol by decoys who lacked identification proving their age decreased by an average of 42 percent (range of 17 to 57 percent decrease). Results of two studies indicated

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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that the effects of enhanced enforcement decreased when enforcement programs were discontinued (Scribner and Cohen, 2001; Wagenaar et al., 2005). One study indicated that enhanced enforcement was correlated with a 20 percent reduction in self-reported alcohol consumption and binge drinking among high school students (Barry, 2004). Publicized enforcement of MLDA and driving while impaired (DWI) laws has also been shown to reduce drinking and driving in a college community as measured by roadside surveys (McCartt et al., 2009).

Enforcement programs, which include age-related compliance checks, are underutilized and require improvements. The National Research Council (NRC) and the Institute of Medicine (IOM) report Reducing Underage Drinking: A Collective Responsibility (2004) discusses the need for enhanced enforcement against retailers who sell to minors. The report explores this issue in the context of the success of tobacco control and youth smoking, citing the Synar Amendment9 as a model to inform underage alcohol sales enforcement. This amendment mandates tobacco sales compliance checks and ties the enactment and enforcement of laws prohibiting the sale of tobacco to minors to state block grant funding for substance abuse prevention. Ultimately, the committee recommended that states bolster compliance check programs using media campaigns and license revocation (NRC and IOM, 2004).

Enforcement programs may be ineffective if perception of a lack of support from the community is high, as law enforcement agencies may not have sufficient incentive to carry out enforcement efforts (Elder et al., 2007). A study of 17,830 students surveyed in the 2007 Oregon Health Teens Survey found that perceived community disapproval of adolescents’ alcohol use and adolescents’ personal beliefs were positively associated with perceived local law enforcement of MLDA laws (Lipperman-Kreda et al., 2010). Enforcement programs that solely target retailers for reducing sales to minors may result in minors substituting retailers with social providers such as friends, family, and strangers (Elder et al., 2007). Therefore, preventing alcohol sales to minors depends on a series of complementary policies and practices that target prevention of purchase, possession, consumption, and internal possession,10 such as compliance checks, social host laws, dram shop liability laws, and others. These poli-

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9 The Synar Amendment was enacted with the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (Public Law 102-321) in 1992 with the goal of reducing youth access to tobacco. The amendment mandates that all states enact and enforce laws that prohibit the sale and distribution of tobacco to individuals under the age of 18. In order for states to receive their Substance Abuse Prevention and Treatment Block Grant, they must comply with the Synar Amendment (SAMHSA, 2017).

10 A minor-in-possession charge requires “evidence of alcohol in the minor’s body, as determined by a blood, breath, or urine test, but does not otherwise require any specific evidence of possession or consumption (e.g., through witness observation or an admission on the part of the minor)” (APIS, 2016g).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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cies and practices will be discussed as strategies to reduce illegal sales to minors in the following sections.

Dram Shop Liability Laws

Dram shop liability laws permit legal action against commercial establishments serving alcohol to underage persons or already intoxicated persons regardless of age (Scherer et al., 2015). (For the history of dram shop liability and insurance, see Sloan et al.’s [2000] Drinkers, Drivers, and Bartenders.) Owners and servers may be held liable when illegal beverage service (i.e., to intoxicated or underage patrons) results in injury, death, or damages from alcohol-related vehicle crashes (Rammohan et al., 2011). Survey data of commercial servers suggest an association between a state’s status of dram shop laws (i.e., strictness) and perceived risk of liability (Sloan et al., 2000). Dram shop liability laws, in combination with enhanced enforcement documenting alcohol service violation history, provide important data for connecting injury caused by intoxicated drivers and the drinking establishment at which they were served (Graham et al., 2014).

The Community Preventive Services Task Force recommends the use of dram shop liability laws to prevent and reduce alcohol-related harms (Rammohan et al., 2011; Task Force on Community Preventive Services, 2011). Using methodology from the Guide to Community Preventive Services, Rammohan et al. (2011) examined 11 studies and found that dram shop liability laws were correlated with a 6.4 percent average decrease in alcohol-related driving fatalities (values ranged from 3.7 to 11.3 percent). Reductions were also found across all studies for other measured outcomes, including all-cause motor vehicle fatalities, alcohol consumption, alcohol-related violence, and alcohol-related diseases.

Using FARS data, Scherer et al. (2015) found that dram shop liability laws were correlated with a 2.4 percent decrease in the ratio of drinking to nondrinking drivers under age 21 involved in fatal crashes (Scherer et al., 2015). The authors estimated that 64 lives had been saved in the jurisdictions that have the law and that 9 more lives could be saved each year if the six states without the law were to adopt it. The authors also found that strong dram shop liability laws were significantly correlated with lower per capita beer consumption.

In 1983 and 1984, two widely publicized server liability cases took place in Texas. Analysis of single-vehicle nighttime crashes in the state from 1978 through 1988 indicated significant decreases of 6.5 and 5.3

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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percent following the 1983 and 1984 case filings, respectively. As the decreases were found to have taken place at the time the lawsuits were filed and not when the courts issued their decisions 3 to 4 years later, increased awareness of server liability laws and concern from retail alcohol establishment owners generated through newspaper publicity are likely to have contributed to the reductions (Holder et al., 1990).

The Community Preventive Services Task Force did not find any studies examining the cost-benefit of dram shop liability laws. However, Rammohan et al. (2011) note that litigation may not be cost-effective or achievable in certain cases, as establishing proof that illegal beverage service took place (and resulted in injury) may be difficult (Martineau et al., 2013). Obtaining legal services may also be especially burdensome for those of low socioeconomic status. Most of the studies examined in the systematic review were conducted prior to widespread enactment of dram shop liability laws in the late 1990s (Rammohan et al., 2011; Task Force on Community Preventive Services, 2011). More research is needed to analyze the effectiveness of these laws, especially as states have enacted shorter statutes of limitation and more stringent requirements for legal evidence.

Social Host Liability

Another complementary policy that is designed to reduce underage and hazardous drinking is social host liability. Social host laws assign criminal or civil liability for providing alcohol to someone under the legal drinking age and/or to an obviously intoxicated adult if damages or injury are caused by that individual (e.g., in a motor vehicle crash) (NHTSA, 2016; Voas and Lacey, 2011). The primary purpose is to hold individuals or noncommercial providers of alcohol liable, whereas dram shop liability applies to licensed establishments. As of 2016, 21 states had general hosting laws, 10 states had social host laws specific to underage parties, and 19 states and the District of Columbia had no social host laws (APIS, 2016h). The purpose of such laws is to deter adults from hosting parties where underage drinking occurs, purchasing alcohol for underage drinkers, providing alcohol for underage persons, and overserving alcohol (Voas and Lacey, 2011). The majority of adolescents obtain alcohol from social sources (Pemberton et al., 2008); thus, they are an important point of intervention to reduce underage drinking and subsequent impaired driving. Additionally, there has been public support for assigning liability to social hosts for alcohol-related injuries (Wagenaar et al., 2001).

Social host liability laws differ from state to state, and implementation is an important factor that requires investigation. Findings from California suggest that social host laws with strict liability and swift, administrative

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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civil penalties could reduce underage drinking in private settings, especially among youth who have already initiated alcohol use (Paschall et al., 2014). While social host laws may send a powerful message, effective dissemination of that message is required for effectiveness (Grube and Stewart, 2004; Holder and Treno, 1997; Voas and Lacey, 2011). In the 2004 NRC and IOM report on underage drinking, the authors posit that the mixed findings on social host laws could be attributable to the lack of a comprehensive program that ensures that the public is aware of potential liability exposure. To that end, the report discusses media campaigns as an integral component of implementing social host liability laws.

Over the past few decades, there has not been a substantial amount of evidence on social host laws and alcohol-impaired driving, and the existing evidence is conflicting (Goodwin et al., 2015; NRC and IOM, 2004; Voas and Lacey, 2011). Early study findings using data from the Behavioral Risk Factor Surveillance System showed that social host laws had a deterrent effect with respect to binge drinking and drinking and driving (Sloan et al., 2000; Stout et al., 2000). More recently, Fell et al. (2014) examined the effects of social host laws on the ratio of drinking drivers under age 21 to nondrinking drivers under age 21 involved in fatal crashes from 1982 to 2010. Social host civil liability laws (allow suing social hosts for injuries caused by underage drinking guests) had a negative but nonsignificant (p = 0.054) effect, and social host prohibitions (prohibit hosting underage drinking parties) had no effect on the ratio of drinking to nondrinking drivers under age 21 in a fatal crash. Dills (2010) investigated the effect of the presence of a social host liability law on self-reported driving after drinking and alcohol-impaired driving fatalities at the state level from 1975 to 2005 among 18- to 20-year-olds. The author found significant reductions of 5 to 9 percent and 3 percent in alcohol-related traffic fatalities and driving after drinking, respectively (Dills, 2010). Given the insufficient body of research around social host laws and alcohol-impaired driving, more research is needed in this area (Hingson and White, 2014; Wagoner et al., 2013).

Responsible Beverage Service and Server Training

Responsible beverage service (RBS) has been studied as a potential point of intervention to reduce excessive drinking and subsequent alcohol-impaired driving (Fell et al., 2017; Graham, 2000; Linde et al., 2016; Rammohan et al., 2011; Saltz, 1987; Scherer et al., 2015; Shults et al., 2001). Research indicates that approximately half of drivers arrested for alcohol-impaired driving had their last drink at a licensed establishment (Fell et al., 2010; Gallup, 2000; O’Donnell, 1985), and this is consistent with self-reported data on driving after binge drinking (Naimi et al., 2009).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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The training for servers typically focuses on serving procedures, signs of intoxication, methods for verifying age, and intervention strategies. There are also aspects of manager training that incorporate the abovementioned, in addition to policy and procedure development and staff supervision (APIS, 2016e). Public acceptance has been relatively high for RBS policies, with a national survey indicating that 89 percent of the population was in favor of policies mandating server training (Wagenaar et al., 2000).

Programs for server training can be mandatory, voluntary, or a combination of both. States with voluntary beverage service training programs typically provide incentives for retailers (e.g., defense in dram shop liability lawsuits, discounts for dram shop liability insurance, or mitigation of fines or other penalties for service violations). It is important to note that incentives such as protection from dram shop liability can have unintended consequences. These protections can hinder the effectiveness of dram shop laws, which have been shown to be effective in reducing alcohol-related harm (Rammohan et al., 2011), as discussed previously. As of 2016, 12 states and the District of Columbia had mandatory service training laws, 20 had voluntary laws, 6 had a combination of mandatory and voluntary policies, and 12 had neither (APIS, 2016e). In the past, there have been federal incentive grants for states that engage in specific server training activities,11 such as training point-of-sale personnel to recognize signs of intoxication, but those have since been rescinded.

In Countermeasures That Work, Goodwin et al. (2015) review the evidence on RBS and conclude that the findings on the effectiveness of server training have been mixed. They note that few studies have examined the effect of RBS on alcohol-impaired driving crashes specifically. The Community Preventive Services Task Force conducted a review of interventions to reduce alcohol-impaired driving, including training programs for servers of alcoholic beverages. Shults et al. (2001) concluded that, based on the rules of evidence presented in The Community Guide, there was sufficient evidence that intensive, high-quality, face-to-face server training (when supplemented with active management support) is effective in reducing the level of intoxication among patrons (and is therefore likely to have an effect on impaired driving if the affected patrons cease drinking or continue elsewhere in a safe environment after leaving). Shults et al. (2001) also noted that optimally, server training would be established in all licensed establishments in a community to have a community-wide effect. However, research on such community-wide alcohol server interventions is limited (Shults et al., 2001). A recent study of demonstration projects that incorporated RBS and enhanced alcohol enforcement for

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11 23 U.S.C. § 410, https://www.gpo.gov/fdsys/pkg/USCODE-2006-title23/pdf/USCODE-2006-title23-chap4-sec410.pdf (accessed October 2, 2017).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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problem bars in two communities also produced mixed findings (Fell et al., 2017). Jones et al. (2011) completed a systematic review of multiple countries (including the United States) and found that server intervention programs designed to reduce alcohol use in drinking environments had mixed effects on patrons’ alcohol consumption. The observed effects on patron drinking were minimal, except where training was mandated (Jones et al., 2011). In summary, more research is needed to determine the critical elements that contribute to the effectiveness of RBS policies and training.

Sales to Intoxicated Persons

Sales to intoxicated persons (SIP) laws make it illegal to sell alcohol to an obviously intoxicated person. These laws, which can be criminal or administrative, exist in every state except Florida and Nevada. In Wyoming, it is only illegal to sell alcohol to an intoxicated person at a drive-through window at a package store. There is substantial variation in state SIP laws with respect to the state’s definition of intoxication, who is held liable (e.g., licensees, servers, or social hosts), the evidence required to establish a SIP violation, and subsequent penalties (Mosher et al., 2009). SIP laws are an example of another alcohol-related policy for which the overall effectiveness likely depends on the quality and consistency of enforcement practices.

Alcohol Law Enforcement

As discussed previously, enforcement is a crucial determinant of adherence to the policies to reduce illegal alcohol sales. Alcohol law enforcement aims to increase compliance with laws by increasing perceived likelihood of arrest among those who are subject to legal restrictions (NHTSA, 2005b). Enforcement approaches can include compliance checks for underage sales, bar inspections, undercover operations, and educational programs (Ramirez, 2017). There is research that suggests the enforcement of policies to limit alcohol service to underage persons and intoxicated patrons reduces alcohol-related harm and improves public safety (McKnight and Streff, 1994; Ramirez, 2017; Ramirez et al., 2008).

Lenk et al. (2014) conducted a survey of randomly selected local and state alcohol enforcement agencies to gather information on enforcement of sales to obviously intoxicated patrons. The findings, which reflected responses from 1,082 local and 49 state agencies, showed that only about 20 percent of local and 60 percent of state agencies conducted enforcement activities to reduce SIP in their jurisdictions. Furthermore, less than half of the agencies employed specific enforcement strategies at least

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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monthly, and for local agencies, enforcement activities were more common when there was a full-time officer who was specifically assigned to such activities.

For alcohol law enforcement agencies, the number of licensed establishments that require monitoring and enforcement varies from state to state. In most states (e.g., Alabama, Utah, Virginia), there are 250 licensees or less per one alcohol law enforcement agent, but in some states (e.g., Missouri, Wisconsin) there are more than 1,000 premises per agent (Ramirez, 2017). Levy and Miller (1995) conducted a cost-benefit analysis of increased enforcement of laws forbidding service to intoxicated patrons, based on a case study in Michigan, and found that the benefits greatly outweighed the costs. Their study findings also demonstrated a 22 percent increase in the number of intoxicated patrons who were refused service after implementing a program that used undercover police officers to monitor service in licensed establishments.

The 2017 County Health Rankings included a review of the evidence on SIP law enforcement. The key finding was that the available evidence indicates that efforts to enforce SIP laws can reduce overservice and alcohol-impaired driving, especially when implemented in areas at risk for excessive alcohol consumption (County Health Rankings, 2017). Another key element of enforcement is the administration of sanctions or legal charges for evidenced violations. States have a number of penalties for violations including fines, license suspensions, and revocations (Mosher et al., 2009), yet these penalties are often reduced or appealed.

Challenges for Enforcement

While promising, enforcement of policies to reduce illegal alcohol sales is largely lacking (Goodwin et al., 2015; Mosher et al., 2009) because of a number of the following factors: cultural norms, lack of political will, lack of a systematic approach to enforcement (Graham et al., 2014; Mosher et al., 2009; NHTSA, 2005a,b; Ramirez, 2017), and lack of resources to detect and track violations (Mosher et al., 2002, 2009; NHTSA, 2005b). For example, in some states, the number of licensed establishments outnumbers the amount of available law enforcement personnel (Ramirez, 2017). Alcohol law enforcement agents have many responsibilities in addition to enforcing alcohol laws (e.g., gaming, tobacco, drugs, and human trafficking) (Ramirez, 2017).

Promising Strategies

Despite the barriers that exist for effective enforcement of alcohol policies, there are promising strategies that have emerged from common

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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practices and the literature that can be applied to enhance enforcement efforts. For example, some states collect data on POLD when an individual is arrested for DWI and then target those establishments (NHTSA, 2005a). In 2012 the National Transportation Safety Board made a safety recommendation to the 50 states, the District of Columbia, and Puerto Rico to require law enforcement agencies to collect POLD data as part of any arrest or crash investigation involving an alcohol-impaired driver (NTSB, 2012) (see Chapter 6 for more discussion of POLD data). In addition to data collection, it is important to publicize enforcement efforts to ensure that there is a high perceived risk of being apprehended and receiving a sanction. Furthermore, developing political will to support ongoing enforcement through research and media fosters sustainability of efforts. Mosher et al. (2009) emphasize the importance of interagency collaboration and adopting a structure of enforceable consequences for violations and adequate penalties that cannot be negotiated or made eligible for exemption for specific licensees (e.g., licensees who have completed RBS training).

As discussed in this chapter, the illegal sale of alcohol subsumes sales to already-intoxicated adults and to underage persons. The available research indicates that both types of illegal sales are related to binge drinking and to increased risk of alcohol-impaired driving. The committee discusses a number of interventions that can reduce illegal sales, binge drinking, and alcohol-impaired driving with varying degrees of evidence. Among some of these policies, the evidence of effectiveness is strong (i.e., informed by high-quality systematic reviews and studies across multiple contexts). This includes MLDA laws (see, for example, DeJong and Blanchette, 2014; Shults et al., 2001; Wagenaar and Toomey, 2002), enforcement of MLDA laws (see, for example, Barry, 2004; Elder et al., 2007; Scribner and Cohen, 2001; Wagenaar et al., 2005), and dram shop liability laws (see, for example, Holder et al., 1990; Rammohan et al., 2011; Scherer et al., 2015). For other illegal sales-related policies, there is a good theoretical justification but mixed evidence of effectiveness depending on the type of policy and degree of enforcement. These include social host liability laws (see, for example, Fell et al., 2014; Paschall et al., 2014; Wagoner et al., 2013) and responsible beverage service practices and policies (see, for example, Fell et al., 2017; Jones et al., 2011; Shults et al., 2001). For laws preventing SIP, there is a strong theoretical basis for their implementation, yet a relative lack of empirical evidence on these policies, in part because most states have them, which limits opportunities for well-designed evaluations.

Research also indicates that enforcement programs are underutilized and require more resources to be effective. To reach the below conclusion the committee relied on evidence ranging from empirical studies

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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evaluating enforcement programs and systematic reviews of studies to legal, administrative, and qualitative data. These include, but are not limited to, the NRC and IOM (2004) report Reducing Underage Drinking: A Collective Responsibility, a Community Preventive Services Task Force review of enhanced enforcement laws prohibiting sales to minors (Elder et al., 2007), a NHTSA (2005b) research report that uses legal and interview data to inform its findings on the role of alcohol beverage control agencies in enforcing alcohol laws, and data from the National Liquor Law Enforcement Association (Ramirez, 2017; Ramirez et al., 2008). The decline in federal funding for the enforcement of underage drinking programs further demonstrates the diminishing resources allocated to such programs (see Table 7-1). It is also noteworthy that the evidence from empirical studies and qualitative data show that quality of implementation and complementary activities (e.g., media publicity and collection of POLD data) to enhance enforcement are important (Elder et al., 2007; McCartt et al., 2009; NRC and IOM, 2004; NTSB, 2012). Furthermore, to reduce excessive alcohol consumption prior to driving at the population level, there is a need for a comprehensive set of policies that minimize the illegal sale of alcohol to underage persons and already-intoxicated persons. Given the evidence presented in this chapter on the effectiveness of policies to reduce illegal alcohol sales and the need for enhanced enforcement of these policies, the committee offers the following recommendation and conclusion:

Recommendation 3-3: Federal, state, and local governments should adopt and/or strengthen laws and dedicate enforcement resources to stop illegal alcohol sales (i.e., sales to already-intoxicated adults and sales to underage persons).

Conclusion 3-1: Some policies to reduce illegal alcohol sales are not effective due to a lack of enforcement activities. In addition, a systematic approach to enforcement (i.e., increased resources, data collection and sharing, multisector collaboration, and publicity) is needed to optimize the effects of such alcohol policies.

Recommendation 3-3 includes the following laws and actions:

  • Strong penalties for licensees who engage in illegal alcohol sales to already-intoxicated adults;
  • Dram shop liability laws without caps;
  • High-quality mandatory responsible beverage service training for managers and sellers;
Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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  • Strong social host laws and other laws to limit adults from providing alcohol to underage persons;
  • Improvement of enforcement of MLDA laws, including passing laws to permit compliance checks using underage decoys and conducting such compliance checks;
  • Collection of POLD data; and
  • Adequate enforcement personnel to enforce existing laws in this area.

POLICIES TO REDUCE THE HARMFUL EFFECTS OF ALCOHOL MARKETING

At least 25 longitudinal studies have found associations between young people’s exposure to alcohol marketing in a variety of forms—from traditional marketing to online marketing to sponsorships and alcohol-branded merchandise—and their subsequent drinking behavior (Anderson et al., 2009b; Jernigan et al., 2016; Smith and Foxcroft, 2009). Another study, completed before the dramatic increase in alcohol advertising on cable television, looked at the effect of alcohol advertising on motor vehicle traffic fatalities and concluded that a complete ban on broadcast alcohol advertising could save between 2,000 and 3,000 lives per year, and ending the tax deductibility of alcohol advertising could prevent approximately 1,300 deaths per year (Saffer, 1997).

One of the distinguishing features of alcohol advertising since 2000 has been the dramatic expansion of advertising, especially for distilled spirits, on cable television. Distillers maintained a voluntary ban on television advertising in general until 1996, and in 2001 struck an agreement with NBC to begin advertising on that broadcast network (Elliott, 2001). However, outcry from Congress and from public health advocates led NBC to back away from the agreement, and distillers in response moved rapidly onto cable networks (Jernigan and O’Hara, 2004). In 2000, distillers spent $4.3 million, or 1.2 percent of their measured advertising budgets, on television; by 2016, this amount had grown to $227.6 million, or 56.8 percent of their budgets (Impact Databank, 2017).

Marketing does not only consist of advertising, but rather rests on the “four Ps” of product, place, price, and promotion (Hastings et al., 2005). (See Chapter 2 for discussions of industry activities within the four Ps.) Other sections of this report have discussed policy options to address the first three Ps. Since commercial speech enjoys strong protection from the First Amendment in the United Sates, alcohol marketing has been primarily governed by industry self-regulation. Findings from a systematic review show that numerous peer-reviewed studies have found this self-regulation to be ineffective (Noel et al., 2016), and there have been

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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significant debates in the United States about how it could be improved. In 2004, the NRC and IOM recommended that the industry move from its then-current voluntary standard of only advertising where at least 70 percent of the viewing, reading, or listening audience was of legal purchase age (that is, over age 21) to a 25 percent maximum for underage audiences immediately, and eventually to a 15 percent maximum for underage audiences. This was based roughly on the proportion of the underage population at greatest risk of initiating drinking—the 12- to 20-year-old group (NRC and IOM, 2004). In 2011, 24 state and territorial attorneys general added their endorsements to the 15 percent standard (Shurtleff et al., 2011). In that same year, alcohol industry trade associations announced a lowering of their standard to 28.4 percent, based on the 2010 census numbers. In 2007, one company—Beam Global Spirits—adopted the 25 percent maximum; an independent evaluation of that standard concluded that, even with imperfect implementation, it led to a reduction in youth exposure to alcohol advertising for that company’s brands compared to its competitors, and at the same time it did not result in an increase in the company’s advertising costs for reaching adult audiences (Ross et al., 2016). The authors concluded that other alcohol companies should consider adopting a similar standard to the 25 percent maximum.

However, the lack of voluntary movement toward a stricter standard by most alcohol companies has resulted in continued disproportionate youth exposure to alcohol advertising. One study examined magazine advertising of alcohol brands most likely to be consumed by young people (determined through a national survey of youth alcohol consumption by brand [Siegel et al., 2013]), and found that such brands were more likely than other brands to advertise in magazines with higher youth readerships, demonstrating the inadequacy of the industry’s voluntary guidelines in protecting youth from disproportionate exposure compared to adults (King et al., 2017).

The industry’s voluntary guidelines also include numerous provisions regarding the content of alcohol advertising. However, independent evaluation of the implementation of these guidelines has found them to be ineffective (Babor et al., 2013). Enforcement of content regulations is also more likely to raise First Amendment issues, which helps to explain why much of the policy debate regarding alcohol industry self-regulation has focused on placement guidelines.

While much of the regulatory authority over alcohol advertising lies at the federal level, and specifically in the U.S. Department of the Treasury, an agency without an explicit public health or safety mission, state and local governments have also demonstrated that they can play a role in reducing both youth and population-level exposure to alcohol advertising. The Center on Alcohol Marketing and Youth’s (2012) report State

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Laws to Reduce the Impact of Alcohol Marketing on Youth: Current Status and Model Policies identifies the following specific actions that states can take:

  • Prohibit false and misleading alcohol advertising;
  • Prohibit advertising that targets minors;
  • Claim state jurisdiction over electronic media, at least theoretically permitting them to require, for instance, higher audience standards for advertising placed in media such as radio that originate locally;
  • Restrict outdoor alcohol advertising in locations where children are likely to be present;
  • Prohibit outdoor alcohol advertising near schools, public playgrounds, and churches;
  • Restrict alcohol advertising on alcohol retail outlet windows and outside areas;
  • Prohibit alcohol advertising on college campuses; and
  • Restrict alcohol industry sponsorship of civic events (e.g., fairs, music concerts, and sporting events).

While no state has employed all of these powers, the fact that they all exist in state law in at least one and often numerous states suggests that there is more potential at the state and local levels for reducing exposure to alcohol advertising than has yet been used.

Another promising strategy regarding alcohol marketing is the use of countermarketing. Countermarketing campaigns are a form of media campaigns that seek to offset pro-alcohol influences and promote health promotion messages (CDC, 2003). They often emphasize the harmful and/or deceptive strategies companies use to market a product that can be harmful for particular audiences (e.g., youth) in an effort to neutralize these influences and promote healthier behavior. While there is very little experience and no studies of effectiveness regarding this for alcohol use, it has been an effective strategy for reducing tobacco use (Apollonio and Malone, 2009). Several well-funded, high-profile tobacco countermarketing media campaigns in California, Florida, and nationally (e.g., the truth campaign) have contributed to reduced rates of youth smoking and adult cigarette consumption in these areas (Farrelly et al., 2002; Hu et al., 1995; Sly et al., 2002). (For more on media campaigns, see the following section, “Education and Awareness.”)

One important consideration in assessing the impact of alcohol marketing and developing interventions to reduce the harmful effects of such marketing is the changing media landscape, particularly for youth. Traditional means of watching television (e.g., cable or satellite television) are being replaced with online streaming services. Of note, Pew Research

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Center’s survey data from 2017 show that 61 percent of adults ages 18–29 use streaming services as their primary means of watching television (Raine, 2017). Such changes in television consumption could potentially have implications for the frequency, duration, and intensity for which youth are exposed to alcohol marketing. Therefore, updated research is needed on the effects of such changes in media consumption on exposure to alcohol marketing among youth.

In this section, the committee has presented an overview of the empirical and historical evidence around alcohol marketing exposure and regulation. To examine the link between alcohol marketing and consumption among underage persons, the committee drew from peer-reviewed systematic reviews of longitudinal studies on youth exposure to alcohol marketing and drinking outcomes (Anderson et al., 2009b; Jernigan et al., 2016; Smith and Foxcroft, 2009). While there is only one study cited that examines and demonstrates a positive relationship between alcohol advertising and motor vehicle crash fatalities (Saffer, 1997), there is a strong theoretical basis for this association, particularly for youth. Given that young people (ages 21–24) are at high risk of alcohol-impaired driving (Lipari et al., 2016; NCSA, 2016) and the available research strongly indicates that they are influenced by alcohol marketing, as evidenced by the systematic reviews cited above, the committee has identified alcohol marketing as an important point of intervention to reduce alcohol consumption, and by extension, alcohol-impaired driving among underage persons. Furthermore, numerous studies have found the alcohol industry’s self-regulation of its marketing to be ineffective and insufficient because the voluntary standards are permissive and vague, not consistently followed, and without penalties for violations (Babor et al., 2013; King et al., 2017; Noel and Babor, 2016; Noel et al., 2016; Siegel et al., 2013). Therefore, the committee recommends:

Recommendation 3-4: Federal, state, and local governments should use their existing regulatory powers to strengthen and implement standards for permissible alcohol marketing content and placement across all media, establish consequences for violations, and promote and fund countermarketing campaigns.

EDUCATION AND AWARENESS

School-Based Education Programs

School-based alcohol education programs aim to prevent or delay youth drinking as well as prevent related risky activities such as drinking and driving and/or riding with drinking drivers. Although educational

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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programs are popular with policy makers, the public, and alcohol-related economic operators, in general school-based educational programs have limited evidence of producing change, particularly at the population level. The available evidence is inconsistent or shows no effect on behavior change related to alcohol alone or in combination with driving (Elder et al., 2005; Foxcroft and Tsertsvadze, 2012; NRC and IOM, 2004; Mann et al., 1986; Shope et al., 2001). However, more research is needed as many education programs have not been evaluated (Anderson et al., 2009a; Goodwin et al., 2015; Lee et al., 2016; Mann et al., 1986; NRC and IOM, 2004; Stigler et al., 2011; Washington Traffic Safety Commission, 2014). In addition, education programs can be costly since they are delivered to relatively small groups of individuals, and their effects degrade quickly unless actively maintained. Anderson et al. (2009a) concluded in The Lancet that while school-based programs are not effective in modifying behavior, they can play an important role in increasing visibility of alcohol on public agendas. Other intermediate outcomes of programs include the promotion of social and emotional competencies and resilience among youth participants (Stigler et al., 2011).

There are a number of limitations with school-based programs and the current literature that examines them. Programs have been criticized for having weak evaluation designs and short follow-up times while only measuring intermediate outcomes such as alcohol knowledge, attitudes, and intent (Mann et al., 1986; Washington Traffic Safety Commission, 2014). There is a documented need for additional robust studies with alcohol-impaired driving outcome measures such as DWIs and alcohol-related crashes; for example, examining driving behaviors of students after an education program and measuring more specific traffic safety outcomes (Elder et al., 2005; Mann et al., 1986; Shope et al., 2001; Washington Traffic Safety Commission, 2014). Some of the alcohol education programs studied have been successful in increasing youth knowledge about alcohol and alcohol misuse, as well as influencing attitudes and intent toward alcohol, but these positive effects usually dissipate after 6 months to 1 year. Therefore, intensity, duration, and quality of the program are key elements that require further investigation.

Despite the limitations and inconsistent evidence on school-based programs, there are some positive spillover effects. For example, school-based programs can engage groups such as Students Against Destructive Decisions (SADD) and parent–teacher associations to raise awareness about alcohol-impaired driving. Elder et al. (2005) cite a number of positive effects of participation in peer organizations such as SADD, including personal growth, social support, and a sense of citizenship in the school community. At the school level, such effects include stronger attitudes against alcohol-impaired driving and riding with an impaired driver,

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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increased knowledge of alternatives, and increased access to alcohol-free events (Elder et al., 2005).

Alcohol Warning Labels

Legislation requiring alcohol warning labels was enacted in 1989, which stated that all alcoholic beverage containers sold in the United States must display the following warning label.

GOVERNMENT WARNING: (1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. (2) Consumption of alcohol impairs your ability to drive a car or operate machinery, and may cause health problems.12

As of 2012, the United States is 1 of 31 countries that require warning labels on alcoholic beverages (WHO, 2014). The scientific evidence on whether warning labels are effective in decreasing excessive drinking is inconclusive. A cross-sectional survey occurring 6 months after implementation of the alcohol warning labels in the United States found that 16 percent of respondents remembered the message about the risks of driving impaired, and about 25 percent of the respondents who reported being heavy drinkers and who had driven under the influence of alcohol in the past had seen the label (Greenfield and Kaskutas, 1993). However, it is important to note that such cross-sectional data do not lend themselves to causal inferences. Another study also found that those who reported driving under the influence of alcohol in the past were more likely to remember the warning label than those who had not (Parker et al., 1994). Other studies found alcohol warning labels to be ineffective in changing behavior and encouraged different approaches (Creyer et al., 2002; Stockley, 2001). For example, the use of color, icons, increasing clarity, contrast, shape and/or size of the message, simplicity, and specificity of the message are all factors that can contribute to consumer awareness.

Research also suggests that providing standard drink labels on alcoholic beverage containers increases the drinker’s accuracy in assessing alcohol content (Stockwell, 1993; Stockwell et al., 1991). Some argue that this would help responsible drinkers moderate their consumption (Kerr and Stockwell, 2012). Others argue against standard drink labels, citing an Australian study that found that young drinkers use standard drink labels in order to select stronger drinks (Jones and Gregory, 2009). Other cues beyond labels, however, can be used to assess alcohol content such as IPA, imperial, or double. Standard drink labels therefore might not provide new information to consumers.

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12 27 CFR § 16.21 subpart C sec 16.21(1).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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In the United States, beer and distilled spirits advertisements are self-regulated by the alcohol industries and do not require that a warning be included in ads (Beer Institute, 2015; DISCUS, 2011). Often, however, consumers are told to “drink responsibly” or “drink in moderation” in these ads. An analysis of advertisements appearing in magazines found that 87 percent of them included a responsibility message but that these messages did not define responsibility and were often used to promote the product rather than convey information (Smith et al., 2014). Not only is the information provided in the responsibility messages vague, but an eye-tracking study found that the responsibility messages in print advertising did not capture the attention of teenage viewers (Thomsen and Fulton, 2007). These findings suggest that ambiguous responsibility messages are ineffective in capturing the attention of consumers, providing helpful public health information, or encouraging drinkers to be responsible and/or moderate in their alcohol consumption. Guidelines for the size, content, and placement of alcohol warning labels are needed in order to increase effectiveness.

Media Campaigns

There is strong evidence, based on findings from a variety of high-quality systematic reviews across numerous health behavior domains, that mass media campaigns can promote meaningful changes in health behavior at the population level when implemented alongside broader, community-level interventions (Hornik, 2002; Wakefield et al., 2010). This work further identifies a variety of factors that increase or decrease the likelihood of success in changing behavior at the population level. Effective campaigns are typically characterized by the following:

  • High levels of exposure among the target audience over an extended period of time;
  • Implementation alongside other complementary interventions (e.g., tax increases or enforcement of legal sanctions against an unhealthy and illegal behavior);
  • Widespread availability and access to relevant products and services (e.g., smoking cessation aids, condoms for safer sex); and
  • Use of formative research and behavior change theory to guide their design (Hornik, 2002; Noar, 2006; Randolph and Viswanath, 2004; Snyder et al., 2004; Wakefield et al., 2010).

The strongest evidence in support of mass media campaign effectiveness in changing behavior stems from evaluations of well-funded mass media campaigns to reduce tobacco use (Wakefield et al., 2010). Work in

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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this area further suggests that behavior change campaigns can have complementary effects on creating a public opinion and a policy climate that supports the passage of stronger tobacco control policies (Niederdeppe et al., 2007, 2017b).

Evidence of Media Campaign Effectiveness in Reducing Alcohol-Related Fatal Crashes

Several systematic and meta-analytic reviews have attempted to assess the causal effect of media campaigns to reduce alcohol-impaired driving and its consequences, both with and without accompanying interventions. Efforts to reduce alcohol-related traffic fatalities in the United States face a variety of challenges to campaign effectiveness (Wakefield et al., 2010). Social norms around alcohol use in general are much more permissive than social norms around drinking and driving (Greenfield and Room, 1997). The alcohol industry spends an enormous amount of resources to promote the sale and use of alcohol. Alcohol use disorder is a widespread problem, as alcohol is an addictive substance. In light of this context, it is perhaps no surprise that several systematic reviews find only limited evidence that alcohol control campaigns are associated with reduced alcohol-related harm (Anderson et al., 2009a; Chisholm et al., 2004; Doran et al., 2008; Spoth et al., 2008), often noting limitations in the breadth and quality of the studies assessing their effects. Several of these reviews, however, note that media campaigns are likely an integral component of multipolicy interventions to reduce alcohol-related harm in general because they support awareness and compliance with policies and may enhance public and policy maker commitment to laws and regulations (e.g., Anderson et al., 2009a; Doran et al., 2008).

Campaigns specific to preventing traffic crashes and fatalities paint a more optimistic picture. Elder et al.’s (2004) systematic review concluded that carefully planned and well-funded media campaigns, when implemented alongside other prevention activities (including increased legal enforcement of drunk driving laws), are associated with a 13 percent decline in alcohol-related traffic crashes. Another study found that strategic efforts to increase news media coverage of efforts to reduce alcohol-impaired driving, combined with other community mobilization and enforcement activities, reduced alcohol-related injury crashes relative to a control community (Holder et al., 2000). Furthermore, Bergen et al. (2014) concluded that sobriety checkpoint programs are effective when well publicized with mass media campaigns to promote awareness of these enforcement initiatives. While Yadav and Kobayashi (2015) did not find sufficient evidence that media campaigns alone or concurrent with increased enforcement reduced alcohol-related fatal crashes, these

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

authors featured different inclusion criteria than several previous reviews, were unable to account for the volume of media campaign exposure achieved by the interventions, and concluded that the heterogeneity of study design and quality precluded definitive conclusions about media campaign effect. Finally, while there is a lack of rigorous evaluation data on the campaign, the Ad Council and the U.S. Department of Transportation’s “Friends don’t let friends drive drunk” campaign that aired in the 1980s is often credited with contributing to a cultural shift that countered the norm of drinking and driving (Ad Council, 2016; Glascoff et al., 2013).

Systematic reviews of the evidence supporting (non-alcohol-related) traffic safety campaigns further underscore the value of media campaigns in conjunction with increased enforcement or other policy interventions. Two reviews found strong evidence that public education campaigns, when combined with enhanced legal enforcement, increase use of child safety seats and reduce related fatal injuries (Zaza et al., 2001) and increase use of safety belts and reduce traffic-related fatalities (Dinh-Zarr et al., 2001; Williams et al., 1996). The public’s perception of the risk of legal consequences is important in determining the effectiveness of media campaigns. This is reflected in the likelihood that a person will drive while impaired (WHO, 2016) and intervene as a bystander (Guerette et al., 2013).

These studies make a strong case that campaigns against alcohol-impaired driving, combined with increased enforcement, have strong potential as a strategy to reduce alcohol-related fatal crashes. Some important caveats are in order, however. The only available study included in a systematic review of designated driver interventions (Ditter et al., 2005) failed to find evidence of behavioral changes in response to a modestly funded designated driver campaign in Australia (Boots and Midford, 1999). This suggests that the content and target of mass media campaigns is likely an important consideration, a conclusion that echoes findings from other behavioral contexts highlighting the importance of using formative research and behavior change theory to guide campaign design (e.g., Noar, 2006; Randolph and Viswanath, 2004). Recent evidence also underscores the need for significant funding to generate widespread levels of campaign exposure in this context (Niederdeppe et al., 2017a).

These findings emphasize the need for well-funded media campaigns that are able to achieve widespread exposure among target audiences (see Hornik, 2002; Wakefield et al., 2010). The definition of a “well-funded” campaign has not been standardized for alcohol-impaired driving, but has been operationalized for anti-tobacco campaigns. For example, CDC cites gross ratings points (GRPs) as an indicator for the recommended budget level and makes the case that between 1,600 and 2,800 GRPs,

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

which equates to about five to seven exposures per month, are sufficient (CDC, 2014). More importantly, this is a rate of exposure that donated time is not likely to achieve. Unfortunately, most recent campaigns against alcohol-impaired driving appear to have relied on donated airtime from broadcasters (Ad Council, 2013, 2016). Sustained, well-funded media campaigns in other behavioral contexts have been funded from one of three sources: tax revenue (e.g., NCI, 2008), industry litigation (e.g., Farrelly et al., 2009), or acts of Congress (Hornik et al., 2008). It therefore seems unlikely that the typical model of relying on donated air time to generate exposure to alcohol-impaired driving related media campaigns is likely to achieve levels of exposure needed to have a large-scale effect on alcohol-related fatal crashes.

Furthermore, the changing nature of the media landscape warrants consideration in the development of media campaigns to reduce alcohol-impaired driving. As highlighted in the section “Policies to Reduce the Harmful Effects of Alcohol Marketing,” traditional means of watching television are changing to online streaming services (Raine, 2017). Given the shifting landscape of media consumption, research into the most effective media by which to disseminate campaigns could optimize efforts to increase exposure to messages that run counter to alcohol-impaired driving.

Cost-Effectiveness Estimates

There are some cost-effectiveness studies on the effect of mass media campaigns on alcohol-related crash fatalities, although these assessments have the same causal evaluation challenges as noted above. Several cost-effectiveness reports that assess mass media campaigns conclude that media campaigns do not affect health outcomes and thus are not considered to be cost-effective (Anderson et al., 2009a; Chisholm et al., 2004; Cobiac et al., 2009). This may be attributable to the variability of mass media campaign studies, as heterogeneity among studies makes it difficult to make any conclusions on the effectiveness of these campaigns and, therefore, the cost-effectiveness of them (Yadav and Kobayashi, 2015).

Some studies demonstrate that these campaigns may be cost-effective under some circumstances, although these conclusions are based on a small subset of the population. Elder et al. (2004) evaluated several alcohol-impaired driving media campaigns in the United States and Australia for cost savings and found three of them to be cost-effective. Effectiveness was measured in terms of the following outcomes: drinking and driving behavior, alcohol-related crashes, and crash-related injuries or fatalities.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

Several studies (see Bergen et al., 2014, for a review) also examined mass media campaigns to make drivers aware of upcoming sobriety checkpoints. These studies found that a combination of sobriety checkpoints and mass media campaigns have the potential to reduce the burden of alcohol-related traffic injuries, and that high coverage of mass media campaigns and a very low frequency of sobriety checkpoints is cost-effective and more efficient than sobriety checkpoints alone.

In summary, there appears to be little research and few clear findings on the cost-effectiveness of media campaigns with respect to alcohol-related fatalities. In many of the studies mentioned above, media campaigns (largely considered in isolation) have not been found to be effective overall, and as a result are not found to be cost-effective. Nevertheless, systematic reviews by both Elder et al. (2004) and Bergen et al. (2014) conclude that media campaigns plus increased enforcement (for Bergen et al. in the context of increased sobriety checkpoints) are both effective and can serve as cost-effective interventions to reduce alcohol-impaired driving and related crash fatalities. Wakefield et al.’s (2010) comprehensive review of systematic reviews makes clear that well-designed and well-funded media campaigns can influence behavior when combined with broader community-level interventions.

In this section, the committee reviews a body of evidence including systematic reviews specific to alcohol-impaired driving (e.g., Community Preventive Services Task Force review by Elder et al., 2004; more recent reviews by Bergen et al., 2014, and Yadav and Kobayashi, 2015), systematic reviews on media effects on other driving-related interventions (e.g., Zaza et al., 2011, on child safety seat use; Dinh-Zarr et al., 2001, on more general use of safety belts), and a comprehensive synthesis of systematic review evidence across a wide variety of behavioral domains (Wakefield et al., 2010). The committee assesses this evidence, along with other recent and relevant studies that were not included in these reviews, with the recognition that media campaigns are rarely conducted in isolation, vary considerably in size and quality, and typically lack randomized designs that permit unambiguous causal inference. Nevertheless, the committee argues that the accumulated body of evidence permits the following conclusion:

Conclusion 3-2: There is sufficient evidence to conclude that well-funded media campaigns are an important component of alcohol-impaired driving enforcement policy interventions to ensure their successful adoption and impact. Campaigns are more likely to be effective when rigorous formative research and behavioral change theories inform their design and dissemination.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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TECHNOLOGICAL INTERVENTIONS

Personal Devices and Technology for Estimating BAC

Interventions that allow drinkers to estimate their BAC levels accurately, and thus better assess their risk, have the potential to reduce alcohol-impaired driving fatalities. There is good evidence that drinkers, and specifically those with high BAC levels, are poor at estimating their BAC (Beirness, 1987; Beirness et al., 1993; Martin et al., 2016; Thombs et al., 2003). Individuals who underestimate their BAC are more likely to judge they are fit to drive when they are over the BAC limit set by state law (Beirness, 1987; Beirness et al., 1993)13 and they are more likely to take more risks while driving (Laude and Fillmore, 2016). Recent work has shown that one’s perception of intoxication has a bigger effect on risk taking than actual physiological levels of intoxication (Corazzini et al., 2015; Proestakis et al., 2013). Making individuals aware of their level of intoxication might reduce risk taking.

There has been research and policy interest since the 1970s in determining whether BAC feedback through breath-testing devices could be used as an intervention to prevent alcohol-impaired driving (Oates, 1978; Russ et al., 1988). Breath-testing devices have been validated against blood alcohol levels (Kriikku et al., 2014; Schechtman and Shinar, 2011; Van Tassel et al., 2004). Theorized positive benefits of BAC feedback include decreasing alcohol consumption to not exceed the BAC limit set by state law and increasing the likelihood of opting not to drive (Russ et al., 1988).

Despite the theoretical benefits, providing BAC feedback through breath-testing devices was not shown to reduce alcohol-impaired driving in a review of studies conducted in the 1970s and 1980s (Russ et al., 1988). The majority of these studies were conducted on the premises of drinking establishments in Canada, New Zealand, and the United States. A more recent study from 2008 found that self-administered BAC feedback enabled individuals leaving drinking establishments to more accurately determine whether they could legally drive, but it did not change individuals’ perceived fitness to drive (Johnson et al., 2008). The lack of behavioral change when presented with information on risk (communicated as BAC) underscores the predictable irrationality of those who repeatedly drive after drinking to above the limit set by state law (Ariely, 2008). For example, individuals who drive after drinking, compared to those who do not, understand DWI laws better but are poorer planners, more

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13 In these two studies, estimation of BAC was measured during a simulated naturalistic social drinking situation (Beirness, 1987) and a voluntary roadside survey of nighttime drivers (Beirness et al., 1993).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

impulsive, and myopic decision makers (Sloan et al., 2014). Some studies have even suggested that BAC feedback has the potential to increase driving after drinking among those with BAC levels less than 0.05% (Bullers and Ennis, 2006; Johnson and Voas, 2004; Johnson et al., 2008). At or below this level, drinkers tend to overestimate their BAC in this range. Therefore, there is concern that BAC feedback in this range could lead to these individuals to decide it is safe to drive since they are under the limit set by state law, despite feeling some effects of impairment. More research is greatly needed to determine the net benefit and unintended consequences of BAC feedback on decisions to drive after moderate drinking.

Although personal breath-testing devices have existed since the 1980s, data are very sparse on who uses them, their accuracy, and their effect on public health.14 Despite variability in accuracy of personal breath-testing devices (Ashdown et al., 2014), these devices do not currently require FDA approval to be marketed to consumers.

Personal breath-testing devices appear to be more common in European countries. One survey estimated 11 percent of Finnish households with licensed drivers owned a personal breath-testing device in 2007 (Radun et al., 2009). In this survey, more men than women reported owning a breath-testing device; 24 percent of those who owned one did not use it. The respondents reported 77 percent used it the day/morning following drinking, rather than while drinking (18 percent) or just before driving home after drinking (6 percent). In 2012, France passed a law requiring a breath-testing device to be carried in every vehicle (BBC, 2012). The law was suspended a year later because of shortages and reported test inaccuracy of the device. The effort was later criticized because of commercial financial conflicts of interest with the breath-testing kit manufacturer. Independent analyses of outcomes are not currently available (Radun et al., 2014).

In the last 5 years, there have been two major innovations that have led to a new generation of personal breath-testing devices marketed to consumers. The first is new fuel cell sensors that can maintain consistent measurements for up to 1 year of use without needing to be professionally calibrated. The second innovation is smartphone connectivity via Blue-tooth or a headphone jack connection (Andrews, 2013). Smartphone applications associated with personal breath-testing devices can now provide an automated interpretation of BAC levels and cautionary messages, as well as the estimated time to return to BAC levels less than 0.02%. These apps track levels over time, and can be used to prompt safety measures such as hailing a rideshare or sending alerts to social contacts. For those

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14 For a list of approved evidential breath-testing devices, see https://www.transportation.gov/odapc/approved-evidential-breath-testing-devices (accessed October 13, 2017).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

with alcohol use disorders, these smartphone-connected breath-testing devices can be used for remote alcohol monitoring via notifications to submit breath samples within a certain time frame. The smartphone camera can be used to verify the identity of the individual submitting the sample, and the submitted samples can be time-stamped and geocoded. A recent, small randomized controlled trial demonstrated that contingency management with financial incentives using this smartphone-enabled remote monitoring approach reduces alcohol consumption among those with alcohol use disorders (Alessi and Petry, 2013). Furthermore, aggregated data collected from smartphone-paired breath-testing devices are able to provide a novel source of data on alcohol consumption, as well as BAC levels among the population who uses them.15 The costs of smartphone-paired breath-testing devices range from $30 to $100 and they are now available in major household, electronic, and online retail outlets.

There is very little scientific literature on the use of newer generation personal and smartphone-paired breath-testing devices for purposes of moderating drinking and reducing alcohol-impaired driving. Industry data indicate there are two main factors cited by users for using smartphone-paired breath-testing devices: (1) making sure their BAC is under the limit set by state law before they drive, and (2) avoiding a DWI. A 2016 survey study by the Colorado Department of Transportation in which 225 bar patrons were given a smartphone-paired breath-testing device reported that using a breath-testing device lowered their risk of a DWI and that the patrons were much less likely to drive impaired compared to prior to using a breath-testing device (Colorado DOT, 2016).16

A major limitation of breath-testing devices is that they require active use and engagement and only provide point-in-time estimates of BAC levels. This could potentially be dangerous if an individual’s BAC is ascending, and they receive a reading that is below the limit set by state law, indicating that it would be safe to drive. Therefore, there is great potential and interest in having passively collected, continuous estimates of BAC as could be collected through transdermal alcohol sensors that measure alcohol content in skin sweat. Starting in the early 2000s, transdermal alcohol sensors have been used for remote monitoring in the criminal justice system (see Chapter 5 for a discussion of monitoring alcohol use among DWI offenders). These devices have included a tamper-resistant ankle bracelet and a wrist-wearable device (Swift et al., 1992).

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15 See, for example, the BACtrack consumption report, https://www.bactrack.com/pages/bactrack-consumption-report (accessed October 13, 2017).

16 The Colorado DOT has since partnered with BACtrack, a personal breath-testing device company, to offer their products to Colorado residents for a discounted price (Colorado DOT, 2017). This partnership and its outcomes have not yet been evaluated.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

These devices capture the presence of alcohol consumption in a continuous, passive fashion (Marques and McKnight, 2007; Sakai et al., 2006) and have been used for contingency management in treatment of those with alcohol use disorder (Dougherty et al., 2014).

However, compared with breath-testing devices, there are more challenges to providing real-time BAC estimates owing to lag time in skin accumulation of alcohol. The mathematical translation of transdermal alcohol content to estimated BAC in real time is an area of active research (Leffingwell et al., 2013). In addition, smartphone-paired transdermal alcohol sensors that could be integrated with smart watches are in development (Gutierrez et al., 2015). Finally, there is emerging research on passively monitoring alcohol intoxication based on how individuals use their smartphone with the ability to accurately detect light drinking and heavy drinking episodes with 96 percent accuracy (Bae et al., 2017).

Like other smartphone-enabled personal monitoring applications and devices, breath and alcohol sensors have the potential to facilitate changes in health behavior, but they are not likely to change behavior in isolation (Patel et al., 2015). These devices will need to be coupled with theoretically guided and evidence-based behavioral engagement strategies to reduce alcohol-impaired driving. These engagement strategies can be made more effective by incorporating feedback loops and concepts from behavioral economics that shape decision making, such as lottery-based designs that offer rewards combined with anticipated regret associated with not securing the reward (Patel et al., 2015). Future research and development is needed to determine whether coupling alcohol monitoring with behavioral strategies that take advantage of smartphone connectivity can lead to reductions in alcohol-impaired driving (Sahabiswas et al., 2016). Promising strategies include ongoing feedback support, real-time notifications of peers and loved ones, leveraging social norms, contingency management, prompting the use of ridesharing services, and pairing with in-vehicle devices and smartphone applications that monitor driving.

In this section, the committee reviews the literature on drinkers’ self-estimates of BAC and whether BAC feedback from personal breath testing reduces decisions to drive at levels consistent with impairment. There is good evidence from multiple studies that drinkers with high BAC levels underestimate their BAC and that those who underestimate their BAC perceive they are fit to drive when their BAC is over the limit set by state law (e.g., Beirness, 1987; Beirness et al., 1993; Martin et al., 2016; Thombs et al., 2003). However, there is a lack of evidence from studies conducted in the 1970s to early 2000s to support that personal BAC feedback reduces alcohol-impaired driving. Starting in 2013, a new generation of consumer-marketed smartphone-paired breath-testing devices has emerged, presenting several opportunities to facilitate novel interventions

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

based on the interpretation and sharing of the data generated by these devices. From a policy perspective, given that breath and transdermal alcohol sensors are increasingly being marketed to consumers and are being used to make decisions about driving after drinking, there is a need for peer-reviewed, objective evidence to verify their accuracy, including research into unintended consequences related to binge drinking and alcohol-impaired driving, before recommending widespread adoption. If it is found that some consistently underestimate BAC, there is a need for more regulatory oversight of this market such as by requiring FDA 510(k) premarket clearance before marketing to consumers.17

Conclusion 3-3: Consumer marketed personal breath-testing devices are an emerging technology with the potential to reduce alcohol-impaired driving by promoting more accurate BAC self-estimation. However, these technologies require further investigation of their accuracy and effects on behavior before promoting widespread use.

Other BAC Estimation Tools

Traditionally, BAC estimation tools have existed in the form of wallet-size cards, often titled “know your limit” and distributed to patrons of a licensed establishment. While “know your limit” cards do not have sufficient evidence to determine their effectiveness, they have been widely used for decades (Johnson and Clapp, 2011). As discussed with the personal breath-testing devices, the limitations and potential pitfalls of estimation tools have been explored in the literature (Johnson and Voas, 2004; Johnson et al., 2008). Another related tool that has emerged with the advent of smartphones and other handheld devices is mobile applications that allow individuals to gauge their BAC levels. Similarly to the “know your limit” cards, these applications allow users to input information on their sex, weight, and the number of drinks consumed during a fixed period of time to calculate their BAC. Some of these applications include an estimated time frame for reaching a BAC of 0.00%. It is important to note that these mobile application estimation tools have not been well evaluated. Nonetheless, they have potential for widespread use given the common platform on which they are offered, which warrants systematic investigation of their effectiveness and potential negative consequences.

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17 A 510(k) is a premarket submission made to FDA to demonstrate that the device to be marketed is at least as safe and effective, that is, substantially equivalent, to a legally marketed device (21 CFR § 807.92(a)(3)) that is not subject to premarket approval (FDA, 2017).

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

CONCLUDING OBSERVATIONS

Throughout this chapter, the committee has identified a number of areas that require further investigation to inform the implementation and design of drinking-oriented interventions. Addressing these evidence gaps would allow for more targeted and evidence-based interventions to reduce alcohol-impaired driving fatalities. The following subjects indicate research areas for which investigation would benefit the field of alcohol-impaired driving:

  • Effects of introducing retail price restrictions on excessive alcohol consumption and alcohol-impaired driving;
  • Specific effects of social host laws on underage alcohol consumption and alcohol-impaired driving;
  • Key elements of effectiveness for responsible beverage service training and policies;
  • Effect of permitting alcohol sales concurrent with or proximal to driving (e.g., drive-through package stores, sale of alcohol at gasoline marts, sale of alcohol at fast-food restaurants) on alcohol-impaired driving and related crashes and fatalities, including spatial analyses;
  • Effectiveness of various strategies to reduce the effect of alcohol advertising on underage drinking and alcohol-impaired driving;
  • Design, messaging, and placement of effective alcohol warning labels; and
  • Effectiveness of BAC estimation tools, such as personal breath-testing devices and mobile applications, in addition to potential consequences or misuse.

While the country has made great strides in adopting alcohol-related policies, programs, and strategies, a revised and comprehensive approach is needed to once again achieve progress in reducing alcohol-impaired driving. It is important to note that progress will require a multicomponent approach, encompassing multilevel interventions that work synergistically. This could include maintaining and enhancing the enforcement of alcohol policies to influence price, availability, illegal sales, and responsible marketing; increasing the use of underused strategies such as age-related compliance checks; and more. This chapter examines the evidence-based and promising interventions that shape the likelihood of drinking to impairment and makes recommendations for how to inform, implement, and optimize these interventions. This is a crucial phase in the sequence of behaviors that lead to alcohol-impaired driving. The next chapter will explore interventions that reduce the act of alcohol-impaired driving itself.

Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
×

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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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Suggested Citation:"3 Interventions to Reduce Drinking to Impairment." National Academies of Sciences, Engineering, and Medicine. 2018. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington, DC: The National Academies Press. doi: 10.17226/24951.
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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, HIV/AIDS, and drownings, among others, and contributing to long-term disabilities from head and spinal injuries. Progress has been made over the past decades towards reducing these trends, but that progress has been incremental and has stagnated more recently.

Getting to Zero Alcohol-Impaired Driving Fatalities examines which interventions (programs, systems, and policies) are most promising to prevent injuries and death from alcohol-impaired driving, the barriers to action and approaches to overcome them, and which interventions need to be changed or adopted. This report makes broad-reaching recommendations that will serve as a blueprint for the nation to accelerate the progress in reducing alcohol-impaired driving fatalities.

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