Water traffic accidents, drowning and alcohol in Finland,

Transcription

1 C Interntionl Epidemiologic] Assocition 1998 Printed in Gret Britin Interntionl Journl of Epidemiology 1998,27: Wter trffic ccidents, drowning nd lcohol in Finlnd, Philippe Lunett, Antti Penttil nd Seppo Srn b Objective To exmine ge nd sexspecific mortlity rtes nd trends in wter trffic ccidents (WTA), nd their ssocition with lcohol, in Finlnd. Mterils Ntionl mortlity nd popultion dt from Finlnd, , re used to nd Methods nlyse rtes nd trends. The mortlity rtes re clculted on the bsis of popultion, per 000 inhbitnts in ech ge group (<1, 1^, 514, 1524, 25^14, 4564, 5*65), nd nlysed by sex nd ge. The Poisson regression model nd X 2 test for trend (EGRET nd SttX softwres) re used to nlyse time trends. Results From 1969 through 1995 there were 3473 (2.7/ 000/yer; M:F = 20.4:1) WTArelted deths mong Finns of ll ges. In 94.7% of the cses the cuse of deth ws drowning. Alcohol intoxiction ws contributing cuse of deth in 63.0% of the ftlities. During the study period the overll WTA mortlity rtes declined significntly (4% per yer; P < 0.001). This decline ws observed in ll ge groups except 5=65 yer olds. The overll mortlity rtes in WTA ssocited with lcohol intoxiction ( ) lso declined significndy (6%; P = 0.01). Conclusions In Finlnd, mortlity rtes in WTA re exceptionlly high. Despite mrked decline in most ge groups, the high mortlity in WTA nevertheless remins preventble cuse of deth. Preventive countermesures trgeted specificlly to dult mles, to the reduction of lcohol consumption in qutic settings nd to the use of personl sfety devices should receive priority. Keywords Wter trffic ccidents, drowning, lcohol, Finlnd Accepted 24 Mrch 1998 Finlnd (popultion 5.1 million) hs 1 km of costline, This study exmines ntionl ge nd sexspecific rtes nd more thn lkes ( km 2 ; 910% of totl lnd) nd trends in WTArelted ftlities from 1969 to 1995 mong Finns 9650 km of inlnd wterwys, nd is, despite its cold climte of ll ges nd their ssocition with lcohol, (men temperture in Southern Finlnd +56 C), wteroriented society widi high mortlity in qutic settings. During..,,, the lst three decdes recretionl nd commercil wter trffic Mterils nd Methods hs incresed mrkedly on the se nd on inlnd wters. 1 " 3 At Mortlity nd popultion dt published by the Centrl the beginning of the 1990s it ws estimted tht there were Sttisticl Office of Finlnd for 1969 Uirough 1995 were used to bots, of which were rowing bots nd smll determine ftl WTA rtes. Mortlity rtes were determined on motorbots, registered motorbots nd siling the bsis of popultion, per 000 inhbitnts in ech ge bots. 3 group (<1, \4, 514, 1524, 25^4, 4564, *65), nd n In recent study it hs been shown tht the overll drown lysed by sex nd ge ccording to the most detiled clssifiction ing rtes in Finlnd re the highest mong the EU member of deth in use during the study period. From 1969 to 1986 countries nd tht 30 40% of ccidentl drownings occur in WTA ftlities were clssified ccording to the 8th Interntionl wter trffic ccidents (WTA). 4 In previous studies more thn Clssifiction of Diseses (ICD8) externl cuse of deth codes: 50% of WTArelted deths in Finlnd were ssocited with E830 (Acddent to wtercrft cusing submersion), E831 (Accidlcohol intoxiction. 5 " 7 ent to wtercrft cusing other injury), E832 (Other ccidentl submersion or drowning in wter trnsport), E833 (Fll on stirs or ldders in wter trnsport), E834 (Other fll from one Deprtment of Forensic Medidne, PO Box 40, University of Helsinki, FIN, evel t0 no^, ^ wter trnsport), E835 (Other nd unspecified Finlnd.,. '' ',. h fll in wter trnsport), E836 (Mchinery ccident in wter Deprtment of PubUc Helth, PO Box 41, University of Helsinki, FIN00014,,,, Finlnd trnsport), E837 (Explosion, fire, burning, in wter trnsport), This pper ws presented in prt t the 14th Interntionl Conference on ^d E838 (Other nd unspecified wter trnsport ccident). Alcohol Drugs nd Trffic Sfety, Annecy, 2126 September From 1987 to 1995 they were ctegorized ccording to Finnish 1038

2 WATER TRAFFIC ACCIDENTS, DROWNING AND ALCOHOL IN FINLAND clssifiction of diseses nd recorded with codes E810 (Submersion in wter trnsport ccident) nd E819 (Other nd unspecified wter trnsport ccidents) nd with fivedigit clssifiction (A: Occupnt of smll motorless bot; B: Occupnt of silbot or motorbot; C: Occupnt of other wtercrft; X: Other, unspecified person). Moreover during the period threedigit clssifiction of ftl WTA (E810, E819) in which lcohol intoxiction (305) ws contributing cuse of deth ws lso vilble. The %2 test for trend (SttXct softwre, 1995) nd Poisson regression model (EGRET softwre, 1994) were used to nlyse time trends. The 95% confidence intervl (CI) ws clculted ssuming Poisson distribution (EGRET) nd n exct binomil CI for proportion (CIA). In grphicl displys twoperiod moving verges were used to smooth the vrition in time series. Informtion on ftl leisure WTA collected through semistructured questionnires 8 during the period by 12 provincil tems supervised by ntionl tem (Ministry of Interior, Finlnd; Deprtment of Forensic Medicine, Helsinki; Ntionl Public Helth Institute, Helsinki) included 291 leisure bot ccidents with 510 people on bord nd ws used to study circumstnces nd risk fctors for ftl WTA OWTA BDrown in WTA I Figure 2 Wter trffic ccidentrelted deths (E830838, 810, 819) nd wter trffic ccidentrelted drowning (E810, 830, 832) in Finlnd, Trend line: twoperiod moving verge Results Rtes During the study period ( ) there were ftl ccidents in Finlnd (verge/yer = , SD = 280; 52.6/ 000/yer; M:F = 2.5:1). Of these 11.7% (n = 8020; verge/ yer = 297.0, SD = 81; 6.1/ 000/yer; M:F = 9.4:1) were drowning nd 5.1 % (n = 3473; verge/yer = 128.6, SD = 28; 2.7/ 000/yer; M:F = 20.4:1) were WTA (E830E838; E810, E819). In 94.7% (n = 3288; verge/yer = 121.8, SD = 28; 2.5/ 000/yer; M:F = 2 3.4:1) of the ftl WTA the cuse of deth ws drowning (E830, E832; E810) (Figures 1, 2). Drowning in WTA ws ssocited in 47.1 % of the cses with motorless bot nd in 46.3% with motorbot. In WTA, where the cuse of deth ws other thn drowning (e.g. nturl deth), motorbot 2 3 Ho 4 5to14 15 to to 44 4Sto64 >65 WTA O WTAJc* Figure 3 Age distribution of wter trffic cdentrelted deths (E830838, 810, 819) in Finlnd, \ 300 The dotted line indictes the ge distribution of wter trffic ccidentrelted deths with lcohol intoxiction ( ). n OAII drown Drown in WTA Figure 1 All drowning (E8I0, 830, 832, 910) nd wter trffic ccidentrelted drowning (E810, 830, 832) in Finlnd, Trend line: twoperiod moving verge. ws involved in 54.2% nd motorless bot in 11.9% of the cses. The ge distribution ws unimodl with single pek in 45_64 yer olds (4.3/ 000/yer). Of the victims, 97.3% were 5»15 yers old nd 41.5% were 2544 yers. The M:F rte rtio (R_R) ws 20.4:1 with the gretest difference between sexes in those 3*65 yers (32.6:1) (Figures 3, 4). Assocition with lcohol During the period , 63.0% (n = 583) of the ftl WTA were ssocited with lcohol intoxiction (verge/yer = 64.8,

3 1040 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY * M:F rtio WTA O M:F rtio WTAlc+ Figure 4 Mle:femle rte rtio of wter trffic cdentrelted deths (E830838, 810, 819) in Finlnd, The dotted line indictes the ge distribution of wter trffic ccidentrelted deths with lcohol intoxiction ( ) SD = 12; 1.3/ 000/yer). In WTArelted drownings mong 5»15 yer olds, 66.0% were ssocited with lcohol intoxiction. Only in one cse ws the victim (mle) younger thn 15. The ge distribution ws unimodl with single pek in 4564 yer olds (2.8/ 000/yer) (Figure 3). The M:FRR ws 26.7:1 with the gretest difference mong 2"65 yer olds (70.8:1) (Figure 4). Ftl WTA ssocited with lcohol intoxiction ccounted for 12.5% of ll ccidentl deths ssocited with lcohol intoxiction (M:F = 8.9:1). Trends Through the 27yer study period, the overll rtes of ftl ccidents, drowning rtes nd WTArelted deths declined significntly (0.4% per yer, P = 0.002; 4.9% per yer, P < 0.001; 4 % per yer, P < 0.001, respectively; Poisson regression nlysis). The decline in WTArelted deths ws significntly greter thn the decline in ll other ccidentl deths ( : E800E827, E840E947; ICD8th revision : E800E804, E82OE935; ICD9th revision) (P < 0.001, x2 test for trend). Conversely, no pronounced difference ws observed between WTArelted drowning nd ll other drowning ( : E910; ICD8th nd 9th revision) (P = 0.03, x2 test for trend). In WTArelted deths significnt interction between time trend nd sex ws observed (P < 0.001, Poisson regression nlysis) with more pronounced decline in mles. Overll, WTArelted deths declined significntly in ll ge groups with the exception of >65 yer olds (Tble 1). During the period the overll rtes of ftl ccidents, drowning, nd WTA ssocited with lcohol intoxiction hve declined significntly (2.5% per yer, P < 0.001; 5.8% per yer, P < 0.001; 5.8% per yer, P = 0.002, respectively; Poisson regression nlysis). The decline in ftl WTA ssocited with lcohol intoxiction ws not significntly different to the fll in ll other ccidents (P = 0.13, x2 test for trend); in ddition the decline in WTArelted drowning ssocited with lcohol intoxiction ws not significntly different thn the decline in ll other drowning ssocited with lcohol intoxiction (P = 0.39, X2 test for trend). The decline in WTA ftlities ssocited with lcohol intoxiction ws more pronounced mong mles (P = 0.002, Poisson regression nlysis) nd significnt only mong 2544 yer olds (8.3% per yer, P < 0.001; Poisson regression nlysis) (Tble 2). During the study period two min legisltive countermesures were introduced in Finlnd to decrese the consumption of lcohol in wter trffic. An Act of Prliement (960/1976) introduced blood lcohol concentrtion (BAC) limit (1.5%o) for bot opertors nd Act 655/1994 reduced further this limit to 1.0%o. In 1992 prevention cmpign to increse the sfety of wter trffic followed the publiction of the results of the nlyticl study on leisure bot ftlities (see prgrph below). When compring the decline in WTArelted drowning with the decline in ll other types of drowning before nd fter the introduction of these countermesures, significnt chronologicl interction ws observed only for Act 960/1976. Such interction ws detected only in the 3yer period following the introduction of Act 960/1976 (WTArelted drowning versus ll other types of drowning: P = 0.003, x2 test for trend). In longer period (6 yers) ll other drowning declined even more thn ftl WTA (P < 0.001, x 2 test for trend). No significnt Tble 1I Time trends in wter trffic ccident mortlity in Finlnd Age All ges < »65 All Deth rtes per 000 popultion % vrition/yer % 95% confidence Intervl Pvlueb (5.2, 2.7) % 6.5% 1.6% 1.2% 1.7% 1.1% 18.2,3.8) ( ) (5.9, 3.3) (1.9, 3.6) (2.4,1.0) (2.5, 0.0) Pvlues. % vrition per yer nd 95% CI rt clculted on the bsis of the Poisson regression model (EGRET softwre, 1994). ' = not significnt {P > 0.05) Interction between time trend nd sex _

4 WATER TRAFFIC ACCIDENTS, DROWNING AND ALCOHOL IN FINLAND 1041 Tble 2 Time trends in wter trffic ccident mortlity ssocited with lcohol intoxiction in Finlnd Age All ges >65 All ge.sex c Deth rtes per 000 popultion _ % vrition/yer 6.0% 10.8% 8.7% 2.8% + 1.2% Pvlues, % vrition per yer nd 95% CI re clculted on the bsis of the Poisson regression model (EGRET softwre, 1994). b = not significnt (P > 0.05). c Interction between time trend nd sex. _ 95% confidence Intervl Pvlue" 10.0, 1.4) (21.7, 1.6) 12.8, 3.6) 2.8) (1.6, 25.7) Tble 3 Summry of the most importnt findings of the ntionl investigtion tem on ftl leisure bot ccidents ( ) Time MyAugust FridySundy 3 p.m.9 p.m. Plce nd wether Inlnd wters, good wether Bot Rowbot Smll bot, outbord motor Person on bord Opertor lone Opertor lone lcoholintoxicted No life jcket on Alcohol *1.5% Rowers Motorbot opertors Cuse of deth Drowning Other nonnturl cuse Disese Deth fter ccident Immeditely In less thn 10 min Hypothermi No effect No sfety jcket In rowing bots In unregistered motorbots In registered motorbots Survivl possibility If life jcket wom 93% Risk of being involved In wter trffic ccident If BAC 1.0%. If BAC 1.5%o 74% 60% 42% 57% 33% 52% 50% 69% 94% 50% 63% 94% 5% 2% 27% 80% 98% 87% 27% IOX 20x 95% CI (69, 79) (54, 65) (36, 48) (50, 65) (28, 39) (46, 58) (44, 56) (61, 76) (91, 96) (40, 61) (56, 70) (91, 96) (3,8) (0.3) (22, 32) (76, 85) (93, ) (82, 92) (13,45) effects were observed during the 3 yers following the prevention cmpign (WTArelted drowning versus ll other types of drowning: P = 0.25, x 2 test for trend). Anlyticl study ( ) 8 ' 9 The nlyticl study on ftl leisure WTA ws performed during the period by n d hoc ntionl investigtion tem (Ministry of Interior, Finlnd; Deprtment of Forensic Medicine, University of Helsinki; Ntionl Public Helth Institute, Helsinki). This study covered ll 291 leisure ftl bot ccidents in Finlnd with 510 people on bord nd 340 victims. Most of the ccidents occurred in inlnd wters (72.5%). The most importnt findings of this study re summrized in Tble 3. The BAC ws determined in 274 bot drivers nd in 176 pssengers (Tble 4). In 58.8% of the bot opertors the BAC exceeded the legl limit (1.5%o). This mndtory limit ws exceeded by 50% of the rowing bot nd by 63.4% of the motorbot opertors. The presence of lcohol in blood (BAC >0%o) ws found in significntly higher proportion in motorbot opertors thn in rowers (P < 0.05, x 2 test). No significnt differences were found between bot drivers on the se nd on inlnd wters. Among rowing bot nd motorbot pssengers the figures with BAC 3=1.5%o were 73.5% nd 62.2%, respectively. Among those on bord who fell into the wter, 72.1% (n = 298) of the victims who drowned nd 68.2% (n = 88) of the survivors hd BAC»1.0%o. The respective vlues for BAC s» 1.5%o were 64.1% nd 53.4%. Only 3.5% of those drowned were using buoyncy id t the time of ccident. Discussion In Finlnd, the high mortlity from WTA (2.7/ 000/yer) hs been continuing problem in recent decdes. The Finnish mortlity rtes from WTA re well documented but difficult to compre with those of other countries becuse lthough ntionwide studies on drowning hve been performed recently in some countries few of them hve focused on WTA or WTArelted drowning; moreover mrked epidemiologicl differences exist between different regions of the sme countries. The Finnish mortlity rtes from WTA re much higher thn those in the US where botrelted drownings declined from 0.6 to 0.4/ 000/yer during the erly 1980s. 10 The proportion of botrelted drownings compred to ll drownings is mrkedly higher in Finlnd thn in the US (43.0% versus <20%). n Although WTArelted drowning represents, in Finlnd, 4050% of ll ccidentl drowning, the mortlity rte from WTArelted drowning (2.5/ 000/yer) lone exceeds the verge EU mortlity rte for ll ccidentl drownings (1.4/ 000/yer). 4

5 1042 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Tble 4 Blood lcohol concentrtion (BAC) in dnvers nd pssengers *15 yers old involved in ftl wter trffic ccidents (n = 274) BAC (%o) Drivers Motorbot (n = 180) Rowing bot (n = 94) Totl (274) Pssengers Motorbot (n = 127) Rowing bot (n = 49) Totl (176) * Totl In Finlnd, ftl WTA is n lmost exclusively dult mle phenomen. More thn 97.3% of the victims re ^15 yers old. The M:F reltive risk (RR) (20.4:1) which is higher thn in the US (<15:1) 12 exceeds mrkedly the M:F RR in ftl ccidents (2.5:1) nd drownings (9.4:1). In fct, exposure to qutic settings, especilly wter trffic, is to lrge extent confined to dult mles, who re devoted to leisure boting minly during the summer seson nd involved in professionl ctivities ll yer. Another fctor which my explin the high rte of ftl WTA, especilly mong dult mles, is represented by the buse of lcohol in qutic settings. Although lcohol use during boting ctivities is n incresingly recognized hzrd ssocited with boting ftlities, reltive risk for ccident nd drowning cnnot be sttisticlly determined without n exposure prmeter (e.g. the number of bot opertor h) nd dt on lcohol consumption in qutic settings. The question of drinking behviour in qutic settings hs recently been ddressed in the TJ<J1317 k ut CO mprble informtion for Finlnd is limited. In pilot study on drunken driving performed in the lte 1970s on the southern Finnish secost it ws found tht 29.7% of 424 motorbot drivers tested positive for lcohol nd mong these only 1.2% hd BAC higher thn the legl limit (1.5%o). 18 The dt on the cses of suspected drunken bot opertors reported to the police do not furnish vluble informtion on the exposure to lcohol in wter trffic. Nevertheless considerble proportion of the victims of WTA during the study period hd consumed lcohol ner the time of deth. The ssocition of ftl WTA with lcohol intoxiction is much higher thn the respective vlues in ll ccidents nd in ll drowning (63% versus 19% nd 46.8%, respectively). Studies on the ssocition between lcohol nd drowning in some other countries reviewed in the lte 1980s indicte tht lcohol my hve been contributing cuse of WTArelted drowning in 1781% of the cses, 19 but in most of these studies the ssocition rnges between 30 nd 50%. In our study, the determintion of lcohol intoxiction s contributing cuse of ftl WTA is bsed only on the deth certificte. No dt on BAC levels, on the intervl * During the period the Finnish police took 3870 blood smples from suspected drunken opertors In wter trffic (97.2% mles). In less thn 0 6% of the cses, the BAC ws <0.5%o. During the period Jnury 1991August 1993 (legl BAC limit = 1.5%.) the BAC ws 2>1 5%. in 78.7% of these cses; during the period September 1994Decembtr 1996 (legl BAC limit = 1.0%.) the BAC ws >1.5%o in 55.4% of the cses. (Source. Alcohol Lbortory, Ntionl Public Helth Institute, Helsinki. Courtesy Dr R Undbohm ) between immersion nd deth nd on the intervl between deth nd postmortem BAC determintion were considered. 20 However, in Finlnd, more thn 97% of the deth certifictes in instnces involving violent deth re bsed on forensic utopsy, nd in lmost ll ftl trffic ccidents n lcohol nlysis is performed. The reltive significnce of BAC in the few cses with prolonged intervl(s) between WTA nd lcohol determintion is generlly tken into ccount by forensic pthologists when certifying the cuse of deth. Moreover the rte of WTA ftlities ssocited with lcohol intoxiction is comprble with the frequency observed in previous studies performed in Finlnd 6 8 ' 9 in which BAC ws nlysed. The nlyticl study performed during the period provided evidence tht the risk of ftl outcome ws higher in people under the effects of lcohol (lox in individuls with BAC >1.0%o nd 20x in individuls with BAC >1.5%o). Tht study lso demonstrted tht the lck of sfety devices on bord, e.g. buoyncy ids, ws, once the ccident occurred, mong the mjor risk fctors for the ftl outcome nd tht in 93% of the ccidents wering life jcket should hve substntilly incresed the survivl possibilities. The insufficient use of sfety devices in the ftl outcomes of WTA hs been underlined lso in previous studies. 12 ' 20 Despite mrked increse in both leisure nd commercil boting, 1 mortlity from WTA hs decresed significntly during the lst three decdes. This decline ws more pronounced thn the decline in mortlity in ll other ccidents, however WTArelted drowning did not decline if compred with ll other cuses of drowning. A significnt interction between time trend, sex nd ge group ws detected. The decline ws observed for ll ge groups, except >65 yer olds, nd ws more pronounced mong men. Overll, WTArelted deths ssocited with lcohol intoxiction lso showed significnt decline during the period The decline in WTArelted drownings ws not significnt when compred with the decline in ll other drownings ssocited with lcohol intoxiction. This decline concerned essentilly mles nd ws significnt only mong yer olds. The resons for these time trends re not der. The introduction in 1976 of legl BAC limit for bot opertors (1.5%o) did not modify the longterm trend in ftl WTA. The subsequent reduction in 1994 of this BAC limit to 1.0%o is too recent to be nlysed. The prevention cmpign lone did not significntly modify the trend in ftl WTA. It is likely tht slow increse in public wreness of the risks relted to wter ctivities

6 WATER TRAFFIC ACCIDENTS, DROWNING AND ALCOHOL IN FINLAND 1043 nd to the use of lcohol in qutic settings, influenced by legisltive countermesures nd prevention cmpigns, hs plyed n importnt role in both the decline of WTArelted drowning nd tht of drowning not relted to WTA. In fct, the decline in drowning not relted to WTA ws even more pronounced thn tht of WTArelted drowning during the study period. Conclusions Despite significnt decline in most ge groups, Finnish mortlity rtes in WTA exceed mrkedly those of other countries with relible dt. In Finlnd, the decline in mortlity from WTA is likely due to incresing public wreness of the risks relted to wter ctivities nd to the use of lcohol in qutic settings s demonstrted by the concomitnt decline in drowning rtes not relted to WTA. However, high WTA mortlity remins preventble cuse of deth. The reduction of the legl BAC limits for bot opertors lone is indequte becuse considerble proportion of ftl WTA continues to be relted to the behviour of those on bord rther thn to impirment of the bot opertor. A longterm informtion nd prevention cmpign directed t both drivers nd pssengers nd specificlly trgeted to dult mles nd to the reduction of lcohol buse in qutic settings, together with the promotion (lso through legisltive ctions) of the use of buyncy ids on bord, could contribute to reducing risktking behviour in wter trffic nd thus further reduce WTA mortlity. References 1 Finnish Mritime Administrtion. Domestic Wterbome Trffic Merenkulkulitoksen tilstoj 3/1997, Helsinki, Finnish Mritime Administrtion. Shipping between Finlnd nd Foreign Countries Merenkulkulitoksen tilstoj 7/1997, Helsinki, Sttistics Finlnd. Trnsport nd Communictions Sttisticl Yerbook for Finlnd Trnsport nd tourism 1997/17, Helsinki, Lunett P, Penttil A, Srn S. Accidentl drowning in EU nd Nordic countries: (Abstrct). Nordisk Rcttsmedisin 1997;3:36. 5 Penttil A, Pikkrinen J. Alkohol im motorbootverkehr und bei todesfsllen durch ertrinken. ZRcchtsmed 1983,25: Pikkrinen J, Penttil A. VesUiikenne, hukkuminen j lkoholi. Duodem 1984; : Pikkrinen J, Penttil A. Alcohol nd ftl ccidents in recretionl boting. A ten yer study on drinking operting in Finlnd. In: Procttdings of the I lth Interntionl Conference on Alcohol, Drugs & Trffic Sfety (T89). Chicgo: Ntionl Sfety CoundL Pikkrinen J, PenttU A, Piipponen S. Kuolemn Johtneet Veneilyonnettomuudet Suomess. Vuosin Publictions of the Ntionl Public Helth Institute A5I1992, Helsinki, Penttil A, Pikkrinen J. Unflle mit todlichem Ausgng im finnischen Wsserverkehr whrend der Freizeit Beitr gerich Med 1990;48: Anonymous. Progress towrd chieving the ntionl 1990 objectives for injury prevention nd control. MMWR 1988;37:13840, Anonymous. Drownings Georgi, MMWR 1985;34: Orlowsld JP. Adolescent drownings: swimming, boting, diving, nd scub ccidents. Peditric Annls 1988; 17:12528, Anonymous. From the Centers for Disese Control. Alcohol use nd qutic ctivities Msschusetts. JAMA 1990;264: Howlnd J, Mngione T, Hingson R, Levenson S, Winter M, Altwicker A. A pilot survey of qutic ctivities nd relted consumption of lcohol with impliction for drowning. Public Helth Rep 1990,105: Glover ED, Lne S, Wng MQ. Reltionship of lcohol consumption nd recretionl boting in Beufort County, North Crolin. J Drug Educ 1995:25: Anonymous. Alcohol use nd qutic ctivities United Sttes, MMWR 1993;42:675, 6S Howlnd J, Hingson R, Mngione TW, Bell N., Bk S. Why re most drowning victims men? Sex differences in qutic skills nd behviors. Am J Public Helth 1996:86: Penttil A, Piipponen S, Pikkrinen J. Drunken driving with motorbot in Finlnd. A pilot study on the southern secost in summer Accident Anl Prevent 1979; 11: "Howlnd J. Hingson R. Alcohol s risk fctor for drownings: review of the literture ( ). Accident Anl Prevent 1988; 20: Wintemute GJ, Teret SP, Krus JF, Wright M. Alcohol nd drowning: nlysis of contribuiting fctors nd discussion of criteri for cse selection. Accident Anl Prevent 1990,22:29196.