STRATEGIES TO REDUCE DRIVING UNDER THE INFLUENCE OF ALCOHOL

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1 Annu. Rev. Public Health : Copyright c 1998 by Annual Reviews. All rights reserved STRATEGIES TO REDUCE DRIVING UNDER THE INFLUENCE OF ALCOHOL William DeJong Department of Health and Social Behavior, Harvard School of Public Health, Boston, Massachusetts 02115; bdejong@edc.org Ralph Hingson Social and Behavioral Sciences, Boston University Medical Center, School of Public Health, Boston, Massachusetts KEY WORDS: drunk driving, general deterrence, alcohol control, mass communications, community-based prevention ABSTRACT The purpose of this review is to update research on the prevention of alcoholrelated traffic deaths since the 1988 Surgeon General s Workshop on Drunk Driving. Four primary areas of research are reviewed here: (a) general deterrence policies, (b) alcohol control policies, (c) mass communications campaigns, including advertising restrictions, and (d ) community traffic safety programs. Modern efforts to combat drunk driving in the United States began with specific deterrence strategies to punish convicted drunk drivers, and then evolved to include general deterrence strategies that were targeted to the population as a whole. Efforts next expanded to include the alcohol side of the problem, with measures installed to decrease underage drinking and excessive alcohol consumption. In the next several years, greater efforts are needed on all these fronts. Also needed, however, are programs that integrate drunk driving prevention with other traffic safety initiatives. INTRODUCTION Modern efforts in the United States to combat drunk driving began with the founding of grassroots organizations such as Mother s Against Drunk Driving (MADD), Students Against Driving Drunk (SADD), and Remove Intoxicated /98/ $

2 360 DEJONG & HINGSON Drivers (RID). Their first success was a widespread change in public attitudes (32). Drunk driving is no longer a source of easy laughs, nor is it shrugged off as an inevitable cost of modern life. Most Americans instead view it as a serious public danger, a violent crime that results from a person s decision to drive while impaired. Emerging from this change in public attitudes came the passage of new laws to impose firm and consistent punishment against convicted drunk drivers, with the hope of decreasing repeat offenses, a strategy referred to as specific deterrence (29). Prevention experts soon recognized that successfully fighting alcohol-impaired driving would require much more than punishing the small number of drunk drivers who are caught and convicted each year. Also required is a program of general deterrence (31). Key strategies include: (a) administrative license revocation for drivers who fail a blood alcohol test or refuse to take one; (b) highly publicized sobriety checkpoints; (c) lowering the per se limit to 0.08% BAC (blood alcohol concentration); and (d ) lowering the per se limit for minors to 0.02% BAC or lower ( zero tolerance ). In recent years several states have implemented some or all of these strategies, based on research evidence of their effectiveness in reducing alcohol-related traffic fatalities. The next phase of drunk driving prevention work began with the 1988 Surgeon General s Workshop on Drunk Driving (45). The singular contribution of this workshop was to broaden the purview of government-sanctioned prevention efforts to include population-based alcohol control policy. At the time of the workshop, the United States had already established a national minimum legal drinking age of 21, a measure that the National Highway Transportation Safety Administration (NHTSA) estimates has saved over 15,000 lives since 1975 (35). The impact of this law demonstrates the value of policy approaches to change the physical, social, economic, and legal environment that drives alcohol consumption. Research on other alcohol control policies also lends support to this approach. The purpose of this review is to update research on the prevention of alcoholrelated traffic deaths since the 1988 Surgeon General s Workshop on Drunk Driving. This review is timely, not only because of the tenth year anniversary of the Workshop, but also because of the ambitious new prevention goal announced by the US Department of Transportation in its Partners in Progress program specifically, to reduce the number of alcohol-related traffic fatalities to 11,000 by 2005 (34). With this announced goal, it is important to reflect on the progress that has been made to date and the reasons for it and to examine the research evidence to identify new areas of promise for drunk driving prevention. We review studies on the impact of general deterrence policies and mass communications campaigns to prevent impaired driving, plus policy measures to reduce

3 STRATEGIES TO REDUCE DUI 361 the availability of alcohol. We conclude by describing future directions for the prevention of alcohol-impaired driving, in particular the integration of drunk driving prevention with other traffic safety initiatives. One area of research not reviewed here is the impact of specific deterrence laws. Persons convicted of alcohol-impaired driving are more likely than other drivers to be subsequently arrested for driving under the influence and to be involved in alcohol-related crashes (37). Specific deterrence laws seek to reduce this recidivism through treatment or rehabilitation, mandatory license suspensions, actions against vehicles and vehicle tags, lower legal BAC limits for people who have been convicted for driving under the influence (DUI), jail sentences, probation, or some combination of these measures. A recent review by Hingson (16) summarizes this literature. RECENT US INCIDENCE DATA The recent US record in decreasing alcohol-related traffic fatalities is remarkable. In 1982, there were 25,165 alcohol-related traffic fatalities, or 57.2% of all fatal crashes, according to NHTSA. In 1996, alcohol was involved in 17,126 crash fatalities, or 40.9% of that year s total. Hence, between 1982 and 1996, the number of alcohol-related fatalities dropped by 32%, and the proportion of crash fatalities involving alcohol fell by 28% (36). Many improvements in traffic safety have occurred since 1982, such as the adoption of laws requiring the use of child restraints in all 50 states and the enactment of legislation mandating the use of seat belts in 49 states. The decline in alcohol-related traffic deaths was independent of these laws, however. Traffic deaths not involving alcohol increased 32% from 18,780 in 1982 to 24,781 in 1996 (36). Despite this record of progress, this has been a time of disappointment and wary concern for prevention experts focused on alcohol-impaired driving. In 1994, there were 16,580 alcohol-related traffic fatalities. In 1995, the number of fatalities increased to 17,274, the first rise in nine years (35), and in 1996, the number stayed approximately the same at 17,126 (36). It is too soon to know whether this is only a temporary interruption of progress or the beginning of a disturbing new trend. What is clear, however, is that continued research is needed to expand the range of evaluated approaches for reducing alcohol-related traffic fatalities. METHODOLOGICAL PROBLEMS The evaluation of policies and programs for drunk driving prevention is fraught with methodological difficulties.

4 362 DEJONG & HINGSON The optimal research design for evaluating specific laws or programs would be a true experimental design, with large numbers of individual communities or states randomly assigned to either a treatment group that is exposed to the intervention or a control group that is not. With large samples, random assignment would ensure that extraneous variables that might influence the outcome measures are distributed equally across the two groups, meaning that any outcome differences between the groups could be more confidently attributed to the intervention itself, rather than to pre-existing differences between the jurisdictions. Clearly, random assignment of states or communities is politically and financially unrealistic. Therefore, to test the impact of a state or community initiative, the research design of choice is a quasi-experimental design in which outcomes for treatment communities or states are compared to similar nontreatment ( control ) jurisdictions. The principal difficulty with the quasi-experimental design is that the treatment and control communities or states might differ in important ways, either before or during the study period. Even when efforts are made to match the two sets of communities or states on relevant variables, there is always the possibility that other unmeasured differences will contribute to or mask any differences in outcome (5). Only the random assignment of very large numbers of communities or states to treatment and control conditions could obviate this problem, which is impossible in nearly all cases. Further complicating the evaluation picture is that, in the realm of drunk driving prevention, it is not uncommon for several laws or programs to be initiated within a relatively short time, which makes it difficult to separate fully the effects of each initiative. Moreover, people who drive after heavy drinking (defined as five or more drinks consumed on a single occasion) are much more likely to engage in other risky driving behaviors, such as speeding, running red lights, driving after other drug use, and failing to wear seatbelts. Therefore, studies need to control for shifts in legislation or law enforcement that might affect these other driving behaviors. Another complicating factor is that publicity about the drunk driving problem is often broadcast across state borders or even nationally, which may serve to diminish the outcome differences that would otherwise be found among states with varying prevention initiatives. Similarly, any underlying national trend in drinking and driving behaviors has the potential to mask the impact of a particular state or community-level initiative. Another research option is the time-series design, which involves the analysis of survey data or other indicators over an extended period of time, both before and after the introduction of the intervention. This design can be used to evaluate national, regional, or local campaigns, subject to the availability of appropriate data. The design is only practicable when there is a signal event

5 STRATEGIES TO REDUCE DUI 363 whose occurrence can be precisely defined in time, thus making it possible to make clear before-after comparisons. Time-series modeling requires that reliable and valid data are available over a lengthy time period. In many cases, the only data available will be broad indicators, such as statistics on alcohol-related traffic fatalities, rather than specific indicators of project objectives, such as greater use of designated drivers. Such measures must often come from survey data. Unfortunately, detailed surveys on particular topic areas often have not been done before. Because most states do not determine the BACs of all drivers involved in fatal crashes, researchers often rely on proxy measures of alcohol involvement, such as single-vehicle, nighttime fatal crashes, which are three times more likely than other fatal crashes to involve alcohol. Even so, such crashes account for less than one half of all fatal traffic crashes, which introduces imprecision in evaluating the effects of legislation or other programs, especially in short-term studies involving small jurisdictions (16). Despite these methodological difficulties, researchers have been able to draw a number of conclusions about the effects of various legislative and programmatic interventions to reduce alcohol-impaired driving. Four primary Table 1 Impact of strategies to reduce driving under the influence of alcohol Strategy Impact a Reference General deterrence policies Administrative license revocation 9% decline in alcohol-related fatal 25 crashes Sobriety checkpoints 17% decline in alcohol-related fatal 26 crashes Lower per se limits 16% decline in the proportion of fatal 18 crashes involving fatally injured drivers at 0.08% BAC and higher Zero tolerance laws 20% decline in the proportion of single- 17 vehicle, nighttime fatal crashes among 15- to 20-year old drivers Alcohol control policies Minimum legal drinking age 10 15% decline in alcohol-related traffic 47 deaths among drivers under age 21 Increased alcohol excise taxes b 15% decline (estimate) in traffic deaths 40 among drivers ages Responsible beverage service c 23% decline in single-vehicle, nighttime 22 fatal crashes a See text for full description of research findings. b Estimate of impact if federal excise taxes on beer had kept pace with inflation since c Impact when 60% of the servers in the study area were trained.

6 364 DEJONG & HINGSON areas of research are reviewed here: (a) general deterrence policies, (b) alcohol control policies, (c) mass communications campaigns, including advertising restrictions, and (d ) community traffic safety programs. GENERAL DETERRENCE POLICIES General deterrence strategies are aimed at dissuading the general public from driving after drinking, in contrast to specific deterrence strategies that seek to prevent people who have been convicted for DUI from repeating their offense. It is true that convicted DUI offenders are at greater future risk than other drivers. However, fewer than 11% of drivers in alcohol-related fatal crashes with a BAC above 0.10% had a DUI violation on their record during the three years prior to the crash. In a given year, if every driver who had been arrested the year before for alcohol-impaired driving could be kept off the road, less than 5% of alcoholrelated traffic fatalities would be prevented, according to one estimate (31). This underscores the important need for laws and prevention programs aimed at general deterrence. The evidence for the following key strategies are reviewed here: (a) administrative license revocation for drivers who fail a blood alcohol test or refuse to take one; (b) highly publicized sobriety checkpoints; (c) lowering the per se limit to 0.08% BAC (blood alcohol concentration); and (d ) lowering the per se limit for minors to 0.02% BAC or lower ( zero tolerance ). Underlying each of these strategies is the idea that people will be deterred from driving after drinking if they perceive a higher risk of apprehension and immediate punishment. The severity of the punishment is not as important in establishing deterrence as is its swiftness and its certainty (39). Administrative License Revocation With administrative license revocation (ALR), law enforcement officials can promptly remove a driver s license if the driver is tested and found to have a blood alcohol concentration (BAC) higher than the legal limit. Court challenges to ALR have been made in several states, so far without success. Evaluations have shown that ALR laws can reduce alcohol-related traffic fatalities. In 1988, for example, one nationwide study showed that ALR laws passed between 1978 and 1985 were accompanied by a 5% decline in fatal traffic crashes (23). Another study pegged the decline in alcohol-related fatal crashes associated with ALR at 9% (25). By mid-1997, 39 states had adopted ALR, but the remaining states accounted for one fifth of the nation s alcohol-related traffic fatalities. Sobriety Checkpoints Research has also established the value of so-called sobriety checkpoints, police roadblocks set up to check for drivers who have been drinking. Checkpoints

7 STRATEGIES TO REDUCE DUI 365 serve two purposes: to apprehend impaired drivers and to increase the perceived risk of apprehension by those who might otherwise decide to drive after drinking (33). Perhaps the most extensive sobriety checkpoint program in the United States was implemented in Tennessee. From April 1994 through March 1995, more than 150,000 drivers were stopped at 900 checkpoints. The program was highly publicized on television. A quasi-experimental study revealed a 17% reduction in alcohol-related fatal crashes in Tennessee compared to five contiguous states during the same period (26). Court rulings on the legality of sobriety checkpoints have made clear that certain standards must be upheld if these operations are to meet constitutional protections against illegal search and seizure. These standards are reflected in guidelines issued by the National Highway Transportation Safety Administration (33). Proper execution of a sobriety checkpoint requires that every driver, or a subset of drivers selected on a systematic basis, be stopped. Due to these courtmandated requirements, police have little time to interview each driver who is stopped to determine if the driver is impaired. As a result, many drunk drivers pass through the roadblocks undetected. Research involving checkpoints where all drivers not detained by police were subsequently tested for alcohol indicates that about half the drivers with BACs above the legal limit are not detained under normal operating procedures (12). The guidelines further specify that if the police officer detects evidence of alcohol use, the driver is to be asked to take a preliminary breath test. Alternatively, the officer can use a passive alcohol sensor to detect alcohol on the driver s breath. If the officer suspects that a driver might be impaired, standard investigative procedures (e.g. field sobriety tests, blood alcohol test) are to be initiated. Passive alcohol sensors increase the detection of drunk drivers in sobriety checkpoints. Passive sensors collect air from in front of the driver s face and can detect the presence of alcohol in the driver s breath. In one recent study, police detected 55% of drivers above the legal BAC limit when not using passive sensors, compared with 71% when using sensors (12). Other researchers found that when passive sensors are used, sober drivers are less likely to be erroneously suspected of alcohol use (24). To have maximum deterrent effect, sobriety checkpoints are best used on a frequent but unpredictable schedule not just a few times each year, but several times a month. Such frequent use is uncommon, in part because many police believe that, to be effective, sobriety checkpoints must be major operations involving dozens of officers. In fact, recent research has demonstrated that, if they are well publicized, small, relatively mobile checkpoints involving only

8 366 DEJONG & HINGSON four to six officers can have as strong a deterrent effect as those involving twice as many officers (43). The deterrence value of sobriety checkpoints depends on the publicity they get. Very few people will be detected and arrested at a checkpoint. In fact, very few drivers will even be stopped during a typical operation. Even so, news coverage about checkpoints communicates to the public that law enforcement officers are fully employed to combat this crime. Without this kind of publicity, few members of the public would even know about the checkpoints (39). Lower Per Se Limits In the United States, most states define driving with a BAC level of 0.10% or higher as illegal per se. From a safety standpoint, this is not a meaningful cut-off point. Even at blood alcohol concentrations as low as 0.02%, alcohol affects driver performance by slowing reaction time, and a BAC level of 0.05% is high enough to negatively affect virtually everyone s driving ability (50). In recent years, several states have lowered the per se limit to 0.08%. One recent study compared the first five states to adopt the 0.08% BAC limit with five nearby states that retained the 0.10% limit. Compared to the other states, those states that adopted the lower limit experienced a 16% decline in the proportion of fatal crashes involving fatally injured drivers at 0.08% BAC and higher. States with the lower per se limit also experienced an 18% decline in the proportion of fatal crashes involving fatally injured drivers at 0.15% BAC and higher (18). It is important to note, however, that the five 0.08 states also had ALR laws during the study period, three of which were implemented within one year of the 0.08% law. Because of ALR s known impact on alcohol-related traffic fatalities, this coincidence limits the study s ability to separate the effect of the 0.08% laws from that of ALR. In Maine, however, the ALR law was in place throughout the baseline period, which did make it possible to establish an independent preventive effect of the 0.08% law. In 1994, Massachusetts simultaneously introduced a 0.08% BAC and ALR laws. Statewide randomized telephone surveys in 1993 and 1996 showed that the percentage of respondents who believed they could consume four or more drinks and drive safely declined from 24% to 15%, while the percentage of those believing they could drive legally after that amount dropped from 18% to 9%. In addition, the percentage of respondents who reported driving in the past month after consuming four or more drinks fell from 9% to 4% (28). Zero Tolerance Laws There has been a move in many states to lower the per se limit for drivers under age 21, usually to between 0.00% and 0.02% BAC. By making it illegal

9 STRATEGIES TO REDUCE DUI 367 for minors to drive after drinking any alcohol, these so-called zero tolerance laws serve to bring driving-after-drinking statutes into conformity with state minimum legal drinking age laws. There is strong public support for zero tolerance policies, with 91% of US adults endorsing the idea of uniform laws under which teenage drivers who test positive for alcohol would immediately have their driver s license revoked (27). By mid-1997, 43 states had adopted a zero tolerance law. Research suggests that these laws can significantly reduce alcohol-related traffic fatalities among youth. One study compared the first 12 states that lowered legal BACs for minors with 12 nearby states that did not. States adopting a zero tolerance law experienced a 20% greater decline in the proportion of single-vehicle, nighttime fatal crashes among 15- to 20-year old drivers. States lowering BAC limits for youth to 0.04% or 0.06% did not experience significant declines relative to the comparison states (17). Zero tolerance laws may be effective because they convey a clear message to youth about the illegality of driving after any alcohol consumption whatsoever. As is the case with other traffic safety measures, the deterrent effect of zero tolerance laws is dependent on achieving general awareness of the law (2). ALCOHOL CONTROL POLICIES Prohibition was a failed experiment in the United States. It succeeded in reducing alcohol-related problems but eventually lost public support because of the continued demand for alcohol products and the underground economy that developed to supply them (1). More recent alcohol control efforts in the United States have been motivated primarily by concerns about youth drinking and the role of alcohol in traffic crashes, homicides, and suicides. What has emerged from research in this area is a clearer understanding that measures to reduce average alcohol consumption in the general population will also serve to reduce the percentage of people consuming at excessive levels, who are at greatest risk for alcohol-related problems, including impaired driving (11). With this evidence in hand, the United States and other countries have implemented several measures to control the availability of alcohol, based on the idea that making access to alcohol less convenient will discourage underage drinking and excessive consumption. Such measures include restricting sales to government-run monopolies, limiting the number and location of alcohol outlets to reduce their density, and restricting the hours and days of sale, all of which have been demonstrated to reduce consumption levels (44). There is also evidence that a higher density of alcohol outlets is associated with increased numbers of alcohol-related traffic crashes (41). Additional research is needed to link the application of these availability strategies with reductions in alcohol-related traffic crashes.

10 368 DEJONG & HINGSON Additional measures to reduce alcohol availability require fuller discussion. These include laws to increase the minimum legal drinking age to 21, increases in alcohol excise taxes, and responsible beverage service programs. Minimum Legal Drinking Age Minimum legal drinking age laws are a key measure for reducing alcohol availability among youth. States adopting age 21 laws in the late 1970s and early 1980s experienced a 10% to 15% decline in alcohol-related traffic deaths among drivers in the targeted age groups, compared with states that did not adopt such laws (47). When President Reagan signed the National Minimum Drinking Age Act of 1984, any state that failed to pass an age 21 law by 1986 risked the withholding of federal highway funds. All 50 states complied. Based on time-series analyses, the National Highway Traffic Safety Administration estimates that age 21 laws across the United States have saved over 15,000 lives since 1975 (35). It is important to note that people ages 21 to 25 who grew up in states with an age 21 law drink less alcohol compared to those who grew up in other states (38). With this kind of evidence in hand, it is not surprising that there is strong public support for maintaining the minimum legal drinking age at 21 (27). Lax enforcement of the age 21 law continues to be a weak link in communitybased prevention. A lack of diligent enforcement sends young people a mixed message about the consequences of breaking the law, thus undermining any possible deterrent effect. Therefore, an increased law enforcement presence, including the use of decoy operations against alcohol merchants, is key. There are other measures to consider that might enhance compliance with the age 21 law: (a) use of distinctive and tamper-proof licenses for drivers under age 21; (b) use and lose laws that impose driver s license penalties on minors who purchase or are found in possession of alcohol; (c) keg registration or other limits on large container sales; and (d ) increased penalties for illegal service to minors, including dram shop laws to make serving a minor a legal cause of action. Research is needed to establish whether these proposals would significantly reduce alcohol consumption and driving after drinking. Increased Alcohol Excise Taxes The demand for alcohol is price sensitive, meaning that as alcohol becomes more expensive, consumption drops. For this reason, prevention experts have examined increased alcohol excise taxes as a potential strategy for reducing alcohol-related problems. According to one recent review of the literature, heavy and dependent drinkers appear to be as responsive to price as are more moderate drinkers (44). Increases in taxes on beer have been shown in one study to reduce motor vehicle fatality rates for young people ages 15 to 24 (40).

11 STRATEGIES TO REDUCE DUI 369 Federal alcohol excise taxes have not kept pace with inflation, nor have they been equalized for alcohol content across the categories of beer, wine, and distilled spirits. For that reason, prevention advocates have called for substantial excise tax increases for beer and wine to match the levels by alcohol content now applied to distilled spirits and for all alcohol excise taxes to be indexed to inflation (44). By one estimate, if federal excise taxes on beer had kept pace with inflation since 1951, the number of 18- to 20-year-olds killed in traffic crashes would have been reduced by 15%. Likewise, if the alcohol in beer had been taxed at the same rate as the alcohol in distilled spirits, there would have been a 21% reduction in traffic fatalities for this age group (40). Responsible Beverage Service Responsible beverage service (RBS) programs have three goals: (a) to prevent alcohol service to minors, (b) to reduce the likelihood of drinkers becoming intoxicated, and (c) to prevent those who are impaired from driving (30). Customers benefit from the lower risk environment, which creates a positive social outing. Alcohol outlets benefit by training their staff in RBS practices, which decreases liability and improves business. The community as a whole benefits from decreased alcohol-related problems. RBS programs can be installed by individual alcohol outlets, but they are more effective when implemented community-wide. A community-wide responsible beverage service program has these key components: (a) community oversight, involving a task force to establish guidelines and monitor the program; (b) management policies and procedures that establish clear expectations about what the RBS program requires; (c) changes in server practices, which are introduced through formal training; and (d ) patron awareness, encouraged through press conferences, special community events, and other promotions. Evaluations of formal RBS programs to train managers and servers have shown them to be effective. For example, an evaluation of a mandatory server training program in Oregon found a direct relationship between the proportion of servers who had received training and the number of single-vehicle, nighttime fatal crashes, which is used as a proxy measure of alcohol-related crashes. By the time 60% of the servers were trained, there was a 23% decline in such crashes (22). MASS COMMUNICATION CAMPAIGNS Mass communication campaigns, primarily on television, have long been a central part of the US effort to prevent alcohol-related driving. Such campaigns can be used to promote a wide range of objectives, which can be divided into three basic types: general awareness, individual behavior change, and

12 370 DEJONG & HINGSON public action. Most recent campaigns have focused on the first two objectives (6). Researchers have noted that there is little evidence that mass communication campaigns significantly alter people s drinking and driving behavior (15, 46). In fact, evaluations of mass media campaigns are rare, partly due to the expense, but also due to the difficulty of setting up a research design that permits meaningful inferences about a campaign s impact (13). This is a problem for the field of mass communications generally, not just in the area of drunk driving prevention. General Awareness General awareness programs are essential to remind people about the risks of driving after drinking, a message that needs constant reinforcement. At the same time, it is clear that accurate information alone is unlikely to motivate people who drink and drive to stop doing so. Thus, general awareness programs are best combined with other programs, in particular those focused on individual behavior change and enhanced law enforcement (6). Concern about causing or being hurt or killed in an alcohol-related crash can be channeled into support for policies that address the problem. Building such support means attacking the existing system of knowledge and beliefs that operate to sustain current drinking and driving norms. Key points include the following: (a) An alcohol-related crash is the foreseeable result of someone s decision to drive after drinking, a decision for which they should be held accountable. (b) Every act of impaired driving is a serious offense, whether it happens to result in a crash or not. (c) Even small amounts of alcohol can greatly reduce a person s ability to respond to road emergencies and to drive safely (50). (d ) Nearly 40% of those who die in alcohol-related fatal crashes are innocent victims, people other than the drinking driver (35). Typically, mass communications campaigns have been designed to reach a broad, undifferentiated audience, not necessarily those at greatest risk for driving after drinking. A recent study established that one subgroup of individuals at high risk for drinking and driving is comprised of predominantly white men, ages 21 to 34, who have a high school education or less, work in blue-collar occupations, and drink beer (14). Formative research with this and other specific subgroups can be used to inform strategic planning for highly targeted mass communications campaigns. Individual Behavior Change: Designated Driver An important objective for several mass communications campaigns is to encourage individuals to change their behavior to avoid driving after drinking. Theories of behavior change suggest that simple exhortations not to drink and drive, by failing to promote specific alternative behaviors, are unlikely to have

13 STRATEGIES TO REDUCE DUI 371 broad impact. These messages typically offer supportive arguments that might increase knowledge and change beliefs, but this is likely to stimulate new behaviors among only a small group of people already predisposed to change. There are three types of specific behaviors that mass communications campaigns have promoted: (a) designating a driver, (b) intervening to prevent alcohol-impaired people from driving, and (c) calling for additional information or to enroll in prevention activities (6). The most extensive research on campaign impacts has been done for the national designated driver campaign. The designated driver concept is a simple strategy for avoiding driving after drinking. A couple or group of friends selects one person to abstain from alcohol and to be responsible for driving, and the others are free to drink or not as they choose (49). In 1993, the US Center for Substance Abuse Prevention and NHTSA issued an official policy statement endorsing the designated driver concept within a comprehensive framework for addressing alcohol-related traffic crashes (4). The use of designated drivers has been heavily promoted since late 1988 through a national media campaign spearheaded by the Harvard School of Public Health s Center for Health Communication. Working with the cooperation of leading television networks and Hollywood production studios, the campaign promotes an emerging social norm that the driver should abstain from alcohol. Communication strategies included a blend of news coverage, prime time public service announcements sponsored by the television networks, and dialogue in top-rated network series such as The Cosby Show and Cheers (10). Between 1987 and 1992, more public service announcements were developed on the use of designated drivers than on any other subject (6). The impact of the campaign was evident in the results of three waves of Gallup surveys. In September 1988, two months prior to the campaign s start, 62% of all respondents said that they and their friends use a designated driver all or most of the time. In early 1989, following a holiday-period campaign blitz, this percentage rose to 66%. By mid-1989 it rose to 72%, a statistically significant increase compared to the precampaign figure. This upsurge was largely due to male respondents, whose use of designated drivers increased from 54% prior to the campaign to 71% by mid-1989 (10). The methodological shortcomings of this quasi-experimental research study make it impossible to state definitively that the campaign was responsible for this upsurge in reported use of designated drivers. The increase might be part of a long-standing historical trend, though the very magnitude of the increases, shown over just nine months, makes this alternative explanation less tenable. Despite its widespread public acceptability and use, the designated driver strategy has been criticized by some public health advocates (8). One of their chief concerns has been that having a designated driver might encourage

14 372 DEJONG & HINGSON excessive drinking by the driver s passengers. One study found a slight, but nonsignificant increase in alcohol consumption among fraternity members who were the passengers of a designated driver (42). The validity of this and other small-scale studies is uncertain, however. More recent data from a national study of college student drinking suggest that the designated driver campaign is having a net beneficial effect (9). A representative national sample of over 17,000 four-year college students completed questionnaires in Students reported whether they served as or rode with a designated driver in the past 30 days and how much alcohol they consumed the last time they did so. Among drinkers, those who had consumed alcohol in the past year, 36% (4746 students) said they served as a designated driver in the past 30 days. Of these, 40% (1908) said they usually binge drink but did not do so the last time they served as the designated driver, with the vast majority either abstaining or having one drink. Among drinkers, 37% (4676 students) reported riding with a designated driver in the past 30 days. Of these, 22% (1031) said they did not usually binge drink but did so the last time they had a designated driver, because of having one or more extra drinks. A sizeable percentage of college students who use the designated driver strategy do not do so consistently. The survey did not address what percentage of times the designated driver strategy was used when it could (or should) have been. However, a relatively high percentage of those students who used a designated driver in the past 30 days also have driven while alcohol-impaired or ridden with an impaired driver during that time. Future efforts to promote this strategy should emphasize the importance of using the designated driver strategy consistently. On balance, these findings provide strong evidence of a sharp drop in the number of impaired drivers on the road as a consequence of the usage of designated drivers. The impact of the national campaign on drunk driving statistics is unclear. Additional research is needed to measure the rate of crash involvement per drinking occasion among college students and others who use designated drivers, compared to those who do not use this strategy. Calls for Public Action A third key objective of mass media campaigns is to stimulate and support public action to address the DUI problem. Few campaigns have sought to build public support for changes in institutional structures, public policy, or law that would reinforce and sustain the efforts of individuals to alter their behavior (6). New research to develop and evaluate such campaigns is badly needed. One form of public action is the formation and effective implementation of school- or community-based programs. In this case, messages can be used to

15 STRATEGIES TO REDUCE DUI 373 position a program or organization as a leader in combatting the problem of alcohol-impaired driving; to recruit new program participants, volunteers, or donors; to maintain the morale of people already involved; and to announce program activities. Public action can also entail working for changes in public policy. In general, recent mass communication campaigns have not worked to achieve any specific changes in public policy. Several messages have emphasized the terrible death toll caused by alcohol-impaired driving, which serves to generate pressure for something to be done, but what that might be is not specified. Once changes in public policy are made, mass media can be used to publicize them so that they can have their full deterrent effect (6, 39). Restrictions on Alcohol Advertising Few prevention advocates have called for outright bans on alcohol advertising, but have instead pushed for advertising reform that would moderate its influence on youth, problem drinkers, and other vulnerable populations (7). One suggested reform, for example, is to end beverage alcohol advertising that portrays drinking as a means to achieve popularity or social acceptance, sexual appeal, or social or financial status (31). Recently, prevention advocates have renewed calls for the Federal Communications Commission to require television and radio stations to run prevention counter-advertising in proportion to the amount of paid alcohol advertising the stations carry. Another proposal is to require broadcast ads for alcohol to include warning information, similar to what is presently required for container warning labels. It should be emphasized, however, that there is no strong empirical evidence showing an impact of alcohol advertising on alcohol-impaired driving (44). COMMUNITY APPROACHES TO PREVENTION Recent evaluations have demonstrated that a comprehensive approach to alcohol control and DUI prevention may work best. Community mobilization, involving a mix of civic, religious, and governmental agencies, appears to be the key to success. Essential to making community-based programming work is the formation of coalitions and interagency linkages that lead to a coordinated approach, with adequate planning and a clear division of responsibilities among coalition members (48). Community-based prevention programs can help establish or reinforce community social norms against underage drinking and driving-after-drinking; provide youth with awareness education and direct training on peer resistance skills; offer structured mentoring, interpersonal counseling, and recreational

16 374 DEJONG & HINGSON opportunities for youth that enhance their basic personal skills while also minimizing their exposure to social and environmental risk factors; and create changes in the environment through regulations and other policies (3). The wisdom of this approach has been reinforced by new research by Holder and his colleagues, which demonstrates the potential power of communitybased coalitions to eliminate mixed message environments that invite irresponsible alcohol use and driving after drinking (21). The investigators worked with three experimental communities, two in California and one in South Carolina, to organize citizen-led programs for more effective community control of alcohol. The programs entailed three key elements: (a) changes in local zoning ordinances to reduce the density of alcohol sales outlets, (b) a community-wide program for responsible beverage service, and (c) enhanced police enforcement of the driving under the influence (DUI) and age 21 laws. All of these elements were backed up by a media campaign designed to enhance supportive local news coverage. The responsible beverage service program centered around the development of alcohol service policies by bars and restaurants, coupled with training of alcohol beverage servers. Clerks at alcohol sales outlets also received training in how to check for legal proof of age. Enforcement of the age 21 law was enhanced through police officer training and increased budget allocations. Police also conducted monthly sobriety checkpoints to apprehend drunk drivers and used passive alcohol sensors during routine traffic stops. In the program communities, relative to three comparison communities, there were statistically significant increases in media coverage of alcohol issues in local newspapers and on local television. There was increased adoption of responsible server policies, and alcohol sales to minors were cut by half. Across all three program communities, there was a 10% reduction in the rate of singlevehicle, nighttime traffic crashes, with the greatest effects found in the two California communities. Recent research by Hingson and his colleagues on the Massachusetts Saving Lives program suggests the wisdom of an even more comprehensive approach, one that integrates community-based drunk driving prevention with other traffic safety initiatives (20). The program not only attempted to reduce alcoholimpaired driving but also targeted other risky driving behaviors that alcoholimpaired drivers are more likely to engage in, such as speeding, running red lights, failing to yield to pedestrians in crosswalks, and failing to wear seatbelts. The underlying idea of the program is that driving after drinking is part of a constellation of unsafe driving practices. Epidemiological research comparing BACs of drivers in single-vehicle fatal crashes with those of drivers stopped at random in nationwide surveys indicates that each 0.02% increase in BAC nearly doubles a driver s risk of being in a fatal crash (50). The risk increases

17 STRATEGIES TO REDUCE DUI 375 more rapidly with each drink for drivers under age 21, who have less experience in driving and more often speed and fail to wear seatbelts (19). In March 1988, in each of six Massachusetts cities, a full-time coordinator from the mayor s or city manager s office organized a task force of concerned private citizens, representatives of key non-profit organizations, and officials representing various city departments (e.g. health, police, recreation, and school). Each community received annually about $1 per inhabitant in program funds. Active task-force membership ranged from 20 to more than 100 persons. An average of 50 organizations participated in each city. The five-year program produced significant results. In the six program cities, compared to the rest of the state, there was a 25% decline in fatal crashes compared with the previous five years. Fatal crashes involving alcohol decreased by 42%, and the number of fatally injured drivers with positive BAC readings dropped by 47%. The proportion of vehicles observed speeding and the proportion of teenagers who reported driving after drinking were cut in half. A major question is whether these changes can be sustained without support from the initial grant sources. CONCLUSION As noted, the US Department of Transportation has announced the goal of reducing alcohol-related traffic fatalities to 11,000 by 2005 through its Partners in Progress program (34). In our view, this ambition cannot be realized by focusing on impaired driving prevention alone. First, state legislation is still needed to bring administrative license revocation, lower per se limits, and other general deterrence strategies to all 50 states. In addition, however, there needs to be a continued focus on alcohol control to lower consumption, especially among youth and problem drinkers. The link between specific alcohol control measures and lower DUI rates will need to be researched carefully as these measures are adopted by individual states. Experience with the minimum drinking age laws continues to provide reason for optimism, however. The future of alcohol control is a comprehensive, community-based approach that includes the following: (a) formation and support of local coalitions that work for change in the physical, social, economic, and legal environment that shapes alcohol consumption; (b) rigorous and well-publicized enforcement of existing laws and regulations; (c) mass media campaigns to communicate moderate drinking social norms and expectations; (d ) education programs to support individual change and to gain widespread support for new alcoholcontrol policies; and (e) installation of systems for early identification, referral, and treatment of people with alcohol-related problems.

18 376 DEJONG & HINGSON Beyond the focus on alcohol control, however, is a need to integrate drunk driving prevention with other traffic safety initiatives. As noted, people who drive after drinking alcohol are more likely than other drivers to speed, run red lights, fail to yield to pedestrians, and fail to wear seatbelts. All of these behaviors heighten the risk of crashing or being injured in a crash. Whether a community program like the Massachusetts Saving Lives program can succeed in other states warrants exploration. Research is also needed on what mechanisms mediate their success in reducing alcohol-related traffic fatalities. Literature Cited Visit the Annual Reviews home page at 1. Aaron P, Musto D Temperance and prohibition in America: a historical overview. In Alcohol and Public Policy: Beyond the Shadow of Prohibition, ed. MH Moore, DR Gerstein, pp Washington, DC: Natl. Acad. Press 2. Blomberg R Lower BAC Limits for Youth: Evaluation of the Maryland 0.02 Law (DOT-HS ). Washington, DC: US Dep. Transp., Natl. Highw. Traffic Saf. Admin. 3. Center for Substance Abuse Prevention (CSAP) Selected Findings in Prevention: A Decade of Results from the Center for Substance Abuse Prevention. Rockville, MD: US DHHS, CSAP 4. Center for Substance Abuse Prevention (CSAP) and National Highway Traffic Safety Administration (NHTSA) Statement on Designated Drivers. Rockville, MD: US DHHS, CSAP 5. Cook TD, Campbell DT Quasi- Experimentation: Design and Analysis Issues for Field Settings. Chicago: Rand Mc- Nally College 6. DeJong W, Atkin CK A review of national television PSA campaigns for preventing alcohol-impaired driving, J. Public Health Pol. 16: DeJong W, Russell A MADD s position on alcohol advertising: a response to Marshall and Oleson. J. Public Health Pol. 16: DeJong W, Wallack L The role of designated driver programs in the prevention of alcohol-impaired driving: a critical reassessment. Health Educ. Q. 19: DeJong W, Winsten J The use of designated drivers by U.S. college students: a national study. Public Health Rep. In press 10. DeJong W, Winsten JA The Harvard Alcohol Project: a demonstration project to promote the use of the designated driver. In Proc. Int. Conf. Alcohol, Drugs and Traffic Saf., 11th, ed. MWB Perrine, pp Chicago: Natl. Saf. Counc. 11. Edwards G, Anderson P, Babor TF, Casswell S, Ferrence R, et al Alcohol Policy and the Public Good. New York: Oxford Univ. Press 12. Ferguson SA, Wells JK, Lund AK The role of passive alcohol sensors in detecting alcohol-impaired drivers at sobriety checkpoints. Alcohol Drugs Driv. 11: Flay B, Cook T Three models for summative evaluation of prevention campaigns with a mass media component. In Public Communication Campaigns, ed. R Rice, C Atkin. Newbury Park, CA: Sage. 2nd ed. 14. Graham JD, Winsten JW, Isaac NE, Kennedy BP Strategic Advertising Plans to Deter Drunk Driving: Final Report. Boston, MA: Harvard Injury Control Cen., Harvard Sch. Public Health 15. Haskins JB The role of mass media in alcohol and highway safety campaigns. J. Stud. Alcohol Suppl. 10: Hingson R Prevention of drinking and driving. Alcohol Health Res. World 20: Hingson R, Heeren T, Winter M Lower legal blood alcohol limits for young drivers. Public Health Rep. 109: Hingson R, Heeren T, Winter M Lowering state legal blood alcohol limits to 0.08 percent: the effect on fatal motor