192

Youth and Other Special Populations

Youth Impaired Driving: Causes and
     Cotintermeasuies

   Michael Klitzner, Ph.D.
Pacific Institute for Research and Evaluation

Traumatic injury is responsible for more deaths among American adolescents and
young adults age 14-24 than all other causes combined (Paulson 1983). Far and away the
leading cause of traumatic injuries is traffic crashes (Robertson 1981; Lewis 1987).
Traffic crashes have been cited as the cause of about half of all accidental deaths in
adolescents and young adults and have also been cited as the cause of half of all spinal
cord injuries (Robertson 1981). Not only adolescent drivers, but also their passengers
(who tend to be adolescents) are at significantly increased risk when compared to older
age groups (Insurance Institute for Highway Safety 1984).

The exact contribution of alcohol use to youth traffic crashes has been debated (e.g.,
Zylman 1973; Cameron 1982). However, the conclusion appears inescapable that alcohol
is a major causal factor (Cameron 1982, Lewis 1987). Young drivers are overrepresented
in alcohol-related fatal crashes even when driving exposure is controlled (Vegega 1984).
Although teen alcohol-related traffic fatalities steadily decreased from 1982 to 1985, they
increased again in 1986 to a level just below that of 1983 (DOT 1987). Unpublished Fatal
Accident Reporting System data for 1987 suggest another downturn, but overall death
rates still exceed those observed in 1985. The reasons for this downturn are not clear but
may reflect increasing public awareness and intolerance and recent changes in
legislation.

The most compelling evidence for a causal link between alcohol and youthful crash
involvement comes from studies of changes in minimum alcohol purchase age (e.g., Fell
1988; Smith et al. 1984; Hingson et al. 1983; Wagenaar 1982u, b, 1983b). Although results
have varied from State to State and from study to study, consistent reductions in youthful
crash involvement have been observed following increases in the minimum purchase age.
Interestingly, most studies that examined the effects of purchase age changes failed to
find meaningful differences in youthful alcohol consumption (Moskowitz 1989). This
may simply reflect the difficulties associated with measuring changes in consumption as
opposed to changes in crash rates. Alternately, it may be that the relationship between
minimum purchase age and crash involvement is not mediated simply by consumption,
but rather reflects more complex changes in youth drinking patterns and drinking
locations.

Crash data reflect only a small segment of the youth cl&king/driving problem.
Overall, youthful drivers are much more likely than their older counterparts to report
driving after drinking (Hingson et al. 1988). Recent survey data gathered from the
Nation's high schools (Bachman et al. 1987) revealed that approximately one in four
seniors had driven after drinking in the 2 weeks predating the survey, and approximately
one in six had driven after having live or more drinks in a row. During the same 2-week
period, two in five seniors had ridden with a drinking driver, and one in five believed the
driver had consumed live or more drinks. Driving while impaired (DWI) and riding with


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impaired drivers (RWID) would appear to be a regular occurrence for a significant
minority of American youth.

Causes and Correlates

Any successful attempt to reduce the extent of impaired driving and riding with
impaired drivers among youth must be rooted in an understanding of the factors that
predispose, reinforce, and enable these behaviors. However, current knowledge of the
causes and correlates of youth DWURWID is incomplete. The majority of relevant
studies have focused on alcohol consumption and related problems rather than on DWI
per se, and only a very limited number of studies have focused on factors related to riding
with impaired drivers. In addition, predisposing, reinforcing, and enabling factors have
often been studied in isolation, complicating assessments of the relative contribution of
different variables or classes of variables to DWI/RWID.

Individual Characteristics

Perhaps the largest body of correlate research has focused on characteristics of
individual youths. These studies noted that personality factors such as aggressiveness,
intolerance of authority, nonconformity, escapism, and immaturity may be associated
with increased probability of driving after drinking (Lightsey and Sweeney 1985; Boyd
and Huffman 1984; DOT 1975; Kraus et al. 1970). DWI has also been associated with
poor academic performance, greater participation in social activities, access to cars
including car ownership, more discretionary income, and working part time (Klitzner et
al. 1987, 1988; Williams et al. 1986).

Other individual-level studies have focused on the stresses of transition from adoles-
cence to adulthood (Pelt and Schuman 1971) and 0" the relationship between stress and
alcohol consumption (e.g., Fomey et al. 1984; Wagenaar 1983u; Koningsberg et al. 1983;
Cameron 1982). A recent study of adolescent DWI offenders (Farrow 1987) suggested
that offenders are more likely than nonoffinders to use risky driving as a stress manage-
ment technique.

Studies that assessed young people's awareness of the physiological and psychological
effects of alcohol revealed that young people are generally ignorant of the effects of
alcohol (Forney et al. 1984; Blane 1983; Hetherington et al. 1979) and are unable to
identify the amount of alcohol that impairs driving performance (Pawlowski 1982).

Several studies have explored the effects on DWI risk of positive attitudes toward
drinking and drinking and driving. Most have focused on attitudes toward alcohol
(Krohn et al. 1982; Milgram 1982; Lowrnan 1981; Douglass 1983; DOT 1975; Kraus et
al. 1970). These studies suggest that normative acceptance of drinking by youth increases
both alcohol consumption and DWI risk. Two recent studies by Klitzner et al. (1987,
1988) found that normative acceptance of DWI was also strongly related to both alcohol
consumption and actual DWI/RWID behavior.

Social Influences

A second broad area of correlate research has focused on social influences, especially
those associated with peer groups. Numerous studies have reported increased alcohol
consumption among youth who associate with peers who drink and/or approve of
drinking (Vejnoska 1982; Stoles and Fine 1981; Krohn et al. 1982; Nusbaumer and
Zusman 1981; Biddle et al. 1980). A study by Finley (1983) implied that peer influence
may be so pervasive as to negate the effect of countervailing influences such as fear of
legal sanctions or parental disapproval. Group centeredness, a probable component of


194

BACKGROUND PAPERS

susceptibility to peer influence, has also been found to increase DWI risk (Kraus et al.
1970; DOT 1975), and a recent study by DiBlasio (1988) found that peer modeling plays
an important role in decisions to ride with intoxicated drivers.

Jessor (1987) recently extended Problem-Behavior Theory (Jessor and Jessor 1977)
to youthful risky driving, including DWI. Problem-Behavior Theory has a 25year history
as a major theoretical orientation for understanding youth substance abuse and related
problems. Jessor's recent work demonstrated that youth who are more influenced by

friends than parents, and whose friends model risky driving behaviors, are more likely
to report risky driving.

Studies of social influence have also focused on the effects of mass media, especially
alcohol advertising, on youth alcohol consumption and DWI. Most advertising research
has examined general populations and has failed to find consistent effects (Frankena et
al. 1985). Studies that looked specifically at youth (Atkin et al. 1983, 1984, Strickland
1983) reported possible effects of advertising exposure on both alcoholconsumption and
DWI, but methodological weaknesses in these studies limit the strength of conclusions
that may be drawn from them (Moskowitz 1989).

Characteristics of Youth Drinking and Youth Driving

A third broad approach to understanding the youth DWI problem has been to explore
the special characteristics of youth drinking and youth driving. For young drivers, risk
of crash involvement begins to increase at very low blood alcohol concentrations (BACs),
and studies suggest that any measurable BAC can result in a significantly increased risk
for younger drivers (Simpson et al. 1982; Farris et al. 1976; Perrine et al. 1971). Thus, the
gap between risky and illegal BACs for youth in most States is large, and "safe"
consumption guidelines publicized for adults may be dangerously misleading for youth.
The more rapid impairment of the younger drinker is reflected in the fact that crash-
involved adolescents are likely to have lower BACs than their older counterparts
(Cameron 1982), and in the'higher risk of fatal crashes for young drivers when compared
to adults with comparable BACs (Bergeron and Joly 1986).

The simultaneous acquisition of driving skills and drinking experience may further
increase the likelihood of crashes (O'Day 1970; Lewis 1987), and youth who DWI may
tend to be riskier drivers in general (Bergeron and Joly 1986). Nataanen and Summala
(1976) also noted the importance of considering the "extra motives" (beyond simple
transportation) that driving may fulfil for youth. These include tension reduction,
meeting the need for competition, showing off, and deliberate risk-taking. Summala
(1987) found that these extra motives may be more important than lack of driving skill
in contributing to poor youth driving performance.

Research conducted in preparation for a National Institute on Alcohol Abuse and
Alcoholism (NIAAA) youth and alcohol media campaign pointed to a number of
structural and contextual factors that may serve to associate youth drinking with youth
driving (URSmacificon 1980). These data suggest that, for many youth, the automobile
represents the only place where privacy may be relatively certain. Drinking and other
negatively sanctioned behaviors are most likely go undetected when undertaken in cars.
Consistent with this assumption, data from the 1986 yearly survey of high school seniors
(Bachman et al. 1987) revealed that over half of all seniors who drank had done so in
cars, and approximately 28 percent reported doing so "some of the times" or "most of
the times." Similarly, a national survey conducted by Grey Advertising (DOT 1975)
revealed that among students who drank, 38 percent reported drinking "while driving
around," and 20 percent reported drinking at drive-in movies within the previous 3
months. Driving constitutes a social occasion for youth, and the ride to and from a social
event constitutes a prelude to and continuation of that event (Farrow 1987). Thus,
drinking in cars may be a simple extension of other teen drinking.


YOUTH AND OTHER SPECIAL POPULATIONS

195

The NIAAA planning data indicated that youth are more likely than adults to drink
all that they possess at any given time, thus eliinating problems of storage or hiding of
contraband alcohol. Moreover, data reported by Vegega and Klitzner (in press), Farrow
(1987), and Bachman et al. (1987) showed that the great majority of teen drinking
occured outside the home. Thus, the structure of teen drinking may lead to the consump-
tion of large quantities of alcohol in settings that subsequently require some sort of
transportation home.

Multiple Correlate Studies

In an effort to assess the relative contribution to DWI/RWID of a variety of risk factors
discussed in the literature, Klitzner and colleagues (1988; Vegega and Klitzner in press)
surveyed and/or interviewed a convenience sample of approximately 1,550 youth in
grades 7 through college in six U.S. cities. In one study (Klitzner et al. 1988), 1,323 youth
completed anonymous questionnaires that assessed lifestyle variables (friends' drinking   '
practices, participation in parties and dates, access to cars), alcohol use variables,
DWI/RWID risk factors, and self-reported DWI/RWID behavior. Of nine risk factors
studied, only one -perceived deviance of DWI- was strongly related to DWI and
RWID. Two other factors-use of alternative modes of transportation and decisionmak-
ing skills-were related to DWI and RWID, but only insofar as they predicted drinking
practices. The remaining six risk factors- awareness of alternative modes of transpor-
tation, self-concept, communications skills, alcohol knowledge, knowledge of local DWI
laws, and susceptibility to peer influence-predicted neither drinking practices nor
DWI/RWID. Despite the failure of these risks factors to predict drinking or DWI/RWID
directly, all nine risk factors were interrelated. Thus, the factors that did not directly
predict drinking, DWI, or RWID may still contribute to overall risk. Drinking practices
were themselves strong predictors of both DWI and RWID, a point discussed later.
In a second study (Vegega and Klitzner in press), indepth interviews were conducted
with 120 youth who reported DWI and 121 youth who reported having ridden with an
intoxicated driver. This study focused on the contribution of situational factors to youth
DWI/RWID. Among the factors assessed were social context variables; social pressures
to drink, drive, and/or ride; perception of immediate risk; destination variables; and
availability of alternative transportation. In general, the results showed that DWI/RWID
is largely a function of the role alcohol plays in the youth culture. Many respondents
suggested that DWI and RWID are "inevitable" because drinking is an "inevitable"
component of adolescent lifestyles.

Despite the current popularity of "peer pressure" as an explanation of youth drinking
and related problems, only about 15 percent of Vegega and Klitzner's DWIs reported
any pressure to drink, and only 13 percent reported any pressure to drive after drinking.
Among RWIDs, less than 7 percent reported that peer pressure contributed to their
decision to ride with the impaired driver. To the extent that DWI and RWID were
situationally determined, they were controlled largely by a perceived need to get home
or to get a passenger home. This finding is consistent with data reported by Farrow
(1987), who found that home was the most common destination for youth engaging in a
variety of risky driving behaviors, including DWI/RWID.

Vegega and Klitzner described a special case of RWTD that occurred when the
impaired driver was a parent or other adult relative. In this case, which represented
slightly more than a quarter of the reported RWID incidents, the youths' apparent
inability to affect parental DWI or to utilize alternative modes of transportation effec-
tively precluded any protective action (other than fastening a safety belt) on the part of
the affected youngster. Here, parents and other adult relatives appeared to make a
significant contribution to the DWI-related risk experienced by youth.


196

BACKGROUND PAPERS

Summary

In general, the factors that predispose, reinforce, and enable youth DWI and RWID
appear to be similar to those risk factors associated with other adolescent health risk
behavior (Jessor 1987). Social and normative influences, risk-taking orientation, and
individual differences in attitudes toward and beliefs about drinking and drinking and
driving all appear to contribute to increased or decreased risk.

Of particular import in considering DWI and RWID specifically, however, is the
powerful role played by alcohol consumption per se in increasing risk of both DWI and
of RWID (for which consumption is not a prerequisite). Indeed, Klitzner et al's (1988)
data revealed that DWI/RWID risks increased directly and potentlyas a function ofboth
quantity and frequency of alcohol consumption. Moreover, among Vegega and
Klitzner's (in press) sample of DWIs and RWlDs, alcohol use was perceived to be an
inextricable part of the youth culture, and DWI/RWID were viewed as "inevitable"
results of the strong association between youth socializing and youth drinking. Thus, it
seems unlikely that meaningful reductions in youth DWURWID can be realized without
significant attention to changes in youth drinking practices.

Countermeasures for Youth

The past two decades have witnessed a rapid expansion in the number and types of
programs and strategies employed to prevent youthful DWI and RWID. A review of 133
youth DWI prevention models (Vegega and Klitzner 1988) revealed enormous diversity
of focus, underlying assumptions, and activities. Youth DWI/RWID countermeasures
include school curricula, clubs, alternative transportation, alternative (alcohol-free)
parties, teen retreats, andsyouth-focused legislation and regulation.

Current DWI/RWID prevention strategies can be grouped into three major
categories - those mainly concerned with the prevention of drinking, those mainly
concerned with separating drinking and driving, and those concerned with preventing
mortality and morbidity when and if DWb'RWID occur. The differences among these
approaches can be illustrated by considering the natural history of DWI and RWID.
Figure 1 presents, in highly simplified flow diagrams, the processes that lead to
DWl/RWID and related mortality and morbidity.

Figure 1. Processes that lead to DWVRWID
      NATURAL PROBLEM HISTORY OF YOUTH DWI

Youth Who-l- >    Youth Who-2- >  Youth Who -3 - > Mortality &
Don't Drink        Do Drink       Drink & Drive   Morbidity

NATURAL PROBLEM HISTORY OF YOUTH RWID

Youth Who-l- >    Youth Who-2- >  Youth Who-3- > Mortality &
Don't Associate     Do Associate     Ride With     Morbidity
With Drinkers      With Drinkers     Drinkers

These flow diagrams indicate three points at which DWI/RWID strategies and
programming can be directed. Point 1 represents strategies that have as their primary
objective the prevention of youth drinking and the establishment of nondrinkinglifestyles
among youth. Such programs attempt to alter the factors that either predispose, rein-
force, or enable drinking among individual youth (e.g., school curricula, "say no"
organizations, intervention programs for users) and attempt to reduce youth access to


YOUTH AND OTHER SPECIAL POPULATIONS                                          197

alcohol (e.g., alcohol-free alternative parties, minimum purchase age increases, server
training, limited outlets, education of retail clerks). Strategies at point 1 would not, of
course, address the problem of youth who RWID when parents or other adults are the
drivers. 1

Point 2 represents strategies that attempt to disassociate drinking and driving. Here,
although youth alcohol use may still be of concern, the major objective is to address risk
factors that lead drinking youth to drive, or that lead youth who associate with drinkers
to be passengers. Examples of strategies at point 2 include SafeRides, designated driver,
alternative transportation, direct intervention (e.g., taking keys), parent/student
transportation "contracts," general and specific deterrence, and a variety of licensing
strategies.

Point 3 represents strategies that attempt to limit morbidity and mortality among
drinking drivers, their passengers, and those with whom they crash. Examples of these
strategies include passive restraints, other vehicle-;elated technologies, highway design
elements such as breakaway sign posts, and so on.

Point 1 Strategies

Many point 1 strategies (those that attempt to reduce youth drinking) have been
extensively studied. In particular, school-based strategies of various types have been the
object of intense research scrutiny for at least two decades. Programs have been
developed and evaluated that focus on arousal of fear of negative consequences,
provision of information, development of "life skills" (e.g., positive self-regard, com-
munication skills, assertiveness, decisionmaking, coping), clarification of values, and,
most recently, "resistance" training.

The literature on school-based alcohol and other drug prevention programs has been
repeatedly reviewed (e.g., Moskowitz 1989; Klitzner 1987; Goodstadt 1985; Wittman
1982). In general, these reviews concur that evidence in support of school-based alcohol
and drug prevention programs is sparse. Although increases in knowledge and changes
in attitudes are often reported, effects on behavior have been weak, inconsistent,
transient, and sometimes in the wrong direction. The failure to demonstrate educational
program effects has been attributed to failures in program models, to failures in program
implementation, and (more optimistically) to weak or inappropriate research designs
(Klitzner and Bell 1987, Moskowitz 1983). Whatever the causes, no scientific mandate
currently exists for adopting any particular school-based approach to alcohol use
reduction and prevention.

Emerging strategies focusing on family education (e.g., DeMarsh and Kumpfer 1985),
management of early antisocial behavior (e.g., Hawkins and Lishner in press), changes
in school and classroom structure (Gottfredson 1987), and school drug and alcohol
policies (Moskowitz 1987) have shown promise and hold out the hope of more effective
responses to youth alcohol-related problems in the future. Until such time as these
strategies are thoroughly researched, however, their appeal remains largely theoretical.

Several strategies to control youth access to alcohol have been studied with varying
results. The uniform purchase age of 21 (e.g., Fell 1988; Hingson et al. 1983; Wagenaar
1982, b, 1983) and increased taxation (Saffer and Grossman 1985; Coate and Gross-
man 1985) have been shown to have an impact on the sequelae of consumption including

1  Some DWI/RWID program developers have labeled point 1 programs as "prevention programs" in
order to distinguish them from point 2 programs, which have been labeled as "intervention programs."This
distinction seems somewhat artificial, since both types of strategies seek to prevent the occurrence of
DWIJRWID.

2  These strategies are the topic of a separate background chapter and will not be discussed further.


198

BACKGROUND PAPERS

youthful crashes, although effects on consumption per se, have been difficult to docu-
ment. Failure to document effects on consumption may be due to methodological
difficulties in measuring such effects, or it may result from the inadequacy of a simple,
direct model of the effects of youth access to alcohol on consumption and related
problems.

The effect of numbers of alcohol outlets per capita on consumption has also received
`some scrutiny, although no studies have focused directly on youth. The results of these
studies have been mixed, with one study demonstrating lower consumption in States with
fewer outlets (Ornstein and Hannens 1985) and hvo studies failing to find such effects
(Hoadley et al. 1984, Schweitzer et al. 1983). A fourth study revealed a correlation
between numbers of outlets and alcohol-related problems including felony and mis-
demeanor DWI arrests in 213 California cities (Watts and Rabow 1983). This study did
not include direct measures of consumption.                     I

Student assistance programs to intervene with alcohol- and drug-using youth (e.g.,

Chambers and Morehouse 1983; Morehouse 1982) have been studied from a process
perspective, but rigorous assessments of student drinking outcomes are not available.
Other popular approaches (e.g., prevention "clubs," alcohol-free recreation, concerned
parent groups) have received minimal research attention.

Point 2 Strategies

Of the available strategies aimed at point 2 (separating drinking from driving),
perhaps the most extensively discussed is deterrence. Unfortunately for the current
discussion, existing research does not generally address specific effects on youth. Ross
(1984,1985) and Moskowitz (1989) provided extensive reviews of various deterrence-
based strategies, including increased penalties, per se laws, enforcement crackdowns,
and administrative license revocation. In general, these reviews showed that enforcement
crackdowns, especially when accompanied by extensive media coverage, can have
short-term (months to a few years) effects. On the other hand, a study of increased
enforcement in France that focused specifically on drivers under 25 (Jayet 1986) failed
to find a deterrent effect.

Recently, concern over the risk of crashes associated with even very low BACs in
youth has motivated some States to adopt a lower legal BAC limit for youth than for
adults. In most of these States, license revocation is either an automatic or discretionary
penalty for violations. Drummond et al. studied a zero BAC limit for first-year drivers
in Australia. Preliminary data disclosed that this law reduced nighttime, weekend
driving- a peak time for youth crash involvement (e.g., Farrow 1987; Robertson 1981).
However, actual crash data concerning the Australian zero BAC law were not available
at the time the research report was prepared.

Hingson et al. (1986, in press) studied the effects of a 0.02 BAC limit and admini-
strative license revocation for 1 year on youth in Maine. Initial results (Hingson et al.
1986) revealed that self-reported DWI and self-reported nonfatal crash involvement
among drivers 19 and under declined significantly when compared to Massachusetts
teens and Maine adults. Declines were most dramatic for teens who were aware of the
law. In addition, actual injury and fatal crashes among Maine teens increased at a much
lower rate than for drivers 20 years old and over. Followup results (Hingson et al. in
press) have generally mirrored the 1986 findings, although differences between Maine
and Massachusetts teens have declined to a nonsignificant level. This lack of difference
appears due to a "catching-up" on the part of Massachusetts teens, perhaps owing to
the high level of antidrug and anti-DWI activity in that State. Hingson et al. also noted
that enforcement of the 0.02 BAC law has become sporadic, and police appear to arrest
juveniles with less regularity than adult offenders.

Several States have experimented with license revocation as a sanction against youth


YOUTH AND OTHER SPECIAL POPULATIONS                                           199

possession of alcohol and other drugs. In recent testimony before the National Commis-
sion Against Drunk Driving (NHTSA, October 198'7), Judge C. Foley of Milwaukee,
Wisconsin, credited such a law with significant reductions in youth DWI between 1982
and 1986. However, the existence of a zero BAC law in Wisconsin, increased public
awareness of the youth DWI problem, and the lack of comparison data render inter-
pretation of these reductions difficult. At this time, the effects of license revocation as a
sanction for youthful alcohol and other drug possession are unproven.

A recently popular strategy for separating drinking from driving is to issue youth
restricted licenses that limit the hours during which they may operate a vehicle. Impetus
for such a strategy derives from the previously cited observation that youth DWI as well
as youth fatal crashes are most likely in the evenings, especially weekend evenings. As
reported by Williams (1987), at least 18 States have some sort of curfew restrictions.
Williams cited a study of restrictions in four States by Preusser et al. (1984) that reported
dramatic reductions in crashes during the restricted hours. He also cited additional data
from New York, Louisiana, and Maryland that supported the efficacy of restricted
driving hours for youth. Despite one study of the Maryland law that did not find effects
on crash rates (M&night et al. 1983), Williams concluded that curfew restrictions can
substantially reduce youth crash involvement.

Other licensing approaches to reducing youth crashes include making drivers'
licenses more difficult to obtain and presenting the license in juvenile court to both the
youths and their parents. Preliminary data from California (Hagge and Marsh 1986)
suggested positive results from making licenses more difficult to obtain, although, as
noted by Williams (1987), the California program had so many facets that it was
impossible to determine which elements contributed to the positive results and which
did not.

Separation of youth drinking from youth driving has also been attempted through
educational strategies. There is little evidence that such programs reduce crash rates
(Williams 1987; Moskowitz 1989). One well-conducted Canadian evaluation of a drink-
ing/driving education program (Albert and Simpson 1985) demonstrated decreased
intentions to DWI, but these decreases were realized at the cost of an increase in
reported drinking frequency. Some critics of drivers' education (Robertson 1980;
Robertson and Zador 1978) have suggested that such programs may actually increase
crash rates by increasing the liccnsure of 16- and 17-year-olds. However, as discussed by
Moskowitz (1989), these claims are based on short-term results and may not justify
possible long-term negative effects of discontinuing drivers' education.

Cognizant of the general failure of drinking/driving education programs, the National
Highway Traffic Safety Administration (NHTSA) sponsored the development of a Peer
Intervention Program (McPherson et al. 1983) aimed at enabling and motivating
youngsters to intervene in the drinking and driving behavior of their peers. The program
provided 8 hours of role-playing as well as 1 hour of alcohol and traffic safety information.
A true experiment with random assignment compared the Peer Intervention Program
to a traditional drinking and driving education program (McKnight and McPherson
1986). Students in the Peer Intervention Program reported statistically significant gains
in intervention behavior at followup intervals of 1 to 4 months. The actual magnitude of
these effects appeared small, although the description of the behavioral measure
provided by M&night and McPherson is too sketchy to determine the meaning of the
differences reported.

Students Against Driving Drunk (SADD) (Anastas 1983) represents an attempt to
change school and community norms with regard to youth DWVRWID. Klitzner et al.
(1987) conducted an evaluation of SADD in two cities in the Western United States.
This quasi-experimental study failed to find effects of SADD on any drinking or
drinking/driving variables. However, weak program implementation in the SADD


BACKGROUND PAPERS

schools, high subject attrition from the research study, and other design confounds limit
the strength of these conclusions.                      \
Alternative transportation (e.g., SafeRides, designated driver) as a means of separat-

ing drinking from driving has not been well evaluated (Klitzner et al. 1988). Klitzner et
al. (1987) provided preliminary data on parent/student contracting. These data showed
that signing contracts increases the likelihood that youth will call parents for a ride.
However, no differences in DWI or RWID as a result of signing the contracts were
observed. This somewhat puzzling result suggests that although signers are calling home,
safer transportation does not result.

Critics of alternative transportation strategies have objected to these approaches on
the grounds that they implicitly sanction youth drinking. Klitzner et al. (1987) failed to
find evidence that signing parent/student contracts had effects on youth drinking or
related problems. On the other hand, Klitzner et al. (1988) found that heavier driers
also reported using more transportation alternatives. The meaning'of this latter result is
unclear. It may, indeed, confirm the fears of critics of alternative transportation
strategies, or it may simply reflect the fact that heavier drinkers have more reasons for
using and opportunities to use transportation alternatives.

Multicomponent Strategies

One common indictment of many attempts to prevent alcohol- and drug-related
problems among youth is too narrow a programmatic focus (Klitzner 1987; Klitzner and
Bell 1987; Goodstadt 1986, Huba et al. 1980). That is, communities have tended to focus
on one kind of response (e.g., a school curriculum, a SADD club, a police crackdown)
to the exclusion of other types of responses.

Recently, some communities have attempted to overcome the narrowness and frag-
mentation of past responses to youth DWI by instituting communitywide, systemic
responses that attempt to institute a coordinated and comprehensive package of mutual-
ly reinforcing countermeasures. Thus, a community might institute a strong anti-alcohol
use school policy, work to restrict alcohol sales to minors through increasing alcohol
beverage control enforcement, rigorously enforce DWI laws, institute roadblocks, ag-
gressively prosecute and heavily sanction youthful DWI offenders, and develop com-
munity resources for the treatment of addicted teens. Ten communities that are
attempting to implement communitywide responses are described by Pacific Institute
(in press).

The communitywide model has considerable theoretical and conceptual appeal, and
many of the strategies communities appear to be using have been shown to be effective
in their own right (e.g., increased enforcement, reductions in alcohol availability to
youth). To date, however, rigorous evaluations of multicomponent, communitywide
anti-DWI programs have been extremely limited.

Perhaps the most relevant research is the Lackland Air Force Base Experiment
(Barmark and Payne l%l), which effectively reduced DWI among airmen through a
variety of normative, informational, and enforcement strategies. However, strategies
shown effective in the highly insular and controlled environment of a m&try hstdation
will not necessarily be effective in the less well-controlled environments of most
American communities.

The communitywide model has shown promise in other health areas, notably the
reduction of risk factors associated with cardiovascular disease (Farquhar et al. 1977;
Puska et al. 1985). However, the effectiveness and feasibility of systemwide responses to
the youth DWI problem awaits further research.


YOUTH AND OTHER SPECIAL POPULATIONS

201

Summary

Current research into youth drinking and driving countermeasures suggests that
effective strategies are available for reducing youth access to alcohol and for separating
youth drinking from youth driving. However, despite the continuing popularity of
strategies focused on developing or changing individual knowledge, attitudes, and skills,
aimost all the effective countermeasures reviewed in this chapter have been regulatory
or legislative in nature.

Recent evidence indicates that the most effective countermeasures will likely be those
that focus on minimum purchase age, alcohoi pricing, limiting alcohol outlets, lower legal
BACs for youth, curfew restrictions on youth driving and other licensing restrictions,
and enforcement. This is not to imply that the search for effective programs focused on
individual youth should be discontinued. However, many individually focused prevention
approaches popular in the 1970s and 1980s appear to have outlived their usefulness.

Issues and Recommendations

Proven technologies exist for reducing the death and disability suffered by youth as a
result of drinking and driving. As discussed, these include restrictions on youth access
to alcohol and restrictions on youth driving. The problem is not so much one of finding
effective countermeasures as it is overcoming societal inertia to implement them. Thus
far, the uniform alcohol purchase age is the only proven countermeasure to be adopted
nationwide. In some States, even the threatened loss of Federal highway funds did not
guarantee speedy legislative action.

Williams (1987) posed the question of whether society is ready to take the steps
necessary to improve the current situation with regard to youth drinking and driving. He
responded: "To the extent that legislative restrictions are necessary to rectify the
situation, [this] question can at present be answered in the negative." A major item on
the Nation's public health agenda should be to educate parents, legislators, and other
concerned citizens about the regulatory measures that can be taken to realize additional
meaningful reductions in youth DWI.

Of course, regulatory responses will only be effective to the extent that they are
enforced (Ross 1984). In general, the quality of enforcement of novel DWI laws
decreases over time, an effect observed in Maine's experience with 0.02 legislation
enacted in 1982 (Hingson et al. in press). Public support must be developed for the
vigorous and continued enforcement of new laws as well as for their enactment.

It is also clear that regulation alone will never be a complete answer to the youth
DWI/RWID problem. Youth wiIl always have access to alcohol and cars. Indeed,
licensing restrictions will never affect all teenagers, since a significant minority of teen
drivers are unlicensed (Klitzner et al. 1988; Williams et al. 1985). Moreover, the high
crash rates of teens continues into the early twenties-an age group to whom purchase
age restrictions do not apply. Thus, in addition to regulatory responses, continued efforts
should be made to develop prevention programs that affect the drinking and drinking/
driving choices of individual young people.

Prevention program development and research need to break away from the unsuc-
cessful models of the past. New approaches are needed that are firmly grounded in an
understanding of the factors that predispose, reinforce, and enable youth alcohol use
and DWURWID. Given the current state of knowledge, such an understanding will
require a program of additional research into the etiology of youth drinking and
DWURWID. This is not to imply that the testing of new program models should be
delayed until a comprehensive and widely accepted set of etiological models is available.


202

BACKGROUND PAPERS

Rather, program research and etiologic research should be seen as complementary
endeavors, with data from one area of inquiry informing theory development and
research activities in the other.

Significant programmatic attention must be paid to youth alcohol consumption per
se. It is possible, in theory, to separate youth drinking from youth driving. However, these
behaviors are currently so inextricably intertwined that successful DWI/RWID preven-
tion programs may ultimately be those with a heavy emphasis on reducing alcohol
consumption.

The youth DWURWID problem is not limited to impairment due to alcohol. Data
from a 1983 survey of 18- to 24-year-olds (Elliot 1987) revealed that one in five respon-
dents had driven while high on marijuana, and nearly one in ten had driven while high
on other drugs. Moreover, the prevalence rate for DWI was twice as high for multiple
drug users as it was for youth who only used alcohol. More research is needed on the
contribution of marijuana and other drugs to crash-related mortality and morbidity, and
future discussions of the youth DWI/RWID problem should specifically address these
substances.

An effort should be made to involve physicians in the national effort to combat youth
drinking/driving. Questions about alcohol use patterns, driving, and seatbelt use should
be part of all doctor visits for teens and should be specifically explored when a presenting
complaint suggests aIcoho1 involvement (AAP 1987; Klitzner and Schonberg 1988).
Moreover, parents of preteens should be counseled concerning the effects of their own
drinking and drinking/driving attitudes and behavior on the behavior of their children.
Parents should also be encouraged by physicians to disallow alcohol consumption by
their adolescent children, including restrictions on attending parties where alcohol is
served (AAP 1987).

Finally, continued efforts should be made to change social norms regarding youth
alcohol use and DWURWID. It has been argued that changes in social norms and values
as a result of two decades of antismoking activities and programs have contributed
significantly to the efficacy of smoking cessation and prevention programs (Polich et al.
1984, Moskowitz 1983; Leventhal and Cleary 1980). Similar changes in drinking and
DWURWID norms toward greater intolerance can facilitate the adoption of effective
regulatory measures (Moskowitz 1989) and can also have a direct impact on youth
behavior (Klitzner et al. 1988). The communitywide approach discussed earlier is one
appealing strategy for effecting normative change because it attempts to involve all
segments of the community in combating the youth drinking/driving problem.

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