57.  Counseling to Prevent Motor Vehicle Injuries



RECOMMENDATION



Counseling all patients, and the parents of young patients, to use occupant restraints

(lap/shoulder safety belts and child safety seats), to wear helmets when riding motorcycles, and

to refrain from driving while under the influence of alcohol or other drugs is recommended (see

Clinical Intervention). There is currently insufficient evidence to recommend for or against

counseling patients to prevent pedestrian injuries. See Chapter 58 for recommendations on the

prevention of bicycling injuries.



Burden of Suffering



In 1993, motor vehicle crash-related injuries were the eighth leading cause of death in the U.S.1

Motor vehicle injuries are a leading cause of death in children and young adults,2 and the leading

cause of years of potential life lost before age 65.3 A total of 40,115 Americans died in motor

vehicle crashes in 1993 (15.6/100,000 population), and more than 3 million suffered nonfatal

injuries (1,212/100,000).4 Over 3,200 of those killed were children under age 16 years.4 In

the same year, 2,444 motorcycle occupants were killed.4 The motorcycle occupant fatality rate is

nearly 20 times higher than for passenger car occupants (25.1 vs. 1.3/100 million vehicle miles

traveled).4 More than 5,600 pedestrians were also killed in 1993 (2.2/100,000).4 The annual

number of motor vehicle fatalities has decreased since the late 1960s, despite an increase in

annual number of vehicle miles traveled.5 Motor vehicle crashes during 1990 resulted in an

estimated total lifetime economic cost of $137.5 billion.6 They account for about one-third of the

total lifetime cost of injury in the U.S.7



Motor vehicle fatality rates are highest for young and elderly adults, while injury rates peak in

young adulthood.1,4 In 1992, motor vehicle crashes accounted for 30% of all deaths in persons

aged 15-24.1 The high mortality rate in older adults reflects a high case-fatality rate, probably

due to increased likelihood of developing serious complications after motor vehicle injuries, as

drivers 65 years of age and older have the lowest rate of crashes per 100,000 licensed

drivers.4,8,9 Motor vehicle fatality rates for males are more than twice that for females.1,4

Although alcohol-related traffic fatality rates have declined by more than one third since 1979,10

alcohol use remains an important risk factor for motor vehicle injuries. An estimated 17,461

persons were killed in alcohol-related motor vehicle crashes in 1993, accounting for 44% of

total traffic fatalities for the year.4 About one third of drivers killed in crashes in 1993 were

intoxicated by alcohol (typically defined in U.S. law as blood alcohol concentration [BAC]  0.10

g/dL).4 The proportion of fatally injured drivers having BAC above 0.10 g/dL is highest for those

aged 21-44.4 In 1992, 1.6 million persons were arrested for driving under the influence of

alcohol or drugs.11 Alcohol-involved crashes have been estimated to account for 40% of

comprehensive motor vehicle crash costs in the U.S.12



Efficacy of Risk Reduction



Driving while impaired by alcohol or drugs and failing to use occupant protection (e.g., safety

belts, child safety seats, motorcycle helmets) are two of the most important risk factors for motor

vehicle injury. (Screening for potential impairment due to medical conditions such as diabetes or

epilepsy will not be addressed in this chapter.13,14) Case series have reported that up to half of

fatally injured drivers have BAC of 0.10 g/dL or higher (although the proportion has declined in

recent decades).4,9,15 Controlled studies have shown that drivers involved or injured in crashes

are more likely to have a BAC of at least 0.10 g/dL than are other drivers.16-18 BAC at or below

0.05 g/dL are also associated with impaired driving skills performance and an increased risk of

motor vehicle crash involvement and fatality, particularly for younger drivers.19-22 In addition

to its role as a risk factor for causing motor vehicle crashes, alcohol use may increase the risk of

death or serious injury during a crash;23,24 this association may be partially confounded by

other high-risk behaviors associated with alcohol use, such as failing to use safety belts and

motorcycle helmets.25-27 Alcohol can also limit the ability of the victim to escape from the

vehicle.15,23 Alcohol-intoxicated survivors with severe brain injuries appear to have longer

hospitalizations and more persistent neurologic impairment than those who were not

intoxicated.28 Evidence that reducing drinking and driving decreases the risk of motor vehicle

injury comes from multiple time series studies demonstrating that raising the legal drinking age

or lowering legal blood alcohol limits can significantly reduce alcohol-related fatal crashes.29-

33



Many alcohol-related motor vehicle crashes may be attributable to problem drinkers. Persons

dying in alcohol-related traffic crashes are significantly more likely to have alcohol-related

arrest histories or autopsy findings suggestive of alcoholism.4,34-36 In a cohort of Swedish men

followed for 20 years, the relative risk of dying in a traffic crash among heavy drinkers was 2.3

times higher than for moderate drinkers and 8 times higher than for nondrinkers.37 One study

has also suggested that alcoholic drivers, when compared to the general driving population, have

more motor vehicle crashes per capita and per vehicle mile driven and more frequent convictions

for impaired driving.38 Screening for problem drinking followed by a brief counseling

intervention has been proven to reduce alcohol consumption (see Chapter 52). Therefore, such

screening is likely to be efficacious in reducing motor vehicle injuries and fatalities.



It has been estimated that drugs (such as marijuana, cocaine, and tranquilizers) may be present in

10-32% of drivers injured in traffic crashes,39-43 although not all studies have been able to

separate the effects of these drugs from those of alcohol and the presence of such drugs does not

necessarily indicate impairment. In case series that tested drivers injured in traffic crashes for

both substances, almost half who tested positive for illicit drugs had negative BAC.41-43 One

study evaluated 175 consecutive subjects stopped by police for reckless driving who were not felt

to be alcohol-impaired based on a negative breath analysis, lack of odor of alcohol, or both.44

Urine testing was performed on 150 (86%), of whom 88 (59%) tested positive for marijuana,

cocaine, or both, while 5% tested positive for alcohol. Whether the illicit drugs caused reckless

driving, or were simply associated with it in persons disposed to multiple high-risk behaviors, is

not established. Simulated driving tests suggest impairment of certain abilities by marijuana and

other drugs, similar to that produced by alcohol.45-47 Thus, evidence indicates that impairment

with drugs other than alcohol may also play an important role in traffic injuries and deaths,

although the relationship is not as well defined as for alcohol.



Use of occupant restraints has been shown to reduce the risk of motor vehicle injury and death.

The efficacy of safety belts has been demonstrated in a variety of study designs that include

laboratory experiments (using human volunteers, cadavers, and anthropomorphic crash

dummies), postcrash comparisons of injuries sustained by restrained and unrestrained occupants,

and postcrash judgments by crash analysts regarding the probable effects of restraints had they

been used.48-53 It has been estimated on the basis of such evidence that the proper use of lap and

shoulder belts can decrease the risk of moderate to serious injury to front seat occupants by up to

55%49,53,54 and can reduce crash mortality by 40-50%.53,54 When brought to the hospital,

crash victims who were wearing safety belts at the time of the crash have less severe injuries,

are less likely to require admission, and have lower hospital charges.50,52 Multiple time series

studies evaluating mandatory seat belt laws have reported significant reductions in motor

vehicle-related injuries, hospital admissions, and fatalities after implementation of such

laws.55-59



Child safety seats are also effective. It has been reported that unrestrained children are over 10

times as likely to die in a motor vehicle crash as are restrained children,60,61 although these

data come from studies with important design limitations. More recent studies suggest that child

safety seats can reduce serious injury by up to 67% and mortality by as much as 71%.62-64 A

20-25% decline in head and extremity injuries for children under age 4 has been reported in

States after enactment of mandatory child restraint legislation.65 Child restraints may also

reduce noncrash injuries (e.g., those due to sudden stops) to child passengers by preventing both

falls within the vehicle and ejections.66 The efficacy of child safety seats may be reduced by

improper use; such misuse has been reported in up to two thirds of children.67 The safety of child

safety seats used in combination with air bags is unknown. Laboratory crash test data indicate a

potential for injury to an infant placed in a rear-facing car seat in the front seat of a vehicle

equipped with a passenger-side air bag.68



Beginning with the model year 1998, all new passenger cars in the U.S. will be required to have

driver- and passenger-side air bags.69 A review by the National Highway Traffic Safety

Administration estimated that air bags increase the effectiveness of lap/shoulder belts by about 5-

10%.70 Recent modeling71 and observational72 studies estimate that air bags prevent 18-19%

of all automobile driver fatalities and 13% of right front passenger fatalities, over and above the

fatality reduction due to seat belt use. The estimated reduction in driver fatalities was about 21%

for unbelted drivers and 9% for belted drivers.72 Air bags are designed to be a supplemental

restraint system, and they do not deploy in low-speed, rear, side, or rollover crashes. Most

reported adverse effects of air bag deployment are minor (e.g., erythema, abrasions, and

contusions), although more serious injuries such as facial fractures have also been

reported.73,74



By wearing safety helmets, persons who operate or ride on motorcycles can reduce their risk of

injury or death from head trauma in the event of a crash. Head injury rates are reduced by about

40-75% among motorcyclists who wear safety helmets.75-77 Multiple time series studies have

reported that rates of fatal and nonfatal injuries have declined significantly in states that have

passed mandatory helmet laws.9,78-81 In one large study, a motorcycle helmet use law was

associated with a 37.5% reduction in fatalities (from 523 in 1991 to 327 in 1992), a 26.5%

reduction in motorcycle fatality rates (from 70.1 to 51.5/100,000 per year), and similar

reductions in admitted and emergency department-treated riders with motorcycle crash

injuries.82 Observed helmet use during the first year of the law was over 99%, compared to 46%

helmet usage before the law.83 States that have repealed mandatory motorcycle helmet laws have

experienced significant increases in motorcycle fatalities.75,84



The epidemiology of pedestrian injury varies by age group. Child pedestrian injuries most often

occur close to home and the majority of events involve children darting out into traffic at

mid-block.85,86 Risk factors for child pedestrian injury are being male and age 5-9 years,4

presumably due to both increased exposure and developmentally related limitations in pedestrian

skills.85,87 In a population-based New Zealand study, child pedestrian injury hospitalization

rates were 1.7/1 million road crossings and 72/100,000 population at age 5 years, declining to

about 0.6 and 40, respectively, by age 9 years with little change thereafter.88 One of the most

important risk factors for adult pedestrian injury is alcohol intoxication. In 1993, 36% of fatally

injured pedestrians over 14 years of age had BAC of at least 0.10 g/dL.88a Elderly persons have

the highest pedestrian death rate, despite studies showing that they may exhibit the most cautious

street-crossing behavior.89,90 Reduced mobility91 and sensory deficits associated with aging

may contribute to their increased risk. As with motor vehicle crash injuries, however, the high

death rate in elderly persons to a large extent reflects a high case-fatality rate.



There is no evidence to date that changes in any of the risk factors for the different age groups

reduces pedestrian injury. Studies have shown that parents of young children may overestimate

the pedestrian skills of their children, implying that teaching parents about developmental

limitations on pedestrian skills might decrease injuries.92,93 Observational studies suggest that

pedestrian visibility affects the risk of motor vehicle-pedestrian crashes.94,95 Several small

experiments have reported that wearing reflective or brightly colored clothing increases

pedestrian visibility and motorists' yielding to pedestrians,96-98 but these studies have

important design limitations. Whether wearing such clothing would reduce the risk of pedestrian

injury has not been studied.



Effectiveness of Counseling



Although the rate of alcohol-related driver fatalities has decreased in recent years, as many as 1.6

million persons continue to be arrested annually for driving under the influence of alcohol or

other drugs;11 this substantially underestimates the total number of persons who drive while

impaired, since only a small proportion are arrested.98a Similarly, while the use of occupant

protection systems and motorcycle helmets has increased substantially in recent years,69,99-

101 at least half of all Americans, and presumably many patients seen by clinicians, either do not

use occupant restraints or do not use them correctly when driving or riding in a motor vehicle.

Thus, it is likely that many patients could potentially benefit from clinician counseling to modify

their behaviors as drivers and passengers in motor vehicles. Since motor vehicle crashes

represent a leading cause of death and nonfatal injury in the U.S., even modest successes through

clinical interventions could have major public health value.



In actual practice, however, little is known about how effectively clinicians can alter any of these

behaviors. Although there is some evidence that persons involved in motor vehicle crashes while

intoxicated demonstrate lower recidivism with alcohol treatment interventions102 and that

community-based educational interventions to reduce alcohol-impaired driving may be

effective,103 there is generally little information from clinical studies on the ability of

clinicians to influence patients to refrain from driving while impaired by alcohol or other drugs.

There is good evidence, however, that brief clinician counseling can reduce alcohol consumption in

problem drinkers (see Chapter 52), which may, in turn, result in reduced drinking and driving.



There have been few studies examining the effectiveness of clinician counseling to increase safety

belt use. Most of the available studies have evaluated counseling parents to increase seat belt use

by their children.104 One controlled trial found increased self-reported safety belt use with

pediatrician counseling compared to mailed information; the interval to outcome assessment was

not specified.105 A second trial found that pediatrician counseling resulted in an immediate

increase in observed safety belt use, but there was no difference in self-reported usage rates

between the study group and controls at 1-year follow-up.106 In the same study, however,

observed seat belt use was highly correlated with the physician's own estimate of the proportion of

visits during which he counseled parents about seat belts.106 A nonrandomized controlled trial

involving adult patients evaluated the effect of improved physician delivery of clinical preventive

services after an intervention that included physician training, physician use of prevention

protocols, and reimbursement for counseling.107 The proportion of patients reporting that they

"began always using seat belts" was significantly higher in the intervention group at 1-year

follow-up. In a questionnaire survey, patients claimed to have increased their use of safety belts

as a result of a brief statement by their physician during a routine office visit,108 but the study

lacked controls and may have been biased by the patients selected. Other measures that have been

proven successful in motivating persons to use safety belts, such as community educational

programs and intensive psychological strate-gies,109 may not be generalizable to the clinical

practice setting.



Stronger evidence that clinician counseling can be effective comes from randomized and other

controlled trials in which parents of newborns and infants were encouraged to use infant safety

seats before this practice became widely mandated by law. These trials often used other types of

interventions in addition to clinician counseling, including written materials, videos, or free or

loaner car seats. Results from such trials indicate that significant immediate or short-term (up to

3 months) improvements in car seat use are possible.110-118 One randomized controlled trial

involving parents of children ages 1-17 years found no effect of clinician counseling and additional

interventions on the use of occupant protection,119 but most of the children were already using

restraints prior to the intervention.



The long-term efficacy of clinician counseling is less clear. One randomized controlled trial in a

military population showed increased reported car seat use at 9-12 months and increased car seat

sales for 10 months after the intervention,112 but in several other trials that included clinician

counseling, significant immediate or short-term increases in car seat use were not maintained at

longer follow-up.113,116-118 A time series study in which nurses conducted educational

sessions in the prenatal period, postpartum period, and at 2-month intervals after discharge

found that proper use of child safety seats had improved compared with rates in the previous year,

suggesting that periodic reinforcement is necessary to maintain high use rates.120



Direct evidence that physician counseling combined with community education programs can

reduce motor vehicle-related injuries to young children comes from a nonrandomized controlled

trial.121 This trial reported a 54% decrease in motor vehicle-related injuries among children

aged 0-5 living in the intervention communities compared to children in the control communities,

despite no difference in self-reported overall restraint use. In a separate analysis in which

persons in both communities were combined, reported car seat use was 12% higher in households

exposed to "participatory" prevention programs (i.e., received specific counseling, materials, or

other interventions), compared to those not exposed. Persons in the intervention communities

were significantly more likely to have such "participatory" exposure than were those in control

communities (55% vs. 34%). The authors were unable to distinguish between the effects of the

various interventions; a similar proportion of subjects reported exposure to pediatrician

counseling (21%) and to community education programs (17%).



Studies of the effectiveness of school-based programs to teach pedestrian skills to children have

shown some improvement in their attitudes and skills,122-124 and one researcher has reported

reductions in child pedestrian crash involvement through safety education films and other

materials.125,126 There is no evidence to indicate whether or not such interventions are

generalizable to the clinical setting.



Recommendations of Other Groups



Mandatory safety belt laws were in effect in 43 states, the District of Columbia, and Puerto Rico

in 1993.4 Child safety seat use is required by law in all 50 states, the District of Columbia, and

Puerto Rico.4 Recommendations specifically urging clinicians to counsel patients to use occupant

restraints (child safety seats or fitted lap/shoulder belts, as appropriate for age) have been

issued by a number of groups. These include the American Medical Association,127,128 the

American College of Physicians,129,130 the American Academy of Family Physicians

(AAFP),131 the American Academy of Pediatrics (AAP),132 the Bright Futures project,133 the

American College of Obstetricians and Gynecologists,134 the Canadian Task Force on the Periodic

Health Examination,135 the Public Health Service,135a and the National Highway Traffic Safety

Administration.136 The AAP has instituted special parent-oriented educational programs ("Every

Ride, Safe Ride") in which pediatricians encourage the use of child occupant protection beginning

with the ride home from the hospital and continuing throughout childhood.137 The AAP, Centers

for Disease Control and Prevention, and the 



Society of Automotive Engineers recommend against the use of rear-facing child restraints in the

front seat of cars with passenger-side air bags.68



In 1993, twenty-five states, the District of Columbia, and Puerto Rico had universal motorcycle

helmet laws; an additional 22 states required only that persons under a specified age (usually 18)

wear a helmet.138 The AAFP,131 the AMA,128,139 and Bright Futures133 recommend that

physicians counsel their patients who are motorcyclists to use approved helmets. The Canadian

Task Force found insufficient evidence to recommend for or against counseling patients to wear

motorcycle helmets.135



In 36 states and the District of Columbia, driving a motor vehicle with a BAC of 0.10 g/dL is a

criminal offense; in 10 states, the limit is 0.08 g/dL.4 In addition, all states prohibit the

purchase of alcohol by persons under the age of 21.140 The AAP,141 the AAFP,131 the AMA,128

Bright Futures,133 and the Centers for Disease Control and Prevention142 recommend counseling

patients to abstain from intoxicants when driving. The AAP also advises parents and children to

discuss the use of alcohol at teen parties, and suggest alternatives to driving while intoxicated or

riding in a vehicle operated by an intoxicated driver.141 The Canadian Task Force found

insufficient evidence to recommend for or against counseling patients to avoid drinking and

driving.135



Bright Futures and the AAP recommend teaching pedestrian safety to children.132,133



Discussion



There is good evidence that persons who use occupant protection devices or avoid driving while

alcohol or drug impaired are at significantly decreased risk of injury or death from motor vehicle

crashes. The evidence is less extensive that counseling by clinicians to adopt these practices is

effective in changing the behavior of motorists or passengers. Since motor vehicle injury

represents one of the leading causes of death in the U.S. and years of potential life lost, however,

interventions of even modest effectiveness are likely to have enormous public health benefit. Most

of the available evidence supports a relatively short-term effect of clinician counseling on the use

of occupant restraints, indicating the need for periodic reinforcement of this message.



There is little published evidence evaluating whether changing pedestrian behavior leads to

reductions in motor vehicle-related injuries or whether clinician counseling can influence

pedestrian behavior. Further study is also needed on environmental controls (e.g., barriers that

prevent pedestrians from crossing in the middle of dangerous roadways) that have the potential to

reduce pedestrian injuries.



CLINICAL INTERVENTION



Clinicians should regularly urge their patients to use lap/shoulder belts for themselves and their

passengers, and for their children who have outgrown safety seats, whenever driving or riding in

an automobile, including automobiles equipped with air bags ("A" recommendation for wearing

seat belts; "B" recommendation for counseling). Operators of vehicles carrying infants and

toddlers should be urged to install and regularly use federally approved child safety seats in

accordance with the manufacturer's instructions and the child's size ("A" recommendation for

child safety seat use; "B" recommendation for counseling parents). Passengers should not ride in

the cargo beds of pickup trucks. Passengers also should not ride in the cargo areas of station

wagons or vans except when those areas are fitted with passenger seats and passengers are

properly restrained in them with seat belts or child safety seats as appropriate for age. Clinicians

may wish to inform their patients of the effectiveness of air bags as a supplement to lap/shoulder

belt use in reducing motor vehicle crash-related morbidity and mortality. Rear-facing infant

seats should not be placed in the front seat of a car equipped with a passenger-side air bag.

Although forward-facing infant seats can be used in this situation, clinicians may wish to inform

parents that the safest seating position in the car is the middle of the rear seat. Those who operate

or ride on motorcycles should be counseled to wear approved safety helmets; this recommendation

is based on the proven efficacy of risk reduction from wearing helmets ("A" recommendation),

although the effectiveness of clinician counseling to increase helmet use has not yet been evaluated

("C" recommendation). Recommendations for bicyclists appear in Chapter 58.



All patients should be counseled regarding the dangers of operating a motor vehicle while under the

influence of alcohol or other drugs, as well as the risks of riding in a vehicle operated by someone

who is under the influence of these substances. This recommendation is based on the proven

efficacy of risk reduction ("A" recommendation) and the effectiveness of counseling problem

drinkers to reduce alcohol consumption ("B" recommendation) (see Chapter 52); the

effectiveness of counseling patients to avoid drinking and driving has not been evaluated ("C"

recommendation). Adolescents and young adults in particular should be encouraged to avoid using

alcohol or other drugs when driving is anticipated and to discuss with their families

transportation alternatives for social activities where alcohol and other drugs are used (also see

Chapters 52 and 53). The optimal frequency for counseling patients about motor vehicle injury

has not been determined and is left to clinical discretion. Counseling is most important for those at

increased risk of motor vehicle injury, such as adolescents and young adults, persons who use

alcohol or other drugs, and patients with medical conditions that may impair motor vehicle safety.



There is currently insufficient evidence to recommend for or against counseling patients or their

parents in order to reduce pedestrian injuries ("C" recommendation). Recommendations for such

counseling for elderly patients and for the parents of school-age and younger children may be made

on other grounds, including high burden of suffering, low cost, and lack of adverse effects. One

measure that may reduce pedestrian injury risk is wearing brightly colored or reflective clothing

to increase visibility to motorists. Educating parents to recognize the developmental limitations on

the pedestrian skills of young children and provide appropriate supervision in situations that

place children at risk for pedestrian injuries may also be effective in reducing pedestrian injury

risk. Although there is insufficient evidence to recommend for or against counseling regarding

problem drinking and alcohol use specifically to prevent pedestrian injury ("C"

recommendation), such counseling can be recommended on other grounds (see Chapter 52).



The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by

Natalie Smith, MD, MPH, and Carolyn DiGuiseppi, MD, MPH.



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