SURGEON GENERAL'S WORKSHOP ON

DRUNK DRIVING

Background Papers

Washington, D.C. o December 14-16, 1988

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
             Public Health Service

Offke of the Surgeon General

  5600 Fishers Ime
Rockville, Maryland 20857


ACKNOWLEDGMENTS

The Surgeon General's Workshop on Drunk Driving was supported by the follow-
ing organizations:

U.S. Department of Defense

U.S. Department of Education
U.S. Department of Health and Human Services
U.S. Public Health Service
  Alcohol, Drug Abuse, and Mental Health Administration
     National Institute on Alcohol Abuse and Alcoholism
      Office for Substance Abuse Prevention
   Centers for Disease Control
   Health Resources and Services Administration
     Bureau of Health Care Delivery and Assistance
     Bureau of Maternal and Child Health and
      Resources Development
    Indian Health Service

U.S. Department of Justice
   Office of Juvenile Justice and Delinquency Prevention

U.S. Department of Transportation
  National Highway Traffic Safety Administration

Editorial support and camera-readycopy were provided by Janus Associates
under contract 85080401.

AN material in this volume is in the public domain and may be used or reproduced without
permission from the Office ojthe Surgeon General or the aurhors. Citation of the source is
appreciated.

The opinions apressed herein are the views of tire authors and participants and do JlOf
necessarily reflect the official position of tlze Ofice of the Surgeon General or any other
sponsoriltg agency of the U.S. Goventr7latt.

Printed 1989


FOREWORD

The combination of drinking and driving claims one life every 20 minutes and injures
hundreds every day. Tragically, the major casualties are the youth of our Nation.
Daily- as a society and as individuals-we make decisions about drinking, about serving
alcoholic beverages, about driving, and about "having fun." These decisions affect our
own lives as well as those of our families, friends, and neighbors. Choices about drinking
and driving can protect our lives or destroy them. Thii serious health and safety problem
is preventable.

Many individuals and concerned groups have campaigned to end this devastation, but
it cannot be reduced without national leadership. The Surgeon General's Workshop on
Drunk Driving was held in December 1988 to devise a combination of strategies for
addressing the problem at the local, State, and National levels. Experts in diverse fields
related to drinking and driving were invited to the workshop to share their expertise and
experiences. Their recommendations, made after 3 days of intense discussion, can be
found in the Proceedings.
The background papers in this volume were commissioned to provide a foundation

for and launch the discussion of the 11 expert panels of the workshop. The authors
presented the state of the art in the different fields and describe the various attempts
throughout the country and the world to prevent alcohol-impaired driving- the trials,
the errors, the successes, and the obstacles. With up-to-date knowledge about the
problem and proposed solutions, and a coordinated comprehensive plan, we are ready
to enlist our country's help in preventing this major threat to our health and well-being.

C. Everett Koop, M.D., Sc.D.
Surgeon General

. . .
III


Workshop' Planning Com,mittee

Jerald H. Anderson
Chairperson

Intoxicated Driving Prevention Task Force
Office of the Assistant Secretary of Defense
Force Management and Personnel
Safety and Occupational Health Policy
U.S. Department of Defense

Loran Archer
Deputy Director
National Institute on Alcohol Abuse and Alcoholism
Alcohol, Drug Abuse, and Mental Health Administration
U.S. Department of Health and Human Services

Amy Barkin

Coordinator for the Drunk Driving Workshop
Office of the Surgeon General
U.S. Department of Health and Human Services

Maura Daly

Senior Policy Analyst
Office of the Secretary
U.S. Department of Education

Roberta Dorn
Director

Concentration of Federal Effort Program
Office of Juvenile Justice and Delinquency Prevention
U.S. Department of Justice

Robert W. Denniston
Director
Division of Communication Programs
Office for Substance Abuse Prevention
Alcohol, Drug Abuse, and Mental Health Administration
U.S. Department of Health and Human Services

Arthur S. Funke, Ph.D.
Chief Psychologist
Child and Adolescent Branch
Bureau of Maternal and Child Health and Resources Development
Health Resources and Services Administration
U.S. Department of Health and Human Services

V


Mary L. Ganikos, Ph.D.
Program Director

Community Prevention and Late Life Alcohol Abuse
National Institute on Alcohol Abuse and Alcoholism
Alcohol, Drug Abuse, and Mental Health Administration
U.S. Department of Health and Human Services

Jan Howard, Ph.D.
Chief

Prevention Research Branch
National Institute on Alcohol Abuse and Alcoholism
Alcohol, Drug Abuse, and Mental Health Administration
U.S. Department of Health and Human Services

Michael T. Impellizzeri
Chief

Special Programs Division
Office of Alcohol and State Programs
National Highway Traffic Safety Administration
U.S. Department of Transportation

Steve Moore

Associate Chief of Staff
Office of the Surgeon General
U.S. Department of Health and Human Services

James L. Nichols, Ph.D.
Deputy Director, Scientific and Technical Affairs
National Highway Traffic Safety Administration
U.S. Department of Transportation

Joan White Quinlan
Prevention Program Coordinator
Special Programs Division
Office of Alcohol and State Programs
National Highway Traffic Safety Administration
U.S. Department of Transportation

Richard J. Smith III
Manager

Injury Prevention Program
Indian Health Service
U.S Department of Health and Human Services

vi


Federal Advisory Group on Followup
  Activities for the Workshop

U.S. Department of Defense

Jerald H. Anderson

Chairperson, DOD Intoxicated Driving Prevention Task Force
Office of the Assistant Secretary of Defense
Force Management and Personnel
Safety and Occupational Health Policy
Room 3A272 The Pentagon, Washington, DC 203014000

U.S. Department of Education

Maura Daly

Senior Policy Analyst

Office of the Secretary, 400 Maryland Avenue, S.W.
Room 4145, Washington, DC 20202

U.S. Department of Health and Human Services

  U.S. Public Health Service

Robert W. Denniston

Director, Division of Communication Programs
Oflice for Substance'Abuse Prevention
Alcohol, Drug Abuse and Mental Health Administration
Room 13A-54 Parklawn Building, 5600 Fishers Lane
Rockville, MD 20857

Arthur S. Funke, Ph.D.

Chief Psychologist, Child and Adolescent Branch
Bureau of Maternal and Child Health and Resources Development
Health Resources and Services Administration
Room 9-21 Parklawn Building, 5600 Fishers Lane
Rockville, MD 20857

Mary L. Ganikos, Ph.D.
  Program Director

Community Prevention and Late Life Alcohol Abuse
National Institute on Alcohol Abuse and Alcoholism
Alcohol, Drug Abuse and Mental Health Administration

Room 16C-03 Parklawn Building, 5600 Fishers Lane
Rockville, MD 20857

vii


U.S. Department of Health and Human Services
US. Public Health Service (continued)

Susan J. Lockhart
  Program Specialist
  Office of the Surgeon General
  Office of the Assistant Secretary for Health
  Room 18-67 Parklawn Building, 5600 Fishers Lane
   Rockville, MD 20857

Richard J. Smith III
  Manager, Injury Prevention Program
   Indian Health Service
  5600 Fishers Lane, Rockville, MD 20857

Bob Vollinger

Presidential Management Intern
Office of the Surgeon General
Office of the Assistant Secretary for Health
Room 18-67 Parklawn Building, 5600 Fishers Lane
Rockville, MD 20857

U.S. Department of Justice

John Dawson

Program Manager
Office of Juvenile Justice and Delinquency Prevention
Room 758,633 Indiana Avenue, N.W.
Washington, DC 28531

Donni Hassler, Ed.D.
  Social Science Analyst
  Office of Juvenile Justice and Delinquency Prevention
  Room 742,633 Indiana Avenue, N.W.
  Washington, DC 20531

U.S. Department of Transportation

James L. Nichols, Ph.D.
  Deputy Director
   Scientific and Technical Affairs
  National Highway Traffic Safety Administration
  400 5th Street, S.W. Room 5130, Washington, D.C 20590

Joan White Quinlan

Prevention Program Coordinator, Special Programs Division
Office of Alcohol and State Programs
National Highway Traffic Safety Administration
400 7th Street, S.W. Room 5130, Washington, DC 20590

. . .
VIII


Abbreviations

402 Programs

408 Programs

410 Programs

ABC
ADAMHA
ASAP
ASTHO
BAC
BIA
CDC
CPL
DDP
DHHS
DOJ
DOT
DUI
DWI

EMS
FARS
FBI
FCC
IACP
IHS
Illegal per se

MADD

MCD

NAB
NAGHSR
NCADD

23 U.S.C. 402 Highway Safety Programs. These formula grants to the
States for highway safety programs are administered by the
Governors' Representatives for Highway Safety.
23 U.S.C. 408-I incentive grants to States for alcohol traffic safety
progr-
23 U.S.C. 410-I incentive grants to States for drunk driving prevention
programs
Alcohol Beverage Control
Alcohol, Drug Abuse, and Mental Health Administration
Alcohol Safety Action Projects
Association of State and Territorial Health Officers
Blood Alcohol Concentration
Bureau of Indian Affairs

Centers for Disease Control
Certified products list
Designated driver programs
Department of Health and Human Services
Department of Justice       '
Department of Transportation
Driving Under the Influence
Driving While Intoxicated

The terms DWI and DUI are synonymous, meaning either driving
while intoxicated or driving while under the influence. These are
general terms referring to the criminal action of driving a motor
vehicle either (1) while "illegal per se" or (2) while impaired, under
the influence, or intoxicated by alcohol or other drugs.
Emergency Medical Systems

Fatal Accident Reporting System
Federal Bureau of Investigation
Federal Communications Commission
International Association of Chiefs of Police
Indian Health Service

Refers to State laws that make it an offense to operate a motor vehicle
whiie at or above a specified blood alcohol level.
Mothers Against Drunk Driving
Multiple Cause of Death file taken from death certificate data by National
Center for Health Statistics
National Association of Broadcasters
National Association of Governor's Highway Safety Representatives
National Commission Against Drunk Driving


NCADI
NCIC
NHTSA

NIDA

NSA
OJJDP
OSAP
PBT
PHS

PI&E

PSA
RADAR

RFP

RID
RWlD

SRP
TEAM
TIPS

National Clearinghouse for Alcohol and Drug Information
National Crime Information Center
National Highway Traffic Safety Administration
National Institute on Alcohol Abuse and Alcoholism
National Institute on Drug Abuse
National Sheriffs Association
Office of Juvenile Justice and Delinquency Prevention
Office for Substance Abuse Prevention
Preliminary breath tester
Public Health Service

Public information and education
Public service announcement
Regional Alcohol and Drug Awareness Resource Network
Request for proposals
Remove Intoxicated Drivers
Riding With Intoxicated Driver
Safe ride programs
Techniques of Effective Alcohol Management
Training for Intervention Procedures by Servers of Alcohol


List of Participants

Ritchie Aanderud. President, Remove Intoxicated Drivers, Washington State,
Puyallup, WA.

Doris Aiken. President, Remove Intoxicated Drivers, Schenectady, NY.
John Allen, PhD. Chief, Treatment Research Branch, National Institute on Alcohol
Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health
Administration, U.S. Public Health Service, Rockville, MD.
Gloria Ames, CDR. Immigration and Naturalization Service, Health Care Program,
Washington, DC.

David Anderson, PhD. Substance Abuse Specialist, Arlington, VA.
Robert Apsler, PhD. Harold Russell Associates, Inc., Winchester, MA.
Loran Archer. Deputy Director, National Institute on Alcohol Abuse and
Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration,
  U.S. Public Health Service, Rockville, MD.
Katherine Armstrong, PhD. Coordinator, Children and School Programs, Oflice of
  Disease Prevention and Health Promotion, U.S. Public Health Service,
Washington, DC.

Charles K. Atkin, PhD. Professor, Department of Communications, Michigan State
University, East Lansing, MI.

Darryl Bertolucci. Mathematical Statistician, Division of Biometry and Epidemology,
National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and
Mental Health Administration, Rockville, MD.
Harold Brandt, MD. Mothers Against Drunk Driving, Baton Rouge, LA.
Rebecca Brown. National Public Policy Committee Chairman, Mothers Against
Drunk Driving, New Port Richey, FL.

Johnny Mack Brown. Sheriff, Greenville County Sheriffs Office, Greenville, SC.
Raul Caetano, MD, PhD. Alcohol Research Group, Berkeley, CA.
Beverly Campbell. Church of Jesus Christ of Latter Day Saints, Washington, DC.
Kay Chopard. Staff Attorney, Prosecuting Attorneys' Training Council, Des Moines,
  IA.

Marlene Cole, LCDR. Veterinary Resources Branch, Division of Research Services,
National Institutes of Health, U.S. Public Health Service, Bethesda, MD.
Ricky Davidson. Chief, Emergency Medical Services Committee, International
Association of Firechiefs, Shreveport, LA.
Galen Davis. Special Assistant to the Governor, Topeka, KS.
Delores Delaney. Member, National PTA, Committee on Health, Virginia Beach, VA.
Robert W. Denniston. Director, Division of Communication Programs, Office for
Substance Abuse Prevention, Alcohol, Drug Abuse, and Mental Health
Administration, U.S. Public Health Service, Rockville, MD.
Ted Doege, MD. American Medical Association, Chicago, IL.
John Donovan, PhD. Research Associate, Institute of Behavioral Sciences, University
  of Colorado, Boulder, CO.

xi


James P. Donovan. Chief, Division of Law Enforcement Services, Bureau of Indian
Affairs, Washington, DC.

Martin R. Eichelberger, MD. Director, Emergency Trauma Service, Children's
Hospital, National Medical Center, Washington, DC.
Vernon Ellingstad, PhD. Department of Psychology, University of South Dakota,
  Vermillion, SD.

Ann Esch. North Carolinians Against Intoxicated Drivers, Winston-Salem, NC.
James A. Far-row, MD. Director, Division of Adolescent Medicine, Director, Reduce
Adolescent Drinking and Driving Project, Department of Pediatrics, University
of Washington, Seattle, WA.

Howard Filston, MD. Duke University Medical Center, Durham, NC.
Mary L. Ganikos, PhD. Program Director, Late Life Alcohol Abuse, Prevention
Research Branch, National Institute on Alcohol Abuse and Alcoholism, Alcohol,
Drug Abuse, Mental Health Administration, U.S. Public Health,Service,
Rockville, MD.

Dean Gerstein. Study Director, National Academy of Sciences, Washington, DC.
Mark Goldman, PhD. Professor of Psychology, Director, Clinical Program, University
of South Florida, Tampa, FL.

Michael Goodstadt, PhD. Director, Division of Prevention, Rutgers Center for
Alcohol Studies, Rutgers University, Piscataway, NJ.
Lawrence'A. Greenfeld. Deputy Associate Director, Bureau of Justice Statistics,
Department of Justice, Washington, DC.
Joseph Gusfield, PhD. Professor, Department of Sociology, University of California
at San Diego, La Jolla, CA.

Frank Hamilton, MD, CAPT. National Institutes of Health, U.S. Public Health
Service, Bethesda, MD.

Maury Hannigan. Deputy Commissioner, California Highway Patrol, Sacramento, CA.
John Harvey. Elementary and Traffic Safety Education Consultant, State Department
of Education;Montpelier, VT.

William Hayes. Manager, New Jersey Highway Safety Office, Trenton, NJ.
Anthony J. Heckemeyer. Presiding Circuit Judge, 33rd Judicial District, Benton, MS.
Sandy Heverly. Mothers Against Drunk Driving, Las Vegas, NV.
Ralph Hingson, ScD. Professor, Chief of Social and Behavioral Sciences, School of
Public Health/College of Medicine, Boston University, Boston, MA.
Harold Holder, PhD. Director, Prevention Research Center, Berkeley, CA.
Jan Howard, PhD. Chief, Research Prevention Branch, National Institute on Alcohol
  Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health
  Administration, U.S. Public Health Service, Rockville, MD.
Michael Impellizzeri. Chief, Special Programs Division, National Highway Traffic
  Safety Administration, Washington, DC.
Michael Jacobson, PhD. Director, Center for Science in the Public Interest,
Washington, DC.

Paul Kamenar. Executive Legal Director, Washington Legal Foundation,
Washington, DC.

Jean Kilbourne, EdD. Board Member, National Council on Alcoholism, West
  Newton, MA.

Michael Klitzner, PhD. Pacific Institute of Research and Evaluation, Bethesda, MD.
John H. Lacy, PhD. Director for Alcohol Studies, The University of North Carolina,
Highway Safety Research Center, Chapel Hill, NC.
Ray Larson, Commonwealth's Attorney, Lexington, KY.

xii


Patricia D. Mail, CAPT. Division of AIDS Programs, U.S. Public Health Service,
&dviile, MD.

Philip May, PhD. Professor, Department of Sociology, University of New Mexico,
Albuquerque, NM.

Michael Mazis, PhD; Professor and Chair, Department of Marketing, American
University, Washington, DC.

Katherine McCarter. Associate Executive Director, American Public Health
Association, Washington, DC.

John McCarthy, PhD. Department of Sociology, Catholic University, Washington,
  DC.

George McCarthy. Chairman, Alcoholic Beverage Control Commission, Boston, MA.
Susan McLaughlin, MSN, RN. Senior Staff Specialist, Center for Nursing Practices,
American Nurses Association, Kansas City, MO.
Allan Meyers, PhD. Associate Dean, College of Liberal Arts, Boston University,
  Boston, MA.

John Moulden. National Transportation Safety Board, Washington, DC.
Joyanne Murphy, LCDR. National Institutes of Health, U.S. Public Health Service,
  Bethesda, MD.

Dennis Nalty, PhD. Director, Oftice of Policy Analysis and Development, South
Carolina Commission on Alcohol and Drug Abuse, Columbia, SC.
Carl E. Nash. Chief, Accident Investigations Division, National Center for Statistics
and Analysis, National Highway Traffic Safety Administration, Washington, DC.
James Nichols, PhD. Deputy Director, Scientific and Technical Affairs, National
Highway Traffic Safety Administration, Department of Transportation,
Washington, DC.

Pcrla Niguidula. Club Operations Specialist, Recreation Services Department, Naval
Military Personnel Command, Arlington, VA.
Robert Niven, MD. Harper Hospital, Department of Psychiatry, Detroit, MI.
Pctcr O'Rourke. Director, Office of Traffic Safety, Business and Transportation
Agency, Sacramento, CA.      .
Howard P. Patinkin. Assistant Deputy Superintendent, Chicago Police Department,
Traffic Division Administration, Chicago, IL.
Terry Pence. Traffic Safety Section, State Department of Highways and Public
Transportation, Austin, TX.

M.W. Perrine, PhD. Director, Vermont Alcohol Research Center, Burlington, VT.
James Peters. Responsible Hospitality Institute, Springfield, MA.
Charles Phelps, PhD. Professor of Economic and Political Science, Director, Public
Policy Analysis Program, University of Rochester, Rochester, NY.
Joan White Quinlan. Coordinator, Prevention Program, Special Programs Division,
National Highway Traffic Safety Administration, Department of Transportation,
Washington, DC.

George L. Reagle. Associate Administrator for Traffic Safety Programs, National
Highway Traffic Safety Administration, Washington, DC.
Nancy Ricci. President, Remove Intoxicated Drivers, Connecticut, Wallingford, CT.
Mary Beth Robinson. Director of Public Relations, National Automobile Dealers'
Association, McLean, VA.

James D. Rogers, Judge. Fourth Judicial District Court, Minneapolis, MN.
H- Laurence Ross, PhD. National Institute of Alcohol Abuse and Alcoholism,
Alcohol, Drug Abuse, and Mental Health Administration, U.S. Public Health
Service, Rockville, MD.

. . .
XIII


Wes Roy. Representative, City of Radcliff, Radcliff, KY.
Sue Rusche. National Drug Information Center of Families in Action, Atlanta, GA.
Micky Sadoff. National President, Mothers Against Drunk Driving, Hurst, TX.
Robert Sal& PhD. Assistant Director, Prevention Research Center, Berkeley, CA.
Lawrence Schneider. Health Services and Facilities Consultant, Office of Emergency
Medical Services, Department of Health and Rehabilitative Services,
  Tallahassee, FL.

William Scott. Director, Office of Alcohol and State Programs, National Highway
Traffic Safety Administration, Washington, DC.
Jerri Shaw. Johnson, Bassin and Shaw, Inc., Silver Spring, MD.
Harvey Siegel, PhD. Professor and Director, Wright State Substance Abuse
Intervention Programs, School of Medicine, Wright State University, Dayton, OH.
Bruce Simon+Morton, EdD, MPH. Associate Professor, Center forHealth
Promotion Research and Development, University of Texas, Health Science
  Center at Houston, Houston, TX.

David A. Sleet, PhD. Professor, Department of Health Science, Graduate School of
Public Health, San Diego State University, San Diego, CA.
Phillip Smith, MD, CDR. Indian Health Service, U.S. Public Health Service,
  Rockville, MD.

Richard J. Smith III, CDR. Manager, Injury Prevention Program, Indian Health
Service, U.S. Public Health Service, Rockville, MD.
Carl Soderstrom, MD. Assistant Professor of Surgery, Associate Director of
Physician Education, University of Maryland, Maryland Institute for Emergency
Medical Services Systems, Baltimore, MD.
Dorothy Stephens, LTJG. Health Resources and Services Administration, U.S. Public
  Health Service, Rockville, MD.

Alvera Stern, PhD. Administrator, Division of Prevention and Education, Illinois
Department of Alcoholism and Substance Abuse, Chicago, IL,
Kathryn Stewart. Pacific Institute for Research and Evaluation, Vienna, VA.
James W. Swinehart, PhD. President, Public Communication Resources, Inc., Pelham
  Manor, NY.

Elsie Taylor. Public Health Advisor, Prevention Research Branch, National Institute
on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health
Administration, U.S. Public Health Service, Rockville, MD.
John M. Templeton, Jr., MD. Childrens Hospital of Philadelphia, Philadelphia, PA.
Stephen Teret, JD, MPH. Director, Johns Hopkins Injury Prevention Research
Center, Johns Hopkins University School of Hygiene and Public Health,
Baltimore, MD.

Rae Tyson. USA Today, Arlington, VA.
Chauncey Veatch, III. President, National Association of State Alcohol and Drug
Abuse Directors, Department of Alcohol and Drug Programs, Sacramento, CA.
Robert B. Voas, PhD. Pyramid Planning, Bethesda, MD.
Alexander Wagenaar, PhD. Associate Research Scientist, University of Michigan,
Transportation Research Institute, Ann Arbor, MI.
Lawrence Wallack, Dr.P.H. Associate Professor, School of Public Health, University
of California, Berkeley, CA.

Julian Waller, MD, MPH. Professor, Department of Medicine, University of
Vermont, Burlington, VT.

Patricia Waller, PhD. Associate Director for Driver Studies, Highway Safety
Research Center, University of North Carolina, Chapel Hill, NC.

xiv


J& Watne. Special Assistant, Attorney General, State of Minnesota, Rosevihc, MN.
Clark Watts, MD, MPH. Professor of Neurosurgery, University of Missouri,
Arlington, VA.

Richard Waxweiller, PhD. Chief, Epidemiology Branch, Division of Injury
Epidemiology and Control, Center for Environmental Health, Centers for
Disease Control, U.S. Public Health Service, Atlanta, GA.,
Elizabeth A. Weaver. Director of Education, Motorcycle Safety Foundation,
Irx-ine, CA.

Allan F. Williams, PhD. Senior Researcher, Insurance Institute for Highway Safety,
Washington, DC.

LIarsha Woodward. President, Remove Intoxicated Drivers, Allen County,
Scottsvik, KY.

Judy Zundel. Special Assistant to the Deputy Assistant Secretary, Indian Affairs
(Trust and Economic Development), Bureau of Indian Affairs, Washington, DC.

xv


Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workshop Planning Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fcdcral Advisory Group onFohowup Activities for the Workshop . . . . . . . .
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
List of P&icipliIltS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
pricing and Availability

Alcohol Beverage Control Policies: Their Role in Preventing
Alcohol-Impaired Driving . . . . . . . . . . . . . . . . . . . . . . . . . . . .
   Alexander C. Wagenaar and Susan Farrell
Advertising and Marketing
Mass Communication Effects on Drinkiig and Driving . . . . . . . . . . . .
    Charles K Atkin

Epidemiology and Data Management
Epidemiologic Perspectives on Drunk Driving   . . . . . . . . . . . . . . . .
   M. W. Penine, Raymond C. Peck, and James C. Fell

Education

Controlling Injuries Due to Drinking and Driving The Context and
Functions of Education   . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Bruce G. Simon+Morton and Denise G. Simons-Motion

Judicial and Administrative Processes

The Effectiveness of Legal Sanctions in Dealing With Drinking Drivers   . .
James L. Nichols and H. Laurence Ross

Prosecution, Adjudication, and Sanctioning: A Process Evaluation of
Post-1980 Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
   James L. Nichols and Kevin E. Quinlan
Law Enforcement

Issues in the Enforcement of Impaired Driving Laws in the United States  .
   Robert B. Voas and John H. Lacey
TransPortation and Alcohol Service Policies
Transportation Alternatives for Drinkers . . . . . . . . . . . . . . . . . . . .
   Robert Apsler

Server Intervention and Responsible Beverage Service Programs . . . . . .
Robert F. Salti

. . .
111

V
vii
ix
xi

1

15

35

77

93

113

136

157

169

xvii


Injury Control

Injury and Disability Prevention and Alcohol-Related Crashes . . . . . . . .  180
  Julian A. Wailer

Youth and Other Special Populations
Youth Impaired Driving: Causes and Countermeasures . . . . . . . . . . . . 192
   Michael Klitzner

Motor Vehicle Crashes and Alcohol Among American Indians and
Alaska Natives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Philip A. May

Drunk Driving Among Blacks and Hispanics . . . . . . . . . . . . . . . . . . 224
   Jan M. Howara', Elsie D. Taylor, H. Laurence Ross,   ,,
   and Mary L. Ganikos

Treatment

Rehabilitation Countermeasures for Drinking Drivers . . . . . . . . . . . . . 234
   Kizth~n Stewart and Vernon S. Ellingstad
Citizen Advocacy

Independent Citizen Advocacy: The Past and the Prospects  . . . . . . . . . 247
John D. McCarthy and Debra S. Harvey

  . . .
XVIII


Pricing and Availability

Alcohol Beverage Control Policies: Their
Role in Preventing Alcohol-Impaired
      Driving '

Alexander C. Wagenaar, Ph.D.
77~ University of Michigan

Susan Farrell

National Institute on Alcohol Abuse and Akoholism

The phrase "alcohol control policies " refers to the entire constellation of laws and
regulations at the Federal, State, county, and city levels that affect how alcoholic
~,cvcragcs are manufactured, packaged, distributed, sold, and consumed. Control
politics are central in any comprehensive discussion of the prevention of impaired
(Iriving because the availability of alcoholic beverages is a necessary condition for
inlpaircd driving. Furthermore, alcohol control policies, interacting with private market
rncchanisms, directly determine the degree to which beverage alcohol is available to
consumers.

Concern with alcohol control policies has grown over the past two decades. Scientists
xnti professionals in the alcohol studies field increasingly recognize that alcohol is a risk
lxtor for a number of health problems, including traffic crashes, at both the individual
:ind societal levels. That is, the more alcohol a given individual drinks, the higher the risk
Ior health problems associated with that drinking, including automobile crash involve-
rncnt (NHTSA 1985). 2

Perhaps more important for public policy, the relationship also holds true at the
:ygrcgatc level. As a society consumes more alcohol, rates of alcohol-related problems
xc likely to increase (Moore and Gerstein 1981). Clearly, the relationship is not
ctnc-to-one, since hundreds of factors contribute to each health problem, including
motor vehicle injuries. For example, an increase in injury risk associated with higher
:Jcohol consumption could be offset by a decrease in risk resuking from other actions,
\uch as increased safety belt use. The important point is that alcohol consumption and
xsociated problems such as traffic crashes are viewed as public health problems, with
;I large population at risk of involvement in alcohol-related crashes. To be most effective,
prevention strategies should reduce risks across the population, rather than focus on the
rclalivcly small segment of society that at any given time exhibits extensive problems with
alcohol (i.e., addicted drinkers). Since customs and patterns of alcohol consumption

I  Warm thanks are expressed to several individuals who provided helpful comments On an earlier draft:
f larold Holder, James Mosher, Joan Quinlan, and Fredrick Streff.
2  Obviously, the relationship bemen alcohol consumption and alcohol problems is not deterministic, but
probabilistic. Increased consumption of alcohol increases the probability of associated problems, such as
`nfficcrashes. IMany individual differences and situation-specific factors affect the Outcome in any given case.


BACKGROUND PAPERS

apparently spread through the population by social diffusion (Skog 1980,1985), alcohol
control measures are likely to affect all consumers of alcohol, including both those with
low-risk drinking patterns and those with high-risk drinking patterns.

Another consequence of the public health view is recognition that very small changes
in behavior by huge populations can result in substantial net benefits to society in terms
of reduced alcohol-related problems. For example, a small reduction in an individual's
alcohol consumption is not likely to have an immediately observable effect on that
person's health.

However, the same proportionate decrease in alcohol consumption across the entire
society is much more likely to have demonstrable benefits in terms of reduced rates of
alcohol-related problems. Therefore, the relevant consideration is not whether a specific
alcohol control policy has an observable effect on given individuals, but whether changes
in behavior (perhaps undetectable at the individual level) cause demonstrable changes
in rates of health problems in the aggregate.

Alcohol control policies might affect impaired driving by two mechanisms. First, such
policies encourage or restrain the total amount of alcohol consumed, and amount is a
risk factor for impaired driving and the injuries that result. Second, specific control
policies alter thepattern of alcohol consumption (i.e., how a given quantity of alcohol is
consumed across time and across situations). For example, it is sometimes suggested
that policies that encourage drinking in one's own home rather than in a bar or tavern
be adopted to reduce the likelihood of impaired driving. Obviously, such policies might
reduce traffic crashes but exacerbate other problems associated with alcohol, such as
household injuries or spouse or child abuse.

This chapter has three objectives. Fist, we describe the types of laws and regulations
included under the broad rubric of Alcohol Beverage Control (ABC) policy. We briefly
discuss many dimensions of ABC policy to encourage a broader consideration of the
mechanisms already available that may be useful in efforts to reduce alcohol-impaired
driving and its damaging consequences. We do not include a lengthy discussion and
analysis of the research evidence for the efficacy of each of these many policy dimensions
in reducing alcohol consumption and alcohol-related problems. For most dimensions of
ABC policy, evaluation research is scarce, and many of the studies that are available have
major research design or implementation problems that limit confidence in the results.
Therefore, the second objective is more modest. We identify ABC policies that have a
significant body of research available, specifically those for which there is a scientific
basis for assessing their utility in reducing impaired driving. The third objective is to
present recommendations for changes in ABC policy and its application, acknowledging
that both scientific and political considerations necessarily influence both the develop-
ment and implementation of public policy.

Alcohol Control Policies

To structure the discussion of the wide variety of alcohol control policies, we have
grouped them into eight categories:

   o  Economic control policies

   o  Marketing control policies

3  This is not to minimize the benefits of relatively small changes in consumption in certain situations. For
example, reducing a driver's blood alcohol concentration from 0.08 g/100 ml to 0.01 g/100 ml by consumption
of hvo rather than four drinks in an hour reduces the risk of involvement in a traffic crash by more than SO
percent (Jones and Joscelyn 1978).


   .  Structure of the distribution system

   0  Beg&&on of individual outlets

   o  Sehmg/serving control policies

   .  Controls on product contents and packaging

   0  Legal availability control policies

   .  Social availability control policies
Some regulations span these categories; we have placed them in the category with
shich they are most closely identified. The major function of the ategori&on is
heuristic-to show the breadth of policies that fall under the term "alcohol control
policy" and to show how specific policies are conceptually related.

3

Economic Control Policies

ne most significant influence of ABC policy on the price of alcohol is the level of
excise and sales taxes on those beverages. Some jurisdictions have special tax rates for
,pcciBc products (e.g., alcoholic beverages containing local citrus products are treated
favorably in Florida). Federal excise tax rates on alcohol vary across beverage types (e.g.,
hccr, tine, distilled spirits). They are levied on the quantity sold (e.g., bottle, barrel,
gallon) rather than on price, and are not adjusted for inflation. Except for a small increase
in the tax on distilled spirits, Federal excise taxes have remained constant since 1951. As
;1 result of this and other factors, the real price of alcoholic beverages has fallen
aut,stantially over the last several decades. State excise taxes on alcohol have been
iucreascd periodically, but also tend to fall behind inflation. In addition, the effective
price of alcohol to consumers is influenced by levels of disposable income available, with
;rlc(~hol becoming less expensive when macroeconomic conditions are favorable and
incomes rise, unless retail alcohol prices rise accordingly.

A number of other economic control policies affect the (nominal) price of alcohol to
consumers. In some States, for some beverage classes, public policy determines the exact
lcvcl of retail price charged to consumers, and prices are uniform throughout the
jurisdiction. In some cases, price levels and variability are controlled, short of specifica-
tion of exact retail prices of alcohol. Minimum/maximum prices can be established
directly, or minimum/maximum markups over wholesale prices can be authorized.
Rcb~tcs of purchase price after the sale arc prohibited in some areas, as are special price
promotions such as "happy hour" discounts. Other inducements to purchase alcohol-
such as coupons, gifts, and prizes-may be regulated or prohibited. Provisions under
which credit can be extended to retailers and consumers for the purchase of alcohol also
idhmcc the cost and accessibility of alcohol.

Finally, the price of alcohol to some consumers is significantly affected by whether
alcohol purchases are tax deductible (Mosher 1983). For those in higher income
categories (i.e., with higher marginal tax rates), tax deductions for alcohol consumed in
the course of business activity effectively reduce the price by one-third.

Marketing Control Policies

Most discussion of ABC policies concerning marketing focuses on restrictions on the
advertising of alcoholic beverages. Advertising may be prohibited outright for some
beverages in some media. More commonly, the content of advertising is regulated.
Content issues include whether prices may be listed, whether the alcohol content of the
advertised beverage may be stated, whether actual consumption of alcohol may be
depicted, and minimum age for models that may be used. Current policies frequently
include limits on more subjective characteristics, such as content that appeals to
"Prurient interests"; is "offensive, gaudy, or blatant"; "' tllustrates women sensuously';


BACKGROUND PAPERS

uses "religious signs or symbols"; or uses words like "booze" or "saloon." Current
Federal regulations include language regarding limits on misleading or deceptive adver-
tisements, although these limits have not been consistently enforced (Mosher and
Wallack 1981). Prohibitions on lifestyle advertising bave been suggested. Lifestyle
advertising closely ties alcohol consumption to personal, financial, athletic, and sexual
satisfaction and success, in contrast to advertising that focuses on specific characteristics
or descriptions of the beverage.

Which media are appropriate for alcoholic beverage advertising is an issue in ABC
policy. Should such advertising be permitted on billboards and in the broadcast media,
where a substantial part of the audience is under the legal drinking age? A similar
question holds for magazines having most of their readers under the legal age. The role
of advertising revenues in influencing media coverage of health and social consequences
of alcohol use is also relevant. The extent of such influence regarding alcohol is currently
unknown. However, research has shown a clear relationship between amount of revenues
received from tobacco advertisers and editorial content on the hazards of smoking.
Publications with large numbers of cigarette advertisements rarely mention the hazards
of smoking in their articles on health (Warner 1985,1986).

In addition to advertising, many other dimensions of the promotion of alcoholic
beverages are susceptible to regulation. Displays and posters promote alcoholic
beverages at the point of sale. T-shirts, jackets, and other clothing reinforce messages of
advertising campaigns. Other products with beverage alcohol names and images are
frequently marketed (e.g., Bud Light Spuds MacKenzie dolls are sold in toy and novelty
stores). Sponsorship of sporting matches, music concerts oriented toward teenagers
(rock concerts), and other events also promotes alcoholic beverages. Alcoholic
beverages are distributed free of charge at special promotions. Fees are paid to movie
producers in exchange for depicting on-screen, integrated into the plot, the use of a
specific brand of alcoholic beverages. This practice constitutes advertising even though
viewers may not perceive it as such.

In addition to controls on alcoholic beverage advertising, requirements for counter-
advertising have been proposed. Requiring advertisements on the hazards of alcohol
("equal-time" policies) and specifying that alcoholic beverage containers have warning
labels regarding those hazards are frequently mentioned as means to partially balance
advertising claims that encourage alcohol use with information on the risks of such use.
(Rarely do proposals for counter-advertisements literally specify "equal time." Typical-
ly, a lower ratio of advertisements to counter-advertisements is proposed, for example,
one counter-advertisement for every four or five advertisements.) Other proposals
include compulsory warning messages in all alcohol advertising (similar to the warnings
in cigarette advertisements) and required warning posters where alcohol is sold or
consumed.

Finally, allowing or limiting the tax deductibility of advertising and other promotional
efforts is another dimension of ABC policy that affects the marketing of alcoholic
beverages.

Structure of the Distribution System

The most commonly noted characteristic of the alcoholic beverage distribution system
in the United States is whether a given State has a monopoly or license system. States
are frequently dichotomized as to whether they have a monopoly on alcohol sales or
whether they license private enterprises to distribute alcoholic beverages. In reality, the
monopoly-license dimension is a continuum, with States distributed at varying points
according to the degree to which they control alcohol sales. Monopolies are frequently
limited to a single class of beverage; for example, distilled spirits may be monopolized,
while beer and wine are not. Monopolies may be limited to the wholesale level, or may


i~,,Tr both &oiesalc and retail sales. Conceptual an! empirjc.? development of scales
, , n,c.sure where each State is on the control contmuum 1~ m the very early stages
;;r,,l~cr and Jams 1987). Such development should be encouraged to help move the
rcsc.rch and policy diSCUSSiOns away from the simplistic tendency to dichotomize
J&&ulion systems.

~~~~~~~~~ to rhe degree to which the distribution system is a public monopoly is the
.Iruz(ult' and power of the agencies responsible for alcoholic beverage control. The
:lu,T,t,c'f and characteristics of the people on the governing board, the nature of the
,,l,~~,~in[ing authority, and the grounds for removal of board members and the agency
,j;rcc[nr affcct how.responsive the control agency IS to local commumty concerns about
.,j<-irhnl outkts.

(;c~vcrnmcnt regulation affects many other dimensions of the distribution system
,[ruclurc, and these dimensions warrant attention regarding their effects on alcohol
iL,nsumption and associated problems such as alcohol-impaired driving. Regulation of
franchi.cc alcohol outlets, amount of competition permitted, degree to which private
,~~~,n~lpolics or oligopolies are permitted, provisions allowing localized prohibition of    '
,,l~~~h~>l salts, and extent of local government or community review of alcohol outlets are
,M]V ;I few of the dimensions of ABC policy that directly affect the structure of the
.IIc;,hoIic hcxrage distribution system (Roth et al. 1987).

l<cgul;ltion of Individual Alcohol Outlets

~1 ;,ny analvsts use the term "physical availability" to refer to the distance in space ad
, ,,,,c tlcrwccn-individuals and a source of alcohol. A number of ABC policies affect when
.,rlk~ \vtlcrc people can acquire alcoholic beverages. Typically, the number and density of
rcl;lil o~l~~t~ is limited by population or geographic area, with varying limits for different
~~~~~~ of ()U~IC~S (e.g., off-premise or on-premise consumption outlets; beer, wine, or
(ii\tittcd spirits outlets). Locations for alcohol outlets are controlled by prohibikms on
.,lcchol outlets that are too close to schools, churches, or another alcohol outlet. When
Iic-cwing new outlets in urban areas, proximity to public transportation should be
~.onGlcrcd to dccrcase the necessity of automobile use by impaired bar and tavern
I).llrc)ns (Ross 1982).

~11 S~atcs limit the days or hours that alcoholic beverages may be sold. Allowable
~~p~.nirl~~ and closing hours vary from State to State, and sales on Sundays and holidays
111 my txz prohibited or restricted to a few hours or to specific types of beverages.

Whether it is easy to open a new alcohol outlet or maintain a current outlet is
inllucnccd by license fees, limits on who may own a license, requirements for reporting
.lnd rccordkccping, financial means requirements, and availability and rates of man-
cl:ltcxy litibility insurance.

ABC policies also influence the nature and design of retail alcoholic beverage
r\t:It)lishmcnts. The types of retail establishments that may sell alcoholic beverages are
JI\~ ofkn restricted. The following types of outlets may be permitted to sell or restricted
from .tclling alcoholic beverages: drug stores, convenience stores, grocery stores, hotels,
rcQW sports stadiums, concert halls, private clubs, restaurants, and fast food res-
I;lurank The architecture, lighting, visibility, number and placement of windows and
clo(P seating arrangements, and other physical characteristics of specific outlets - par-
`icularly those for on-premise consumption-are typically circumscribed to some de-
Srcc. A number of ABC statutes and regulations specify other products that an alcohol
`~lct maYa may not, or must, sell. For example, all on-premise alcohol outlets may be
rcquircd to sell food or nonalcoholic beverages. The minimum portion of total revenues
"lowable from food sales may be specified. Whether gasoline stations and convenience
5*orcs that Sell gasoline should be allowed to sell beverage alcohol is currently under
dchatc in several States. Other activities in alcohol establishments may be restricted; for


6

BACKGROUND PAPERS

example, nude dancing may be prohibited in places where alcohol is served. Many such
regulations on specific alcohol outlets affect whether a new outlet opens, the charac-
teristics of that outlet, the specific segment of the market it appeals to, the pattern of
drinking encouraged by the establishment, and, as a result, the risk of alcohol-impaired
driving.

Selling/Serving Control Policies

In addition to policies affecting alcohol outlets, many statutes and regulations, as well
as a large body of case law, affect specitic practices concerning how alcoholic beverages
are sold or served. Some types of sales/serving practices are simply prohibited. On-
premise consumption of alcoholic beverages has been limited to beer and wine in some
jurisdictions, prohibiting sale of liquor by the drink. Self-service is not always allowed.
Purchase of drinks "by rounds," where one person purchases drinks for a large group,
may be prohibited. Size of serving containers may be controlled, prohibiting sales by the
pitcher, for example. Serving alcohol to certain categories of `consumers is typically
prohibited. Such categories may include underage patrons, intoxicated drinkers,
"habitual drunkards," or "known alcoholics." Finally, training may be required for those
who sell or serve alcoholic beverages.

At least half of alcohol-related traffic crashes involve drinking at an on-premise
establishment, even though only about a quarter of all alcohol sold is distributed by
on-premise outlets (O'Donnell 1985). As a result, regulation of on-premise outlets may
be particularly important for the prevention of impaired driving.

The best known dimension of ABC policy related to selling and serving practices is
"dram shop" liability, that is, liability of sellers or servers for damage caused by alcohol-
impaired persons. The typical case involves a bar patron who leaves an establishment
after consuming large amounts of alcohol, and, while driving home, causes a traffic crash
that maims or kills another motorist. The exact nature of the server's liability varies
considerably across jurisdictions and is the consequence of complex interactions among
statutory specifications, case law, and common law. Furthermore, administrative, civil,
and criminal sanctions may be involved. Liability has typically been limited to commer-
cial sellers/servers of alcoholic beverages. However, there have been cases in which social
hosts have been held liable for damage caused by intoxicated guests, particularly if the
guests are under the legal age.

Controls on Product Contents and Packaging

The amount of alcohol in alcoholic beverages is the most relevant product-content
issue in terms of preventing impaired driving. Federal law currently prohibits labeling
beer to show alcohol content unless State law requires such labeling. Beverages with very
low alcohol content are frequently not considered alcoholic beverages. If such products
(e.g., "near beer" with 0.5 percent alcohol) are marketed to underage drinkers, and if
these drinkers use them as a gateway beverage before moving on to "real" beer,
regulation might be considered appropriate. On the other hand, if consumption of
very-low-alcohol beverages displaces consumption of beverages with higher alcohol
content, tangible benefits in terms of reduced alcohol-impaired driving may result.
Low-alcohol beer (2-3 percent alcohol) is another product that may affect alcohol-
impaired driving, depending on whether the beverage substitutes for the same quantity
of higher alcohol beverages or leads to adding new drinking occasions to existing
consumption patterns.

A major component of the marketing strategies of alcoholic beverage industries'is the
development of new brands that are positioned to appeal to specific segments of the
market. For example, some brands of beer are marketed to working-class males, others
to upper middle-class males; some are targeted to blacks, others to women. Because


.h markct segmentation is central in efforts to increase alcohol consumption, SOme
;yzc.rchers have suggested that commo$fizafioq of the %.efage alcohol market be
,,-idcred (McGuinness !988>. Cpnfmdtlzatlon mvolves htmg the market to a small
numkr of products and dlfferentlatmg them based on .pr$ct content, rather than on
[hc image of the product and the market-segment for which d 1s positioned. For example,
!hr kc. market might be restricted to hght, medmm, and heavy beer, based on alcohol
il,nrcnt. With the exception of specifying the type, all packaging.and labeling would be
i,lcnlicd across all brands. The implications of such a move toward generic alcoholic
1Yvcr3ges are complex and would represent a dramatic change from the current market
rwcwre.

-

Incrcscd understanding of the nature of beverage alcohol markets and the potential
rc,lC `,fABC policy in structuring those markets to minim& risks associated with alcohol
m3v help identify less dramatic (and more feasible) regulatory changes that nevertheless
miiht minimize adverse effects on public health. For example, wine coolers are new
pr;Klucts that have been sumssftiy marketed in recent years. They are &signed to
~l~pca] to a different population from traditional wine drinkers. Even more recently, w&e
<oc)lcrs have been packaged in single-serving boxes that are idistin~ishable from boxes
contrrining fruit juice or punch (Trauma Foundation 1988). Effects of such new &oh&
~~roducts on drinking patterns and risks have not been studied, but they may warrant
,~Jditiwlal attention.

Fin:lIIy, many detailed regulations deal with how various alcoholic beverages may be
,,;&;lgcd. Container size (e.g., miniature versus larger bottles of distilled spirits),
nurnbcr of containers per case, position of any required tax stamps, ingredient labeling,
,IIK~ warning labels are a few examples. As noted already, warning labels may be one
conlponcnt of a larger effort to inform the public about the hazards of alcohol, particular-
ly when rclatcd to driving.

I ,rgal Availability Control Policies

`III~ principal limit on legal availability of alcohol is the minimum drink+ age. In all
S~;I(CS, alcohol may not be sold to those under the age of 21, and those under 21 are
1~ L)hilGtcd from purchasing, possessing, or consuming alcohol. Specific legislative lan-
F,:::IK~ vrrrics from State to State. Some States prohibit all consumption of alcohol by
unclcragc individuals; others prohibit purchase or possession for personal consumption.
hl;my States permit exceptions for religious ceremonies. Such legal proscriptions clearly
~1~1 not prcvcnt underage youth from acquiring alcohol; youth get alcohol from older
lricnds and associates as well as from establishments that sell to youth despite the law
(1 lingson ct al. 1983). Nevertheless, minimum-age statutes clearly make it more difficult
l'c)r youth to obtain and consume alcoholic beverages.

Other legal availability control policies limit the locations and times when alcoholic
tlcvcragcs may be consumed. Open container laws in many States prohibit possession of
.ln open container of alcoholicbeverage in a motor vehicle that is being driven on a public
rc)ad or highway. Consumption of alcohol in public is frequently prohibited, particularly
On publicly owned property such as parks, plazas, and school grounds. Consumption of
dlcohol is prohibited or restricted where risks associated with consumption are perceived
to bc high, or where many nondrinkers are present, such as in sports stadiums and
Wformance halls. Separate sections for nondrinkers may be required. Alcohol con-
sumption is frequently prohibited on the job, especially by those whose positions directly
3rrcct public safety, such as commercial pilots, large-truck drivers, and railroad en-
gineers. Policies mandating random or periodic testing of workers for alcohol (and other
drums) are currently under debate. Which occupations involve public safety to such a
dcSee as to warrant such testing remains an open question.


BACKGROUND PAPERS

Social Availability Control Policies

"Social availability" denotes the extent to which social norms regarding appropriate
or inappropriate consumption of alcoholic beverages encourage behavior patterns that
increase the risk of adverse effects of alcohol. The term is imprecise, and its definition
is neither broadly accepted nor consistent. Nevertheless, it does point out possible public
policies that may affect social norms regarding drinking, but that do not specifically
regulate the distribution and sale of alcohol. For example, the depiction of alcohol use
in movies and on television helps define social norms regarding drinking. The number
of drinking occasions shown on prime-time television is disproportionate. Wallack and
others (1987) found an average of 11 drinking occasions per hour during prime time in
the fall of 1984. Depictions of alcohol consumption might be delayed until late in the
evening to reduce the extent to which children and adolescents are exposed to them.
Films might be rated with regard to their depiction of alcohol and other drugs, and these
ratings provided to potential viewers.

Research Evidence: ABC Policies and
Alcohol-Impaired Driving

Many dimensions of ABC policy are potentially relevant to reducing alcohol con-
sumption, and thereby to reducing the death, disease, disability, and damage associated
with use of alcoholic beverages, including motor vehicle crashes. Based on our broad
knowledge about how economic, physical, and social environments influence people, the
possible role of these policies must be considered in efforts to prevent alcohol-related
problems, including traffic crashes.

However, stating clearly the known effects of each of the many dimensions of ABC
policy is much more difficult. First, each specific policy dimension alone may have an
effect so small as to be unidentifiable given available data and research technology.
Nevertheless, their effect as a whole may be substantial. Second, no scientific literature
exists on most of these dimensions of ABC policy, and limited research results are
available for others. Excellent comprehensive reviews of the literature on many facets of
ABC policy have already been published (Holder 1987; Ashley and Rankin 1988) and
therefore will not be repeated here.

Of all the dimensions of ABC policy, two have been studied in detail, particularly with
regard to their effects on traffic crashes. For these, sufficient scientifically credible
evidence is available to make unambiguous policy recommendations.

Minimum Drinking Age

The minimum legal drinking age is perhaps the most thoroughly studied dimension
of ABC policy. Furthermore, most of the studies explicitly focused on the effects of the
minimum age on motor vehicle crashes. In the early 197Os, 29 States lowered the
minimum age at which young people could legally purchase, possess, and/or consume
alcoholic beverages (or at which alcoholic beverages could legally be sold to them). Soon
afterward, there was a "dramatic increase" in the rate of alcohol-related crashes involv-
ing 18-, 19-, and 20-year-olds, according to a review by the General Accounting Office
(GAO 1987).

Many studies of the lowered legal age laws were made, and a number of reviews have
been published (Wagenaar 1983; Whitehead 1980). Reviewers concurred that, in the
better designed studies (Cook and Tauchen 1984; Douglass et al. 1974; Whitehead et al.
1975; Williams et al. 1975), a decrease in the minimum drinking age was associated with


PRICING AND AVAILABILITY

an increase in the rate of alcohol-related crashes among young drivers directly affected
by the change in the Iaw.

Persuaded in part by this evidence, States began to raise their minimum drinking ages
in 1976 - and a new generation of studies followed, In 1985, Congress asked GAO to
review these studies critically and evaluate the degree to which they provided empirical
support for Federal and State efforts to raise the legal drinking age (GAG 1987).

The GAO's search of the literature identified 32 studies of the impact of increasing
the minimum drinking age on traffic crashes involving young people in the age group
directly affected by the law. However, many of these studies were judged to be of
insufficient scientific quality to inform policy decisions. Of the 14 studies that did meet
GAO's methodological criteria, 4 addressed fatal crashes across several States and 5
addressed fatal crashes in individual states (Arnold 1985; DuMouchel et al. 1985; Emery
1983; FDCA 1983; Hingson et al. 1983; Hoskin et al. 1986; Klein 1981; Lillis et al. 1984;
Maxwell 1981; Schroeder and Meyer 1983; Wagenaar et al. 1981; Wagenaar 1987;
Williams et al. 1983). 4 The remainder addressed crashes with other outcomes, such as
injury and property damage. With one exception, these studies explored the effect of
changes in the law on the number of young drivers involved in fatal or injury-producing
crashes, whether or not the driver was killed or injured.

The GAO concluded that significant reductions in motor vehicle crashes among
young people occurred in almost every State examined (GAO 1987). Further, despite
differences iu study design, analytic methods, outcome measures, and State charac-
teristics, the reported reductions were often of similar magnitude. The findings provided
by the four multi-State studies of fatal crashes lend themselves most easily to generalii-
tion. These studies reported reductions ranging from 5 to 28 percent. Studies of in-
dividual States obtained similar results. The GAO noted that results from multiple
studies using multiple methods are rarely so consistent. States that did not show
significant reductions in traffic crashes generally had small populations and few crashes,
making it difficult to distinguish chance outcome from the effects of the law. Most of the
studies reviewed by GAO addressed the immediate effect of raising the minimum
drinking age. Two, however, explored the effects over the long term and found them to
be sustained (Wagenaar 1987; DuMouchel et al. 1985).

Two studies meeting GAO's criteria for scientific adequacy (Lillis et al. 1984, Perkins
and Berkowitz 1985) found that an increase in minimum drinking age was followed by a
decrease in self-reported incidence of driving after drinking among young persons
directly affected by the change in the law. However, both studies focused on New York,
so the extent to which these results can be generalized to other jurisdictions is unknown.

Alcohol Price and Excise Taxes

With the exception of a 1985 increase in the distilled spirits tax (from $10.50 to $12.50
per proof gallon), Federal excise taxes on alcoholic beverages have remained constant
for nearly four decades. If the Federal excise taxes on alcoholic beverages had increased
by the same percentage as consumer prices between 1951 and 1985 (314 percent), they
would have risen from $10.50 to $43.48 per proof gallon for distilled spirits, from $0.29
to $1.20 per gallon for beer, and from $0.17 to $0.70 per gallon for wine containing not
more than 14 peicent alcohol, Since most studies indicate that the price of.alcoholic
beverages influences consumption of alcohoi (Ornstein and Levy 1983; Levy and Sheflin

4  A number of the studies that GAO identified in the form inwhich theyoriginallyappeared-conference
papers and government reports-have since been published in the scientific literature. In their original
version, most of these (Wagenaar 1986; DuMouchel et al. 1987, Hoskin et al. 1986; Saffer and Grossman
1987~~) met GAO's criteria for scientific qualit)r, others did not (Males 1986).


10

BACKGROUND PAPERS

1983), the concern about the effect of current tax policy on alcohol-related problems is
growing.

Three studies have specifically addressed the effect of changes m-the real price of
alcoholic beverages on motor vehicle crashes. Cook (1981) studied the impact of 38
changes in State taxes on distilled spirits that occurred in the 30 States with license (rather
than monopoly) systems between 1960 and 1975. Although these tax increases were
relatively small, nearly two-thirds of them were followed by a greater reduction (or
smaller increase) in the auto fatality rate than occurred in the median State in the same
year. Cook concluded that an increase in taxes on distilled spirits tends to reduce the
rate of traffic fatalities.

Saffer and Grossman (1987~) explored the extent to which variations in State excise
tax rates on beer contribute to fatal motor vehicle crashes among young people. They
found that States with higher real beer taxes have lower motor vehicle fatality rates for
three separate age groups (15-17, 18-20, and 21-24). Based on these results, they
estimated that if the Federal excise tax on beer had been indexed to inflation since 1951,
the number of 18- to 2O-year-oh& killed in motor vehicle crashes in 1975-81 would have
been reduced by 15 percent. If alcohol in beer had been taxed at the same rate as alcohol
in distilled spirits, the number of 18- to 2O-year-olds killed would have been 21 percent
lower. And a combination of these two tax policies would have reduced the number killed
by 54 percent. Saffer and Grossman (1987~) also suggested that tax policy may be a more
potent instrument than a uniform minimum drinking age of 21 for reducing traffic deaths
among young people-in part because evasion is not possible. In another study, using
different methods, Saffer and Grossman (1987b) estimated that a lOO-percent increase
in the tax on beer (approximately $1.50 per 24-unit case) would reduce highway deaths
27 percent among 18- to 2O-year-olds, 18 percent among 15- to 17-year-olds, and 19
percent among 21- to 24year-olds.

Discussion ancfPolicy Recommendations

To initiate the discussion, we offer three recommendations. First, no policy changes
should be considered that may result in an increase in the degree to which alcoholic
beverages are available without careful analysis, study, and public debate on the potential
deleterious effects of such a policy change on alcohol consumption and associated health
and social problems. Permitting retail sales of distilled spirits for on-premise consump-
tion where that particular form of sales had been prohibited is an example of a modest
policy change that may not be expected to have a demonstrable effect on alcohol use and
problems. However, careful analyses of such a policy change in North Carolina found
that a significant increase in alcohol consumption and traffic crashes followed the policy
change (Blose and Holder 1987; Holder and Blose 1987). A broader recognition is
needed of the many dimensions of ABC policies and of their potential role in the
prevention of alcohol-related problems. Making informed decisions regarding ABC
policies will require a substantially increased commitment to research and evaluation of
specific ABC policy dimensions.

Second, the minimum legal drinking age of 21 should be retained, and enforcement
of the age-21 policy should be strengthened. The weight of the evidence clearly shows
substantial benefits of the age-21 policy in terms of reduced traffic deaths and injuries.
The burden of proof now rests with those suggesting a lower age to demonstrate the net
benefits of such a change.

Finally, Federal excise taxes on alcoholic beverages should be adjusted for fairness
and equity in three dimensions. First, Federal excise taxes should be equalized according
to ethanol (pure alcohol) content across all types of beverages by an increase in the rates


PRICING AND AVAllABlLlrY

11

for beer and wine to those of distilled spirits. Second, the resulting equal tax rate should
be adjusted for past inflation by an increase that reflects changes in the Consumer Price
Index for the previous year. The extant research evidence shows that an increase in the
excise tax could have the largest long-term effect of all policy and program options
available to reduce alcohol-impaired driving. Therefore, States should also change their
excise taxes to equalize rates across beverages, adjust for past inflation, and index for
future inflation. The proposed changes in alcohol taxes do not represent a radical change
in policy. They simply increase fairness by taxing all alcohol at equivalent rates and
correct for the unfortunate effects of inflation over the past two decades.

me we acknowledge the size and political power of the alcoholic beverage in-
dustries, the time appears to be right for such a change in excise tax policy. A "window
of opportunity" (Kingdon 1984) for correcting the continuing erosion of alcohol excise
taxes may appear in the next year or so. A broad concern with healthier lifestyles (e.g.,
diet, exercise, stress reduction), concern about medical care cost containment, and
increased disapproval of drug use are providing a climate in which increased excise taxes
on alcohol are supported. The huge Federal budget deficit will create continuing
pressures to raise revenues and minimize program costs. Increases in alcohol excise taxes
meet these needs well. They raise revenues and decrease levels of major health problems
and their associated costs, and they do not require resources for new program develop-
ment and implementation.

Public support for increased alcohol taxes is high. A recent Statewide probability
survey in Michigan found 86 percent of the population in favor of increasing the alcohol
excise tax to pay for programs to combat alcohol-impaired driving (Wagenaar et al.
1988). In an October 1986 Gallup poll, 66 percent of respondents approved of doubling
the Federal excise tax on alcoholic beverages (Gallup 1987).

Finally, increased excise taxes can be recommended based on equity and justice
arguments. Consumption of alcoholic beverages costs society billions of dollars in
medical care, social damage, and lost productivity (NLL4A 1987). Those costs are
shared by all through general sales and income taxes, insurance premiums, and prices
of the goods and services consumed. An increased excise tax would result in a higher
proportion of those costs being paid by those who consume alcohol (Mosher and
Beauchamp 1983). Some may even want to term the excise tax a "user fee" rather than
a tax, since only those who consume this particular hazardous product have to pay it, and
its function is to ensure that consumers pay a higher proportion of the true costs of the
product.

Arguments can also be made against increasing the excise tax on alcoholic beverages.
The first is that such a policy may affect "social" driers but not the heavy drinkers who
are causing social and health problems. Alcoholics, because of their addiction, will obtain
alcohol no matter what the price, this argument contends. On the contrary, research has
shown that addicted users of alcohol respond to price changes along with nonaddicted
users (Cook 1981; Cook and Tauchen 1982). Even if addicted drinkers were less
responsive to price, about half of alcohol-related traffic fatalities are caused by non-
addicted or "social" drinkers (Vmgilis 1983). A substantial decime in this portion of the
traffic crash problem resulting from an excise tax increase would be a major success in
itself.

The second argument against an excise tax increase is that excise taxes are regressive
and fall disproportionately upon lower income families. It is true that lower income
consumers pay a higher proportion of their disposable income for a particular product;
however, alcoholic beverages are not necessities but, rather, discretionary goods. In
addition, alcohol consumption is positively related to income-those at higher income
levels consume larger quantities of alcohol and would therefore pay more of the tax.
Furthermore, regardless of income level, significant benefits will accrue to families in
which heavy alcohol users reduce their consumption because of the tax.


12

BACKGROUND PAPERS

A third argument against an increase in the excise tax rate is that government revenues
wih fall, ifin fact the policy is successful in reducing alcohol use. However, the best overall
estimates of the price elasticity of alcohol are typically more than 0.4,but less than 1.0
(Levy and Sheflin 1983). As a result, an increase in excise tax rates from current levels
will result in both increased government revenues and reduced consumption of alcohol.

Conclusion

Our objectives in this chapter were to:

o  increase awareness of the complex multidimensional nature of alcohol
beverage control policy in the United States,

o  review research on effects of selected ABC policy dimensions on
alcohol-related traffic crashes, and

o  stimulate discussion regarding the most promising dimensions of ARC
policy for the reduction of alcohol-impaired driving.

While it is unlikely that there will be universal agreement with every specific point in our
analysis, most scientists studying alcohol policy issues appear to support the recommen-
dations offered here. Nevertheless, this chapter has only outlined the approximate
boundaries of the dialog. Continued research, policy analysis, and discussion among
scholars, policymakers, and others will help further delineate the many issues involved.
Finally, health education efforts are needed to increase awareness among the general
public of the effects of ABC policy and to build public support for policy changes
necessary to effectively reduce alcohol-impaired driving and its life-disrupting conse-
quences.

REFERENCES

Arnold, RD. Effeit of Raising the Legal LkinkingAge on Driver Involvement in Fatal Crashes: The
  Eqxrienceof Thirteen States. Washington, DC: National Center for Statistics and Analysis,
    1985.

Ashley, MJ., and Rankin, J.G. A public health approach to the prevention of alcohol-related health
  problems. Annual Review of Public Heaith 9233-71, 1988.
Blase, J.T., and Holder, H.D. Public availability of distilled spirits: Structural and reported
  consumption changes associated with liquor-by-the-drink. Journal of Studies on Alcohol
   48(4):371-379, 1987.

Cook, P J. The effect of liquor taxes on drinking, cirrhosis and auto accidents. In: Moore, M.H.,
   and Get-stein, D.R., eds. Alcohol and Public Policy: Beyond the Shadow of Prohibition.
   Washington, DC: National Academy Press, 1981. pp. 255-285.
Cook, P J., and Tauchen, G. The effect of liquor taxes on heavy drinking. BellJournal ofEconomics
   13:379-390, 1982.

Cook, PJ., and Tauchen, G. The effect of minimum drinking age legislation on youthful auto
   fatalities, 1970-1977. JournafofLegaZStudies 13:169-190, 1984.
Douglass, R.L.; Filkins, L.D.; and Clark, F.k The Effects of Lower LegalLIrinkingAges on Youth
   Crash Involvement. Report No. UM-HSRI-AI-74-1-2. Washington, DC: National High-
   way Traffic Safety Administration, 1974.

DuMouchel, WA; Williams, AF.; and Zador, P. Raising the Alcohol Purchase Age: Its Effect on
   Fatal Motor Crashes in 26 States. Washington, DC: Insurance Institute for Highway Safety,
    1985.

DuMouchel, W.A.; Williams, AF., and Zador, P. Raising the alcohol purchase age: Its effect on
   fatal motor crashes in 26 states. Journal of Legal Studies 16:249-266,1987.
Emery, J. Young drinking drivers invoived in fatal crashes. Statewide froblem Zdentification for
   F.Y. 1984 Highway Safety Plan. Des Moines, IA Governor's Highway Safety Office, 1983.


PRICING AND AVAILABILITY

Florida Department of Community Affairs, Bureau of Highway Safety. Relation of the Legal
  DrinkingAge to Young Drivers' Involvement in Traffic Accidents. Tallahassee, FL, 1983.
Gallup, G. Alcohol Use and Abuse in America. Report NO. 265, October 1987.
General Accounting Office. Drinking-Age Laws: An Evazkation Synthesis of Their Impact on
  Highway Safety. Report GAO/PEMD-87-ld. Washington, DC: GAO, 1987.
Hingson, R.W.; Scotch, N.; Mangione, T.; and others. Impact of legislation raising the legal
  drinking age in Massachusetts from 18 to ZO.AmeticanJozunalofPublzkHealth 73(Z): 163-
   170,1983.

Holder, H.D., ed. Control Issues in Alcohol Abme Prevention: Strategies for States and Com-
   munities. Greenwich, CT: JAI Press, 1987.

Holder, H.D., and Blase, J.T. Impact of changes in distilled spirits availability on apparent
  consumption: A time-series analysis of liquor-by-the-drink. British Journal of Addiction
   82523631, 1987.

Holder, H.D., and Janes, K. Control of Alcoholic Beverage Availability: State Alcoholic Beverage
  Control Systems Having Monopoly Fzznctions in the United States. Berkeley, CA: Preven-
   tion Research Center, 1987.

Hoskin, A.F.; Yalund-Mathews, D.; and Carraro, B.k The effect of raising the legal minimum
  drinking age on fatal crashes in ten states. Journalof Safety Research 17(3):117-121, 1986.
Jones, RX, and Joscelyn, RB. Alcohol and Highnq Safeq 1978: A Review of the State of
  Knowledge. Ann Arbor: The University of Michigan Highway Safety Research Institute,
    1978.

Kingdon, J.W. Agendas, Alternatives and Pzdblic Polices. Boston: Little, Brown, 1984.
Klein, T.M. The Effect of Raising the Minimzcm Legal DrinkingAge on Traffic Accidents in the State
  of Maine. Washington, DC: National Highway Traffic Safety Administration, 1981.
Levy, D., and Sheflin, N. New evidence on controlling alcohol use through priceJountalof Smdies
   on Alcohol 44:929-937,1983.

Lillis, R.P.; Williams, T.; and Williford, W.R. "Special Policy Consideration in Raising the Mini-
  mum Drinking Age: Border Crossing by Young Drivers."Paper presented at the National
   Alcoholism Forum, Detroit, MI, 1984.

Males, MA. The minimum purchase price for alcohol and young-driver fatal crashes: A long-term
   view. Jozrmal of LegalStudies 15(1):181-211, 1986.
Maxwell, D.M. Impact Analysis of the Raised Legal Drinking Age in Illinois. Washington, DC:
  National Highway Traffic Safety Administration, 1981.
McGuinness, T. "Marketing and Aggregate Consumption of Alcoholic Beverages." Paper
  presented at the 35th International Congress on Alcoholism and Drug Dependence,
  sponsored by the International Council on Alcohol and Addictions, Oslo, Notway, July 31
   through August 6,1988.

Moore, M.H., and Gerstein, D.R., eds. Alcohol and Pzzblic Poky: Beyond the Shadow of Prohibi-
   tion. Washington, DC: National Academy Press, 1981.
Mosher, J.F. Tax-deductible alcohol: An issue of public health policy and prevention strategy.
  Journal of Health Politics, Policy and Law 7(4):8X%88, 1983.
Mosher, J.F., and Beauchamp, D.E. Justifying alcohol taxes to public officials. Jozzmal of Pzzblic
   Healttz Policy 4(4):422-438, 1983.

Mosher, J.F., and Wallack, L.M. Government regulation of alcoholadvertising: Protecting industry
  profits versus promoting the public health. Journal of Pllblic Health Poky 2(4):333-353,
    1981.

National Highway Traffic Safety Administration. Alcohol and Highway Safety Z984: A Review of
  the State of the Knowledge. Technical report DOT-HS-806-569. Washington, DC:
   NHTSA, 1985.

National Institute on Alcohol Abuse and Alcoholism. Sixth Special Report to the U.S. Congress on
   Alcohol and Health. Rockville, MD: the Institute, 1987.
O'Donnell, MA Research on drinking locations of alcohol-impaired drivers: Implications for
   prevention polices. Journal of Public Health Policy 6510-525, 1985.
Gmstein, S.I., and Levy, D. Price and income elasticities of demand for alcoholic beverages. In:
  Galanter, M., ed. Recent DevelopmentinAlcoholism. Volume 1. New York: Plenum, 1983.
Perkins, W.H., and Berkowitz, AD. "Attitudes and Behavioral Responses to Changes in the Legal
  Drinking Age in a College Population." Paper presented at the annual conference of the
  Alcohol and Drug Problems Association, Washington, DC, 1985.

13


14

BACKGROUND PAPERS

Ross, H.L. Lkterring the Drinkkg Lkiver: Legal Policy and Social Control. Lexington, MA:
   Lexington Books, 1982

Roth, R.; Shigehuni, L.; and Masher, J.F. "Assessing Alcoholic Beverage Control Systems for the
   Prevention of Alcohol-related Problems." Paper presented at Alcohol Policy Conference
  V: Community Applications to the Prevention of Alcohol Problems. Charleston, SC,
   November 3,1987.

Saffer, H., and Grossman, M. Beer taxes, thelegal drinking age, and youth motor vehicle fatalities.
   Journal of Legal Studies 16:351-374,1987u:
Saffer, H., and Grossman, M. Drinking age laws on highway mortality rates: Cause and effect.
   Economic Inquiry 25:403417,1987b.

Schroeder, J.K., and Meyer, E.D. Infikence ofRaisingtheLe&kinkngAge in Illinois. Springfield,
   IL: Illinois Department of Transportation, Division of Traffic Safety, 1983.
Skog, O-J. Social interaction and the distribution of alcohol consumption. Iour& of Drug Issues
   10:71-92, 1980.

Skog, 0-J.~ecollectivityofdrinkingcultures:Atheoryofthedistributio~ofalcoholconsumption.
   British Journal ofAddiction 80:83-99,1985.
Trauma Foundation. You can't judge a cooler by its cover. Bulletin of Alcohol Policy 7( 1):2,10,
    1988.

Vingilis, E. Drinking drivers and alcoholics: Are they from the same population? In: Smart, R.,
   and others, eds. Research Advances in Alcohol and Drug Problems. Volume 7. New York:
   Plenum, 1983.

Wagenaar, AX. Alcohol, Young Drivers, and Traffic Accidents: Effects of Mininuun Age Laws.
   Lexington, MA Heath, 1983.

Wagenaar, AC. Preventing highway crashes by raising the legal minimum age for drinking: The
   Michigan experience 6years later. Journal of Safety Research 17:101-109,1986.
Wagenaar, AC, Effects of minimum drinking age on alcohol-related traffic crashes: The Michigan
   experience five years later. In: Holder, H., ed. Controllssues in AlcoholAbusePrevention;
   Strategies for States and Commun ities. Greenwich, CTz JAI, 1987. pp. 119-131.
Wagenaar, AC.; Douglass, R-L.; and Compton, C.P. Raking the Legal DrinkingAge in Michigan
   and Maine: Final Report. Ann Arbor: University of Michigan Highway Safety Research
   Institute, 1981.

Wagenaar, AC.; Molnar, LJ.; Streff, F.M.; and Schultz., R.H. Michigan Omnibus State Safety
   Survey: Fall 1987.. Ann Arbor: The University of Michigan Transportation Research
   Institute, 1988.

Wallack, L.; Breed, W.; and Cruz, J. Alcohol on prime-time television. Journal of Studies on
   Alcohol 48( 1):33-39, 1987.

Warner, K-E. Cigarette advertising and media coverage of smoking and health. New England
   Journal of Medicine 312:384-388, 1985.

Warner, KE. Selling Smoke: Cigarette Advertising and Public Health. Washington, DC: American
   Public Health Association, 1986.

Whitehead, P.C. Research strategies to evaluate the impact of changes in the legal drinking age.
   In: Wechsler, H., ed. MinitnumlkinhingAgeLaws:An Evaluation. Lexington, MA: Heath,
    1980.

Whitehead, P.C.; Craig, J.; Langford, N.; MacArthur, C.; Stanton, B.; and Ferrence, R.G. Change
   in the drinking age: Impact on young drivers. Journal of Studies on Alcohol 36: 12081223,
    1975.

Williams, AF.; Rich, R.F.; Zador, P.L.; and Robertson, S.L. The legal minimum drinking age and
   fatal motor vehicle crashes. Journal of Legal Studies 4:219-239, 1975.
Williams, AF.; Zador, P.L.; Harris, S-S.; and Karpf, R.S. The effect of raising the legal minimum
   drinking age on involvement in fatal crashes. Journal of Legal Studies 12: 169-79,1983.


15

Advertising and Marketing

Mass Communication Effects on
   Drinking and Driving

      Charles IL Atkin, Ph.D.
Depariment of Communication, Michigan State University

This chapter e xamines the role of mass communication in both preventing and
encouraging alcohol consumption and drunk driving, particularly among young people
in our society. It begins with an overview of public communication concepts~ relating
drunk-driving behavior to advertising and public service campaigns and to entertainment
and news media presentations, and then describes basic theoretical processes and
topical literatures. The closing section identifies issues for discussion, suggests strategies
for improving media influence, and recommends promising avenues for research.
The public may be influenced in a number of ways by exposure to media communica-
tions. The strongest effect generally occurs at the cognitive level (awareness, knowledge,
beliefs, and images), with more modest effects at the affective level (attitudes, values,
norms, interests, saliences, and intentions). In terms of overt behavior, key outcomes
include:

a. alcohol drinking patterns (frequency/quantity of consumption, hourly rate,
settings),
b. driving practices (driving after moderate drii drunk driving, general risky
driving), and

C. interpersonal prevention actions (persuading companion to drink moderately,
prohibiting teen child from attending drinking parties, insisting on designated
driver arrangement, serving driver nonalcoholic drinks, intervening to prevent
intoxicated driver from taking the wheel).

These behavioral outcomes are interrelated, such that an effect on one behavior indirect-
ly contributes to other actions. For example, messages stimulating consumption of a
greater quantity also increase drunk driving; messages prompting interpersonal per-
suasion, in turn, reduce the quantity consumed before driving.

The scope of relevant media content ranges from hard news about police crackdowns
on driving while intoxicated (DWI) to fictional entertainment portrayals of reckless
driving, and from sensual commercial promotion of alcohol brand images to fear-
arousing informational messages showing twisted wrecks. Several linkages between
content presentations and audiencebehaviors are particularly noteworthy, the literature
review will examine most closely the direct connections between: (a) alcohol advertising
and drinking patterns, (b) entertainment programing and both drinking patterns and
risky driving acts, (c) news stories and drunk-driving practices, and (d) public service
campaigns and drinking, drunk driving, and prevention activities.

This chapter focuses on mass media communication rather than conventional alcohol
f?iurketing efforts (e.g., on-campus beer promotions, beer tie-ins with professional sports
teams, positioning of wine coolers as quasisoft drinks, distribution of premixed cocktails


16

BACKGROUND PAPERS

through convenience stores). The marketing perspective is primarily represented in the
public service campaign section as a set of methods and strategies adapted by social
manketing practitioners'to unsell alcohol abuse and drunk driving. (Thcee interchange-
able terms-social marketing campaigns, information caiupaigns, and public service
campaigns- all refer to a series of promotional messages in the public interest that are
intended to benefit individuals in the audience and/or to improve society as a whole.)

A number of theories are applicable to understanding the influence of mass com-
munication on drinking and driving coguitions, attitudes, and behaviors. These general
conceptions will be-briefly reviewed before the empirical research for each specific topic
area is examined. The first five perspectives are stimuhrs centered (focusing on message
potency), while the rest are receiver centered (assigning a major role to audience
predispositions in determining response to media presentations).
Social reaming theory focuses on responses to messages portraying human models,
vicarious learning of behaviors and consequences occurs by example through imitation
and contagion mechanisms (Bandura 1977). The effect of a message is enhanced by
models that are celebrities, high in status, or similar to the observers, and by depiction
of positive social and personal reinforcement. Three processes explain the influence of
visualized portrayals, especially in TV entertainment programing, commercials, and
public service spots:

1. Observational learning, which is the transmission of social information about
novel forms of behavior that may lead to imitative actions, for example, a public
_ service announcement (PSA) showing successful physical intervention
techniques to prevent drunk driving. Symbolic modeling can also shape
definitions of normative social practice, for example commercials portraying
appropriate situations for beer consumption.

2. Altering inhibitions governing overt expression of previously learned responses,
for example, a film depicting early-morning drinking that reduces guilt about
this practice, or .a soap opera dramatizing humiliation of DWI arrest that
inhibits driving after drinking.

3. Z-ZesponskfaciZitation, which is the modeling enhancement of socially sanctioned
behaviors by a simple reminder cue to perform acts already established in the
observer's repertoire, for example, a wine ad that prompts drink-pouring.

Vedaf learning is a label encompassing a family of utilitarian-oriented persuasion
theories such as instrumental learning and hierarchy-of-effects, which conceive of the
individual as proceeding through attention, comprehension, yielding, and retention
stages resulting in formation and change of beliefs and eventually of attitudes and
behaviors (see McGuire 1981; Flay 1981; Bettinghaus 1986). The key elements are the
presentation of relevant incentives (promised rewards and threatened punishments as
the motivation for accepting the recommendation), the credibility or attractiveness of
sources, and the structure, evidence, or arguments of the message appeals. This
framework applies primarily to purposive media messages (e.g., anti-drunk-driving
PSA's citing casualty statistics, or liquor magazine ads featuring substantive reasons for
purchasing the product).

Cultivation theory focuses on the formation and shift of beliefs about society (e.g.,
perceived prevalence of drunk-driving behavior). Based on cumulative absorption of
media content, viewers derive conceptions skewed toward the predominant portrayals
(Gerbner et al. 1986; Signorielli 1987). Whiie thii perspective has been primarily applied
to fictional wntent, it is also pertinent to news effects on perceptions of reality.

Agenda setting (McCombs and Gilbert 1986) is a theorectical model predicting that
an issue or attribute that is frequently and prominently presented in the mass media will
be regarded as more important and assigned a high priority in the thinking of the receiver.


,qjVERTlSlNG AND MARKETlNG

For example, heavy news emphasis on a topic such as dnmk driving will increase the
pubhc's perception that the problem is significant. Constant emphasis ottcamaraderie
in beer advertising will elevate the salience of this attribute relative to safety concerns.

Classical conditioning applies to the affective impact of certain alcohol presentations,
particularly in advertising, where an initially neutral stimulus is repeatedly paired with
an unconditioned stimulus eliciting a favorable/unfavorable response; for example,
linking alcohol consumption to masculinity, or associating drunkenness with joviality.

uses-and-gratifications theory posits that individuals selectively use media channels
and messages to satisfy needs (Rubin 1986). Psychological predispositions and social
contextual factors shape motivations of receivers, who actively select media stimuli for
specific purposes such as guidance or enjoyment. For example, readers who are in&u-
mentally motivated to learn how to evade police detection will seek out and extract
pertinent information from news stories, and TV viewers who watch soap operas for
plotline excitement may not notice incidental portrayals of drinking. In addition, wgni-
tive dissonance mechanisms explain certain exposure decisions. For example, drunk
drivers may selectively avoid threatening messages about safety consequences.

Cognitive-response perspectives focus on the thoughts that the receiver generates
while processing messages (Petty and Cacioppo 1981). Rather than passively wnsuming
information, the person relates the content to prior knowledge and experience, and
forms new connections or arguments. For example, receivers might think favorably about
bars in response to a magazine ad showing a bar setting, or might raise critical objections
and rehearse circumvention strategies when hearing a news story about drunk-driving
roadside checkpoints.

Expectancy-value approaches emphasize the role of audience value predispositions
in the formation of attitudes toward a behavior (Ajzen and Fishbein 1980). Attitude is
conceived as a function of expectancies (e.g., beliefs about the likelihood of crashing or
the probability of social approval for moderate drinking) and evaluations (e.g., positive
or negative valence of an attribute or outcome).

17

Mass communication theorists also examine supplemental interpersonal inffuences,
which can extend, reinforce, or counteract the effect of mediated messages. Relevant
processes include:

a.  two-step flow (e.g., a news viewer relays an item about police crackdown to
nonexposed coworkers; friend doesn't let friend drive drunk after hearing radio
PSN,

b. opinion sharing (e.g., wviewers of TV drama shape each other's evaluative
reactions to humorous depiction of drunkenness),

C. social influence (e.g., advertising-induced tendency to drink excessively is rein-
forced by prodrinking peer pressures), and

d. social norms (e.g., anti-drunk-driving magazine message is counteracted by
perceived appropriateness of males driving after drinking).

Research Literature

Empirical evidence assessing mass communication influences on drinking and driving
behaviors is underdeveloped and often methodologically flawed. The greatest research
attention has been devoted to the effects of advertising on alcohol consumption, owing
to societal concerns and regulatory interest in this issue.


18

BACKGROUND PAPERS

Alcohol Advertising

The mass media annually carry a billion-and-a-half dollars of advertising for beer,
wine, and spirits, far exceeding expenditures for prevention and education by govem-
ment and nonprofit agencies. Major content analyses by Atkin (1987) and Finn tid
Strickland (1982,1983) showed that lifestyle portrayals are featured along with brand
symbolism, as attractive and youthful (but not underage) characters display enjoyment
(but not intoxication). Among the benefits frequently linked to the alcohol products are
social camaraderie, romance, masculinity/femininity, adventure, relaxation, and ele-
gance. Relativeli few ads portray alcohol in hazardous contexts such as vehicle scenes,
or depict negative driig consequences such & hangovers, accidents, diseases, or
embarrassment. Alcohol advertising practices have been subject to extensive criticism
(Jacobson et al. 1983; Postman et al. 1987). Congress considered a ban on alcohol
advertising in 1985 hearings.

Atkin (19@,1989u, b) presented detailed assessments of the theqretical mechanisms
by which these advertising messages influence both consumption patterns and risky
driving behavior, particularly effects of TV commercials on adolescents. Thii chapter
first summarizes the extensive empirical literature on advertising and drinking, then
reviews a study focusing on drunk driving.

Drinking

In two recent reviews, Smart (1988) concluded that "alcohol advertising is, at best, a
weak variable affecting alcohol consumption," while Atkin (1988) stated that "ads
stimulate higher consumption by both adults and adolescents.. . there is a sufficient basis
for rejecting the inference of null effects and for rejecting claims that advertising exerts
a powerful influence on drinking behavior." The preponderance of the evidence suggests
that advertising is a contributing factor that increases consumption to a modest extent,
based on three types of investigations.

Six major experiments tested the effect of advertising messages on drinking behavior
(Brown 1978; McCarty and Ewing 1983; Kohn et al. 1984; Kohn and Smart 1984; Sobell
et al. 1986; Kohn and Smart 1987). The studies do not provide conclusive evidence, owing
to the equivocal mixture of null and positive findings along with serious conceptual and
methodological deficiencies (particularly in experiments showing apparent null effects).
The critical review by Atkm (1988) interprets this set of results as suggesting limited
prodrinking effects. Other experiments relying on verbal responses show that both sexual
imagery and celebrity endorsements enhance the effect of advertising on youthful
drinkers (Freidman et al. 1977; Atkin and Block 1981,1983; Kilboume et al. 1985).

A second set of econometric studies and quasi-experiments based the analysis on
aggregate statistics representing alcohol sales and advertising expenditures over time or
across locales (Simon 1969, Ackoff and Emshoff 1975; Smart and Cutler 1976; Bourgeois
and Barnes 1979; Ogborne and Smart 1980, Duffy 1981; McGuinness 1983, Schweitzer
et al. 1983; Ornstein and Hanssens 1985, Wilcox 1985; Franke and Wilcox 1987). This
type of research produces mixed findings, basically showing that advertising accounts
for slightly higher levels of consumption; but these techniques have restricted potential
for precisely tracing the effect of commercial messages.

Third, several major correlational surveys provide the most externally valid data on
the advertising-consumption relationship (Atkin and Block 1981; Strickland 1982,1983;
Atkin et al. 1984; A&in and Block 1984). Despite ambiguities about causal direction, the
data suggest that televised beer ads mildly increase beer drinking, that magazine liquor
ads have a modest positive influence on consumption of spirits, and that the effect of
traditional wine advertising is weak.


ADVERTISING AND MARKETING

Drunk Driving

Advertising has potential for direct effects on drunk driving, based' on occasional'
content portrayals juxtaposing moving cars with scenes of beer drinking in TV commei-
&& and the association of alcohol and professional racing cars, and on more subtle
linkages between beer and the challenging excitement of speed and macho risk taking
(see Postman et al. 1987). However, overt depictions of vehicles occur in a just a tiny
percentage of ads, and characters are never shown drinking in the context of driving.

19

Advertisements rarely warn the audience about the dangers of drinking before or
during driving, which precludes learning about this risk and possibly deemphasizes
salience of unsafe consequences. Indeed, the audience may infer that safety is not a
significant issue based on portrayals of characters consuming alcohol away from home
settings without any recognition of how they will achieve safe transportation.

Advertising may also produce indirect effects that increase the likelihood of drunk
driving. Many ads promote driig in bars and in outdoor locations. To the extent that
drinkers are influenced to consume more alcohol in these nonhome settings, the chance
of driving after drinking is greater. Further, the effect of advertising in stimulating greater
frequency and quantity of drinking heightens the odds of drunk driving.

In a sample of adolescents and younger adults, Atkin, Neuendorf, and McDermott
(1983) found that advertising exposure was significantly related to a drinking-driving
index (higher levels of driving after drinking, drunk driving, drinking while riding,
drinking while parked, and estimated drii limit for safe driving). For example, 39
percent of heavily exposed individuals reported having driven "when you were really too
drunk to drive," compared to 28 percent of lightly exposed respondents. This exploratory
study has methodological shortcomings, and the evidence must be regarded as tentative.

Entertainment Media

Television programing is considered influential in shaping both drinking and driving
behaviors, particularly among youthful viewers (Atkin 1989a, 1989b). Other entertain-
ment media play a minor role because oflimited reach and frequency (e.g., fihns, books)
or low-potency content (e.g., radio, recordings). Televised depictions of drinking are
remarkably prevalent, as are risky driving portrayals, but specific presentations involving
drunk driving are infrequent.

Drinking

Content analyses over the past decade have documented that two-thirds to three-
fourths of all prime-time episodes present at least one drinking incident involving
characters ordering, pouring, holdmg, sipping or talking about alcohol (Greenberg et al.
1979; Lowry 1981; Greenberg 1981; Cafiso et al. 1982; DeFoe et al. 1983; Breed and
DeFoe 1984; Futch et al. 1984; Hansen 1986; Wallack et al. 1987). The most comprehen-
sive measurements have been performed by researchers at the Prevention Research
Center. In the most recent study, Wallack, Breed, and Cruz (1987) reported 10.6 drinks
per hour in 1984, continuing a trend that moved upward from 4.8 hourly acts in 1976 to
7.6 in 1978 to 8.7 in 1981. Fictional characters drii 10 times as much alcohol as soft
drinks, even though real life Americans consume twice as much soft drink beverages.

While much of thii alcohol driing is gratuitous and incidental, more central and
vivid depictions (e.g., bar and party drinking, heavy drinking, intoxication, and significant
plot implications) still average well over one per hour. Most of the motivations and
consequences associated with alcohol consumption are either positive or neutral, but
TV occasionally portrays deficit reasons for drinking (e.g., escape, tension relief, crisis
management, coping) and adverse outcomes (status loss, strained relationships, social
disapproval, and health and safety risks).


BACKGROUND PAPERS

In an attempt to change the portrayal of alcohol in TV programing, Breed and DeFoe
(1982) helped develop a white-paper guideline for Hollywood writers and producers.
Through cooperative consultation, creative personnel became more sensitive .to the
implications of the'way drinking is depicted. However, the evidence of content analysis
is not in convincing in demonstrating major reductions in quantity consumed or improve-
ments along qualitative dimensions..

Very little research examines actual effects on the viewing audience. -0 laboratory
experiments examined responses of preteens to televised fictional drinking portrayals.
In one study, Ketch, Coulter, and Lipsitz (1986) found slightly more favorable attitudes
toward drinking after subjects saw a montage of scenes showing characters consuming
`alcohol. In the second (Rychtarik et al. 1983), exposure to A4L4.S.H. martini scenes
increased the youths' perceived appropriateness of serving liquor to adults.

These meager results hardly begin to address the question of entertainment effects,
but several likely forms of influence can be hypothesized bask&on cultivation, social-
learning, and expectancy-value theories. First, the sheer quantity of depicted drinking
acts should cultivate the perception that alcohol consumption in society is frequent and
widely practiced. Viewers, especially adolescents, are more apt to consider d&king as
a routine, commonplace part of everyday life that is highly normative and appropriate
in a varied array of social situations. Second, viewers can be expected to develop
generally favorable stereotypes of drinkers, display imitative consumption after
vicariously experiencing the attractive modeling acts, or feel less inhibited about per-
forming certain proscribed drinking behaviors. By contrast, the depictions of characters
decIining drink offers may increase performance of that act. Third, prodrinking attitudes
may evolve as the audience learns about the predominantly portrayed positive conse-
quences of TV d&king, which outweigh the problematic outcomes.

Drunk Driving

The only content analysis focusing specifically on drunk driving is a qualitative study
by Breed and DeFoe (1985436). Rather than quantitatively tabulating incidents of
conversations about drunk driving or actual driving after drink&, the authors describe
37 selected examples embedded in 700 hours of prime-time programing observed
between 1976 and 1986. They conclude that the "attitude toward DWI was negative
throughout the period studied," pointing to scenes judged as educational in Lou Grunt,
CHiPs, Six Million Dollar Man, Happy Days, Starsky and Hutch, RoCyord Files, and
Cagney and Lucey (e.g., portrayal of DWI arrests and accidents, and warnings by
companions not to drive). Breed and DeFoe also identified problematic scenes (e.g.,
humorous or nonserious treatment of drunk driving) and critical omissions (e.g., depic-
tion of a character drinking heavily at party and then appearing later in another
location-presumably having driven there). Although DWI scenes are relatively rare,
the authors argued that the potential for effect is substantial because the televised stories
feature "heightened visualization and identification permitted by the medium, as per-
sonalized and dramatized."

One study explored the effects of a TV program that modeled a social intervention
to prevent drunk driving (Atkiu 1989a). An episode of Valerie's Family featured a
teenage party in which a drunken guest is physically restrained from driving. In before-
after survey of young adolescents, those who viewed the on-air program were slightly
more likely than nonviewers to say they would employ physical intervention with a drunk
friend.

Driving

Vehicle use is pervasively presented on television, as most programs shot in nonstudio
settings prominently feature driving. A comprehensive 5-year content analysis found four
to five driving scenes per hour (Greenberg and Atkin 1983). Most driving was routine.


ADVERTISING AND MARKETING

21

However, one-fifth of the scenes depicted chase/escape driving, and several types of
noisy or risky driving incidents were frequently portrayed. Quick braking appeared in
25 percent of all driving scenes, brakes squealing in 24 percent, tires screeching in 23,
percent, speeding beyond the apparent lit. in 20 percent, quick acceleration in U)
percent, weaving through traffic in 5 percent; leaving the road or ground in 5 percent,
amessive driving in 5 percent, autobatic stunts in 4 percent, and other illegal driving
such as recklessness, forcing a car off the road, or changing drivers while moving in 8
percent. Endangering acts were depicted almost once per hour. Almost 9 out of every
10 drivers were male, and three-fourths were in their twenties and thirties.

In terms of cons.equences, 9 percent of driving scenes portrayed positive outcomes
for the driver, for example, impressing other people, escaping pursuers, power, and
emotional satisfaction. On the negative side, death and injury were relatively rare,
occurring in less than 1 percent of the scenes at a rate of one casualty each 5 hours. In
only a few instances were immediate legal penalties imposed on bad drivers; one-tenth
of speeding incidents and one-fourth of other illegal driving behavior resulted in police
apprehension. The rate of safety belt use on TV was 1 percent in the late 197Os, but rose
to the 20- to 25-percent range in the mid-1980s (Atkin 1989u; Geller 1988).

To date, no investigations have measured the effect of these portrayals on real-life
drivers. Based on audience ratings, it can be estimated that the typical TV viewer
annually sees several thousand irregular driving acts and hundreds of instances where
people are endangered, usually performed in an engaging manner by attractive charac-
tcrs who suffer minimal,harm. Media theory suggests the following types of effects might
bc expected:

o  Viewers may vicariously acquire and imitate an array of unique and
novel driving acts.

o  Inhibitory constraints may be reduced as viewers learn that dangerous
driving practices are commonplace and normative.

o  External inhibitions may be minimized by the relatively infrequent
portrayal of serious negative consequences such as legal punishment,
social disapproval, and physical harm resulting from illegal or high-risk
  behavior.

   o  The prominent presentation of dramatic chase scenes, risky actions,
   and erraticvehicle handling may contribute to the feeling among some
   thrill-seeking viewers that risky driving is an exciting, exhilarating,
   glamorous, and challenging activity.
It should be noted that the absence of explicit drunk-driving depictions precludes
direct modeling or disinhibition of this particular behavior. Nevertheless, a response to
the other basic risky driving predispositions that TV induces may be generalized to the
drunk-driving situation. Moreover, affirmative anti-drunk-driving messages are notably
absent in entertainment content (e.g., demonstrations of intervention acts, modeling of
decisions not to drive after drinking or not to drink before driving, portrayals of accidents
or arrests as a result of drunk driving).

News Media

Over the past decade, both news reports and feature stories about drunk driving have
increased in number, with newspaper and newscast items covering crashes, arrests,
adjudication, policies, prevention approaches, and advocacy efforts. For example, one
local study showed 16 times as many newspaper articles about DWI in 1983 than in 1980
(Luckey et al. 1984). Much of this heightened coverage can be attributed to the publicity-
oriented activities of organized action groups such as Mothers Against Drunk Driving
(MADD) and Remove Intoxicated Drivers (RID), which have sensitized journalists to
the issue.


22

BACKGROUND PAPERS

The most powerful role of the news media is in setting the agenda of policymakers
and the general public, as more frequent and prominent coverage raises the salience of
drunk driving, stimulates public discussion, and serves to legitimize the seriousness of
the problem and attempts to address it (see Wallack 1989). In additioh, news stories
contribute togreater levels of audience awareness and information concerning this topic,
and may have important effects on beliefs (e.g., probability of arrest or accidents), social
attitudes (e.g., disapproval of drunk drivers), and political opinions (e.g., support for
tougher countermeasures). The potential for influence is enhancedby the high credibiity
attributed to the news media by readers and viewers.

According to a statewide survey by Atkin, Garramone, and Anderson (1986), 60
percent of the public relies on newspaper and TV news sources for learning about
chances of arrest, conviction, and penalization. These sources outscore PSAs, interper-
sonal conversations, driver's education classes, observation of police activities, and
experience with police or courts. Further, among the half of the sample who reported
having seen recent news stories about local police efforts to catch drunk drivers, the vast
majority say that they subsequently believed the chance of arrest to be greater, that they
were more likely to warn others about the need to drink safely before driving, and that
they were more careful to drink safe amounts.

An analysis of crash-related fatalities in Great Britain during the 1983 Christmas
Crusades against drunk driving showed a significant decrease attributable in part to
unusually intensive news media publicity (Ross 1987). A combination of heightened
police enforcement and news stories emphasizing the law's deterrent threat (particularly
the risk of apprehension) was apparently effective in decreasing drunk driving during
the crusade month and the following month as well.

Grunig and Ipes (1983) studied the effect of intensive newspaper coverage of the
drunk-driving issue in Maryland, focusing on State legislative deliberations about age-21
minimum for drinking and tougher DWI penalties. They concluded that the publicity
produced an agenda-setting effect, leading to high levels of problem recognition and
involvement, and acceptance of simple solutions such as increased penalties.

Public Service Iuformation Campaigns

In the mid-198Os, announcements on drunk driving became the most prevalent type
of PSA on television owing to efforts of Federal agencies, citizens groups, and the
National Association of Broadcasters. Brewers such as Coors and Anheuser-Busch also
placed prevention messages on TV, and Seagrams continued magazine campaigns to
discourage drunk driving and alcohol misuse. The National Highway Traffic Safety
Administration (NI-ITSA), the National Institute and Alcohol Abuse and Alcoholism,
the National Safety Council, the American Automobile Association, State hiiway safety
agencies, and local police have used a variety of other channels including pamphlets,
billboards, road signs, bumper stickers, cocktail napkins, litter bags, matchbooks, en-
velope stuffers, movie theater slides, radio spots, and TV talk show appearances.

A collection of campaign materials compiled by NHTSA appears in the handbook
Drunk Driving Public Information Program Strategies and Planning Guide (DOT 1985).
This guide lists hundreds of specific message ideas, classified into enforcement, alcohol
effects, community, accident, arrest, sanctions, parent-youth, intervention, self-monitor-
ing, and rehabilitation categories. It also includes a management planning checklist.

The research literature evaluating the effects of campaigns to prevent drunk driving
is meager. After a thorough review of published studies and technical reports, Haskins
(1985) concluded, "During the last 15 years, very little has been learned about the role
of mass communications in drinking-driving despite the expenditure of many millions of
dollars for campr@ns and substantial amounts for research." Swinehart, Grimm, and
Douglass (1974) tested reactions to two dozen magazine ads, discovering that the most


~vERTISING ANfJ MARKETWE

effective ones featured brief copy, dramatic graphics, emotional appeals, and specific
action recommendations. The most elaborate field experiment was conducted by Wor-
den, Wailer, and Riley (1975) .in evaluating the Vermont CRASH program. Theso
authors found that the campaign produced .signiicant improvements in knowledge,
attitudes, and behaviors (especiahy when supplemented with countermeasures); how-
ever, this effect evolved dowl~, with an increase in the second year of the campaign
                                                 
Atkiu and Atkin (1986) carried out a project designed to stir&ate parental preven-
tion of teenage attendance at drinking parties (and resultant drunk driving), The
parent-based approach was control-oriented, stressing actions to minii teenager
access to alcohol and opportunities for heavy drinking through rulemaking, survei&nce,
and punishment. Messages were disseminated to parents in two experimentaI corn--
munities through newspaper stories, radio PSAs, and pamphlets. In a postcampaign
survey of parents, Atkin (1986) found that parents were strongly infiuenced; they showed
evidence of greater awareness of the problem, elevated concern, more networking with
other parents, more communication ,with teenagers about drunk driving and party
attendance, and intensified monitoring. However, this effect on parents translated into
only a slight indirect effect on bottom-line teenage drinking and drunk driving rates, as
measured in student surveys.

In general, mediated drunk-driving campaigns appears to have had relatively little
effect on drunk driving. This lack of significant influence is consistent with studies of
related campaigns in the domains of safety belt promotion, substance abuse prevention,
and other health practices (Atkin 1979; Blane and Hewitt 1980, Atkin 1981b; Flay 1981;
Wallach and Barrows, 1982-83; Hewitt and Blane 1984; Ma&off 1985; bat& et al.
1986, Rice and Atkin 1989).

23

In the past decade, specialists working in the fields of social psychology have made
major advances in the development of conceptual frameworks for designing effective
information campaign strategies (Flay et al. 1980, McGuire 1981; Dunn and Rogers
1986), mass communication (Mendelsohn 1973; Atkin 1981a; Grunig and Ipes 1983; Rice
and Atkin 1989), public health (Albert 1981; Anderson and McCuUough 1981; DHHS
1983; WaIIack 1984), and social marketing (Fox and Kotler 1980; Bloom and Novelli
1981; Solomon 1981; Kotler 1982; Novelli 1984, Kotler 1984)These perspectives provide
practical guidance for determining appropriate sources, message appeals, and channels
for prevention campaigns. The most comprehensive approaches have been developed
by social marketers, who stress the importance of the price, the place, and the product
as weil as the promotion elements emphasized by others. Experts agree that a critical
beginning point for successful campaigns is formative evahtation.

Using Formative Research for Designing Campaigns

One key reason why campaigns to combat drunk driving have achieved only limited
effectiveness is the lack of adequate evaluation research. Typically, goals are formulated
and messages produced in an unsystematic fashion based on hunches of program
planners and creative inspiration of copywriters and artists, patterned after normative
standards of the genre. In developing campaign strategies for influencing the audience,
commercial advertisers and social marketers rely extensively on market segmentation
analysis, consumer opinion surveys, focus group interviews, and message pretesting.
These approaches can be readily adapted to assist the planning and design of drunk-
driving campaigns.

This section illustrates the formative process with selected findings from a series of
surveys and supplemental focus group interviews (with teenagers, parents, party hosts,
and the general public) carried out as part of a social marketing analysis for a NHTSA
drunk-driving-prevention project (Atkin et al. 1986; Atkin and Freimuth 1989).


24

BACKGROUND PAPERS

Identification of Target Audiences

Effective campaigns seldom `aim at a broad cross-section of the public, focusing
instead on specialized segments of the overall audience. Formative research data help
identify the high priority target subgroups: which categories of individuals are at risk,
which are most receptive to persuasion, and which are in a position to influence high-risk
persons through interpersonal intervention.

Survey measures with representative samples are typically used in segmenting the
audience along a number of dimensions defmed in terms of demographic and
psychographic characteristics, social role, behavioral risk profile, predispositions, future
behavioral intentions, and media exposure patterns.

In the case of drunk driving, the surveys show that 16- to 24-year-old males who drink
heavily at weekend parties are far more likely to drive while intoxicated or ride with a
drunk driver. This high-risk segment constitutes less than 5 percent of the population.
The research also indicates that several other target audiences display promising poten-
tial for attempting interpersonal intervention to prevent drunk driving: parents of high
school students (who can prohibit theirteenagers from attending unsupervised drinking
parties), adult party hosts (who can discourage excessive drink@ by guests, or arrange
alternative transportation for intoxicated drivers), and female passengers riding with
heavy-drinking dates or mates (who can warn their drivers not to overconsume, or take
over the driving role on the ride home). In terms of receptivity, parents are an example
of a-favorably predisposed audience because most disapprove of teenage drinking,
believe that teenage drunk driving is a serious problem, and desire to know techniques
to prevent their son or daughter from becoming involved in drunk-driving incidents.

Target Behavior Specification

Typically, the ultimate goal of a campaign is bottom-line behavioral change, such as
reducing the incidence of drunk-driving acts. However, most practices are a product of
various component behaviors; for example, drunk driving may be reduced if the driver
either abstains from alcohol, drinks limited quantities, or allows a sober person to drive
home. These behaviors in turn are determined by social and environmental factors such
as availability of attractive nonalcohol drinks or suggestions by companions to limit
consumption. Formative research is helpful in specifying which particular behaviors and
external factors are most influential in altering the focal practices, and which are most
amenable to change through campaign messages. These variables are then incorporated
as concrete objectives in the campaign plan.

In the case of social intervention to prevent drunk driving, survey research reveals two
examples of priority target behaviors. One potentially effective tactic is to encourage the
female passenger to drive the car back from a drinking occasion; the data show that
women tend to become less intoxicated than their male drivers, yet most allow the male
to drive. Findings also show that half of young adults planning to ride back with a driver
hesitate to put pressure on that person to stay sober enough to drive safely, while most
drivers say they would respond cooperatively to such dissuasion by cutting back on'
consumption. Thus another important target behavior is more frequent attempts by
companions to prevent their driver from exceeding the safe drinking limit.

Regarding target audience receptiveness to behavioral recommendations, the survey
of party hosts asked the sample to rate 22 potential hosting techniques in terms of
acceptability: how comfortable they would feel in using each strategy, and how offensive
they believed each strategy would be regarded by guests. Results indicate that certain
techniques are highly acceptable, for example, actively offering food to drinkers, arrang-
ing for another guest to drive an intoxicated person home, or expressing concern that a
driver is drinking too much. However, other actions are disdained, for example, having
guests check in car keys on arrival, or warning drinking drivers about accident risks,
stopping service of alcohol 2 hours before the party's end. Such formative evaluation


~t/EATlSlNG AND MARKETING

data enable designers to narrow the list to the most promising techniques, and to isolate
leti acceptabie but critically important behaviors that would require extra persuasive
emp~sk in order to be changed.

Intermediate Response Elaboration

AS a means to achieving the behavioral objectives, campaign messages must first
influence preliminary or intermediate target variables along the response chain, ranging
from exposure and processing to learning and yielding to actual use. In particular,
campaign designers face certain barriers that must be overcome; these individual
resistance points often involve misconceptions, dysfunctional attitudes, and behavioral
inhibitions. Isolating the most crucial response stages is facilitated by an understanding
of the characteristics and predispositions of the target audience. Focus groups and
sample surveys are both valuable tools that provide topic-specific background informa-
tion for mapping the domains of knowledge and lexicon, beliefs and images, attitudes
and values, salience priorities, and efficacy and skills.

howledge and MO&Research illuminates the target audience's entry-level aware-
uess and information-holding about the subject of the campaign, identifying what is
&eady known, what gaps exist, what confusions must be clarified, and what misinfor-
mation must be corrected. The level of familiarity with and comprehension of topic-
related vocabulary and terminology can also be ascertained.

For example, only one-quarter of the surveyed drinkers knew that 0.1 percent blood
alcohol content (BAC) is the legal level that would result in arrest for driving under the
influence. Just half realized that eating food before drinking substantially reduces
intoxication, and one-fifth incorrectly think that drinking coffee helps to sober up a
driver. People have diverse meanings for key terms such as "social drinker" and
"moderation," diverse labels for the state of intoxication, and limited understanding of
concepts such as intervention and designated driver.

Beliefs and imuges.Since many campaign message strategies seek to alter subjective
conceptions such as perceived social norms or estimated probability of outcomes
associated with the behavioral practice, it is important to be precise in measuring the
preexisting cognitive orientations held by individuals. For example, data show that
drinkers underestimate the degree of social disapproval of drunk driving (fully two-fifths
believe that others excuse drunk driving, while just 5 percent of the public is actually
tolerant) and overestimate the statistical risks of both crashes and police apprehension
(the typical driver perceives that the odds of arrest while driving drunk on a given evening
are 1 in 100, while police figures show the chances are 1 in 2,000). Such data tell a
strategist that messages should feature information about social norms, but shouldn't
emphasize facts about arrest probability.

AUU&S and va[ues.Affective predispositions are also a significant consideration in
message design, particularly evaluations of outcomes associated with practices. Depend-
ing on the direction, intensity, and structure of relevant values and attitudes, the
campaign may concentrate on creation, conversion, reinforcement, or activation. The
latter two strategies are appropriate for most drivers, who already hold a negative
attitude toward drunk driving and regard the crash and apprehension consequences as
undesirable. Messages that intensify the negativity of outcomes (e.g., monetary costs of
conviction or difficulty of coping without a license) appear to be promising. On the other
hand, the research shows that most men dismiss the embarrassment or threat to mas-
culinity resulting from a wife or girlfriend driving them home, indicating that this
presumed obstacle need not be addressed in campaign appeals.

Salienceprior&%s.Research also provides guidance concerning which cognitive and
affective orientations need to be made more or less salient. Since most drivers already


26

BACKGROUND PAPERS

believe that there is a substantial risk of crash involvement, but only one-fourth con-
sciously contemplate this possibiity, increasing,the perceived importance of this out-
come would lead drivers to give it greater weight relative to other factors when setting a
limit oy deciding whether to consume additional drinks. By contrast, most regard drunk
driving as .a serious problem facing society, indicating little need for campaigning
designed to raise this issue on the public's agenda

E'I and &i&For certain practices, many well-intentioned and highly motivated
people fail to carry out appropriate acts because they lack subjective performance
competency. If research shows that this lack is a barrier, messages can emphasize
personal efficacy enhaucement or provide specific skills training. For example, survey
findings demonstrate that, although most companions agree that it is important to help
drivers limit consumption and to prevent intoxicated friends from driving, many of them
wish they knew better techniques for discouraging excessive drinking or handling a drunk
friend who insists on driving.

Channel Consumption Ascertainment

In deciding which channels are most efficient and effective for disseminating cam-
paign messages, strategists need to determine the mass media preferences and interper-
sonal communication patterns of target audiences. While some basic exposure figures
are available from commercial audience measurement services such as Neilsen, special-
ized surveys provide a much more elaborate and relevant array of data.

Ata general level, it is useful to know the following information about the intended
receivers:

.  Amount of time spent watching TV, listening to the radio, and reading
magazines and newspapers

o  Use of specific media (local radio stations, magazine titles)

o Attention to various types of media content (news, public service
messages)

o Exposure to secondary channels (movie theater slides, pamphlets,
direct mail, billboards, bumper stickers, posters, matchbooks)

0  Interpersonal contact networks
Topic-specific data are more pertinent to campaign planning:

o  Consumption of media presentations containing subject matter that
complements or competes with campaign messages (product ads, news
items, feature stories, entertainment portrayals)

o  Interpersonal communication about the topic (interactions with
opinion leaders, informal conversations, peer pressures)

o  Exposure to prior campaign messages (attention to topical PSA's and
posters)

Beyond sheer exposure, formative researchers can obtain credibility ratings for media
channels, vehicles, and content categories, and measure audience recall and evaluative
reactions to messages disseminated in previous campaigns. For example, the drunk-
driving surveys found the following:

o  Teenage male drinkers tend to listen to rock music stations, while adult
party hosts are heavy readers of local newspapers.

o  The typical person is exposed each day to a dozen prodrinking
portrayals in beer commercials and prime-time shows and to several
depictions of risky driving behavior in crime dramas.


ADVERTISING AND MARKETING

27

.  One-fourth of adults have tried to verbally discourage a drunk person
from driving.

o Teenage drivers perceive moderately strong peer pressure to avoid
getting drunk if driving.

o Young adults attend to an average of &JO anti-drunk-driving TV PSAs
per week, but almost no promoderation spots.         

o  More than half the public has noticed news stories about local police
efforts to catch drunk drivers.

o Many teenage drinkers discredit safety threats featured in PSAs.

preliminary Component Evaluation

Before campaign stimuli are drafted, strategic and creative approaches are facilitated
by both informal feedback and formal ratings of prospective source presenters, message
themes, persuasive arguments, and stylistic devices. In the drunk-driving project, focus
group discussions explored reactions to altruistic as opposed to fear appeals for motivat-
ing intervention attempts, and examined the appropriateness of humorous as opposed
to serious treatment of the subject. Survey questionnaires presented listings of several
dozen spokespersons, arguments, and claims under consideration for campaign mes-
sages. Believability and effectiveness scores for each component were measured along
ascaleofOt010.

Armed with background information collected in the preproduction phase of cam-
paign design, the strategy and research specialists are in a position to work with creative
personnel in the following tasks:

o  Formulating potential message ideas (and specific headlines, slogans,
copy points, layouts, formats, art work, music. and special effects)

o Selecting visible source presenter talent to appear in the messages

o Determining the most appropriate media for communicating the
  material

As stimulus construction progresses, research makes further contributions in the form
of message pretesting.

Pretesting Research

Pretesting is the second basic phase of formative evaluation that is conducted in
developing campaign messages. This term describes the process of systematicallygather-
ing target audience reactions to preliminary versions of messages before production in
final form (Atkin and Freimuth 1989). Pretesting can help determine which of several
alternative ideas or draft message executions are most effective, or it can identify
strengths and weaknesses in single prototype executions. Significant progress has been
made toward standardizing and implementing production testing methods in general
health campaigns, with the initiation of the Health Message Testing Service program
(Bratic et al. 1980) and the preparation of a pretesting handbook (HHS 1984).

Issues, Strategies, and Recommendations

This final section identifies issues for discussion, suggests strategies for minimizing
deleterious effects and enhancing positive impact, and recommends priority research
directions. The categories in thii section are the same as the first four categories in the
research literature section. The subject of alcoholic beverage marketing is specifically
covered under the alcohol advertising topic.


28

BACKGROUND PAPERS

Alcohol Advertising

A key question is whether a clear connection exists between alcohol advertising and
.drunk4riving behavior, particularly among youthful drivers: If so, what changes in the
nature of advertising practices would reduce drinking by drivers (or driving by drinkers)?
Would a ban on broadcast advertising lead to less drinking and thus reduce the incidence
of drunk driving? Would eliminating vehicle portrayals in ads help minimize problematic
effects? Should advertisers disclose safety risks involved in consuming their products in
a driving context? Would it be beneficial if ads depicted positive role modeling, such as
drivers refusing drinks or companions intervening to discourage excessive drinking or
prevent drunk driving?

This first set of issues can be addressed in part in philosophical or intuitive terms, but
the ultimate answer requires precise research data demonstrating the actual effects of
advertising on key outcomes. Investigations are needed to isolate the features of adver-
tisii content that contribute to higher and lower levels .of excessive drinking and drunk
driving. Conclusive evidence will require longitudinal research with multiple data points,
particularly over the formative teenage years during and following the onset of drinking
and the initiation of driving. Special attention should be devoted to new products that
are introduced; indeed, priority should be given to studies of wine cooler advertising.

Based on the current literature showing relatively modest degrees of harmful effects
and the pragmatic political barriers to fundamental change, broad-scale restrictions on
advertising do not appear to be promising. Instead, attempts should be made to eliminate
a small array of the most problematic practices, to insert additional disclaimers and
positive role modeling in ads, and to increase the number of brand-sponsored public
service ads that promote moderation or warn against drunk driving This approach will
require discussion of the social responsibiity of the advertismg, media, and alcohol
industries, and of the role of government and advocacy organizations in implementing
reform. The optimum arrangements for collaborative efforts between representatives of
the industry, the public health sector, and other interested parties should be aggressively
explored.

Problematic. effects of marketing practices have yet to be investigated by social
scientists. Among the four Ps of marketing (product, place, price, and promotion), this
panel's attention should focus on promotional activities since other panels are dealing
with the lirst three components. Several types of marketing activities warrant examina-
tion:

o  Alcohol promotions to underage college students (campus newspaper
ads, sponsorship of drinking events, spring-break promotions)

o  Tie-ins with professional athletic teams and promotion of d&king at
sporting events

o  Sponsorship of automobile races and product endorsements by race
  car drivers

o  Licensing of youth-oriented clothing and toys featuring brand names,
logos, or trade characters

Entertainment Media

The issues involving the entertainment media closely parallel those raised with
advertising. What changes in the nature of TV portrayals would reduce drunk driving?
Is the entertainment industry responsible for "social engineering" of appropriate drink-
ing and driving practices? The potential for successful collaboration seems promising,
owing to the precedent of the alcohol white paper (Breed and DeFoe 1982) and recent
efforts of Harvard's Center for Health Promotion and the Entertainment Industries


ADVERTISING AND MARKETING

29

Council to encourage depictions of designated drivers and safe party hosting in TV
programs.                             
Thus, the highest priority is determining which types of content are most problematic

and which portrayals should be'emphasized. The sheer pervasiveness of drinking on TV
is probably less critical than the n&ture of motivations and consequences. Whether
viewers see 100 or 200 drinking acts per week may not make much of a difference, but
the ratio of positive to negative depictions can significantly determine attitudinal and
behavioral outcomes (e.g., downplaying deficit motives and more realistically repre-
senting harmful consequences involving driig and/or driving). Increased modeling
of certain responsible behaviors would also be beneficial (e.g., declining drinks,.choosing
nonalcoholic beverages, stopping drinking before intoxication, intervening to prevent
drunkenness or drunk driving). Research is needed to specify exactly how these various
portrayals influence the audience (especially young viewers), and how the material
should be packaged for maximum effectiveness.

News Media

AS with advertising and entertainment, a general issue concerns the extent to which
journalists are responsible for adjusting their professional news standards to accom-
modate the public interest in covering drunk driving. This problem is more complicated
in the case of the news media owing to press freedom and autonomy priorities. Among
the specific issues are whether editors and writers should adopt practices such as
reporting whether drinking is involved when describing accidents, and identifying names
of drunk drivers arrested after accidents or convicted of DWI. These practices are widely
endorsed by the public in the Atkin, Garramone, and Anderson (1986) survey.

Several approaches to improving news media treatment appear to be promising.
Efforts should be made to generate more extensive news coverage of drunk driving in
newspapers and local television newscasts. The publicity tactics developed by antismok-
ing advocates can be examined and adapted to drunk driving (see ACS 1987; AI 1988).
There is also a need for more stories reporting newsworthy aspects of the problem about
which the pubhc is ignorant and misinformed, such as BAC levels, penalties for convic-
tion, and host liability. Special efforts should be made to work more closely with news
media personnel who cover the alcohol and drunk-driving beats, perhaps by convening
annual conferences at State or national levels to update gatekeepers on the latest
information on these problems.

Research is required to identify the types of content in news and feature messages
that attract audience attention and influence the beliefs and attitudes of key subgroups
such as drinking drivers and interveners. For example, tests could be performed to:

a. determine the relative effect of news items emphasizing the likelihood of getting
caught versus the severity of punishment,
b.  measure the extent to which apprehension of the social stigma of news publicity
is induced by local newspaper identification of drunk drivers, or

C. ascertain the effect of stories reporting the arrest of well-known people.

Public Service Information Campaigns

The first issue concerns the degree of current and potential impact of anti-drunk-
driving campaigns. Are present information campaigns working well enough, or are
additional efforts needed? Can mass media education and persuasion have a meaningful
effect in preventing drunk driving, or should resources be redirected elsewhere? Is it
necessary to place paid ads in order to reach target audiences effectively?
Second, discussion should explore various forms of coordination that can be


30

`&KGROUND PAPERS

developed to enable more comprehensive campaign programs. How can cooperation
between government agencies, private organizations, and the mass media be further
enhanced? How can campaign messagesbe better coordinated withlocal police enforce-
ment efforts and judicial handling of drunk driving cases?   `1      -
A third set of issues involves the specification of campaign objectives: Should cam-
paigns recommend absolutely no drinking,before driving, or set more realistic guidelines
such as one drink per hour? What should be the balance between messages fundamen-
tally discouraging excessive consumption of alcohol and messages focusing on drinking
only in the context of driving? Should campaigns intensively focus on specific occasions
such as graduation or holiday periods? Or should they run continuously with a lighter
schedule of messages? What portion of campaign efforts should be targeted to drivers,
to companions, to hosts, and to the general public? For example, interventions can be
performed at several points:

o Parents can prevent party attendance by teenagers (precluding the
opportunity to drink and drive).                     I

o  Designated driver arrangements can prevent drivers from drinking.

o  Companions and hosts can persuade drivers to limit drinking before
driving.

   o  Friends can prevent intoxicated drivers from driving.
Campaign strategies can be improved in a number of ways. Concepts and principles
from-the fields of mass communication and social marketing should be refined and
implemented by designers of anti-drunk-driving campaigns. Channelsbeyond the stand-
ard TV PSA should be used more extensively, especially alternatives nearer in time to
the drinking and driving event (e.g.,radio spots heard on the way to a bar, onsite reminder
signs). New message themes and appeals should be created, with more emphasis on
positive persuasive incentives and concrete demonstrations for carrying out good inten-
tions. A portion of campaign materials should be devoted to countermessages that
inoculate young people against undue influence from problematic themes and depictions
in ads and entertainment'programing. Research examinin g the relative effectiveness of
various sources, messages, and channels in anti-drunk-driving campaigns would be
useful in improving the design and construction of stimuli.
Summative evaluation research is also needed to trace the naturalistic effect of
campaigns, using sophisticated and sensitive methods proposed by Haskins (1985).
However, at this time a higher priority should be placed on formative evaluation
research. More extensive use of preproduction research and message pretesting is one
of the more promising avenues for increasing the effectiveness of public communication
campaigns. Formative evaluation techniques provide campaign strategists and message
producers with valuable information for decisions along each step of the design process
from identifying target audiences to refining rough executions.
Formative research has played an instrumental role in the success of educational
television programing produced by the Children's Television Workshop, ranging from
the development of Sesame Streel to the recent Be Sman Don `t Start campaign aimed at
predrinkers (Atkin 1989c). Formative evaluation has been centrally featured in a number
of recent health campaigns, and is a mainstay in the commercial campaign sector.
However, such research is still the exception rather than the rule in the drunk-driving
public service domain. It is rarely conducted during development of mass media cam-
paigns because of insufficient funding, lack of technical expertise, and minimal apprecia-
tion for the value of background information and feedback. Until this important form of
evaluation is given higher priority by managerial and creative personnel, drunk-driving
campaigning will continue to be be handicapped and only sporadically influential.
Finally, the creation of a new handbook for campaign design would make a major
contribution. Thii document could incorporate social marketing principles, persuasive


~vERT~SING AND MARKETING

grategy guideline% and evaluation research techniqties in a practical package that could
b used at national, State, and local levels to improve the effectiveness of public service
i&rlIlidOn Wnpaigns-

REFERENCES

Ackoff, R.L.., and Emshoff, J.R. Advertising research at Anheuser-Busch. Sloan Management
   &vi&v l&l-15,1975.

Advocacy Institute. Smoking Co~Z Media Advqcucy Guidelines. Report to the National Cancer
   Institute. Washington, DC Advocacy Institute, 1988.
Ajzen, I., and Fshbein, M. UnderstandingAttitudes and ??edicting Social Behavior. Englewood
   cliffs, NJ: Prentice-Hall, 1980.

Albert, W.G. General models of persuasive influence for health education. In: Leather, D.S.;
   Hastings, G.B.; and Davies, J.K., eds. Health Education arid the Media. Oxford: Pergamon
   Press, 1981.

merican Cancer Society. Smoke S&c&: Z7te Smoking Cowl Media Handbook. Nav York:
   AC& 1987.

hdcmn, K, and McCullough, J. Application of marketing principles to improve participation in
  public health programs. Joumal of Community HeaZth 6(3):216-222,198l.
Atkin, CK Research evidence on mass mediated health communication campaigns. In: Nimmo,
   D., ed. Communication Yearbook 3. New Brunswick, NJ: Transaction Press. 1979.
   pp. 655668.

Atkin, C.K. Mass communication-research principles for health education. In: Meyer, M., ed.
   Health Education by Television and Radio. Munich: Saur, 1981~. pp. 41-55.
Atkin, CK Mass media information campaign effectiveness. In: Rice, R.E., and Paisley, WJ., eds.
    Public Co mmunication Campcrigns. Beverly Hills: Sage, 1981b. pp. 265-280.
Atkin, C.K "Parent-Based Prevention of Teenage Drinking and Driving." Paper presented to
   North American Congress on Alcohol and Drug Problems, Boston, 1986.
Atkin, C.KA Critical Review of Media Eficts on Alcohol Comumption Potterns. Report prepared
   for the Alcoholic Beverage Medical Research Foundation, Baltimore, MD, 1988.
htkin, C.K Alcoholic-beverage advertising: Its content and impact. Advances in Substonce Abuse
   Suppl. 1267~287,1987.

Atkin, C.K Television socialization and risky driving by teenagers. Alcohol Drugs, and Driving
   5(l), 198%

Alkin, C.K Effects of televised alcohol messages on teenage drinking patterns. Jo& ofAdoZes-
  cent He&h Care, 9(2):121-134,1989b.

Atkin, C.K Be smart. Don't start! In: Rice, R., and Atkin, C, eds. Atblic Communica.tion
  Camp&m. Newbuty Park, CA: Sage, 1989c. pp. 224-227.
Atkin, C.K, and Atkin, J. Michigan Parent Group Handbook Preventing Teenage Drinking and
  Other Drug Problems. Lansing, MI: Michigan Substance Abuse and Traffic Safety Infor-
   mation Center, 1986.

Atkin, C.K, and Block, M. Content and Effecti ofAIcoho1 Advertising. Prepared for the Bureau
  Of Alcohol, Tobacco, and Firearms, Pub. No. PB82-123142. Springfield, VA: National
   Technical Information Service, 1981.

&kin, C.K, and Block, M. Effe&vencss of celebrity endorsers. Journal of Adver&ing Resemch
   235741, 1983.

Atkin, C.K, and Block, M. The effects of alcohol advertising. In: Kinnear, T.C., ed. Advunces in
  conmuner &se&t, Volume 11. Provo, UT: Association for Consumer Research, 1984.
   pp. 688693.

Atkin, C.K, and Freimuth, V. Formative evaluation research in campaign development. In: Rice,
  R., and Atkhi, C., eds.Public Communication Campaigns. Newbury Park, CA: Sage, 1989.
   pp. 131-150.

Atkin, C.Ic; Garramone, G.M.; and Anderson, R. "Formative Evaluation Research in Health
  Campaign Planning: The Case of Drunk Driving Prevention." Paper presented to Inter-
   national Communication Association Annual Conference, Chicago, 1986.
Atkin, C.Ic, Hocking, J.; and Block, M. Teenage drinking: Dces advertising make a difference?
   bmal of Communimtion 34: 157-167,1984.

31


                                       BACKGROUND PAPERS

Atkin, C.K.; Neuendorf, K.; and McDermott, S. The role of alcohol advertising in excessive and
   hazardous drinking. Journal of Drug Education 13313325.1983.
Bandura, A. SocialLeaming Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977,
Bettinghaus, E. Healtti promotion and the knowledge-attitude-behavior continuum, preventive
   Medicine 15:4X-491,1986.
Blanc; H.T., and Hewitt, LB. Alcohol, public education, and mass media: An overview. Alcohol
   He& and Research World 5( 1):2-$1980.
Bloom, P.N., and Novelli, W.D. Problems and challenges in social marketing. JoumaZof Markefing
   45:79-88,1981.
Bourgeois, J.C, and Barnes, J.G. Does advertising increase alcohol consumption? Journal of
   Advertising Research 19: 19-29,1979.
Bratic, E.; Greenberg, R.; and Peterson, P. HMTS Improving the quality of public service
   announcements through standardized pretesting. Journal of rhe Academy of Marketing
   Science 9( 1):40-5 1,198O.
Breed, W., and DeFoe, J. Effecting media change: The role of cooperative consultation on alcohol
   topics. Journal of Communication 32~99.1982
Breed, W., and DeFoe, J. Drinking andsmoking on television, 1950-1982 JoumaZofPubZic He&
   Policy 5:257-270,1984.
Breed, W., and DeFoe, J. Television portrayals of drinking and driving. Zntmnufioti QuurrerZy of
   Community Health Education 6(4):273-283,1985&j.
Brown, R.k Educating young people about alcohol use in New Zealand: Whose side are we on?
    British Journal on Alcohol and Alcoholism 13: 199-204,1978.
Cafiso, J.; Goodstadt, M.; Gariington, W.; and Sheppard, M. Television portrayal of alcohol and
   other beverages. Journal of Studies on Alcohol 43123243.1982
DeFbe, J.; Breed, W.; and Breed, L. Drinking on television: A five-year study. Journal of Drug
  - Education 13%~28,1983.
Department of Health and Human Services Making PSAs Work. A Handbook for Health Com-
   munication Z+ofessionals. NIH Pub. NO. 832485, Washington, DC the Department,
     1983.
Department of Health and Human Services Retesting in Health Communicafio~: Merhods,
   Examples, and Resources for Zmproving Health Messages and Materiak. NIH Pub. No.
   84-1493, Washington, DC: the Department, 1984.
Department of Transportation LIrunkDritigRiblic Znformation&ogram Slrafegies and Planning
   Guide. DOT HS 806 680, Washington, DC: the Department, 1985.
Duffy, M. The influence of prices, consumer incomes and advertising upon the demand for
   alcoholic drink in the United Kingdom: An econometric study. British Jozunalon Alcohol
    andAlcoholism 16:20@20,1981.
Dunn, S.P., and Rogers, R. W. Protection motivation theory and preventive health: Beyond the
   health belief model. Health Educarion Research 1(5):153-161, 1986.
Finn, TA, and Strickland, D. A content analysis of beverage alcohol advertising, #2. Television
   advertising. Journal of &dies on Alcohol 435X54-989,1982.
Finn, T.A., and Strickland, D. The advertising and alcohol abuse issue: Across media comparison
   of alcohol beverage advertising content. In: Burgeon, M., ed. Communication Yearbook.
   Beverly Hills, CA: Sage, 1983. pp. 850-872
Flay, B. On improving the chances of mass media health promotion programs causing meaningful
   changes in behavior. In: Meyer, M., ed. Health E&cation by Teletiion andRadio. Munich:
   Saur, 1981. pp. 56-91.
Flay, B.R.; DiTecco, D.; and Schlegel, R.P. Mass media in health promotion: An analysis using an
    extended information-processing model. Health Education Quarterly 7(2):127-147,198O.
Fox, K., and Kotler, P. The marketing of social causes: The first 10 years. Jo& ofibfarkering
    44~24-33, 1980.
Franke, G., and Wilcox, G. Alcoholic beverage advertising and consumption in the United States,
   1964-1984. Journal ofAdverti&g 16:22-30,1987.
Friedman, H.; Termini, S.; and Washington, R. The effectiveness of advertisements utilizing four
   types of endorsers. Journal ofridvetiing 6:22-24,1977.
Futch, E.; Lisman, S.; and Geller, M. An analysis of alcohol portrayal on prime-time television.
   International Journal of the Addictions 19:403-410,1984.
Geller, ES. A behavioral science approach to transportation safety. Bulletin of the New York
   Academy of Medicine, in press.


33

Gerbner, G.; Gross, L; Morgan, M., * and Signorielii, N. Livingwith television: The dynamicsof the
  cultwtion process. In: Bryant, J., and Zillmann, D., eds. Perspectives on Media E'cts.
  Hillsdale, NJ: Eribaum, 1986. pp. 17-40.                                 \

Greenberg, B. Smoking, drititing, and drugging in top-rated TV series. JoumaZ of Drug Education
  11(3):227-233.1981.

Greenberg, B., and Atkin, C. The portrayal of driving on television. Journal of Commun ication
   33~44-55.1983.                                 
Greenberg, B.; Femandez-Coliado, C.; Graef, D.; Korzenny, F.; and Atkin, C. Trends in use of
  alcohol and other substances ?n television. Journal of Drug Education 9:243-253,1979.
Grunig, J.E., and Ipes, D.A. The anatomy of a-campaign against drunk driving. mlic Rektions
   &view 936-52, 1983.

flansn, A The portrayal of alcohol on television. Health Ea'ucation Journal 45(3):127-131,1986.
~&ins, J.B. The role of mass media in alcohol and highway safety campaigns. Journal of Studies
  on Alcohol 46( 10): 184-191,1985.

klc&t, LE., and Blane, H.T. Prevention through mass media communication. In: Miller, P.M.,
  and Nirenberg, T.D., eds. Revenrion of Alcohol Abuse. New York: Plenum, 1984.
  pp. 281-323.

Ja~bson, M.; Atkins, R.; and Hacker, G. The Booze Merchanti: The Inebriating of America.
  Washington, DC: Center for Science in the Public Interest, 1983.
sltxxrne, W.E.; Painton, S.; and Ridley, D. The effect of sexual embedding on responses to
  magazine advertisements. JoumaZ OfAdvertising 14:48-56,1985.
Kohn, P.M., and Smart, R.G. The impact of television advertising on alcohol consumption: An
  experiment. Journal of Studies on Alcohol 49295301,1984.
Kohn, P.M., and Smart, R.G. Wine, women, suspiciousness and advertising. Journal of Studies on
   Alcohol 48:161-166,1987.

Kohn, P.M.; Smart, R.G.; and Ogborne, AC. Effects of two kinds of alcohol advertising on
  subsequent consumption. Journal ofAdvertising 13:34-41,1984.
Ketch, J.B.; Coulter, M.; and Lipsitz, A. Does televised drinking influence children's attitudes
   toward alcohol? Addictive Behaviors 11:67-70,1986.
Kotler, P. Marketingfor Non-profir organiurtions. Englewood Cliffs, NJ: Prentice-Hall, 1982,
Kotler, P. Social marketing of health behavior. In: Fredericksen, L.W.; Solomon, L.J.; and
  Brehony, IL4 eds. Marketing Health Behavior Principles, Techniques, and Applications.
  New York: Plenum Press, 1984. pp. F-39.

Leathar, D-S.; Hastings, G.B.; O'Reilly, KM.; and Davies, J.K. HeaZth Education and the Media
   ZZ. Oxford: Pergamon, 1986.

Lowry, D. Alcohol consumption patterns and consequences on prime time network TV. Jour-
   nalism Quarterly 58:38,1981.

Luckey, J.W.; Richichi, E.; and McGaughey, K. Print Media Coverage of Drinking and Lkiving.
  Chapel Hill: University of North Carolina School of Public Health, 1984.
Manhoff, R. Social Marketing: New Imperative for Public Health. New York: Praeger, 1985.
McCarty, D., and Ewing, J.A. Alcohol consumption while viewing alcoholic beverage advertising.
  l'?teZntemationalJoumaloftheAddictions 18:1011-1018, 1983.
McCombs, M., and Gilbert, S. News influences on our pictures of the world. In: Bryant, J., and
  Zillmann, D., eds. Perspectives on Media Eficfs. Hillsdale, NJ: Erlbaum, 1986. pp. l-16.
McGuinness, T. The demand for beer, spirits and wine in the United Kingdom. In: Grant, M.;
   Plant, M.; and Williams, A., eds. Economics andAlcohol: Conwmption and Control. New
   York: Gardner Press, 1983. pp. 238-242.

McGuire, W. Theoretical foundations of campaigns. In: Rice, R., and Paisley, W., eds. Public
  Communication Campaigns. Beverly Hills: Sage, 1981. pp. 41-70.
Mendelsohn, H. Some reasons why information campaigns can succeed. Public Opinion Quarterly
   37:50-61,1973.

Novelii, W. Developing marketing programs. In: Frederickscn, L.W.; Solomon, L.J.; and Brehony,
  KA, eds. Marketing Health Behavior Ainciples, Techniques, and Applications. New York:
   Plenum Press, 1984. pp. 58-89.

Ogborne, AX., and Smart, R.G. Will restrictions on alcohol advertising reduce alcohol consump-
  tion? British Journal of Addiction 75:293-2%, 1980.
timstein, S.I., and Hanssens, D.M. Alcohol control laws and the consumption of distilled spirits
  and beer. Journal of Consumer Research 12:200-213,1985.


34

BACKGROUND PAPERS

Petty, R., and Cacioppo, J. &titudes and Persuasion: Clawic and Contemporaq Appmaches.

Dubuque, L& Wm. C. Brown, 1981.

Postman, N.; Nystrom, L; Strate, L,`and Weingartnet, C. Myths, Men. and Beer: An AnaZysk of
    Beer co mmercials on .Brwdcart Tel&ion. Falls Church, VA: AAA Foundation for
   Traffic Safety, 1987.
Rice, R., and Atkin, CK Public Conuwtic at& Campaigns. Newbury Park, CA: Sage, 1989.
Ross, H.L. Britain's Christmas crusade against drinking and driving Journal of Studies on Alcohol
   48(5):476+X& 1987.

Rubin, A. Uses, gratifications, and media effects. In: Bryant, J., and Ziiimann, D., eds. Peqectives
   on Media Effects. Hillsdale, NJ: Eribaum, 1986. pp. 1-16.
Rychtarik, R.G.; Fairbank, J.k; Alien, CM.; Foy, D-W.; and Drabman, R.S. Alcohol use in
  television programming: Effects on children's behavior. Addictive Behavior 8: 19-22,1983.
Schweitzer, S.; Intriiigator, M.; and Saiehi, H. Alcoholism: An econometric model of its causes, its
   effects an its control. In: Grant, M.; Plant, M.; and Wiiliims, A., eds. Economics and
   Alcohol: Consumption and Cona&. New York: Gardner Press, 1983. pp. 107-127.
Signorielli, N. Drinking, sex, and violence on television: The cultural indicators perspective. JoumaZ
   of Lhg Education 17(3):245-260,1987.                   .,
Simon, J.L. The effect of advertising on liquor brand sales. Journal of Markefhg Research
   9:301-313, 1969.

Smart, R.E. Does alcohol advertising affect overall consumption? A review of empirical studies.
   Joumal of Studies on Alcohol 49(4):314-323,1988.
Smart, R.G., and Cutler, R.E. The alcohol advertising ban in British Columbia: Problems and
   effects on beverage consumption. British Journal ofAddiction 71:13-21,1976.
Sobeli, L.C; Sobeii, M.B.; Riley, D.M., Klajner, F.; Leo, G.I.; Pavan, D.C.; and Cancilia, A. Effect
   of television programming and advertising on alcohol consumption in normal drinkers.
   Journal of Sties on Alcohol 47:333-340,1986.
Solomon, D. Asocial marketing perspective on campaigns. In: Rice, R., and Paisley, W., eds. public
   Communication Campaigns. Beverly Hills: Sage, 1981. pp. 239264.
Strickland, D.E. Alcohol advertising: Orientations and influence. International Journal ofAdver-
   ti&.ng 1X)7-319,1982

Strickland, D.E. Advertising exposure, alcohol consumption and misuse of alcohol. In: Grant, M.;
   Plant, M.; and Williams, A, eds. Economics andALcohol: Conswqion and Controk, New
   York: Gardner Press, 1983. pp. 201222.

Swinehart, J.W., Grimm, AC., and Douglass, RLA Study of 2SZ'rintAd~ertisements on Lkinking
   and Driving. Ann Arbor: University of Michigan Highway Safety Research Institute, 1974.
Wallack, L. Drinking and driving: Toward a broader understanding of the role of mass media.
   Journal of Public Health Policy 5(4):4714%, 1984.
Wallack, L. Mass media and health promotion: A critical perspective. In: Rice, R., and Atkin, C.,
    eds. Public Comnzunic ation Cegns. Newbury Park, CX Sage, 1989.
Wallack, L., and Barrows, D. Evaluating primary prevention: The California "winners" alcohol
   program. International Quarterly of Community Health Education 3(4):307-336,1982-83.
Wallack, L.; Breed, W.; and Crux, J. Alcohol on prime-time television. Journal of Studies on
   Alcohol 4&33-38,1987.

Wilcox, G.B. The effect of price advertising on alcoholic beverage sales. Journal of Advertising
   Research 2533-38, 1985.

Worden, J.Ic, Wailer, J.A.; and Riley, TJ. The Vermont Public Education Campaign in Alcohol
   and Trajjic Safety. Montpelier, VT: Department of Mental Health, 1975.


35

Epidemiology and Data Management

Epidemiologic Perspectives on
    Drunk Driving

M.W. Perrine

Vermont Alcohol Research Center, Burlington, Vermont

Raymond C. Peck

      Research and Development Office
California Department of Mot& Vehicles, Sacramento, California

James C. Fell

National Centerfor Statistics andAnalysis, National Highway Tmfic Safety
        A&n&istration, Washington, D. C.

What is the one element found in approximately half the U.S. highway fatalities? This
question has been raised over the last few decades and the answer is still the same:
Alcohol. This answer generates another question: If a single, identifiable element is
involved in such a large portion of a serious public health and public safety problem,
should it not receive top priority for investigation, in'tervention, and prevention?

Alcohol produces both pleasure and pain, euphoria and depression. Alcohol also
produces many jobs and billions of dollars in tax revenues to the States and to the Nation.
Each year, alcohol also produces unintentional death to thousands and injury to millions.
When mixed with driving, alcohol is the basis for a major public health and public safety
problem. In our automotive society, the car is used for almost all facets of social activity.
Therefore, since alcohol is involved in many aspects of social behavior, driving after
drinking is a relatively frequent occurrence. Fortunately, the vast majority of such
driving-after-drinking instances do not result in crashes. One very important task for
researchers is to identify variables that differentiate between those driving-after-drink-
ing instances that do result in a crash and those that do not.

How do we learn about the contribution of alcohol to unintentional injury and death
on the highways? In attempting to do so, we still find a large gap between description
and explanation that, at this time, can be bridged only provisionally through inference.
Two widely separated research approaches have been used to date as a basis for inferring
the contribution of alcohol to highway crashes: epidemiologic and experimental.

NOTE: Primary responsibility forparts of this chapter is as follows: J.C Fell, the subsection entitled "Alcohol
fnvolvement in Fatal Highway Crashes"; RC. Peck, the subsection entitled Tharactersitics of Drunk
Dfiw-s"; M.W. Perrine, all other sections. The first author is grateful to Robert B. Voas for early discussions
of this chapter and for material p&i&d in the sections on "Other Roadside Research" and "Enforcement
Checkpoints." Preparation of M.W. Perrine's part of this chapter and production of the manuscript were
supported by PHS Research Grants .4,474, AA06926, and AA07876 from the National Institute on Alcohol
Abuse and Alcoholism.


36

BACKGROUND PAPERS

The epidemiology of alcohol and highway safety can be traced from the first review
of the problem presented in 1933 (Miles 1934). Over the years, high blood alcohol
concentration (BAC) has &en thoroughly implicatedin serious and fatal injury highway
crashes by post hoc epidemiologic studies. Most evidence for relating-this alcohol
contribution to highway crashes has been obtained by examination of the distribution of
BAC both among drivers involved in actual crashes (fatal and nonfatal) and- on the
basis of case-control roadside surveys-among drivers using the highways, but not
involved in crashes at the time. A number of such case-control studies have demonstrated
that alcohol is overrepresented among deceased drivers relative to drivers in the popula-
tion-at-risk using the highways at corresponding times and places (e.g., Borkenstein et
`al. 1964, 1974; Perrine et al. 1971; for reviews see NRC 1987; NHTSA 1985; Perrine
197%; b).

The second approach consists of controlled administration of alcohol in experiments
conducted on isolated variables that are assumed to be relevant for actual driving.
Alcohol impairment of real-world driving performance is then typically inferred from
the mosaic of these bits of behavior examined separately in the laboratory, in driving
simulators, and in instrumented cars driven on closed courses (NRC 1987).

Both research approaches to the study of drunk driving are necessary and have been
productive (NRC 1987; Perrine 1976). However, this chapter is limited to epidemiologic
aspects; it is organized as follows:

A discussion of the scope of the drunk-driving problem from an
epidemiologic perspective

A brief outline of the major components involved in studying the problem
by means of the available data sources
A review of the most relevant literature, focusing on alcohol involvement
in fatal as well as nonfatal highway crashes and in noncrash drivers; crash
risk and alcohol; and characteristics of drunk drivers
An examination of current issues and problems

Scope of the Problem

The primary problem clearly consists of those motor vehicle crashes that result in fatal
injuries. It is now generally well established that alcohol is involved in approximately half
of all such fatal crashes. For example, the total number of highway fatalities in 1986 was
46,056, of which some 24,000 (52 percent) involved alcohol. More specifically, BACs
exceeded the typical legal limit (0.10) in 41 percent of all fatal crashes.

An estimated 4.8 percent of deaths in the United States during 1980 were directly or
indirectly attributable to alcohol (NIAAA 1987). Of these, motor vehicle crashes were
the largest single cause of death. Approximately 26,000 deaths in 1980 were attributed
to alcohol in motor vehicle crashes; these deaths constituted about 27 percent of the total
number of deaths (approximately 98,000) attributable to alcohol (NIAAA 1987, p.6).
The number of alcohol-involved motor vehicle deaths is about two times that of the
second largest single cause of alcohol-involved death, namely, homicide (approximately
12,000 or 12 percent) (NIAA4 1987, p-6).

The scope of the alcohol and traffic safety problem has recently been reviewed briefly
both from a public health perspective (NIAAA 1982,1985,1987) and from a public safety
perspective (NHTSA 1985,1987b; NRC 1987). In this chapter, the problem is examined
further to provide a more integrated synthesis of the literature from both these
perspectives.


EPIDEMIOLOGY AND DATA MANAGEMENT

Major Components of the Study

37

Aside from epidemiologic methodology considerations, the major components in-
volved in the present perspective on drunk driving consist of the data sources. The two
primary sources of data for this area are offtcial records and surveys of various types.
The official records consist primarily of the following:
The citation report for driving under the influence of alcohol (DUI)
The accident report, if alcohol is involved
  The prosecutor record
  Court records

Department of Motor Vehicle records
Treatment/service provider records
Probation department records

Of special importance are those reports of accidents in which a fatality resulted, since
these data are collected at the State level and then forwarded to the Fatal Accident
Reporting System (FARS) of the National Highway Traffic Safety Administration
(NHTSA). As an example of using such data, analyses of DUI processing from the point
of the arrest citation through the other official records, including the postconviction
countermeasures, have been prepared for the State of California (Perrine 19&1;
Helander 1986; Peck 1987).

The other major source of data for epidemiologic studies consists of surveys. The
main varieties are:

roadside surveys,

telephone surveys (in recent years, the random-digit-dialing telephone
SuNeY),
household surveys, and

special location surveys (bars, jails, etc.).

Of these various types, only the roadside surveys can obtain direct measurements of
the major criterion variable- namely, BAC- from drivers actually using the roads at the
time. All the other survey methods depend on self-reported information from the
respondents, including data concerning driving after drinking. Thus, only the direct
measurement of BAC at roadside can be used to provide criterion measures for
estimating alcohol crash risk and for evaluating the impact of countermeasure programs
on the motoring public.

Review of the Most Relevant Literature

Alcohol Involvement in Fatal Highway Crashes

In 1986, 46,056 people were killed in traffic crashes (NHTSA 1988), which are the
leading cause of death for Americans age 6-34 (Richardson 1985). Traffic fatalities in
1986 resulted in 1,425,517 years of potential life lost before age 65, an amount greater
than deaths from cancer, heart disease, and all other causes. Traffic crashes cost society
approximately $74 billion annually in terms of damage, insurance costs, injury treat-
ments, lost work, and so forth. (NHTSA 1987c). Since 1900, over 2,600,OOO Americans
have died in traffic crashes; that is 1,500,OOO more than the total number of Americans
killed in all the wars in U.S. history.


38                                                        BACKGROUND PAPERS

It is well known that `alcohol is a leading factor in traflic crashes. It was involved in
over half of thetraffic fatalities in 1986, resulting in close to 24,000 deaths (NHTSA 1988).
Each year, nearly 560,000 additional people suffer injuries in alcohoi-related crashes -
an average of one person injured every minute of the day. About 43,000 of these injuries
are serious (NHTSA 1988).
During the 198286 period, approximately, 119,000 people lost their lives in alcohol-
related traffic crashes-an average of one alcohol-related fatality every 22 minutes over
the past 5 years. About two out of five Americans will be involved in an alcohol-related
crash in their lifetime (NHTSA 1987u). Approximately 1800,000 drivers were arrested
in 1986 for DUI - an arrest rate of about 1 out of every 90 licensed drivers in the United
States (Greenfield 1988).

The problem is especially devastating for young people. In 1986, more than 40 percent
of all teenage deaths resulted from motor vehicle crashes. Over half of these were alcohol
related, making alcohol-related traflic crashes the leading cause of death for teenagers.
For traffic crash victims age 20-24, close to 70 percent of the 8,000 who died in 1986 were
in alcohol-related crashes (NHTSA 1988). The probability that a given death is due to
a traffic fatality is 55 times as great for a ul-year-old male as for a 65year-old male; the
corresponding ratio for females is 43 (Evans 1987).

The average BAC of drinking drivers involved in fatal crashes was 0.15 in 1986
(NI-ITSA 1985). The legal intoxication limit in most States is 0.10. In a recent survey of
drivers jailed for drunk driving offenses, over a quarter of the drivers had consumed at
least 20 beers or 13 mixed drinks within 3-4 hours before they were arrested (Greenfield
1988). Research has shown that a driver with a BAC of 0.15 has a 26times greater
probability of beii involved in a crash than a sober driver (NHTSA 1985).

FARS indicated that 41 percent of the traffic fatalities in 1986 involved either a driver
or a pedestrian with a BAC of 0.10 or greater. This percentage translated to 18,890
fatalities. An additional 11 percent (5,100 fatalities) involved a driver or pedestrian with
some alcohol (BAC = 0.01-0.09). Only 48 percent of the fatalities involved all drivers
and pedestrians with zero alcohol.

Alcohol involvement did vary by time of day, day of week, and type of crash (table 1).
Seventy-seven percent of the fatal crashes that occurred between 8 p.m. and 4 a.m. on
any night of the week involved alcohol. Alcohol was also much more prevalent in
single-vehicle crashes than multiple-vehicle crashes. Almost half the collisions resulting

Table 1. Alcohol involvement in fatal crashes: 1988

Crashes

             BAC
       0.01-0.09 0.10 and higher
N (pzznt) (percent)   (percent)

Fatal

Daytime (4 a.m. - 8 p.m.)
Nighttime (8 p.m. - 4 a.m.)
Weekday
Weekend (8 a.m. Fri - 4 a.m. Mon)
Single vehicle
Multivehicle
Nonoccupant

(pedestrian/bicyclist)

41,062   48      11         41
23,828    67       9         25
16,900   23       14        63
22,700   59      9        32
16,277   35      12        53
17,114   38      11        51
16,244   58      11 -        31
7,704   51       9         40


EPIDEMIOLOGY AND DATA MANAGEMENT
Table 2. Drivers and nonoccupsnts (pedestrians/bicyclists) involved in fsul
    crsshes: 1986

BAC

39

       0.00   0.014.09 0.10 and higher
N    (percent) (percent)   (percent)

-

All drivers          60,297       66       8         26
Driver fatalities        26,613      52      9        39
surviving drivers       33,684      77       8        15
Nonoccupant fatalities     7,770      64      7        29
Male drivers         46,622      63      9         223
Female drivers        G734       79      6        15

in a nonoccupant (pedestrian or pedalcyclist) death involved alcohol, mostly on the part
of the pedestrian.

When examining data for all drivers involved in fatal crashes, keep in mind that in
multiple-vehicle crashes, at least two drivers are involved in one crash. In 1986,60,297
drivers were involved in the 41,067 fatal crashes. Twenty-six percent of these drivers were
legally intoxicated (BAC greater than or equal to 0.10) at the time of their crashes (table
2). Of the 26,613 drivers who were killed in their crashes, 39 percent were legally
intoxicated compared with only 15 percent of the drivers who survived fatal crashes. Male
drivers were almost twice as likely to have over 0.10 BAC at the time of their crashes as
female drivers (28 percent versus I.5 percent).

Alcohol involvement did vary substantially by driver age in 1986 (table 3). While 21
percent of teenage drivers were legally intoxicated at the time of the crash, an additional
13 percent had also been drinking. Drivers 28-24 years old had the highest alcohol
involvement rate: 47 percent. In contrast, only 7 percent of drivers age 65 and older were
legally intoxicated at the time of their crash.

Examining certain combinations revealed that while almost two-thirds of the fatal

Table 3. Alcohol involvement by driver age, 1986

Driver's BAC

Driver's age

0.00
(percent)

O.Ol-.09   0.10 and higher
(percent)    (percent)

N*

16-19          66          13          21        7,854

20-24          53          12         35       11,427
25-34          59         8         33       16,163
35-54          72         6         22       14,305
55-64          81         5         14       4,017
65 and older        89          4          7       4,881
All ages         66          8         26       60,297

o N = Number of drivers in age group where age was known.


40                                                       BACKGROUND PAPERS

Table 4. Drivers involved in fatal crashes, 1986

iAC -

N

O.Ol-.09
(percent)

0.10 and higher
(percent)

Male/weekend/night

10273       38        14           49

Female/weekday/day   6,503       90         3           7
Driver age groups
15-20         10,467       64        13           23
21-44        34,518       60         9           31
45 and older     W@       82         5.          13

crashes involving a male driver on a weekend night were alcohol related, only 10 percent
of the crashes involving a female driver in a weekday crash in the daytime involved alcohol
(table 4).

Alcohol involvement was also found to vary considerably by the type of vehicle driven
(indicating the type of driver, in most cases) (table 5). Drivers of motorcycles involved
in fatal crashes had by far the highest alcohol involvement rate: 54 percent. Only 3 percent
of heavy-truck drivers involved in fatal crashes had BACs over 0.10. Drivers of older
vehicles were more often legally intoxicated than drivers of newer vehicles (34 percent
versus 22 percent).

Intoxicated drivers in fatal crashes also tended not to use safety belts. Of the fatally
injured drivers who were at zero alcohol, 20 percent were wearing safety belts compared
with only 7 percent of. the fatally injured drunk drivers. Thirty-six percent of the
zero-alcohol surviving drivers were reported as using belts, in contrast to only I.5 percent
of the intoxicated surviving drivers.

Contrary to some popular misconceptions, the victims of alcohol-related fatal crashes
are most often the drinking driver or drinking pedestrian. Two-thirds (66 percent) of the
23,990 victims of alcohol-related crashes in 1986 were the drinking driver or driig
pedestrian (table 6). An additional 28 percent of the victims were passengers in the

Table 5. Drivers involved in fafal crashes, 1986

BAC

Drivers of:

     0.00   0.01-0.09  0.10 and higher
N   (percent) (percent)   (percent)

Motorcycles            4,542     46      I.3
Passenger cars         35,920    65     9
Light trucks and vans       11,724     63      8        29
Medium trucks             653     92       3         5
Heavy trucks            4,355     95       2         3
Older vehicles (older than 1976)  13,168     59      9        34
Newer vehicles (1984-87)     15379     70      8        22


EPIDEMIOLOGY AND DATA MANAGEMENT                                             41

Table 6. Alcohol-involved fatal crash victims, 1986

N    Percent '

Drinking drivers killed                   13,190      55
Drinking pedestrians and pedalcyclists killed        2pJ 11
Passengers in drinking driver's vehicle killed         4,800      20
Sober drivers killed in crash with drinking driver's vehicle    1,680       7
Passengers in sober driver's vehicle killed in crash
with driiig driver                        960        4
Sober pedestrians/pedalcyclists kiied by drinking driver     720       3
    Total                       =,=J      100

drinking driver's vehicle. Additional analyses revealed that in fatal crashes where BACs
were known for drivers and their passengers, 36 percent of the time the driver was legally
intoxicated but the passenger was not.

Table 7 shows the basic trend with regard to the alcohol problem in fatal crashes over
the past 5 years. The percentage of drivers in fatal crashes who were intoxicated
(BAC = 0.10 or greater) at the time of the crash decreased from 30 percent in 1982 to 26
percent in 1986-a Gpercent reduction, which is substantial. The reduction was
especially great for teenage drivers (table 8). While 29 percent of the teenage drivers in
1982 were legally intoxicated, this amount dropped to 21 percent in 1986, a 28percent
reduction. While this teenage driver trend is encouraging, one must still keep in mind
that teenage driver involvement in fatal crashes per mile driven is substantially higher
than other driver age groups (Fell 1987).         .

The nature of this S-year alcohol reduction trend was examined in the following

manner. Specific decreases of certain types of drivers and certain types of crashes were
compared with the overall reduction. If these specific reductions were substantially
greater than the overall reduction, then that would indicate that these drivers or
conditions were affected most, Figure 1 summarizes the key fmdings concerning the
nature of the reduction.

The largest reductions noted were for teenage drivers (28 percent), followed by
teenage pedestrians killed in collisions (26 percent). Also affected were drivers of vans
(23 percent reduction), female drivers (21 percent), and drivers who survived the fatal

Table 7. BACs for all drivers involved in fatal crashes, 1982-86
               (in percents)

BAC

1982

1983

1984

1985

1986

198246 change

0.00           61     62     64     66     66

0.01-0.09         9     9     9     8.     8
0.10 and higher     30     29     27     26     26      -14

N         56,029  54,656  57,512  57,883  60,297


42

BACKGROUND PAPERS

Table 8. BACS for teenage (l&19) drivers Involved in fatal crashes

BAC          1982

(m percents)          \       -

1983    1984    1985    1986   198286 change

0.00           58     61     6%    67     .66

0.01-0.09        13     13     13     11     13

0.10% and higher    29     27     24    -22     21      -28
N`         7,467   7,050   7,366   7,151   7,854

crashes (17 percent). The absolute reduction was also larger in weekday crashes (17
percent) and in multivehicle crashes (16 percent).

Drivers age 25-34 had only a slight reduction during this S-year period (6 percent).
Motorcycle drivers, with the highest percentage of alcohol involvement to begin with,
experienced no change in the percentage of drivers legally intoxicated during this period.
Pedestrians age 20-64 also had no reduction in the percentage legally intoxicated
between 1982 and 1986. Late night crashes and single-vehicle crashes showed only
modest reductions in the percentage of drivers who were at 0.10 BAC or higher (6
percent and 9 percent, respectively).
The average BAC of drinking drivers in fatal crashes in States where most of the
drivers were tested showed a modest decrease from 0.165 in 1980 to 0.153 in 1986.

Alcohol consumption per capita decreased in the United States between 1982 and
1986. But if that decrease was a prime factor in the decreased alcohol involvement of
drivers in fatal crashes, then a similar reduction should have occurred in intoxicated adult
pedestrians in fatal crashes, which was not the case.

All drivers

0        10       20       30

-13%

Teen drivers

Van drivers

I                           -1 28%

1                123%

Female drivers

I                t 21%

Surviving drivers

II 21%

Teen pedestrians          r                   126%
Daytime crashes (6 a.m.-6 p.m.)   I                :  1 17%

Weekday crashes
Multivehicle crashes

I ...         1 17%

B               1   16%

Figure 1. Nature of alcohol reduction in fatal crashes, 1982-88
  Decrease in percentage drunk (BAC = 0.10 or higher)


EplDEMlOLOGY AND DATA MANAGEMENT

Table 9. Nature Of alcohol reduction among fatally injured &iv- with
   known BACs in 15 good reporting states*
            (percents)

43

BAC of fatally 1980   1981   1982   1983   1984  l985   1986   l980-86
injured drivers                         change

00      39    40    41    43    46    49    48    +23

.01-m     11    11     11    10    11    10    12     +9

m-.19    27    26    25    25    23    22    22    -19

.20+     24    23    23    21    m    19    18     -25

-

*Test and report BACs on 85 percent of fatal drivers.

The nature of the reduction of alcohol in fatal crashes does seem to point to main
effects in responsible social drinkers, i.e., substantial reductions in daytime crashes, by
female drivers, drivers of vans, and teenagers. However, there is some evidence that the
percentage of drivers with very high BACs is also decreasing, at least in the 15 "good-
reporting" States in FARS. Table 9 shows that, in 1980, almost a quarter (24 percent) of
the fatally injured drivers in these States had BACs of 0.20 or greater. That portion in
1986 was 18 percent, which was a 25-percent reduction-greater than the reduction for
the drivers at BACs between 0.10 and 0.19. Most researchers would agree that drivers
at 0.20 BAC or greater are most likely problem drinkers or alcoholics. Yet the percentage
of drivers at these levels has decreased significantly since 1980 (in that l5-State sample).
Are these problem drinkers finding alternatives to driving? Are they confining their
drinking to their homes? Have many of them stopped drinking? More research is
necessary to answer these important questions.

Alcohol in Noncrash Drivers

Accurate determination of alcohol actually present in drivers whiie they are using the
highways can be estimated only by obtaining measurements from samples of these drivers
at roadside. (Thus, self-reported drink&-and-driving data from telephone or household
surveys are not considered here.) Measurement of alcohol in noncrash drivers is general-
ly obtained at roadside for four major purposes:

1.  To estimate the contribution of alcohol to crash risk

2. To provide data for describing a particular problem by identifying and specify-
ing relevant parameters

3. To provide data for evaluating the results of any changes in circumstances
surrounding the particular problem, whether they result from unplanned
  natural events or from controlled countermeasures

  4. To foster general deterrence of drunk driving and to enforce DUI laws
Research designed to accomplish the first purpose involves case-control studies.
Activities designed for the fourth purpose are currently referred to as either enforcement
checkpoints or sobriety checkpoints. Studies designed for the second or third purpose
have a broader range of objectives. Useful epidemiologic data can be obtained from
activities designed for any of these four purposes, but the most fundamental question is
addressed in investigations of alcohol and crash risk by means of case-control studies.


44

BACKGROUND PAPERS

Case-Control Roadside Surveys and Alcohol Crash Risk
That alcohol is found in approximately 50 percent of fatally mjured drivers tested does
not necessarily prove that alcohol actuaily contributed to the occurrence of these crashes.
To begin building a case for or against the actual contribution of alcohol, it is first
necessary to determine the extent to which fatally injured drivers with alcohol are
representative of drivers with similar ekosure, but not involved in the crashes. Thus, it
is necessary to compare the distribution of BACs obtained from control or comparison
drivers randomly selected while passing the same place as the crashes and at equivalent
times. By comparing these two sets of data, it is then possible to determine the similarities
and differences between the two sets of drivers in terms of the percentages of each with
`no alcohol, with detectable alcohol, with medium BACs, with high BACs, and so forth.
For example, a number of studies have indicated that between 40 and 50 percent of
fatally injured drivers examined .had BACs of 0.10 or higher. If we had been able to
examine the other motorists who were actually driving at the s&e times and places that
these fatal crashes occurred, and if we had found that about 45 percent of these
noncrash-involved drivers also had BACs of 0.10 or higher, then we would have no basis
for concluding anything at all about the contribution of alcohol to highway crashes. That
is, the percentages of high-BAC drivers in the fatally injured sample would have been
the same as the percentage of high-BAC drivers in the comparison sample from the
population-at-risk-namely, about 45 percent. Therefore, in this hypothetical instance,
high-BAC drivers would have been neither under- nor overrepresented in terms of the
percentage of the population-at-risk made up of high-BAC drivers, namely, about 45
percent.

Conversely, if we had found a significant difference between the percentage of
high-BAC fatally injured driers and the percentage of high-BAC control drivers from
the same population-at-risk, then we would be able to make some strong inferences about
the relative contribution of alcohol to these fatal crashes. Thii line of reasoning provides
the logical basis for attempting to obtain these BAC data from the population-at-risk
using the case-control design with roadside research surveys.

The first such study was conducted in Evanston, Illinois, 50 years ago by Holcomb
(1938), and several more studies have been conducted in the United States and abroad
since that time. These case-control studies have been analyzed from a variety of perspec-
tives and summarized in a number of publications (Hurst 1973, 1985; NHTSA 1985;
Perrine 1975u, b; Reed 1981; Zylman 1971). However, the material that follows in this
subsection is taken primarily from the most recent review (NRC 1987). In alI these
reviews, a consistent pattern is revealed by the case-control studies: crash risk increases
sharply as BAC rises.

The relative probability of being involved in a crash is defined as the ratio of the BACs
of comparison drivers to those of drivers involved in crashes. This probability remains
roughly equivalent for crash-involved drivers compared with noncrash drivers up to
about 0.08 BAC (figure 2). (However, these relative risk curves understate the risk of
involvement at low BACs.) Although the rate of increased risk varies across studies (m
part because some studies examine all crashes and some examine only fatal crashes), the.
risk increases after about 0.08 BAC in all cases and increases dramatically after 0.10
BAC in most studies.

The curves depicted in figure 2 are based on groups of drivers of different ages who
have varying experience with alcohol and with driving. Because of the heterogeneity of
control groups and the lack of perfect comparability, the effect of alcohol at low BACs
is masked by other variables. For example, the major shortcoming of the Grand Rapids
study (among the most cited case-control studies) is the lack of comparability between
the drivers involved in crashes and the control drivers regarding the frequency of
consuming alcohol. This lack of comparability is the source of the apparent improvement
in crash risk at low BACs in the Grand Rapids data (the much debated "Grand Rapids


45

EPIDEMIOLOGY AND DATA MANAGEMENT

Grand Raplds data (5,965 total crashes)
Grand Raplds data (300 total or serlous crashes)
Evanston data (270 Injury crashes)
Toronto data (423 total crashes)
Manhattan data (34 fatal crashes)
Estimated approxlmate extenslon of Manhattan trace
Vermont data (106 fatal crashes)
Huntsville data (615 Injury crashes)
Adelaide data (299 Injury crashes)

    :
    :
   :
   :
   :
   :
  :
  :
:
:
:
-0

0   .02   .04  106   .06   .lO   .12   .14   .16   .18   .20   .22   .24

                  BAC %WN

Figure 2. Relative probability of crash involvement as a function of BAC. (Hurst
1985.) Reprinted with permission.

dip") and the understatement of the risk of crash involvement at low BACs. Hurst (1973)
noted that the control group had a higher percentage of drivers who were regular
consumers of alcohol. Their apparently greater tolerance for alcohol had made them
safer drivers at low BACS than the drivers involved in crashes at low BACs, presumably
because the latter had less experience as drinkers. Hurst recalculated the relative risk
of crash involvement in the Grand Rapids data based on the drivers' self-reported
frequency of alcohol consumption (figure 3). He drew three conclusions from the results.
First, drivers with frequent experience as drinkers are less likely to be involved in crashes
than light and medium drinkers at comparable BACs. Second, regardless of the
tolerance for alcohol, the risk of crash involvement increases with BAC. Third, the curves
greatly underestimate the risk for the average driver at any BAC; they only demonstrate
the relative hazard to drivers who regularly drink and drive. The curvilinear relationship
between relative risk of crash involvement and BAC is therefore caused in part by the
comparison of drivers with varying degrees of experience as drinkers and experience
driving under the influence of alcohol. When experience with alcohol is controlled for,
the risk of crash involvement increases with BAC without evidence of a threshold effect.

As noted by Perrme (197%) in his review of the literature, the relative risk of
involvement is not the same as evidence of causality. Given the many interacting factors
that may contribute `to a crash (and the lack of data on many of them), the role of atry
single factor is difficult to isolate. Three of the case-control studies deserve special
attention because they also estimate the effect of alcohol on the probability of being
responsible for a crash.

The methodology for estimating crash responsibility was first developed by McCarroU
and Haddon (1%~) in their case-control study of fatal crashes in Manhattan. They


6ACKGFIOUND PAPERS

SELF-REPORTED DRINKING FREQUENCY

. . . ..a. YEiRLY OR LESS     .-'
-0- MONTHLY        -= .

6.0 i - - WEEKLY
     --- BXNVEEK
4.0     - DAILY

I 1        I         I         I        I

0      .02      34      .06      .08

                      BAC, %W/V
Figure 3.  Relative probability of crash involvement by self-reported drinking fre-
quency (Hurst 1973). Reprinted with permission from theJoorna/ofSafetyResearch,
a joint publication with the National Safety Council and Pergamon Press, Ltd.

categorized the crashes into five classes, the first three of which were assigned
responsibility:

1. Only one vehicle involved

2. Two vehicles involved but only one moving

3. More than one vehicle involved and in motion, with responsibiity assigned
based on circumstances of the crash (cases in which there was any doubt were
excluded from this category).

The Manhattan study is based on a sample of 43 drivers fatally injured in crashes that
occurred between June i950 and June 1960. For the 26 drivers in the assigned respon-
sibility classes, 19 (65 percent) had positive BACs, of which 14 (46 percent) had BACs
greater than 0.10 . Of these 14 drivers, 12 had BACs of 0.25 or greater. Of 156 drivers
randomly selected as controls at or near the sites of the crashes, 39 (25 percent) had
positive BACs, of which only 8 (5 percent) were at or above 0.10 .

The Grand Rapids investigation involved by far the largest sample of all the case-con-
trol studies (5,985 crashes of all types) (Borkenstein et al. 1964,1974). By comparison,
the 423 cases in the Toronto study constituted the next largest sample (Lucas et al. 1955;
Hurst 1985). Using McCarroll and Haddon's method for assigning responsibility,
Borkenstein, Crowther, Shumate, Zill, and Zylman estimated that 3,305 of the involved
drivers were responsible for the crash that occurred. They used the innocent drivers as
controls.

The Vermont study was the third to estimate crash responsibility, based on 106 cases
(all fatal crashes) (Per&e et al. 1971). These crashes resulted in 113 fatalities, and 97 of
the drivers were assigned responsibility, again relying on the method developed by
McCarroll and Haddon. Of the drivers judged responsible, 60 percent had positive
BACs and 46 percent had BACs at or above 0.10. Perrine, Waller, and Harris (1971)
also calculated a crash-responsible curve, but in contrast to the Grand Rapids study, the
drivers stopped at roadblocks were used as controls.


EPlDEtdlCL~Y AND DATA MANAGEMENT

U `GRAND RAPIDS DATA. 3305 CRASHES.
       DRIVER ASSUMED RESPONSIBLE
- MANHAlT'AN DATA, 24 FATAL CRASHES,
       DRIVER ASSUMED RESPONSIBLE
o----Q VERMONT DA-t-As 75 FATAL CRASHES.
       DRIVER ASSUMED RESPONSIBLE

1             I    I    I    I    I    I    I    I
   .02  .04  .08  .08  .lO  .12  .14  .18  .18   90

8AC % (WA') OF DRIVER

Figure 4. Relative crash responsibility for drivers assumed responsible and those
not assumed responsible as a function of BAC, where 1 .O = relative probability at zero
alcohol. (Hurst 1973.) Reprinted with perniission from theJourna/ofSafefyReseafch,
a joint publication with the National Safety Council and Pergamon Press, Ltd.

Hurst (1973) replotted the curves from these three studies on a logarithmic scale to
facilitate comparison (figure 4). Although risk of crash responsibility increases as BAC
increases in all three studies, several disadvantages with the underlying data should be
noted.

The trend in the Manhattan data is based on a very small number of crashes: 25
responsible drivers with positive BACs. In addition, the trend at the higher BACs is
greatly understated. For the fatal crashes in which the driver had a BAC of 0.25 or higher
(about half those in the driver-responsible category), no driver in the control group had
an equivalent BAC. "Hence, the relative hazard calculated from the case/control ratio
would be infinite within the range, were it possible to graph it" (Hurst 1973).

One of the shortcomings of the relative risk curve estimated in the Grand Rapids
study is the inclusion of drivers involved in single-vehicle crashes in the group of
responsible drivers. Although the responsibility of the driver is not in question, because
of the nature of the crash, a control driver is not available. The published data do not
provide sufficient detail to allow the curve to be compIeteIy recalculated without the
single-vehicle crashes to determine the effect of including these crashes, but the available
data suggest that the curve would shii to the right. It would still accelerate after 0.04
BAC and at an exponential rate, but the curve would not rise as quickly as shown in
figure 4.


48

BACKGROUND PAPERS

One problem with the Vermont data is the small number of crashes in the sample. In
the comparison of crash risk as BAC rises, one. or two drivers are responsible in some
of the BAC ranges. Chance occurrence could distort the results when-so few drivers are
                                                               /
the basis of the calculations.

Despite the weaknesses in the case-control studies, some important conclusions can
be drawn. In several of the case-control studies done in the United States and abroad, a
consistent increase in risk of crash involvement has been shoti. When experience with
drinking is controlled for, this risk increases with BAC without any evidence of a
threshold effect (or dip). The three studies that attempted to estimate crash respon-
sibility showed that the risk of causing a crash increases even more rapidly than the risk
of crash involvement as BAC increases (NRC 1987).

Another important aspect of the alcohol contribution to crash risk is reported by Voas
(NHTSA 1985). To emphasize the signilicance of the difference in BAC between drivers
assumed to be responsible versus those assumed not to be responsible for crashes, Hurst
(1974) also presented an additional calculation on the data from the Grand Rapids study.
His results for the drivers assumed to be responsible are represented by the center plot'
in figure 4. However, the probability of being innocently involved in a crash remains
essentially level and does not increase with increasing BAC, the plot is basically flat and
would lie between the relative crash probability of 1 and 2 in figure 4. The same result
was found in the Huntsville/San Diego study by Farris, Malone, and Lilliefors (1977).
These results provide further evidence for the causal role of alcohol in crashes.

Other Roadside Research

The success and utility of the case-control procedures for investigating alcohol crash
risk stimulated interest in using the roadside survey technique for evaluating alcohol
safety programs by measuring the change in the number of high-BAC drivers actually
on the roads. Standardized procedures for conducting roadside surveys were developed
(Perrine 1971) and applied successfully in 28 of the 35 Alcohol Safety Action Projects
(ASAPs) funded by the bepartment of Transportation between 1970 and 1975 (Voas
1972; Carr et al. 1974). In these programs, the roadside surveys were used to evaluate
project effectiveness (Levy et al. 1978) by serving as a means to collect data used as the
primary criterion or dependent variable (BAC). Roadside surveys were conducted
before and after program implementation to measure the change in average driver BAC
(ii any) resulting from project activities (Lehman et al. 1975). When used for program
evaluation, sampling was conducted during periods when a high percentage of drinking
drivers was on the road (i.e., Friday and Saturday nights) rather than at times and places
at which accidents had occurred. By a return to the same sites, changes over time can be
measured.

Roadside surveys provide a more direct method of evaluating alcohol safety counter-
measure programs than does the use of accident data, because highway crashes result
from a large number of factors (weather, roadway construction, economic conditions,
etc.) that are unrelated to the evaluation of enforcement activities. The BAC values of
drivers serve as an intermediate measure between action programs and the ultimate
criterion of accident prevention. While a reduction in the average BAC of drivers on the
road does not guarantee a reduction in crashes, the relationship between driver BAC
and risk of crash involvement is close enough to make this measure a credible criterion
for program effectiveness.

During the ASAP period (1970 through 1974), some 77 roadside breath-testing
surveys of nighttime drivers were conducted. In addition, a national roadside breath-
testing survey was conducted in 1973, and a computer archive of these 78 roadside
surveys is stored at the University of Michigan Highway Safety Research Institute
(Lehman et al. 1975). The tile contains breath-testing results, demographic data, and so
forth, for some 78,000 randomly selected drivers, as well as 2,700 passengers. Analysis


EPIDEMIOLOGY AND DATA MANAGEMENT

49

of these aggregated data show the following percentages of drivers with BACs at or
exwe&mg 0.10: 1 percent of weekday-early drivers, 3 percent of weekend-early drivers,
and 6 percent of weekend-late and weekday-late drivers. Significant reductions in the
percentages of drivers above the legal limit (0.10 BAC) were demonstrated for those
jurisdictions that used this evaluation method (Levy et al. 1978).
Based on the utility of this roadside BAC measure in the ASAP program, it was
applied again in a 4-year study of a special DUI enforcement effort in Stockton,
California (Voas and Hause 1987). In this study, survey procedures were modified to
permit low cost and low profrle surveys that were conducted every weekend for 3 k years
(Hause et al. 1982). Drivers with a BAC of 0.10 or greater on Friday and Saturday nights
decreased from 88 per thousand before the Stockton project to 50 per thousand during
the third year.

The roadside survey technique also permits (through an application of Bayes'
Theorem) estimation of the probability that a driver at a given BAC will be arrested by
the police. This procedure was first applied by Beitel, Sharp, and Glauz (1975) to the
ASAP survey data in Kansas City. Hause, Voas, and Chavez (1982) used the same
procedure in Stockton. These studies provided roughly similar results indicating that the
chances of being arrested at a BAC of 0.15 is roughly 1 in 100, while the chance of arrest
at 0.10 BAC is half that amount, about 1 in 200. Since both these studies involved intensive
enforcement programs, they provide a reasonable indication of the maximum arrest rate
that can be achieved with traditional patrol methods.

The ASAP experience with roadside research surveys and with the success of the
manual for conducting and evaluating them (Perrine 1971) provided the basis for
subsequent international activity. An invitational international workshop was conducted
in Paris in an attempt to coordinate the methodology for roadside research surveys to
be implemented in other countries in order to maximize the comparability of the
obtained data. The workshop resulted in a useful manual (Carr et al. 1974) and comple-
mented parallel activities being conducted under the auspices of the Organization of
Economic and Cooperative Development. As a result of these activities, use of roadside
surveys for international comparisons of countermeasure programs was stimulated in
Canada, the Netherlands, Norway, Sweden, and Finland. The resulting data permitted
an international comparison of driver BACs (Voas 1982), which indicated that ap-
proximately 12 percent of drivers on weekend nights were at or above 0.05 BAC in
Canada, the Netherlands, and the United States, whereas less than 2 percent of drivers
were at this level in Scandinavian countries.

Although use of roadside research surveys has diminished in the United States since
the end of the ASAP activities in the mid-197Os, the technique continues to be used
effectively in other nations, for example, Canada, Australia, Denmark, and Norway.
Nevertheless, a few studies of the population-at-risk in the United States either have
been conducted recently or are currently being conducted. In the spring of 1986, U.S.
National Roadside Breathtesting Survey II (Wolfe 1986) was conducted in a repre-
sentative sample of 32 localities, 18 of which had participated in the 1973 U.S. National
Roadside Breathtesting Survey I (Wolfe 1974). Statistically significant reductions were
found in the percentage of medium and high BAC drivers sampled at high-risk times
(Friday and Saturday nights from 10 p.m. to 3 a.m.). Drivers at or above the illegal BAC
of 0.10 decreased from 5.0 percent in 1973 to 3.1 percent in 1986, drivers at or above a
BAC of 0.05 decreased from 13.5 percent in 1973 to 8.3 percent in 1986. It should be
noted that the breathtest completion rates were 86 percent in 1973 and 92 percent in
l986.

In Vermont, a large-scale roadside research study involving a projected 42,000
nocturnal drivers sampled at high-risk times (Friday and Saturday nights from 10 p.m.
to 3 a.m.) is currently being conducted. It is funded by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA, Grant AAO7876). This 5-year field study is primarily


50

BACKGROUND PAPERS

designed to determine the prevalence of drivers with high alcohol tolerance, and to
determine their salient and differentiating characteristics. Since the high alcohol tolerant
driver is apparently rare, a large number of motorists (42,ooO) driving at high-risk times
must be stopped and screened for BAC to identity a sufficient number of such people
(40 to 60) to be able to conduct a meaningful study. In the process of conducting this
field study, a large number of people will be breathtested using both the new passive
alcohol sensor and the more traditional hand-held evidentiary devices. Approximately
4,000 of these motorists, sampled across the full distribution of BACs, will participate in
extensive.personal interviews concerning self-reported background data; drinking, driv-
ing, drinking-and~driving, drugs-and-driving information and attitudes; and selected
personality characteristics. Data will also be gathered on these motorists' driver records,
performance on the most valid field sobriety tests (gaze nystagmus, walk-and-turn, and
standing steadiness), and ratings on clinical signs of intoxication. With a test completion
rate of % percent, the results from the first 650 drivers indicate that 3.7 percent had a
BAC of 0.10 or higher, whereas 10.2 percent had a BAC of 0.05 or higher. Although the
sample size isstill relatively small, these 1988 data show a decrease in distribution of
BAC when compared with data obtained in a 1974Vermont study (Perrine 1976) of 1,663
drivers at high-risk nocturnal times (Thursday, Friday, and Saturday nights between
1030 p.m. and 3 a.m.): 4.6 percent had a BAC of 0.10 or higher and 14.7 percent had a
BAC of 0.05 or higher. Thus, these roadside studies of the high-risk population would
seem to show that some progress is being made in the war on drunk driving, if motorists
with BACs in excess of the legal standard (0.10) are taken as the criterion.

Enforcement Checkpoints

Police officers conduct sobriety checkpoints at which they stop motorists at random
and test them for breath alcohol. Such activities are conducted primarily for enforcement
purposes, although they also serve as general deterrence. Although useful data for
epidemiologic purposes are available from these enforcement checkpoints, few sys-
tematic studies have been conducted to analyze such data. If they were analyzed carefully
and properly, these data could provide a valuable source of relatively low-cost informa-
tion concerning the population-at-risk. In a recent Charlottesville, Virginia study, Voas,
Rhodenizer, and Lynn (1985) evaluated the effectiveness of such sobriety checkpoints,
especially in comparison with the drivers arrested for DUI by traditional roving patrols.
In addition, thii study found evidence of police biases in those arrested, whereby both
young drivers and women were underrepresented among arrested drivers, while minority
and very high BAC drivers were overrepresented. Thus, such studies clearly demonstrate
that researchers can avail themselves of enforcement checkpoints as an opportunity to
collect valuable data for epidemiologic purposes.

Characteristics of Drunk Drivers

During the past 20 years, numerous statistical and clinical studies have been published
on various aspects of the drinking driving problem. However, surprisingly little rigorous
research has been published on characteristics of convicted DUI offenders, particularly
when contrasted with the vast literature on problem drinkers/alcoholics, and on charac-
teristics of drivers involved in fatal accidents. As suggested by Zylman (1974) and by
Moskowitz, Walker, and Gomberg (1979), the population arrested and convicted of DUI
offenses is not typical of impaired drivers in general or of drivers involved in alcohol-re-
lated accidents. The mean BAC of convicted DUI offenders in California during 1984
was 0.18-a concentration far in excess of the State's 0.10 limit per se, and well beyond
the level at which impairment occurs. In one of the few formal statistical studies of
differences between alcohol-involved fatal accident drivers and convicted DUI of-
fenders, Fridlund and Hagen (1977) used discriminant function analysis in comparing
146 DUI offenders in Los Angeles County with a sample of 191 alcohol fatalities. The
DUI conviction group had significantly more prior DUIs, more prior reckless-driving


EPIDEMIOLOGY AND DATA MANAGEMENT

51

convictions, and more prior moving t&tic convictions. The differences on the incidence
of DUIs and reckless convictions was large, with the DUI group having about three times
as many entries during the prior 3-year period.
Moskowitz, Walker, and Gomberg (1979) conducted a detailed review of the litera-
ture on DUI offender characteristics. This subsection relies heavily on their monograph
for the pre-1979 literature, but concentrates on recent studies and studies not included
in the 1979 review for its primary source references. However, a few pre-1979 studies of
special importance are reviewed here as primary references even though they are also
included in Moskowitx et al. (1979);

Moskowitz, Walker, and Gomberg organized their review by type of offender char-
acteristic (prior driver record, age, etc.), and reached the following conclusions with
respect to each domain:

o  Marital status: DUI con&tees are much more likely to be divorced, separated,
or widowed than are non-DUI control populations. Some studies have reported
five- to sixfold differences in rates compared with control populations.

o  Employment history: Convicted DUI offenders are more likely to be un-
employed, with rate differentials ranging from two- to fourfold higher across
  various studies.

o  Occupation: Convicted DUI offenders are more likely to have lower status
occupations. DUI offenders in blue collar jobs averaged 65 percent across
studies compared with-5l percent for control samples.

o  Income: Convicted DUI offenders tend to have lower incomes- about 18
percent lower than controls across the reviewed studies.

o  BAC: The mean BACs for the offenders averaged from 0.18 to 0.28. (Statewide
California figures have consistently averaged 0.18.)

o  Drinking behavior: DUI offenders drink more often and consume more alcohol

per sitting than do non-DUI populations. Beer is the preferred beverage of DUI
offenders. The findings of the Southern California study by Pollack (1%9) are
typical. Pollack reported that 18 percent of DUI drivers drank every day
compared with 11.5 percent for a control sample. In terms of drinks per sitting,
35.2 percent of the DUI sample typically consumed five or more drinks com-
pared with 5.7 percent of the control sample.

o  Reason for drinking: Convicted DUIs (and alcoholics) are more likely to drink
to release tension and to cope with stress.

o  Problems caused by drinking: Convicted DUIs are much more likely than
controls to exhibit poor health, family disorganization, financial problems, and
poor job performance.

o  Prior alcohol treatment history: Convicted DUIs are more likely than controls
to have previously entered some form of alcohol treatment program. The
median across 20 studies was 6.0 percent, with a maximum of 42.5 percent. (Thii
characteristic is highly dependent on the institution and delivery systems of a
particular region, and would be expected to vary across jurisdictions and over
time.)

o  Problem drinking status: Studies using the Michigan Alcoholism Screening Test
(MAST) indicate that 54-74 percent of convicted DUIs fall in the pioblem-
drinking and alcoholic range. Studies using the Mortimer-Filkins test produce
slightly lower prevalence figures.

o  Driving after drinking: Convicted DUIs are much more likely than controls to
drive after drinking. Pollack (1%9), for example, reported that 49 percent of
DUI offenders admitted to driving at least once a week after two drinks
compared with 12 percent of a control sample.


52

BACKGROUND PAPERS

o  Total prior- arrests: Convicted DUI offenders are more likely to have prior
arrests for both alcohol and nonalcohol offenses.

o  Driving history: Convicted DUI offenders have substantially more driving
record entries of all types than do controls (more DUIs, more alcohol and total
accidents, more moving traffic violations, and more license actions). The rate
increases across studies and variables range from 100 percent to 500 percent.
The driving record histories of convickd DUIs are also substantially worse
those of medically diagbosed alcoholics.

o Personality traits: Convicted DUIs have a significantly higher prevalence of
personality trait disorders. They are more `likely than controls to exhibit
neuroticism, depression, paranoid ideation, low self-esteem, and to have a lower
sense of personal responsibility and control and greater. feelings of aggres-
sion/hostility.

o  Stress: Convicted DUI offenders are more likely to report experiencing stress
from family, financial, and job problems.                .I

o  Education: Convicted DUI offenders are more likely to be high school dropouts
and have fewer years of education.           \

o  Age: Convicted DUI offenders tend to be slightly older than non-DUI controls,
with the highest disproportionate concentration in age interval 304.

a  Race: Most convicted DUI offenders are white, but minority groups (hispanics
and blacks) are overrepresented compared with their representation in the
population.

o Sex (not covered by Moskowitz): The great majority of convicted DUI offenders
are male. The range for females is from 5 to 20 percent, depending on the
characteristics of the specific DUI population (first versus repeat offenders),
region, and so forth. A large statewide sampling in California indicates that 13
percent of those convicted for a DUI offense in 1982 were female (Tashima and
Peck 1986). Among fust and second offenders, females accounted for 17
percent and 10 percent, respectively.

Drinking Status

It is clear from the above summary that persons convicted of drunk driving offenses
deviate greatly from the general driving population on a wide variety of characteristics.
That DUI offenders contain a disproportionate number of problem drinkers would be
expected, of course, since the offense of drunk driving is, per se, a problem associated
with the consumption of alcohol.

The number of drinks required to produce manifestly detectable impairment in
driving and the BACs typically attained by DUI offenders implies a level of alcohol
consumption that is statistically deviant. Given the very low probability that any given
incident of impaired driving will result in detection (arrest or accident), the percentage
of DUI offenders who were simply unlucky, in the sense of getting caught in a rare
instance of impaired driving, would be relatively small. One would therefore expect most
DUI offenders to be heavy consumers of alcohol.
Most of the empirical literature, and most authorities in the area, agree with this
conclusion, although controversy has developed over the percentage of DUI offenders
who are alcoholics in the clinical disease context. This controversy stems more from
semantic and epistemological complexities than from disagreements over data, and is
not pursued here.

Lest the impression be created that opinion and data are unanimous on the drinking
status of DUI offenders, the results of a recent California study of first offenders will be
summarized in detail. This study was carried out by the Pacific Institute for Research


EPIDEMIOLOGY AND DATA MANAGEMENT
and Evaluation (PIRE); it was commissioned by the State of California pursuant to
Assembly Bill 3405 (Stewart et al. 1987).
The major objective of ,the PIRE study was to develop a model curriculum and
rehabilitation program for use by courts in sentencing fmt-offender DUI cases. HOW-
ever, this review will only consider that component of the study pertaining to offender
characteristics (natural variation component).
Detailed biographical, drinking habit, and arrest-incident information &as collected
by questionnaire on 5,052 respondents from 26 frst-offender treatment programs
throughout California. The authors reported the following statistics from an analysis Of
the questionnaire responses:

    o  Median number of drii on day of arrest: 6

    o  Median BAC upon arrest: 0.16

    o  Median number of days in past year with four or more drinks: 60

    0  Median number of days in past year with eight or more drii 4

    o  Percentage who did not feel intoxicated upon arrest: 35 percent

    0 Median number of previous days in past year driven while impaired: 1

    0  Percentage with prior DUI arrests: 20 percent
The authors categorized the drinking pattern responses into two typologies for
comparison with a statewide general population survey. The more complex of the
typologics was a ir-point continuum: abstainers, infrequent drinkers, light monthly, light
weekly, moderate weekly, and frequent heavy. Using a probit analysis to adjust for
p~~pulation differences, the authors found no significant differences between the drmk-
ing frequency of the two groups after abstainers were removed from the general
population sample.
The difference was significant, however, in the frequency of heavy drinking (five or
more drinks at least once a week), with substantially more of the DUI offenders falling
into that category. Nevertheless, fewer than 30 percent of the first offenders were placed
in this category. In commenting on these findings, the authors concluded:
While defining a "typical pattern of drinking for all subjects is difficult, the
  median frequencies of use conditional upon the level of use at arrest is
  revealing: 40 percent of the subjects reported having had 8 or more drii
  on the day of their arrest. The median frequency of use at this level among
  these subjects was 14 occasions over the previous year and only one occasion
  in the preceding 30 days. A pattern of use including drinking 8 or more drinks
  at least weekly over the previous year was reported by only 20 percent of
  these subjects. Thus, for the majority of subjects, drinking at the level of use
  at which they were arrested is relatively infrequent (pp. 27-28)

      . . . first offenders are not unlike the general population of drinkers in
  California in terms of the typical frequency of use. However, it appears that
  the incidence of heavier drinking is greater among first offenders (p. 32)
Thc authors also included a measure of alcohol dependency in their study. Subjects
c`n"`@-tcd a Z-item Alcohol Dependency Scale (Skinner and Allen 1982), and the
`c0rcS werc compared with those of clinically diagnosed alcoholics. Ninty-two percent
`If `hc subjects pioduced scores "~&&~g a low level of alcohol dependency." The
aUt hors went on to conclude "the dramatic differences in these distributions suggest that
d'pcndcnCT symptoms among first offenders are quite low, as compared to alcohol
`rcJlmcnt groups;)
Thc resu*& and conclusions of the PIRE study are at odds with prevailing opinion
id most Prior studies in this area. If the findings are accepted at face value, the great


54

BACKGROUND PAPERS

majority of first offenders fall within the bounds of social drinking Even the percentage
characterized as heavy does not seem extreme.            \       1
There are several `possible explanations. Fist, the PIRE study was limited to first
offenders, and it is known that the percentage of problem drinkers among first offenders
is lower than among repeat offenders.
Second, problem drinkers and DUI offenders are known to understate their drinking,
sometimes dramatically. Stewart, Epstein, Greenewald, Laurence, and Roth (1987)
acknowledge this possibility and recommend caution in interpreting the study f&lings.
Although previous studies are also subject to reporting biases, many have included
clinician interviews, psychometric instruments employing lie scales, and a variety of
public agency data. No evidence is presented in the PIRE study to indicate that
procedural controls were used to minimize the tendency of people to "fake good" or
employ various forms of self-denial.                         .s

Third, the first-offender survey only involved offenders who were sentenced to an
alcohol program and who agreed to cooperate by completing the questionnaire. In
California, 23 percent of first offenders are not assigned to programs. Approximately I.5
percent of the sample did not return a questionnaire.
There are also inconsistencies in some of the values derived from the self-report. For
example, it would have taken more than a median of six drinks to produce a median BAC
0.16. The fact that 35 percent of the subjects did not feel intoxicated when arrested and
that only 14 percent acknowledged being definitely intoxicated is cause for further
suspicion.

Finally, it is difficult to accept the median estimate of only one incident of driving
while impaired in the previous 12 months. The suggestion is that many of the subjects
were not being candid in their responses.
The PIRE report also contains a description of first offender biographical and
socioeconomic characteristics. The statistics of interest are summarized below:

o  Male: 81 percent

   o  Single: 46 percent

   o  Divorced, widowed, or separated: 21 percent

   o  White: 68 percent

   o  Hispanic: 22 percent

   o  Black: 3 percent

   o High school dropouts: 22 percent

   o  Median age: 30

   o  Unemployed or employed part-time: 30 percent

   o  Median income: $16,500
These demographic characteristics are reasonably consistent with the portrayal from
the Moskowitz review, particularly when allowance is made for differences in time and
region. The percentages for ethnic minorities are somewhat lower than would be
expected based on California ethnicity composition and prior evidence showing that
some minorities (e.g., Hispanics) are overrepresented in DUI populations. It is impor-
tant to recognize that the PIRE sample is limited to offenders entering first-offender
programs and, within this subset, to those who returned the questionnaire. These factors
could alter the representativeness of the sample.

Prior Driving Record

It is also clear that DUI offenders have statistically deviant driver records before their


EPIDEMIOLOGY AND DATA MANAGEMENT

55

DUI arrest. Although one would expect overinvolvement in previous alcohol-related
accidents and convictions, the extent of DUI offender overinvolvement in nonalcohol
related incidents is not widely recognized.

Statewide, data from Tashima and Peck (1986) indicate the following pretreatment
w-month rates for representative statewide samples of 29,097fmt and7,797repeat DUI
offenders:

             Mean non-DUI   Mean total  Mean non-DUI related
               accidents  accidents      convictions

   First offenders       .17        36      13

   Second offenders     .1g        .45          1.4
The above rates are more than twice the rates expected fora similarly stratified (age and
sex) population of non-DUI drivers.

The Tashima and Peck (19&i) study and numerous previous California studies
indicate that nonsuspended DUI offenders also accumulate worse non-DUI driving
records (total accidents, total moving violations, etc.),jXlowing conviction for a first or
repeat DUI offense (Sadler and Perrine 1984; Hagen et al. 1978; Hagen 19T7, Arstein-
Kerslake and Peck 19235).

The most detailed analysis was performed by Arstein-Kerslake and Peck, who
compared the subsequent 4-year driving records of first and repeat DUI offenders from
Sacramento County with a general population group that was similarly age-sex stratified.
The first and repeat offenders were grouped into quartiles based on their actual and
predicted DUI recidivism. Except for the first quartiles (i.e., lowest 25 percent in terms
of recidivism expectancy), all quartiles had substantially worse accident and traffic
conviction records. The differences were also highly significant when summed across
quartiles.

The above relationship between DUI offenses and driving behavior in general has
been addressed by a number of other investigators (Maisto et al. 1979; Raymond 1971;
Denberg 1974). Donelson, Beimess, and Mayhew (1985) consider the issue from the
impaired problem-driver paradigm addressed in Simpson's (1977) paper. This heuristic
paradigm views the convicted DUI population as containing drivers whose drinking is
subordinate to a larger problem of high-risk negligent driving. The alcohol impairment
can combine, additively or synergistically, with negligent driving to increase risk, but the
underlying problem-driving behavior exists independent of alcohol.

Although Donelsou, Beirness, and Mayhew stress the hypothetical nature of this
paradigm, the premise that impaired drivers who drive aggressively and unlawfully are
more likely to be apprehended is in no way hypothetical. It has also been established that
DUI offenders with a prior history of moving violations represent substantially greater
accident risks than DUI offenders with clean records (Sadler and Perrine 1984;
McConnell and Hagen 1980; Peck and Kuan 1983).

The linkage between problem driving and DUI offenses is the very essence of a recent
study by Donovan, Umlauf, and Salzberg (ii press). These investigators followed the
driving records of 254 non-DUI-involved problem drivers over a 3-year period sub-
sequent to initial `identification. Approximately 11 percent of the sample had a DUI
conviction during that period-a rate live times greater than that of the general male
driving population in Washington State. The study was replicated on a sample of 38,695
driver record fdes. The authors found that drivers with four or more moving violations
were greatly overinvolved in subsequent DUI offenses, with 16.9 percent receiving an
initial DUI conviction during a 3-year followup period. The DUI rate was particularly
Pronounced for males under age 30.


56

BACKGROUND PAPERS

DUI Recidivism

How do frost offenders compare to repeat offenders on the various characteristics
described above? This question is, of course, related to the question of recidivism
correlates and is best addressed by longitudinal recidivism studies.

The actual rate of recidivism cannot be dete.rmined in any general sense because it is
inextricably tied to the length of the followup period, the length of record retention in a
given State, the DUI arrest rate of a particular region or State, regional plea reduction
practices, and the effectiveness of DUI countermeasures. In California, approximately
35 percent of all DUI convictions each year involve `drivers with prior DUIs within the
preceding 5 years.

Recidivism prediction was directly addressed by Ellingstad (1974) as part of the
evaluation of the South Dakota ASAP. Diicriminant analyses, performed separately for
problem and nonproblem driers, assessed the predictabiityof a dichotomous DUI
recidivism measure using 14 variables related to prior .wnviction history, demographic
characteristics, drinkii pattern, and Mortimer-F&ins score. The problem-drinker
group yielded the highest level of prediction. For the 1,744 problem-drinker clients, of
whom only 12.6 percent were actual recidivists, prediction of subsequent Zyear DUI
recidivism was significant at the 0.001 level. However, only 4.4 percent of the variance in
recidivism was accounted for by the discriminant function (multiple R -0.209). Of the
14 variables used for the recidivism analysis, only 6 had a significant u&&ate relation-
ship -with recidivism: prior DUI convictions, reckless convictions, total convictions,
marital status, drinking pattern, and Mortimer-Filkins score. All relationships were in
the expected direction - that is, less favorable values were associated with increased
recidivism.

The level of recidivism prediction reported by Ellingstad (1974) was greater than that
reported by Burch (1974) in her analysis of the Los Angeles ASAP. A multiple regression
analysis was conducted for approximately 1,000 clients with the objective of predicting
subsequent 7-month DUI recidivism using treatment, age, accident, and wnviction
measures as predictor variables. The actual 7-month recidivism rate in the sample was
approximately 1. percent. The analysis indicated that 2.4 percent of the variance in
recidivism could be accounted for by the seven predictor variables (R = 0.155, p c 0.01).
The relatively low level of prediction reported by Burch results at least in part from the
brief 7-month period during which recidivism data were collected.

As part of the evaluation of the El Cajon Drinking Driver Countermeasure Program,
Wendlmg and Kolodij (l!V7) collected data on driving history, criminal arrest record,
probation officers' evaluation of problem-drinking severity, and Mortimer-Filkins diag-
nostic scores from 1,740 DUI offenders. These measures served as predictors of the
yearly rate of recidivism (DUI and reckless-driving convictions). The duration of data
collection subsequent to treatment ranged from 0 to 72 months. Stepwise multiple
regressions were performed for each half of the sample, and then each equation was
applied to the other half of the sample in order to provide a measure of cross-validation.
Although Wendling and Kolodij report impressive Rs in the range of 0.40, the high levels
of classification error upon cross-validation indicate that the construct multiple Rs were
inflated.

Development of a prediction model to identify likely recidivists among a sample of
Los Angeles DUI offenders was one of the main objectives of Pollack, Dideuko,
McEachern, and Berger (1972). Three models were developed and evaluated: multiple
regression, discriminant function, and empirical bayes. The authors reported a hi
degree of classification accuracy for drivers with extremely high predicted recidivism
expectancies. However, since these drivers represented only a small part of the total
recidivist population, it could not be concluded that recidivism can be accurately
predicted. On the contrary, the data indicated that the classification error would be
substantial for drunk drivers with nonextreme recidivism expectancies. Although no


EPIDEMIOLOGY AND DATA MANAGEMENT

57

multipIe R or overall classification accuracy was cited, the authors reported that the best
prediction would achieve an 11-percent increase in predictive accuracy over what would
he expected by chance prediction. Increased recidivism was associated with lower
education, younger age, and a higher incidence-of traffic accidents, traffic violations, and
nontraffic arrests.

McGuire (1975) assessed the predictability of accidents and alcohol-related wnvic-
tions for DUI 2,255 offenders who had participated in the Orange County Alcohol
Traffic Safety project. Convicted DUI offenders were assigned to one of a -number of
alternative countermeasure programs, Driver record recidivism data were collected for
15 months after treatment assignment. McGuire performed stepwise regression analyses
of driver record, psychosocial, and psychometric variables to identify wvariates sig-
nificantly related to accidents and alcohol-related convictions. The significant predictors
of subsequent accidents were sex, age, court-martial (ii in service), number of accidents
in last 3 years, and number of traffic tickets in last 3 years, yielding a multiple R of 0.20.
Surprisingly, subsequent alcohol-related convictions were slightly less predictable than
subsequent accidents (R = 0.14). The significant predictors of alcohol-related wnvic-
tions were marital status, number of full-time jobs in last 5 years, frequency of smoking,
number of tattoos, and number of traffic tickets in last 3 years. No cross-validation
analysis was performed.

Arstein-Kerslake and Peck (1985) used multiple regression and discriminant function
techniques to predict the Cyear DUI rate, subsequent to treatment, of large samples of
first- and second-time DUI offenders selected from Sacramento County. The best
multiple R was 0.27, which shrank to 0.21 on cross-validation. The regression equations
and correlation coefficients indicated that recidivists were more likely to:
  o Be younger

o  Be single or divorced

o  Have more prior DUI offenses
o ' Have more nonalwhol moving traffic violations
o Bemale

o Have blue collar occupations ' :

o  Have more nonmoving traffic violations

o  Be ethnic minorities

o  Have previous alcohol treatment or disuhiram use

o  Have exhibited negative attitude ratings during the intake interview

o  Have received intake recommendations for more intensive alcohol
  treatment

   o  Have higher BAC levels
Most of the above recidivism correlates are intuitively plauible and on&tent with the
prior literature. Simply put, DUI offeders are more likely to recidivate if their driig
probem is more severe and their driving record reflects numeous non-DUI- and DUI-
related violations.

Arstein-Kerslake and Peck (1985) also developed regression models for predicting
program compliance-that is, successfully completing the rehabilitation program. Pro-
gram compliance proved much more predictable than DUI recidivism. In addition,
persons with a high likelihood of being noncompliant tended to have extremely high
subsequent accident rates.

Multivariate and Taxonomic Studies of DUI Offender Characteristics
One limitation of simple univariate studies is that they fail to consider the inter-


58

BACKGROUND PAPERS

relationship among the set of variables beii evaluated to characterize a given sample
of DUI offenders. Although regression and disc&inant function procedures partial out
intercorrelations in producing linear composites that maximally differentiate between
groups`(e.g,, offenders versus nonoffenders), these techniques are focused on the sole
objective of diicrimination with respect to a single statistical criterion. As a result, they
do not provide a portrait of the offender population in terms of the complete array of
measurements and the more general dimensions underlying those measures.

In recent years, a number of investigators have attempted to develop multivariate
typologies of DUI offenders through factor and cluster analysis procedures (Arstein-
Kerslake and Peck 1985; Wells-Parker et al. 1985). These efforts to construct empirically
anchored multivariate typologies were preceded by a number of attempts to produce
rational typologies through less formalized statistical or clinical methods. A brief sum-
mary of this literature follows.

Intuitive and univariate typoEogi4s.  The concept of distinguishing drinkers on a con-
tinuum of severity (social, problem, alcoholic; light, modest, heavy, primary versus
secondary alcoholism) has a long history. (Some research on DUI typologies has been
referred to above in connection with the literature on univariate characteristics of DUI
offenders.)

Cahalan, Cism, and Crossley (1%9) and Jellinek (1960) provide detailed examples of
analytic systems, based on a complex of medical, sociopsychological, and drinking-style
parameters. Many of the ASAPs developed clinical and statistical taxonomies for
classifying convicted drunk drivers. These efforts have been reviewed by Epperson,
Harano, and Peck (1975), Ellingstad (1974), and Nichols (1974). Although it is difficult
to formulate a coherent generalization about the success of these efforts because of the
diversity and limitations of the validation methods, the various systems had some utility
in elucidating characteristics of convicted DUI offenders and in differentiating offenders
from drivers in general. The following characteristics were often used to create
problem-drinking continuums, and each has been found to differentiate convicted DUI
offenders from non-DUI populations:

o Scores on psychometric and personality tests, such as the Minnesota
Multiphasic Personality Inventory (MMPI)

o  Scores on tests specifically designed to detect problem driers and
alcoholism, such as the Mortimer-Pi&ins and MAST

o  Quantity-frequency index scores

o  Blood alcohol levels at time of arrest or accident involvement

o  Prior record of DUI offenses and alcohol-involved accidents

o  Prior arrests for public drunkenness and alcohol-associated
  misdemeanors

   a  Other criminal offenses
Many of these variables were discussed above in connection with the univariate studies.

Nichols and Reis (1974) concluded that number of prior DUI offenses and BAC were
among the two most useful indicators for classifying DUI offenders into a problem
no-problem dichotomy, and they used this dichotomous system to classify DUI offenders
across many of the ASAP sites. A description of the complete classification criteria is
presented in table 10.

After 24 months of follow-up from the point of treatment classification, Nichols and
Reiss reported that 15 percent of the problem-drinker group had been rearrested
compared to 8 percent of the nonproblem group.

Eppcrson, Harano, and Peck (1975) regressed the BAC values for a sample of 1,366


EPIDEMIOLOGY AND DATA MANAGEMENT

59

Table 10. Department of Transportation problem drinker classification
   criterion

1. Diagnosis as an alcoholic by a competent medical or treatment authority.

                       OR
2.  Self admission of alcoholism or problem drinking.

                       OR
3.  Two or more of the following:

   a.  A BAC of 0.15 or more at time of arrest
  b. A record of one or more prior alcohol-related arrests

   C. A record of previous alcohol-related contacts with medical, social, or
   community agencies
  d. Reports of marital, employment, or social problems related to alcohol
   e. Diagnosis of problem drinker on the basis of approved structured written
   diagnostic interview instruments (e.g., MAST, Mortimer-Fillrins, National
   Council on Alcoholism (NCA), Johns Hopkins diagnostic tests)

DUI arrestees against a pool of several driver record measures obtained on each subject.
Higher BAC values were found to be associated with significantly higher (p < 0.05) rates
of prior alcohol-related accidents and DUI convictions. The authors concluded that a
combined criteria of prior offense frequency and BAC should be included in any
problem drinker driver taxonomy. In another component of the same study, they
reported that hvo psychometric tests, the Risk Addiction Profile and Mortimer-Filkins,
produced significant discrimination between a group of DUI arrestees with BACs in
excess of 0.20 and a group of non-alcohol-involved negligent drivers.

A number of authors have commented on the criterion problem in validating
problem-drinker taxonomies- a problem that emanates from the difficulties in defining
what constitutes problem driiing and aIcoholism (Epperson et al. 1975). As a result,
different classification schemes and diagnostic procedures can diverge greatly in their
respective problem-drinker incidence rates. Table 11 from Filkins, Mortimer, Post, and
Chapman (1973) provides an apt illustration of the problem.
These data, based on a sample of 709 DUI offenders from three ASAP sites,
nevertheless provide some indication of the percentage of the convicted DUI population
whose drinkmg patterns deviate from social use levels.

Vingiles (1983) reached similar conclusions in her extensive review of the literature
on DUI d&king status classification. The DUI offenders classified as problem drinkers
ranged from 2 percent to 89 percent across the various studies. Vmgilis estimated that
X-50 percent of DUI offenders would most likely be alcoholic.

Sutker, Brantley, and Allain (1980) evaluated the MMPI profiles of 500 DUI of-
fenders, allof whom were found to share mild antisocial tendencies. Four profile patterns
were identified and were found to differ significantly on levels of self-reported driig.
Profile groups also differed significantly in race, age, and education. The authors
reported a strong association between elevated levels of self-reported drinking and
patterns in which indices of depression and social deviance were also elevated. Compar-
ing profile patterns of DUI offenders with those of alcoholics and psychiatric patients
revealed only a modest overlap among the groups.

Fine, Stoles, and Mulligan (1975) used clinical rationale to develop a three-group
classification typology for 1,500 DUI first offenders. The three groups were diieren-
tiated primarily by quantity, frequency, and circumstances of alcohol consumption.


80

BACKGROUND PAPERS

Table 11. Percentages of drivers classified into three drinker categories by
    various classification methods

Scale       Social drinkers Excessive drinkers  Problem drinkers

MF questionnaire
MF interview
Total MF
CRIT'
Presentence investigation
Psychometrist

.62          26            A.2
.71          SK           22
.64          .19            .17
.17         .29            53
.52          30            .18
A6          .21            33

o Combined criterion consisting of driver record and medical and social agency records.

Struckman (1975) grouped DUI offenders into four categories: social drinker, prob-
lem drinker, serious problem drinker, and chronic alcoholic. This drinker-type diagnosis
was based on information from a number of sources, including driving record, criminal
arrest record, Mortimer-Filkins test, and interviews. The reliability of this classification
strategywas quite good, but no significant recidivism diierences were found for control
group subjects classified into drinker types.

Home1 (1980) developed a typology based on biographic, demographic, driver record,
and criminal record data. Home1 hypothesized the existence of six operationally
anchored groups of convicted DUI offenders: never-convicted-again drivers, minor
motoring offenders, serious motoring offenders, dedicated drinking drivers, criminal
offenders, and drive-disqualified offenders. The description of group differences based
on measures such as marital status, age, occupational status, income, BAC, driver record
entries, and response to penalties provided a logical characterization of subtypes within
the DUI offender population. No attempt was made to substantiate the hypothesized
typology statistically, either by comparison of mean differences for cases classified using
this typology, or by cross-validation on an independent sample of DUI offenders.

Formal multivariate tahomies.   Only a small number of DUI-offender studies
employing formal methods of factor and cluster analysis have been reported in the
literature, and they are of relatively recent origin. Among the earliest was a study by
Steer, Fine, and Stoles (1979). These authors applied a hierarchical cluster analysis
technique to three indices of drinking status (BAC and quantity-frequency indices) and
psychoneuroticism swres collected from 1,500 first and repeat DUI offenders. The
analysis produced a number of types, but the resultant hierarchical structure was
complexand difficult to interpret. The authors therefore resorted to a simpler procedure
of forming 16 clusters from abmary mean split of the four measures (24 = 16). The seven
most predominant subtypes, containing 87.6 percent of the cases, were found to differ
significantly on several relevant externalvariables: ethnicity, number of prior DUIs, prior
treatment for alcoholism, prior drug use, and father's alcohol use.

Swles, Fine, and Steer (1984) classilied 124 non-DUI high-risk drivers using the
Sixteen Personality Factor Questionnaire (16PF). Through Modal Profile Analysis, 91.1
percent of the drivers were assigned to one of seven types, named on the basis of the
largest high swre trait: intelligent, shrewd impulsive, shrewd controlled, warmhearted
resourceful, warmhearted adventurous, assertive, and resourceful. The authors wn-
eluded that the 124 high-risk drivers were easily able to distort their responses on the
16PF in a socially desirable fashion, and that the utility of the 16PF for assessing
personality disturbance within the high-risk driver population must be questioned.


EPIDEMIOLOGY AND DATA MANAGEMENT

Donovan and Marlatt (1982) identified five subtypes through hierarchical cluster
analysis of 17 driving-attitudinal, personality, and hostility measures from 172 DUI
offenders. These five subtypes .were externally validated through comparison on
demographic, drinking, and driving-risk variables. Subtypes 2 and 5 were less deviant
than the other three subtypes. Subtype 2, in addition to being the largest group, also
presented the highest overall level of emotional adjustment. Subtype 2 members had the
lowest levels of driving-related aggression, depression, sensation seeking, and overt and
covert hostility. Subtype 5 members had slightly higher scores on these dimensions, but
the remaining three subtypes expressed much more deviant levels of these risk-
enhancing characteristics. Subtypes 1 and 4.were found to have particularly high levels
of risk-enhancing traits (e.g., high levels of driving-related aggression and hostility, and
low levels of assertiveness, perceived control, and emotional adjustment). The remaining
subtype (subtype 3) was characterized by high levels of depression and resentment and
low levels of assertiveness and emotional adjustment.

Donovan, Queisser, Umlauf, and Sal&erg (1984) continued investigating these per-
sonality subtypes through analysis of subsequent 3-year driving records. Subtype mem-
bership was not a significant predictor of DUI recidivism or accidents. However,
significant differences were found for other violation types.

Wells-Parker, Cosby, and Landrum (1985) used an inverse factor-analytic procedure
(Q-mode factor analysis) to develop a typology of 353 DUI offenders who were referred
to a probation and rehabilitation program in Mississippi. The variables used in the
clustering consisted of 45 measures representing different types of traffic- and criminal-
offense information available from driver and criminal record files.

The cluster analysis resulted in five subgroups that the authors characterized as
follows: low (overall) offense group, mixed (offense) group, traffic (moving violations)
group, public drunkenness group, and license offense (equipment and licensing viola-
tions) group. The classification accuracy of the cluster groups was verified through a
multiple-diicriminant-function procedure. Incorrectly classified individuals were moved
to the group indicated by the discriminant function. There was an overall agreement of
84.4 percent between the two classification procedures.

The authors cross-tabulated the typology against several external measures and found
statistically significant relationships on the majority of the comparisons. In most
instances, the relationships were intuitively plausible. Of particular interest were
relationships with BAC, Mortimer-Pilkins scores, drinking status, and subsequent 24
month accident and DUI recidivism rates. The public drunkenness and license groups
had the highest percentage of offenders with Mortimer-Pilkins swres in the problem
drinker range (24 percent versus 5 percent for all groups combined). The public
drunkenness group also had the highest BAC levels, and by far the highest rate of
subsequent accidents. The license group and publicdrunkenness groups had the highest
DUI recidivism rates. The low offense, mixed, and traffic groups had comparatively
lower proportions of problem drinkers, and lower rates of recidivism. The low offense
and mixed groups also had the lowest accident rates, in contrast to the traffic group,
which had the second highest accident rate of the five types. These three groups were
substantially younger than the other two, and the traffic group was youngest of the five
(mean =33.1 versus 42.8 for groups 4 and 5 combined).

The authors compared the characteristics of their typologies with those of Steer, Fine,
and Stoles (1979) and Donovan and Marlatt (1982). Although the resulting typologies
reflect a number of dissimilarities, all three exhibited types that varied in terms of
problem-drinker status (severity), age, and the extent to which the driving record reflects
a general disregard for traffic laws (elevated moving violation and accident rates).

kwmnen~o DVI mender Typology S&u&~  Probably the largest multivariate typol-


BACKGROUND PAPERS

ogy study of DUI offenders was that of Arstein-Kerslake and Peck (1985). The primary
objectives of this study were to:

   1. develop and cross-validate DUI offender typologies based on psychometric and.
   nonpsychometric variables and                          .

  2. assess the extent to which DUI recidivism and DUI treatment-program com-
   pliance can be predicted from traffic safety, criminal record, demographic, and
   psychometricvariables. '
These analyses were performed on data from 7,316 DUI offenders initially collected
during the operation of the California Driving Under the Influence (CDUI) project in
Sacramento, California, from September 1977 through January 1981 (Reis 1982u, b). The
Reis analyses focused on the question of the relative effectiveness of various randomly
assigned countermeasures and did not address the data from classification or prediction
perspectives.

Two sets of variables were used as scores in constructing lirst-offender, repeat-
offender, and total sample typologies: the psychometric domain and the descriptive
(nonpsychometric) domain.
The psychometric variables were:
  Conforming compliance/acting-out aggressiveness
  Extroversion/introversion
  Sanguine, self-confident/anxious, depressed
  Moralistic, conservative/nontraditional, unconstrained
  Paranoid-suspicious/naive trust
  Residential stability
  Alcohol consumption/quantity-frequency
  Alcohol problems
  Physical health problems
  Treatment receptiveness
Financial status, employment situation
  Familial interaction, living situation
   Social interaction and involvement
The descriptive variables were:
  49
  Average BAC at arrest
  Intake diagnosis - a clinical rating of drinking problem severities
   Client attitude at intake
  Average monthly income
   Educational level
  Marital status
  Number of marriages
  Number of dependants
  Occupational socioeconomic status
   Intake test score-standardized or modified Mortimer-Filkins test
  Traffic conviction record - moving and nonmoving
   Traffic accident record


EPIDEMIOL~Y AND DATA MANAGEMENT

63

Alcohol-related accidents and convictions
Criminal record entries

The psychometric variables are scales on the Life Activity Inventory (LAI) and were
selected because their factorial structure and psychometric properties have been well-
established (Reis 1982u, b). Both the psychometric and descriptive variables were
standardized before performing the cluster analysis.
It should be noted that the descriptive domain variables were available for the entire
sample, whereas the measures in the psychometric IAI domain were only obtained on
the subsample of 2,889 assigned to followup interview conditions in the Reis study.
A K-means cluster program identified nine clusters from analysis of the psychometric
variable domain. These DUI offender types were characterized on the basis of their
average scores on both psychometric and nonpsychometric variables. Descriptions of
the nine clusters follow.

o  Negligent Operator (cluster 1): Members express behaviors commonly as-
sociated with negligent operators (youthfulness, acting-out aggressiveness,
etc.). Levels of social interaction are high, and levels of residential stability and
financial status are low. This group had the highest rate of alcohol-related and
total accidents and the second highest rate of moving traffic violations. They
also had the highest rate of drug arrests and the lowest rate of program
compliance.

o Pre-DUI Alcoholic I (cluster 2): This has a strong, alcohol-related component,
but not as extreme a-cluster 3. This group had high level of mistrust, higher
than average conservatism and depression, and high levels of aggressiveness. It
also had a very high percentage of minorities (55 percent) and the highest rate
of moving, nonmoving, and reckless driving convictions. The group was
predominantly composed of first offenders (63 percent).

o  DUI-Alcoholic (cluster 3): A number of measures indicate an extreme alcohol
problem and a high traffic-safety risk. Thii group had the highest levels of
anxiety-depression, and aggressiveness, and the highest quantity frequency
index. It also had high levels of health problems.

o  Pre-DUI Alcoholic II (cluster 4): This cluster is descriptively similar to cluster
2, although these two cluster groups do diier with respect to psychometric
measures. Cluster 4 expressed high levels of introversion and isolation and high
  levels of lack of constraint.

o  "Mid-Life Crisis" Problem Drinker (cluster 5): Members report high levels of
stress in interpersonal relationships, high levels of physical health problems,
high unemployment, and high average age. A relatively large number perceived
alcohol as a problem in their lives despite having the lowest Q-F index.

o Deceptive Problem Drinker (cluster 6): Levels of socially desirable attributes
were surprisingly high, and levels of improbable response were very high as
measured by the "lie" scale.

o  White-Collar Controlled Problem Drinker (cluster 7): A relatively high per-
centage of persons employed in white collar occupations appear to be control-
ling their drinking and pose a relatively low traffic safety risk. This cluster
exhibited high levels of conforming-compliance, self-confidence, and trust, and
a comparatively low Q-F index.

o  Blue Collar Controlled Problem Drinker (cluster 8): Members possess at-
tributes similar to cluster 7, except for their generally lower level of
  socioeconomic status.

o  Social-Normative Problem Drinker (cluster 9): Age distribution is simiiar to
clusters 2 and 4, but cluster 9 members express much higher levels of


BACKGROUND PAPERS

   socioeconomic status and socially desirable attributes. It may well be that these
   persons tend to consume excessive amounts of alcohol in settings in which such
   behavior may not be considered deviant (i.e., socially normative).
Statisti&lly,signiticant differences in subsequent Qyear accident rate, traffic convic-
tion rate, and DUI recidivism were found among the nine psychometric clusters.

64

A separate K-means cluster analysis was performed on nonpsychometric variables
(driver record, criminal record, and intake interview). Descriptions of the 10 clusters
follow:

o  Cluster 1: Lowest average age (22.0 years); lowest average BAC at arrest;

one-fourth without high school diploma; high percentage of males (92 percent);
relatively low percentage of persons married or cohabitat& highest number
of moving and nonmoving violations; 67 percent fust offenders.

o  Cluster 2: Average age 24.0 years; relatively high levels of educational attain-
ment and white collar employment; lowest average income; average levels of
acting-out aggressiveness; exclusively unmarried; 82 percent male; 74 percent
  first offenders.

o  Cluster 3: Average age 24.2 years; one-fourth without high school diploma; 91
percent male; highest average score on accident composite measure and drug-
alcohol composite measure; high levels of alcohol problems and treatment
receptivity; 58 percent multiple offenders.

o  Cluster 4: Average age 30.4 years; highest percentage of females (32 percent);
no never-marrieds, 78 percent either separated, divorced, or widowed, highest
percentage of first offenders (78 percent).

o  Cluster 5: Average age 33.2 years; smallest descriptive cluster; above-average
incidence of accident and convictions; high percentage of minorities (36 per-
cent); very high levels of hostility and suspicion as judged by diagnostic coun-
selor; 56 percent first offenders.

o  Cluster 6: Average age 34.6 years; above average income; high percentage of
blue-collarworkers; highest number of dependents; highest percentage cur-
rently married (84 percent); highest percentage of minority members (37
percent); 61 percent first offenders.

o  Cluster 7: Average age 35.1 years; above-average incidence of accident and
convictions; very high levels of criminal record entries; contains all persons who
refused the BAC test associated with entry arrest (approximately 50 percent of
cluster 7 members); highest proportion unemployed (42 percent); largest
descriptive cluster; 59 percent multiple offenders.

o  Cluster 8: Average age 35.7 years; very high score on alcohol problem severity
on psychometric inventory administered at intake (refers to standardized score
on Mortimer-Ftii or CDUI scale-both tests were used at different times
during the operation of the CDUI project); high levels of acting-out aggressive-
ness and depression; high levels of perceived alcohol problems and physical
health problems; high levels of treatment receptivity, lowest level of satisfaction
in marriage or marriagelike relationship; highest percentage of multiple Of-
fenders (71 percent).

o  Cluster 9: Average age 38.6 years; highest occupational status (83 percent
white-collar - professional/technical, management/administration, sales); high
levels of educational attainment (41 percent 4 or more years of college); high
levels of marital stability and familial and social interaction; low levels of
acting-out aggressiveness; 62 percent fmt offenders.

o  Cluster 10: Average age 53.0 years; no members under 30 years old; 95 percent
of members over 40 years old; relatively high unemployment (39 percent);


E~KIEMIOLOGY AND DATA MANAGEMENT

  relatively low average income; lowest levels of educational attainment (49 per-
  cent with fewer than 12 years education); high percentage of females (24 per-
  cent) and minorities (30 percent); 50 percent married more than once;
  46 percent currently divorced or widowed; lowest levels of acting-out aggres-
  siveness; high levels of introversion and physical health problems; low levels of
   familial and social interaction; 64 percent multiple offenders.
Comparisons of the descriptive clusters on subsequent Cyear driver record indicated
staristicalIy significant differences in fatal accident rates, accidents involving alcohol,
moGng traffic convictions, and DUI recidivism. Clusters 1,3,5, and 7 tended to have the
poorest records, whereas cluster 9 consistently had the lowest number of driver record
entries.

Beth the psychometric and descriptive (nonpsychometric) solutions were cross-
validated using a 25-percent subsample not used during the information of the cluster
solution. In addition, the cluster solutions were submitted to discriminant function
analysis. In each case, differences among clusters based on relevant clustering variables
were substantial, resulting in 89.9 percent correct classification for members of the
psychometric cross-validation subsample and 67.6 percent correct classification for
members of the descriptive cross-validation subsample. For the psychometric cluster
solution, 86.8 percent of the variance in cluster membership was explained by five
discriminant functions. For the descriptive cluster solution, live functions accounted for
80.2 percent of the variance in cluster membership.

Since Arstein-Kerslake and Peck performed separate cluster analyses within each
domain, the resultant typologies did not constitute a single integrated system. They were
able, however, to investigate the structural relationship between the two by cross
tabulating the two systems. The end product of this analysis was a contingency table
showing how membership in the psychometric domain clusters were distributed across
each category of the descriptive variable typology. The results are summarized in table 12.

Although the relationship between the two typologies was significant, the association
was quite low (Cramer's v =0.22, p-z 0.001). Thus, the two systems are much more
independent than they are overlapping.   .
It would be possible to view table 12 as a two-dimensional taxonomic system if one of

the dimensions can be viewed as subordinate to the other. For example, if one considers
the psychometric typology to have logical precedence over the descriptive taxonomy,
then one could view the groups of the former as types and those of the latter as subtypes.
To illustrate from table 12, consider the DUI alcoholic type (type 3). We find that 64
percent of this group "maps" into descriptive subtypes 7 and 8. Hence, these combina-
tions could be numerically coded as 3.7 and 3.8. Both subtypes 7 and 8 clearly reflect
serious alcohol problems and the psychosocial manifestation of alcoholism. Therefore,
they corroborate the psychometric taxonomy (DUI alcoholic) but provide some addi-
tional differentiation. Subtype 7 manifests more antisocial traits (criminal record),
resistance to authority (implied consent chemical test refusal), bad driving record
(accidents, moving violations, prior DUIs), and high unemployment. Subtype 8 appears
to have the most acute alcohol problem but the members appear more receptive to
treatment and to be aware of their problems.

Arstein-Kerslake and Peck point out that the clusters vary greatly in terms of their
similarity/dissimilarity and that many of the clusters would not be fned in time. Intuitive-
ly, one would expect flux with persons changing clusters as they age and experience
deterioration or improvement in their drinking status and its relation to driving. For
example, it is known that some young people pass through a period of excessive drinking
and use of alcohol in conjunction with driving. Such people might not be labeled social
drinkers, even though many will eventually leave the drinking-driver population and
never progress to alcoholism. A longitudinal repeated-measures factorial study would
be required to validate the hypothesized transitions empirically.


66

BACKGROUND PAPERS

Table 12. Cross tabulations of correspondence between psychometric cluster membership
   and descriptive cluster membership                                  -

count                  Psychometric clusters
Row percent                                              Row
Column percent  1     2     3     4    5     6   .7    8     9   total

1          .37 25
         20.9   14.1
         10.6  13.7

2          86    29
         21.2 7.1
         24.7   15.8

3          48     9
         22.0 4.1
         13.8 4.9

10    27     3    21     9     6    39 177
5.6   15.3    1.7   11.9    5.1    3.4   22.0 1.1
3.2    7.2    1.4    5.4    2.6    2.4    8.5

21
5.2
6.7
26
11.9
8.3

4          39 25
         12.8 8.2
         11.2   13.7

5           9    .7
         10.7 8.3
         2.6 3.8

16
5.3
5.1

5
6.0
1.6

6           9     9    15
         3.6 3.6    6.0
         2.6 4.9    4.8

7          %    45    111
         13.1 6.1  Pi.!
        27.6 24.6   35.2

8          16 18    89
         6.3 7.1   35.0
         4.6 9.8   28.3

9           2     3    15
         1.2 1.2    5.8
         0.9 1.6    4.8

10         5 13
         2.5 6.4
         1.4 7.1

Column total 348    183
         12.0 6.3

7
3.5
2.2

315
10.9

74    16    54     8
18.2   3.9   13.3    2.0
19.7    73   13.8    2.3

47    14    13    14     8    39   218
21.6    6.4    6.0    6.4    3.7   17.9 7.5
12.5    6.4    3.3    4.0    3.2    8.5

41
13.5
10.9

13
15.5
3.5

19    57
6.3   18.8
8.6   14.5

8     9
9.5   10.7
3.6    2.3

20
6.6
5.7

13
15.5
3.7

11    76 304
3.6   25.0   10.5
4.4   16.6

7    13 84
8.3   15.5 2.9
2.8    2.8

12
4.8
3.2
94'
12.8
25.1

19
7.5
5.1

14
5.4
3.7

34
16.8
9.1

375
13.0

8    39    85    63     9    249
3.2   15.7   34.1   25.3    3.6 8.6
3.6    9.9   24.4   25.3    2.0

77    95    71    65    81   735
10.5   129    9.7    8.8   11.0 25.5
35.0   24.2   20.3   26.1   17.7

2.8     5    28    36    23 254
11.0    2.0    7.9   14.2    9.1 8.8
12.7    1.8    5.7   14.5    5.0

4    42   100    29    49 259
1.5   16.2   38.6   11.2   18.9 9.0
1.8   10.7   28.7   11.6   10.7

43    57     9    21    13    202
213   28.2    4.5   10.4    6.4 7.0
19.5   14.5    2.6    8.4    2.8

220    392   349   249   457 2,888
7.6   13.6   12.1    8.6   15.8 100.0

Chkquare = 1162.3 with 72 dj significance = O.OGOO
Eta (descriptive cluster dependent) = 0.35
Cramer's lambda = 0.22


EPIDEMIOLOGY AND DATA MANAGEMENT

67

It is instructive to note that Arstein-Kerslake and Peck failed to uncover any group
labeled social drinkers. The following quotation illustrates their reasoning
  "Hapless social drinker" does not constitute a sizable enough portion of the
  DUI offender population. to be identified as a separate subtype. In an
  intuitive sense, there are three dimensions which seem to characterize the
  differences between the nine psychometric clusters: (1) consumption of
  alcohol (moderate to excessive), (2) problem drinker predisposition (tran-
  sient to chronic), and (3) negligent operator characteristics (none too many).
  Different weightings on these.dimensions for each cluster contribute to the
  differential accident/conviction levels `among clusters. Even those clusters
  with low accident/conviction levels (e.g., very low negligent operator charac-
  teristics) have high enough levels on other dimensions (e.g., problem drinker
  predisposition) to preclude their being classified as "social driers."
The above conclusion requires clarification and tempering Each cluster is really an
aggregation of people into averages, and some of the clusters imply relatively moderate
levels of alcohol consumption. Individualvariation may be substantial within groups and
latent subtypes that were too small in number to emerge as a distinct type. Obviously
some of those among convicted DUI offenders could be characterized as social drinkers.
However, as Stewart., Epstein, Gruenewald, Laurence, and Roth (1987) point out, the
very term "social drinker" is imprecise and of dubious scientific value. It can be more
meaningful to talk about the amount, frequency, and pattern of alcohol consumption,
and about points on this continuum where problems are liiely to occur.

Discussions and Conclusioh

The preceding review of the literature on DUI offender characteristics indicates that
convicted offenders differ from the general driving population on a wide range of
variables. Although they share some of the same characteristics as problem (negligent)
drivers, alcohol-involved accident drivers, and alcoholics, the overlaps are not large with
any of the three in an absolute statistical sense. The convicted DUI offender represents
a combination of the traits of all three, plus a substantial amount of unique DUI-offender
characteristics.

The research on multivariate typologies and other taxonomic systems indicates that
the DUI-offender population contains some distinct subgroups, or types, and there is
some consistency across studies in the structure of the taxonomies and the subgroups
resulting from them. These classification systemsmay be useful in providing insight
concerning etiology of problem drinking (driving) and in suggesting potentially effective
modes of treatment.

The concept of the impaired problem drier has merit and is consistent with some of
the typoIogies described above. To a limited extent, DUI recidivism can be predicted,
and the characteristics of recidivists clearly indicate a profile of persons with progres-
sively increasing drinking problems and negligent-driving problems. Nevertheless, the
results of Arstein-Kerslake and Peck (1985) suggest that the majority of first offenders
are statistically indistinguishable from repeat offenders and represent equally high
accident risks. This finding suggests that most first offenders are problem-drinker drivers
who have simply not yet had their second DUI offense.

Current Issues and Problems

The major problems and questions in this area are identified and briefly discussed in
this section. Extensive discussion of these topics is unnecessary since they follow imme-
diately from the literature review presented above. In addition to the major headings


BACKGROUND PAPERS

used in the literature review, a subsection focused on the data management aspects of
the problem is included below.

Alcohol Involvement in Crashes

The most fundamental problem in establishing alcohol involvement in highway
crashes stems from the incomplete testing and reporting of BAC data. Enormous
progress has been made during the past decade in obtaining BAC data from fatal crashes
through FABS, by means of which the States are expected to report all relevant
information to NHT!$A. Although a few States report BAC data for all fatal crashes
within their borders and approximately one-third of the States report the BAC in at least
85 percent of their fatal crashes, most States fall far short of acceptable reporting
standards for thii crucial bit of information from each fatal crash. Overall, BAC data are
now reported to FARS for 74 percent of fatally injured drivers, but for only 45 percent
of the surviving drivers involved in fatal crashes. Thus, the shortfall of data for this latter
category of driver represents another major problem.              .

Far fewer BAC data are available for surviving drivers injured in highway crashes,

primarily because American hospitals generally will not release such information.
Consequently, estimates of the legally impaired drivers injured in highway crashes range
from 20 percent to 40 percent, with the best estimate being around 25 percent. This
question is currently being addressed in Ontario, Canada, in a research project funded
by NIAAA (principal investigator: Evelyn Vingilis).

Data on BAC are especially scarce for crashes with property damage only, i.e., those
collisions involving reportable damage to property but none to humans. Although these
crashes are of less importance for epidemiologic research than the two previous
categories involving human injury, it would nevertheless be useful to obtain BAC data
across the full continuum of reportable crashes for the sake of fully explicating the
relation of alcohol amount to the relative seriousness of the crash.

Alcohol and Noncrash Drivers

The traffic safety community is experiencing a shortfall of up-to-date information
concerning the population-at-risk, i.e., drivers who are not involved in crashes. Although
BAC data are the most important, it is also necessary to obtain additional information
concerning age, gender, purpose of trip, perceived risk of being stopped at an enforce-
ment checkpoint, perceived risk of being arrested for drunk driving, and so forth. Such
data are crucial for evaluating the progress and current status of both public health and
public safety programs. As noted above, NIAAA is currently supporting a research
project focused on alcohol tolerance among drinkiig drivers that is obtaining substantial
information about the nocturnal population at risk (principal investigator: M.W. Per-
rine). Data from this 5year roadside survey of 42,000 driverswill be reported as obtained
over the course of the next 4 years of field activity.

Characteristics of Drunk Drivers

The present state of research knowledge already permits differentiation within the
category of drunk driver. Indeed, recent research provides for an increasing number of
differentiations not only among drunk drivers, but also among drinking drivers, as
described by Perrine (1987). However, further increases, refinements, and validations
of such differentiations among drinking drivers are necessary in order to address the
major problems in this area more effectively. The specific shorter term goals for such
efforts should be:

o early identification of potential DUI offenders through increased
differentiation among drinking drivers,


EplDEMlOLOGY AND DATA MANAGEMENT

0  more accurately targeted sanctions for convicted DUI offenders,

o more accurately individualized referrals of DUI offenders from the
courts to selected treatment programs available in the locality,

o more individually customized counseling and treatment programs for
DUI offenders,

0  increased success rates in terms of alcohol treatment program
compliance and completion, and
. lower recidivism rates.

Although these goals are focused initially on specific deterrence and the convicted DUI
offender, the broad longer term goals involve aspects of both general deterrence and
public education (Perrine 1987).

The NIAAA is currently supporting a research program designed to address the
above goals through grants concerned with the probabilities of drunk driving among the
U.S. public and among convicted DUIs (AA06774 and AAO6926, principal investigator:
M.W. Perrine). This research program is based upon 15 concurrent, interrelated projects
that focus on live different but interdependent segments of the American drinking and
driving public: the general driving population, the nocturnal driving population, the
convicted DUI first-offender population, the convicted DUI multiple-offender popula-
tion, and those arrested for DUI, but not convicted. The basic rationale for this approach
derives from analyzing.the known characteristics of those in these interrelated popula-
tions to determine the similarities among those who "get into trouble with alcohol," as
well as the differences between those who do and those who do not (Perrine 1987). The
results of this ongoing research program should enable developing much more specilic-
and thus much more effective-means for prevention and intervention in this major
public health problem area.

69

Data Sources and Management         .
Much epidemiologic research on drunk driving (as in many other areas) depends on
data collected by third parties and available in the form of of&al records. Thus, the
adequacy, utility, and validity of such research are seriously constrained by the accuracy
and completeness of the data themselves, as well as by the data collecting and data
reporting. The systems for DUI processing (from the point of arrest through the
monitoring of adherence to the imposed sanctions) vary greatly from State to State, but
apparently all such systems are prone to loopholes and failures. Indeed, it is necessary
to analyze the individual State DUI processing systems carefully, not only to understand
their functioning, but especially to identify points for dropouts and other failures. Only
by so doing can the accuracy and completeness of the resulting DUI data be assessed.
An extensive evaluation of the drunk-driving countermeasure system in the State of
California has recently been completed, funded by the NHTSA. The first of the eight-
volume series is concerned with an analysis of DUI processing from arrest through
postconviction countermeasures (Perrine 1984). The objectives of the project were to
develop process flow charts and a description for the whole DUI system, as well as to
identify sources of system inefliciency or modes of circumvention of specific provisions
of the laws and the system. The interorganizational task force formed to accomplish these
objectives represented all major constituencies in the DUI countermeasure system: law
enforcement agencies; prosecutors; municipal, superior, and juvenile courts; pro-
gram/service providers; State and county alcohol-program administrators; probation
officers; and the Department of Motor Vehicles (DMV).
A subsequent study was conducted to identify deficiencies in the California DUI
countermeasure system and to evaluate empirically the frequency with which DUI
offenders avoid timely processing or circumvent system countermeasures owing to these


70

BACKGROUND PAPERS

deficiencies (Helander 1986). To accomplish these objectives, a sample of DUI of-
fenders was tracked all the way through the system in order to describe and analyze the
flow of the system.                     `\      .

A total of 3,959 Din offenders-arrested by 44 law enforcement agencies in seven
sample counties was tracked through the DUI system from the point of arrest through
postconviction countermeasures. A separate sample of 701 convicted DUI offenders
referred to alcohol education/treatment programs in the seven sample counties was
identified from program provider records and tracked through DMV, court, and pro-
gram records. The principal results were:

0 Probability of conviction for a DUI offender varied widely, depending on the
  county and court in which the offense was adjudicated. The use of sanctions
  also varied widely by county and court.

o  Most alcohol education/treatment program dropouts were not reported to the
DMV by the courts, and a substantial percentage of DUI offenders avoided
license suspension as a result.

o  Nine percent of drivers arrested for DUI were under license suspension or
revocation at the time of arrest. Only 20 percent of these drivers were convicted
for the offense of driving while license was suspended or revoked.

o  A surprisingly large percentage of DUI offenders was unlicensed or had more
than one driver record, that is, they had multiple licenses under different names
or errors in the files (e.g., wrong name or date of birth) created additional
- records that were not charged to the driver.'

Based on the study findings, Helander (1986) concluded that:

a  The probability of punishment for DUI offenses must be increased in order to
produce any large-scale impact on the problem of drinking and driving.

o  The citation and conviction rates of those who drive while suspended or revoked
must be improvedif license suspension is to remain an effective and credible
traffic safety countermeasure.

o  If the DUI countermeasure system is to function as a true system, goals and
objectives must be developed along with a management information system to
assess the achievement of those goals and objectives.

o  Improvement is needed in the accuracy of records in the DUI countermeasure
system.

The final volume in this series evaluating the California drunk driving countermeasure
system consists of an overview of study findings and policy rewmmendations prepared
by Peck (1987). Among many other important findings, Peck emphasized the need to
improve the management information system and monitor its quality control through
periodic process evaluations. For example, it is necessary to monitor:

o  time lags in the processing system;

o  characteristics of the plea bargaining process, as well the plea
bargaining rate;

o  the rate of dismissal of prior DUI convictions;

1  In California, all traffic convictions for moving traffic violations and for major violations, such as drunk
driving, are reported to the DVM and placed on the driver's driving record tile. The driving record also
includes fatal and injury accidents and property damage accidents involving more than $50 to a vehicle. The
driver record entries are retained from 3 to lOpars, depending on the nature of the offense. Other States
have similar file systems, although the specific p&visions and Mention periodswill vary from State to State.


EPIDEMIOLOGY AND DATA MANAGEMENT

71

.  the rate of compliance with imposed sanctionS;

o the rate of completing the sanctions (especially the
treatment/education programs);

,  the incidence of jury trials, and

0  the incidence of implied consent refusals to submit to a breathtest.
Some of the more serious shortfalls identified in the data system are (Peck 1987):

o  accurate reporting of the BAC at the time of arrest;

o  accurate determination of the offense status (whether a first, second,
third, or more DUI offense);
. dete r-mining whether a jail sentence was imposed, but more important,
determining whether it was actually served to completion;
. determinin g whether community services were actually performed
. dete rmining positively through affiimative evidence that the alcohol
treatment program had actually been completed by the DUI offender.

Research Questions

In 1987, as part of a continuing effort by NIAAA to assess research opportunities and
needs in the field, a. series of meetings focused on issues in alcohol research on safety
and trauma. A series of papers provided solicited advice on extramural research
priorities (these papers are published in a special issue of Contempomry Drug Problems,
Spring 1988). In addressing the research issues, needs, and opportunities in the area of
alcohol, trauma, and traffic safety, Per&e (1988) formulated a number of specilic
questions that should be addressed through epidemiologic and field studies. These
questions are also appropriate to consider in the present context.

o How frequently does driving actually occur after drinking among the U.S.
motoring public?

o How firm is the linkage between social drinking activities and subsequent
driving activities?

o Why are some drivers involved in crashes after drinking, whereas others are
not-even at the same BACs?

o To what extent do fatally injured drivers with high BACs differ from other high
BAC drivers who crash but are not fatally injured, or are not injured at all, or
who are not even involved in a crash?

o  To what extent is alcohol involved in crashes, and to what extent is alcohol
responsible for crashes?

A number of research questions and issues were also formulated concerning
idiosyncratic characteristics of drinking drivers (Perrine 1988), namely;
o What characteristics can be identified to distinguish among the various
  groups/types of individuals across the spectrum of drinking drivers?

a To what extent is it possible to differentiate drinking drivers who avoid detec-
tion, accidents, and conviction of DUI from drinking drivers who are arrested
  and convicted of DUI?

o To what extent is it possible to identify future DUI offenders in advance, that
is, before the fact? At what point or stage of development is such identification
possible?

o To what extent is it possible to identify potential DUI reoffenders or recidivists
in advance, for example, after the fust DUI offense but before the second? At
what point or stage of development is such identification possible?


72

o  To what extent do such advance indicators of DUI consist of stable, persistent
characteristics, as opposed to more tempdrary and transitional aspects? In
other words, to what extent does a person have a "predisposition'?o become a
DUI offender?

o To what extent do factors other than alcohol contribute to high-risk d&king
and driving and ultimately to alcohol-involved crashes?

   o Is a drinking driver a potential DUI offender when actually alcohol-impaired,
   or simply when the BAC is 0.10 or higher?
These questions may prove valuable in designing new research projects to investigate
further the role of alcohol and traffic safety.

Recommendations

A number of recommendations emerge clearly from the foregoing literature review
and examination of current issues and problems. The most important of these recom-
mendations are listed below without further comment.

Develop policies and procedures to ensure that uniform and consistent alcohol
data are obtained for all highway crashes.
Develop policies and procedures to ensure that accurate alcohol data are
obtained for commercial motor-vehicle operators using the highways.
Determine feasibility of gathering accurate data on drivers under 0.10 BAC at
enforcement checkpoints.

Develop more effective roadside survey policies and techniques to collect
increasingly valid data on drunk driving (e.g., incidence and prevalence,
changes in distribution of alcohol concentration).
Develop a, central monitoring, record keeping, and reporting capability for
drunk driving data.

Develop and test a valid, cost-effective surrogate for roadside surveys in order
to evaluate countermeasure programs and to monitor public awareness and
perception of risk.
Determine more accurately the characteristics of drunk drivers to facilitate
early identification and counseling, to encourage more accurately targeted
sanctions for convicted DUI offenders, to encourage more customized coun-
seling and treatment programs for DUI offenders, and thereby, it is hoped, to
obtain increased success rates in terms of alcohol treatment compliance and
completion, as well as lower recidivism rates.

REFERENCES

At-stein-Kerslake, G.W., and Peck, R.C A Typological An+is of Cabfomia DUZ venden and
  DUZ Recidivism Correlates. Technical Report. Washington, DC: National Highway Traffic
   Safety Administration, 1985.

Beitel, G.; Sharp, M.; and Glauz, W. Probability of arrest while driving under the influence of
   alcohol. Jownal of Studies on Alcohol 36237~256,197s.
Borkenstein, R.F.; Crowther, R.F.; Shumate, R.P.; Ziel, W.B.; and Zylman, R. T?ze Role of the
   Drinking Driver in %z$c A&den& Bloomington, IN: Department of Police Administra-
   tion, Indiana University, 1964.

Borkenstein, R.F.; Crowther, R.F.; Shumate, R.P.; Ziei, W.B.; and Zylman, R. The role of the
  drinking driver in traffic accidents. (The Grand Rapids Study). Blutalknhol, ll(Supple-
   ment l):l-132,1974.


~plDEMloLoGy AND DATA MANAGEMENT

Burch, H.E. Preliminary Analysis of the Rehabilitation Countermeasure: AnaZytic Study for 1973.
  Contract No. DOT-HS-161-2-252. Washington, DC: National Highway, Traffic Safety
   Administration, 1974.

&h&n, D.; Cisin, I.H.; and Crossley, H.M. Amer@n Drinking Practibes: A Nuhonal Study oj
   Drinking Behavior and Attitudes. New Haven, CT: College and University Press, 1%9.
Cur, B.; Borkenstein, R.F.; Perrine, M.W.; Van Berkom, L.C.; and Voas, R.B. ZnremationuZ
   Conference on Research Methodologyfor Roadside Swveys of Linking-Diving. Technical
  Report No. DOT HS-801-220. Washington, DC: National Highway T&tic Safety Ad-
   ministration, 1974. pp. l-75.

Denberg, D. Recidivism and Cot%ion Involvement of Zmpaired Drivers in Ontario. (Substudy No.
   587). Toronto:`Addiction Research Foundation, 1974.
Donelson, AC.; Beirness, DJ.; and Mayhew, D.R. Characteristics of drinking drivers. Zmpaired
   Dn'ving. Report No. I. Ottawa: Department of Justice, Canada, 1985.
Donovan, D.M., and Marlatt, GA Personality subtypes among driving while-intoxicated of-
   fenders: Relationship to drinking behavior and driving risk. Journal of ConsuZhiig and
   Clinical Psychology 50(2):241-249,1982.

Donovan, D.M.; Queisser, H.R.; Sal&erg, P.M.; and Umlauf, R.L. Intoxicated and bad drivers:
   Subgroups within the same population of high-risk drivers. Journal of Studies on Alcohol
   46(5):375-382,1985.

Donovan, D.M.; Umlauf, R.L.; and Sal&erg, P.M. Bad drivers: Identification of a target group
   for alcohol-related prevention and early intervention. JorvnaZ of Studies on Alcohol in
    press.

Ellingstad, V.S. An Analysis of Alcohol Rehabilitation Efforts. AnaZytic Study 6. Contract No.
   DOT-HS-045-l-061. Washington, DC: National Highway Traffic Safety Administration,
    1974.

Epperson, W.V.; Harano, R.M.; and Peck, R.C. Final Report to the Legislature of the State of
  California in Accord wirh Resolution Chapter 152, 1972 Legi&ive Session. Senate
   Concurrent Resolution 44-Harmer. Sacramento, CA: Department of Motor Vehicles,
    1975.

Evans, L. Fatal and severe crash involvement vs. driver age and sex. 31st AnnuaZ Proceedings,
  American Association for Automotive Medicine. New Orleans, LA: General Motors Re-
   search Laboratories, September 1987. pp. 59-76 .
Fell, J.Alcohol Involvement Rates in Fatal Crashes:A Focus on YoungDrivers and Female Drivers.
   Technical Report No. DOT-HS-807-184. Washington, DC: National Highway Traffic
   Safety Administration, 1987.

Wilkins, L.D.; Mortimer, R.G.; Post, D.V.; and Chapman, M.M. Field Evaluation of Court
  Procedures for Zdentifring Problem Drinkers. Technical Report No. DOT-HS-O31-2-303.
   Washington, DC: National Highway Traffic Safety Administration, 1973.
Fine, E. W.; Stoles, P.; and Mulligan, M. Under the influence: Characteristics and drinking practices
   of persons arrested the first time for drunk driving, with treatment implications. Public
   Heahh Reports 90(5):424-429,1975.

Fridlund, G., and Hagen, R. Characteristics of DWDrivers. Menlo Park, CA: Stanford Research
   Institute, 1977.

Greenfield, L.khkDriving. Special Report, NCJ-109945. Washington, DC: U.S. Department
   of Justice, Bureau of Justice Statistics, February 1988.
1 Iqgen, R.E. Effectiveness of License Suspension or Revocation for Drivers Convicted of Multiple
   Driving-Under-the-ZnfZuence menses. Technical Report NO. NTIS CAL-DMV-RSS-77-
   59. Sacramento, CA: Department of Motor Vehicles, 1977.
Ifagen, R.E.; Williams, R.L.; McConnell, EJ.; and Fleming, C.W.hEvaluarion ofAkohoIAbuse

Treatment m an Alternative to Llrivers License Suspension or Revocatzon. Fial Report to
the Legislature in Accord with SB 38 - Gregorio. NTIS No. PB291534. Sacramento, CA:
Department of Motor Vehicles, December 1978.

Hause, J.; Voas, R.; and Chavez, E. Conducting voluntary roadside surveys: The Stockton
   experience. In: Valverius, M.R., ed. Proceedings of the Satellite Conference to the Eighth
  Zntemational Conference on Alcohol, Drugs and Traffic Safety. Stockholm: The Swedish
  Council for Information on Alcohol and Other Drugs (CAN), 1982. pp. 104-113
IIc!ander, CJ. The California DUI countermeasure system: an evaluation of system processing
  and deficiencies. Volume 5 of An Evaluation of the CaZifomia Drunk Driving Counter-

73


74

meuszue System. Technical Report CAL-DMV-RSS-86-97. Sacramento, CA: California
Department of Motor Vehicles, 1986.

Holcomb, R.L. Alcohol in traffic accidents. IoumuZofrherhmericen A4e&uZ,4ssociufZon 111:1076-
   1885,1938.                                      -
Homel, R. Pen&es and the Drink Driver A Study of &se-Thousand wend&s. Vohune 1.
  Research Report No. 7. New South Wales, Australia: Department of the Attorney
   General, 1980.

Hurst, P.M. Epidemiological aspects of alcohol in driver crashes and citations, Journal of Sufq
   Reseaxh 5:130-148,1973.

Hurst, P.M. Epidemiologiml aspects of alcohol in driver crashes and citations. In: Perrine, M.W.,
    ed. AZcohol Drugs, Md Dr&g. Technical Report DOT HS-801-096. Washington, DC:
    National Highway Traffic Safety Administration, 1974.
Hurst, P.M. Blood alcohol limitsand deterrence: Is there a rational basis for choice? In: Moskowitz,
    H., ed.Alcohot Dnrgst a& @iv& Abstracts a& Reviews l(l-2):121-130,1985.
Jellinek, E.M. The Disease Concept ofAlcoholism. Highland Park, NJ: Hillhouse Press, 1960.
Lehman, R J.; Wolfe, AC.; and Kay, R.D. A Computer Archive of ASAP Roadside Breathtesting
   Surveys, 2970-1974. Technical Report DOT-HS801-502. Washington, DC: National
    Highway Traffic Safety Administration, 1975.
Levy, P.; Voas, R.; Johnson, P.; and Klein, T.M. An evaluation of the Department of
    Transportation's alcohol safety action projects. lournal of Safety Research lO(4): 162-176,
      1978.

Lucas, G.W.H.; I&low, W.; McCall, J.D.; Griffith, B.A.; and Smith, H.W. Quantitative studies of

the relationship between alcohol levels and motor vehicle accidents. In: Proceedings of the
Second International Conference on Akohol and Road Trafic. Toronto: Garden City
Press Cooperative, 1955.

Maisto, Sk; Sobell, L.C.; Zelhart, P.F.; Conner& GJ.; and Cooper, T. Driving records of persons
  convicted of driving under the influence of alcohol. Journalof Studies on Alcohol 40( 1):70-
   77,1979.

McCarroll, J.R., and Haddon, WJ. A controlled study of fatal automobile accidents in New York
  City. loumal of Chronic Diseases 1581 l-826,1%2.
McConnell, EJ., and Hagen, RE. Design and Evaluation of a Crash Prediction Sbategv. Report
   No. 76. NTIS No. PB81-142671. Sacramento, CA: Department of Motor Vehicles, 1980.
McGuire, EL. An Evaluation of the Orange County Alcohol TM~~c Safety Reject. Irvine, CA:
   University of California, 1975.

Miles, W.R. Alcohol and motor vehicle drivers. In: Proceedings of the Thirteenth Annual Meeting
  of Highway Research Board. Washington, DC: Division of Engineering and Industrial
   Research, National Research Council, 1934.

Moskowitz; H.; Walker, J.; and Gomberg, C Characteristics of Dwls, Alcoholics and Control.
  Prepared for California Department of Alcohol and Drug Abuse. Los Angeles, CA:
   University of California, 1979.

National Highway Traffic Safety Administration. Alcohol and Highway Safety Z984: A Review of
  the State of the Knowledge. Technical Report No. DOT-HS806-569. Washington, DC:
  Supt. of Dots., U.S. Govt. Print. Off, 1985.

National Highway Traffic Safety Administration. Dnurk Driving Facts. Washington, DC National
   Center for Statistics and Analysis, US Department of Transportation, 1987~.
National Highway Traffic Safety Administration. National Accident Sampling System Z985: A
   Report on Trafic Accidents and Injwies in the United Sfates. Publication No. DOT-HS-
   807-074. Washington, DC: US Department of Transportation, 19876.
National Highway Traffic Safety Administration. The Economic Cost to Sock@ of Motor Vehicle
  Accidents. 1986 Addendum. Washington, DC: US Department of Transportation, OfI&
   of Plans and Policy, 1987~.

National Highway Traffic Safety Administration. FataZAccident Reporting System 1986:A Review
  of Information of Fatal Trafjic Accidents in the United States in 1986. Publication NO.
  DOT-HS-807-245. Washington, DC US Department of Transportation, 1988.
National Institute on Alcohol Abuse and Alcoholism. Drinking and driving. Alcohol Heahh and
   Research World 7( 1). 1982

National Institute on Alcohol Abuse and Alcoholism. Alcohol, other drugs, and safety. AZcohoZ
   Health and Research World 9(4), 1985.

National Institute on Alcohol Abuse and Alcoholism. Sixth Special Report to the U.S. Congress on


~pl~EMioLoGy AND DATA MANAGEMENT

  Alcohol and Health DHHS Publication No. (ADM) 87-1519. Washington, DC: U.S.
   Department of Health and Human Services, 1987.
National Research Council. Zen, Alcohol Md Other opiorrp. Limits for Truck ami Bus Drivers.
  Special Report 216. Washington, DC: Transportation Research Board, 1987.
Nichoh,J.L,and Reis,R.E.0teA4o+r~fortheEvakfionofASAPRe/rabL%a&.o~Effort.Technical
  Report No. DOT-HSXtl-244. Washington, DC: US Dept of Transportation, NHTSA,
    1974.

Peck, R.C. An overview of study findings and policy implications An Evaluation of the California
   Drunk Driving Counterme~s System, Ftnal Vol. Technical Report CAL-DMV-RSS-
   87-112. Sacramento, CA: California Department of Motor Vehicles, 1987.
Peck, R.C., and Kuan,. J. A statistical'model of individual accident risk prediction using driver
   record, territory and other biographical factors. Accident Analysis andRevention
   15(5):371-393,1983.

Perrine, M.W. Methodological considerations in conducting and evaluating roadside research
   surveys. Technical Report, DOTHS-800-471. Washington, DC: National Highway Traffic
   Safety Administration, 1971.

Perrine, M.W. Alcohol and highway safety (Chapter 6). In: Second Special Report to the US.
   Congress on Alcohol and Health. DHEW Pub. No. (ADM) 75-212 Washington, DC:
   Supt. of Does., U.S. Govt. Print. Off, 1975a.

Perrine, M.W. Alcohol invohement in highway crashes: A review of the epidemiological evidence.
   In: Schultz, R.D. ed. Clinics in PZusric Surgery 2(l): 1 l-33, 1975b.
Perrine, M.W. Alcohol and highway crashes: Closing the gap between epidemiology and ex-
   perimentation. In: Vol. 11, Modem Problems of Phwmacopsychiatty Alcohol. Base&
   Switzerland: .Karger, 1976. pp. 22-41.

Perrine, M-W. Analysis af DUI Processing From Arrest Through Post-Conviction Counter-
   measures. VOI! 1. An Evaluation of the Cahfomia Drunk Driving Countermeasure System.
   Technical Report CAL-DMV-RSS-84-89. Sacramento, CA: California Department of
   Motor Vehicles, 1984.

Perrine, M.W. Varieties of drunken and of drinking drivers: A review, a research program, and a
   model. In: Noordzij, PC., and Roszbach, R., eds. Alcohot hugs and Tmffic Safety - T86.
   Amsterdam: Elsevier, 1987. pp. 105-113.

Perrine, M.W. Alcohol, trauma and traffic safety: research issues, needs and opportunities.
   Contemporary Drug?Yoblems, 15( 1):83-93,1988.
Perrine, M.W.; Wailer, Jk, and Harris, LS.Akohol and Highway Safeq: Behavioral and Medical
   Aspects. Technical Report, DOT HS-800-599. Washington, DC: National Highway Traffic
   Safety Administration, 1971.

Poliack, S. Drinking Driver und Trufic Safety Project, Vol f and II. Los Angeles: Public Systems
   Research Institute, University of Southern California, 1%9.
Pollack, S.; Didenko, 0.; McEachem, A; and Berger, R.M. "Drinking Driver and Traffic Safety
   Report." Final Report Vol. 3. US Department of Transportation. NHTSA Contract No.
   FH-11-7099. University of Southern California, Public Systems Research Institute, 1972
Raymond, A. Drinking-Driving Convt?tions - A Symptom of &o)rolism? Melbourne: The St.
   Vincent's Summer School of Studies on Alcohol and Drugs, 1971.
Reed, D.S. Reducing the cost of drinking and hiving. In: Moore, M.H., and Cerstein, D.R., eds.
   Alcohol andPublic Policy: Beyond the Shadow of prohibition. Washington, DC National
   Academy Press, 1981. pp. 336-387

Reis, R.E. The Traffic Safe&v Effectiveness of Education Programs for First mense DrunkDrivers.
   Technical Report, DOT Contract HS-6-01414. Washington, DC: National Highway Traf-
   tic Safety Administration, 1982~.

Rcis, R.E. The Traffic Safety Effectiveness of Education Rograms for Multiple @ense Drunk
   Drivers. Technical Report DOT Contract HS-6-01414. Washington, DC: National High-
   way Traffic Safety Administration, 19826.

Richardson, HA. Motor Vehicle Traflc Accidents as a Leading Cause of Death in the United States.
  Research Notes, Number 85-4. Washington, DC: NH'lXA, US Dept of Transportation,
   October 1985.

Sadler, D.D., and Perrine, M.W. The Long-Term Traffic Safety Imprzcr of a Pilot AlcoholAbuse
   Treatment as an Alternative to License Suspensions. VoL 2: An Evaluation of the California
  Drunk Driving Countermeasure System. Technical Report, CAL-DMV-RSS-84-90.
   Sacramento, CA: California Department of Vehicles, 1984.

75


76

Stoles, P., Fine, E.W., and Steer, RA Personality characteristicsand drinking patterns of high-risk
  drivers never apprehended for driving while intoxicated. Journal of Studies on Alcohol
   45:411-414 1984.
Simpbon, H.M. "The Impaired-Driver Problem vs. the Impaired Pioblem l&xx." Paper
   presented at the Association of Llfe Insurance Medical Directors of American. Toronto,
   Canada, 1977.

Skinner, HA., and Allen, B.A. Alcohol dependtince syndrome: measurement and validation.
   Joumal ofAbnonnal Ps@o@y 91:199-m, 1982
Steer, R& Fine, E.W., and Stoles, P.E. Classification of men arrested for driving while lntoxi-
   cated, bnd treatment implications. Joumal of Studies on Alcohol 40(31)%X229,1979.
`Stewart, K-, Epstein, L., Gruenewald, P., Laurence, S., and Roth, T. 23re Caliifbnsin First DUI
  offender Evaikation proiect. Prepared for California Office of Traffic Safety. Walnut
   Creek, CA Pacific Institute of Research and Evaluation, 1987.
Struckman, D.L. An Analysis of Binkzr Diagirapip and RefkaL SD: ASAPAhalydc Study No. 5 -
   1975. Contract No. DOT-HS-045l-061. Washington, DC: National Highway Traffic
   Safety Administration, 1975.
Sutker, P.B., Brantley, PJ., and Allain, A.N. MMPI response patterns and al&ho1 consumption
   ln DUIx#fenders. Jozunal of Conwlfing and Clinical Pvhologv 48(3):350-355,198O.
Tashima, H., and Peck, R. CAn Evaikation of the Specijic DeMrent EffectsofAltemative Sanctions
   for First and Repeat DUI meruiers. Vol3. An Evahuh& of the Californk Drunk Driving
   Countenneaszue System. Technical Report CAL-DMV- RSS&95. Sacramento, CA:
   California Department of Motor Vehicles, 1986.
Vingilll, E.R. Drinking drivers and alcoholics: Are they from the same population? In: Smart, R.G.;
   Glaser, F.B.; Israel, Y.; Kalant, H.; Popham, R.; and Schmidt, W. eds. Research Advances
   inAlcohol and DrugprObkms Vol. 7. New York Plenum Press, 1983. pp. 299-342
Voas, R.B. ASAP program evaluation methodology and overall program impact. In: ASAP
   Evaluation of Oprations, I972 Technical Report, DOT-HS880-874. Washington, DC
   National Highway Traffic Safety Administration, 1972
Voas, R.B. LXnking and Driving Scandinavian L+aws, Tough Peru&s, and United States Altema-
   fives. Technical Report, DOT Contract DTNH-22-82-P-05079. Washington, DC: Nation-
   al Highway Traffic Safety Administration, 1982
Voas, R.B., and Hause, J.M. Deterring the drinking driver: The Stockton experience. Accident
   Analysti and Bevention 19(2):81&Q 1987.

Voas, R.B., Rhodeniqx, AE, and Lynn, C. Evahution of CXarloftesviUe Checkpint Opemrions.
   Technical Report, DOT Contract DTNH-2283-C-05088. Washington, DC: National
   Traffic Safety Administration, 1985.

Wells-Parker, E.; Cc&y, P.; and Landrum, J.W. Classifying the DUZ mnder: A Cks&?rAnalysis
   of Arrest Histories. Technical Report. Mississippi: Mississippi State University, 1985.
Wendling, A., and Kolodij, B. An Evaktion of the El Cajon Drinking Driver CouWrmeaswe
  Program. Washington, DC: National Highway Traffice Safety Administration, 1977.
Wolfe, A.C. 1973 U.S. National Roadside Breathtesting Survey: procedures Md Results. Interim
   Technical Report, DOT-HS-801-241, NTIS No. PB-238-042 Washington, DC: National
   Highway Traffic Safety Administration, 1974.

Wolfe, AC. Nah'onal Roads& Breathtesting Survey: tie&es and Results. Washington, DC:
   Insurance Institute for Highway Safety, 1986.
Zylman, R. Analysis of studies comparing collision- involving drivers and non-involved drivers.
   Journal of Safety Research 3: l&128,1971.
Zylman, R. A critical evaluation of the literature on `alcohol involvement' in highway death.
   Ace&n, AnaIysis and lkvention 6(2), 1974.


Education

Controlling Injuries Due to Drinking &xi
   Diiving: The Context and
     Functions of Education

Bruce G. Simons-Morton, Ed.D., M.P.H.
University of Teras Medical Branch, Galveston, Teras

  Denise G. Simons-Morton, M.D., M.P.H.
Center for Health Promotion Research and Development
University of Texas Health Science Center, Houston, Texas

The importance of education in motor vehicle crash (MVC) injury control has been
the subject of intense debate. Some view education as a failure and a distraction from
the more serious business of environmental control of injuries (Robertson et al. 1974;
Robertson 1986), while others view education as a necessary element of the dynamic
process of altering social norms (Wallack 1984), gaining public support for environmen-
tal controls (Moore and Gerstein 1981; Malfetti 1985), and implementing effective injury
control interventions (Simons-Morton et al. 1989a)., Changing behavior and creating a
protective environment are two essential and complementary approaches to the preven-
tion and control of MVC injuries, each of which can be approached through education
(Bergman 1982; Moore and Gerstein 1981).

In this chapter we present a conceptualization of the role of education in preventing
injuries due to drinking and driving, describe the health problem context necessary for
understanding the role of education, discuss the societal context for educational ap-
proaches, provide examples of the utility of education in MVC injury control, discuss
major issues regarding public education for injury control, and provide recommenda-
tions for research. From our perspective, education is the major component of health
promotion and an important intervention approach in public health.

The Role of Education

There appears to be a controversy over whether injuries due to drinking and driving
should be addressed through changing personal health behavior or through environmen-
tal protection (Robertson 1986). In fact, they can and must be addressed through both
(Moore and Gerstein 1981). Personal behavior determines whether individuals drink
and drive; social and physical environmental factors influence whether individuals drink
or drink and drive; and environmental conditions can help decrease injury in those

NOTE: Preparation of this chapter was supported in part by CDCcontract # DHHS 200-86-0836 and NIH
Training Grant # 5 T32 HLO7555-04.


78                                                   BACKGROUND PAPERS

individuals who suffer MVCs due to drinking and driving. Education has an important
role in influencing each of these factors.

Figure 1 shows how education can influence four types of related outcomes: (1) per-
sonal alcohol and safety behaviors of at-risk individuals and their proximal others,
(2) social norms regarding alcohol and safety behaviors and environmental constraints,
(3) environmental factors that influence personal behaviors, and (4) protective environ-
mental factors.

The essential differences between the four avenues for education are who is being
influenced (at-risk individuals, the general public, or decisionmakers in organizations,
communities, or governments) and what are the objectives (changes in personal health
behaviors, societal norms, or environmental conditions). In each case, the ultimate
outcome of education is behavior change, either personal health behavior or decision-
maker actions, to reduce risk of injury. Behavior change is mediated by knowledge,
attitudes, skills, experience, and reinforcement, and is greatly influenced by the larger
sociophysical environment.

TARGETS OF EDUCATION    OEIJECTIVES OF EDUCATION     HEALTH GOALS

Personal alcohol

Social norms regarding
drinking. drinking/driving

Environmental influences
on personal behavior

Reduced incidence
and severity of
alcohol-related
MVC injuries

communities, and
govemnlctlts

Figure 1. The role of education in reducing motor vehicle crash injury due to drinking and driiing.

The Context for Education: Review of the Problem

To understand better the role of education in alcohol-related injury control, it is useful
to review briefly the literature on drinking-and-driving injuq drinking and drink-
ing/driving behavior; environmental influences on drinking, drinkingldriving, and safety
behavior; and environmental protection.

Alcohol and MVC Injury

Injury is the fourth leading cause of death in the United States, and MVCs are the
leading cause of injury deaths (Baker 19&I). Of the 75,000 U.S. deaths attributable to


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79

alcohol annually, an estimated 32 percent are due to MVCs (Stoudemire et al. 1987).
Half of fatal MVCs involve alcohol (NIAAA 1987). Drinking and driving dramatically
increases the risk of MVC injury and death (Rubin et al. 1983).
Risk for alcohol-related MVC death is well distributed across population groups
(Baker 1984) and affects not only drinking drivers, but also innocent passengers and
pedestrians. Adolescents and young adults, however, are at extreme risk. MVC is the
leading ame of death for persons age I.524 years, accounting for 40 percent of all deaths
(Malin et al. 1982). Persons age 16-25 years account for about 28 percent of total miles
driven but are involved in an estimated 42 percent of all alcohol-related MVC fatalities
(Fell 1982). Persons age 18-25 are involved in fatal crashes at a rate four times that of
26- to 35year-olds (Malii'et al. 1982). Males at all ages are at greater risk for alcohol-
related MVC deaths, with the disparity in risk between males and females greatest during
adolescence and young adulthood (Johnston et al. 1987; Schoenbom 1988).

Substantial evidence shows that impairment of driving abiity occurs at blood alcohol
concentrations (BAC) below 0.10, and some impairment occurs at less than 0.05 BAC
(Moskowitz and Robin 1988). The relationship between drinking and MVC severity
is particularly acute for young (inexperienced) drivers (Malin et al. 1982). Consequently,
safe driving may be compromised by the effects of even relatively small amounts of
alcohol.

Thus, alcohol-related MVC injury and death are major public health problems
affecting all age groups. Adolescents and young adults, especially males, are at par-
ticularly high risk and thus are prime targets for educational efforts directed at influ-
encing them and their environments.

Drinking and Drinking/Driving Behavior

Drinking and driving behavior can best be understood in the context of normative
patterns of drinking. The percentage of driers increases with age from early adoles-
cence into young adulthood. In one study, the percentage who reported ever drinking
increased from over 30 percent in eighth grade to over 70 percent by tenth grade and
more than 90 percent by twelfth grade (Johnston et al, 1987). About 65 percent of high
school seniors and 75 percent of 21- to 22-year-olds had used alcohol in the past 30 days.
About 37 percent of high school seniors and 45 percent of 19- to 28-year-o& reported
drinking live or more drinks in a row during the prior 2 weeks (Johnston et al. 1987).
Hence, despite legal sanctions against drinking, most youths experiment with alcohol,
and many underage youths drink regularly. Young males tend to initiate drinking earlier,
drink more frequently, and drink greater amounts than females of the same age
(Johnston et al. 1987).

In national surveys that asked U.S. adults (18-65 years old) about their drinkiig during
the previous 2 weeks, 20 percent reported abstaining, 40 percent reported drinking fewer
than two drinks, 30 percent reported drinking three to four drinks, and 10 percent
reported drinking five or more (Thomberry et al. 1986). About 8 Percent of adults
reported drinking daily, and nearly 25 percent reported drinking five or more drinks in
one day at least five times in the past year (Schoenborn 1988). Males at all ages were
more likely than females to drink daily, to be heavy drinkers, and to drink and drive
(Schoenbom 1988).

Drinking and `driving behavior parallels the pattern of alcohol use, placing younger
Persons at greater risk than older persons. Thirty-four percent of 16-year-old high school
students reported having driven after drinking during the last month, and 18 percent of
males and 10 percent of females reported doing so weekly (Williams et al. 1986). By age
18,53 percent of males and 39 percent of females reported having driven after drinkiig,
while 30 percent of males and 11 percent of females reported doing so weekly (Wiiiams
et al. 1986).


80                                                   BACKGROUND PAPERS

Table 1. Objectives of education for three targets of education

TARGETS OF At-risk population
EDUCATION  and proximal others

MEDIATING
VARIABLES

TYPES OF    Personal alcohol and
OBJECTIVES  safety behaviors

SPECIFIC
OBJECTIVES

General public

Knowledge
Attitudes
Skills

Knowledge
Attitudes
Skills

Social norms regarding
drinking, drinking/driving
and environment

Decrease or abstain
from drinking
Refrain from driving
after or while drinking
Refrain from riding with
a drinking driver
Discourage others from
drinking and driving
or riding with a
drinking driver

Social nonacceptance of
drinking and driving
Provision of social
alternatives to drinking
and drinking/driving
Support of environmental
controls on drinking/
driving
Support of environmental
protection from MVC
injuries
Obeyance of alcohol
and safety laws
Performance of motor
vehicle safety practices

              \
Decision makers in      Decision makers in
organizations, communities
and governments     organizations, cornmu*
            and governments

Knowledge       Knowledge
Attitudes            Attitudes
Skills              Skills
Actions           Actions

Environmental influences   Environmental
on personal behavior     protection

Responsible alcohoi-set%er,
practices
Provision of transportation
alternatives (e.g., taxi
service, free rides)
Limited alcohol advertising
Higher alcohol cost/taxes
Alcohol sales restrictions
Open-container laws
Drunk-driving laws
Seatbelt laws
Lower speed limits
Law publicity and
enforcement

Manufacture of safer
motor vehicles
Installation of
occupant protection
devices (airbag,
passive restraints)
Development of
safer roads

Older adults reported driving after drinkmg less frequently than younger adults, and
about half the percentage of females as males reported driving after drinking at least
once in the past year (NCHS 1988). Among 18- to 2%year-old males, more than 36
percent reported driig and driving in the past year (NCHS 1988). Among adults, a
small percentage of repeat offenders accounted for a disproportionate burden of the
drinking and driving problem (Smith and Falk 1987). The great number of people who
occasionally drink and then drive, however, appear to account for most MVC deaths.

Drinking and driving can be viewed as the product of twin social phenomena - exces-
sive dependence on automobiles for transportation and social norms favoring routine
consumption of alcoholic beverage. Thus, the problem of drinking and driving cannot
be separated from the more general problems of transportation safety and alcohol
consumption. Total alcohol consumption is positively associated and a host of social and
health problems, including risk of injury and legal problems (Gerstein 1981), and
presumably is associated with drinking and driving.

One goal in injury control is to reduce the prevalence of driig and driving, which
may require alteration in the normative patterns of alcohol consumption-the frequency
and amounts of alcohol drinking that are socially acceptable and the situations in which
it is acceptable to drink (Simon+Morton et al. 1989b). According to Rose (1985), in
situations in which a large proportion of the population is at some risk, it is desirable to
alter the population mean level of risk factors, "toshift the whole distribution of exposure
in a favorable direction" (p.37). Such an approach seems eminently suited to the problem
of drinking and driving, for which the population goal would be a downward shift in the


EDIJCAT~C"'

frequency and amount of drinking, the mean number of drinking/driving events, and the
,uu&er of circumstances in which it is socially acceptable to drink.

Adolescents and Youfig Adults

A variety of factors that can be influenced by education is associated with alcohol
coasumption and with drinking and driving among adolescents. These factors include
knowledge, skills, expectations, and social norms and acceptance.

Many adolescents overestimate the number of drinks that will impair their ability to
drive (Williams and'Lund 1986). Adolescents with better social skills (Donovan et al.
1983), some religious affiliation (Donovan et al. 1983; Miller and Nirenberg 1984,
Coombs et al. 1985), and higher academic achievement (Donovan, et al. 1983; Onei and
Jones 1986) are less likely to drink. Expectations of improved cognitive and driving ability
(Onei and Jones 1986) may predispose a person to drink and drive. Students who drink
and drive tend to be those who drive in a more deviant manner, have greater access to
alcohol and to cars, and engage in more social activities outside the home (Williams and
Lund 1986). Adolescents who drink and drive are likely to associate with peers who drink
dud report that their parents are not important in controlling their behavior (Williams
and Lund 1986). Many adolescents feel there are few social alternatives to drinking
(Glytm 1981).

Environmental Influences on Behavior

Cost and availability of alcohol and the age of legal drinking are some environmental
factors that influence drinking and driving. By raising the minimum age at which
alcoholic beverages can be purchased to 21, fatal nighttime accidents involving drivers
under age 21 were decreased by 28 percent (Smith and Falk 1987) and motor vehicle
fatalities in 18- to 21-year-old drivers were reduced 18 percent (Saffer and Grossman
1987). Higher costs for alcoholic beverages, especially beer, can reduce consumption,
cspccially by adolescents (Stoudemire et al. 1987). Saffer and Grossman (1987) esti-
mated that a lOO-percent increase in the taxes.on beer would reduce highway mortality
by 27 percent. Limiting young persons to daytime driving may also reduce drinking and
driving events (Baker 1987).

A range of programs, policies, and practices have been initiated to reduce the
prcvalcnce of drinking and driving. These include provision of alcohol-free recreational
activities (NHTSA 1987) and alcohol-free gathering places (O'Donnell 1985), desig-
nated-driver programs (Apsler et al. 1987), taxicab services, safe ride home programs
(Prugh 198&), and deterrence legislation such as DWI laws. Other environmental
changes and laws have been instituted to alter drinking patterns, such as responsible-
server programs (Mosher 1987; Saltz 1987), sales restrictions (Mosher 1985; Hacker
1986; Saffer and Grossman 1987), taxes (Mosher and Beauchamp 1983), legal drinking-
age requirements (Smith and Falk 1987), and host liability (Prugh 1986~).

Behaviors related to automotive safety are influenced by lower speed liits (Baker
19887; NIAAA 1987) and seatbelt laws (Fisher 1980; Williams and Lund 1986).

Education of decisionmakers in organizations such as schools, restaurants, bars, and
alcohol retail outlets is crucial for the widespread adoption of voluntary approaches, and
education of legislators and enforcers is important for maintaining existing protective
laws and initiating-new ones.

Environmental Protections

Several factors that protect against MVC injuries, alcohol-related or not, have been
identified. Occupant protection devices -safety belts and airbags - reduce injury in-

81


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BACKGROUND PAPERS

cidence and decrease severity of injury (Bigelow 1982; William and Lund 1986). The
mandatory installation of airbags in automobiles produced in 1989 and thereafter
promises, to substantially curtail mortality and morbidity (Wii and Lund 1986).
Safer automobile designs can reduce injury incidence in the event of a crash, safer road
designs can reduce the likelihood of the most serious collisions, and lower speed limits
can reduce injury severity (Moore and G&stein 1981; Baker 1984,1987, NIAAA 1987).
Widespread adoption of these environmental protection policies and conditions is an
important goal in injury control and one that requires education of the public and of
governmental decisionmakers.

Targets and Objectives of Education

The behavior of three groups is important in preventing injury due to drinking and
driving: (1) individuals who might drii and drive and their proximal others-peers,
parents, and teachers- who may influence their behavior, (2) the general public, and
(3) decisionmakers who can adopt or implement alcohol or injury control policies,
practices, or programs. Table 1 shows some of the possible objectives of education for
each of the three targets.

At-Risk Individuals and Proximal Others

Individuals who drink and who drink/drive form an important target group. As long
as alcohol remains highly available, people will drink despite changes in environmental
supports for nondrinking behavior. While abstinence may be a desirable goal for some
individuals, different behavior goals may be appropriate for others (Simons-Morton et
al. 1989b). Depending on the target population, behavior objectives may include
(1) delaying initiation of drinking, (2) reducing the frequency of driig, (3) reducing
the amount drunk on each occasion, (4) refraining from drinking before or while driving,
(5) refraining from riding with drivers who have been drinking, and (6) discouraging
others from drinking and driving or riding with drinking drivers.

Mediating factors for personal behavior change in the individual and proximal others
include changes in knowledge about alcohol and its effects, improved social skills, and
increases in perceived availability of alternative activities to drinking. Youths should be
taught peer resistance skills and skills in selecting one's peer group.

The effects of a specific message, such as don't drink and drive, can be more effective
if modeled and reinforced by a variety of sources (Bandura 1986). Parents and other
youth leaders can be trained to be more effective supervisors and models, but age peers
may be the most important in this regard.

Adolescents and young adults, in particular, can be trained to restrain their friends
and acquaintances from driving after driing. Spouses and siblings can be trained to
reinforce family members for not driving after drinking. Workmates and colleagues who
socialize can be encouraged to take turns as the designated sober driver.

The Public

The general public is an important target of education because the knowledge, beliefs,
attitudes, and practices of the public shape social norms regarding drinking and drinking/
driving and dictate public tolerance of governmental policy regarding alcohol use and
environmental protections. The task of educating at-risk individuals to moderate their
drinking behavior and to not drink and drive might be much easier if the prevailing social
norms supported such moderation. Such changes in social norms are important not only


EDUCATION

in shaping the attitudes and practices of youths regarding alcohol, but also for maintain-
ing individuals' health behavior changes. Further, the adoption and success of public
policies regarding environmental control of and influences on both drinking and environ-
mental protection may be limited by the public's acceptance of these restrictions on
personal freedom (Malfetti 1985; Runyan and Earp 1985).

Objectives for the general public can include the following: (1) a public informed
about the effects of drinking on behavior and health, (2) social acceptance of only
low-risk drinking, (3) adoption of moderating serving practices (e.g., serving food,
nonalcoholic beverages, and more dilute forms of alcohol), (4) adoption of social
practices that decrease drinking/driving events (e.g., offering rides to intoxicated friends,
providing places to sleep after a party), (5) safety-related behaviors such as honoring
speed limits and wearing seatbelts, and (6) support of environmental controls for
drinking, drinking/driving, and environmental protection (e.g. occupant protection and
roadway design).

Decisionmakers

One key to successful injury control is the widespread adoption of quality programs,
practices, policies, and environmental protective factors. Hence, the appropriate target
of education is often an organizational or governmental decisiomnaker whose actions
can effect such changes. Such decisionmakers include government representatives and
legislators, school administrators, managers and owners of alcohol-serving and-selling
establishments, and designers and manufacturers of automobiles.

Decisionmakers can be educated to increase their knowledge about the drinking and
driving problem and its importance in relation to other health problems, particularly in
relation to other drugs. Decisionmakers must also be convinced that proposed interven-
tions are effective, cost-effective, without substantial social side effects, and without
detrimental financial consequences. Further, decisionmakers must be provided with
program, practice, and policy options that can be implemented through integration with
existing structures. For example, the adoption of a health education curriculum by a
school may depend not only on its content and methods, but also on how well it can be
integrated into the existing school structure (Parcel et al. 1988). Similarly, practices,
policies, and laws that can readily be integrated with those already in existence, and that
have public support, may be more likely than others to be adopted.

Environmental influences on drinking and driving include practices in alcohol-serving
or-selling establishments. The necessity of these establishments abiding by legal restric-
tions on sales is self-evident. Other potential contributions are the establishment of
taxicab services, designated-driver policies, and trained servers. Server training
programs have been highly effective in altering the actions of servers so they discourage
further drinking by intoxicated patrons and encourage them to take a safe ride home
(Mosher 1987; Saltz 1987). The widespread diffusion of server training programs ap-
Pears to be warranted.

Depending on their roles, objectives for decisionmakers can include the following:

o  Decisionmakers informed about the problem of drinking and driving

. Enforcement of existing laws such as alcohol sales restrictions

o  Adoption of policies and practices to decrease drinking and driving
  events (e.g., server training, taxicab service, designated-driver policy,
  restrictions on alcohol serving)

o  Implementation of educational programs

o  Development and manufacture of safer automobiles and roads

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BACKGROUND PAPERS

o Support of environmental controls for drinking, drinki@driving, and
environmental protection

o ? Passage of alcohol-related or safety legislation

The Process and Quality of Education

Education L a process of facilitating learning and behavior change through the
acquisition of new knowledge, attitudes, and skills. A variety of educational approaches,
some of which are listed in table 2, is available for health education for personal behavior
change, public education, and education for adoption of environmental controls on
drinking and environmental protection (Greene and Simon+Morton 1984, Green 1984;
Simons-Morton et al. 1989b).

Social marketing of moderate drinking practices can be accomplished'by information
dissemination and persuasive communications delivered by mass media. Individual
education, training, and counseling are available for addressing personal health be-
havior. Organizational change and policy formation, community organization, citizen
advocacy, lobbying, political action, and diffusion can be employed to promote adoption
by decisionmakers of environmental controls or environmental protections. While each
of these approaches employs unique intervention methods, each is essentially an educa-
tional process.

Table 2. Educational approaches for influencing the at-risk population,
   general public, and decisionmakers.

Teaching
Training
Counseling
Consulting
Information dissemination
Persuasive communications
Citizen advocacy
Community organizing
Social action

Education for Personal Behavior Change

The task of education directed toward personal behavior change is to develop in
individuals the acquisition of relevant knowledge and the mastery of essential skills that
enable them to develop better control over their personal health behavior, and to foster
attitudes conducive to their doing so. For injury prevention due to alcohol-related
MVCs, both alcohol and automotive safety behaviors are important.

Of all the settings available, the school provides by far provides the best opportunity
for alcohol prevention education for youth (Malfetti 1985). School curricula are the
foundation of school-based alcohol prevention education. Not all curricula, however,
are equal. Of 29 alcohol curricula reviewed by Rundall and Bruvold (1988), all were
credited with improving knowledge and 19 with changing attitudes. Curricula that also
addressed social norms and social skills, however, were much more likely to change
alcohol behavior. Curricula that are most effective include not only information trans-


EDUCATION

mission but also personal skills training (Stoudemire et al. 1987) and peer and parental
involvement (NIAAA 1987, Hanson 1988). To improve the potential for success, school
drug and alcohol prevention programs should focus on changing social norms related to
alcohol consumption, should be comprehensive, and should foster collaboration among
schools, parents, local service organizations, and other community structures
(Stoudemire, et al. 1987; Pentz 1987, Hanson 1988). A mnnber of model school-based
programs are available (NIAAA 1987; Marshall, et al. 1985).
The clinical setting provides numerous opportunities for patient education about

drinking and driving, particularly during "teachable moments" after MVC injuries have
occurred. Providers of clinical care can give patients advice, counseling, information,
and other education durmg both emergency and routine clinical visits (Lewis and
Gordon 1983).

Worksite health promotion programs are another possible avenue for educating
at-risk individuals about drinking and driving. Most existing worksite health promotion
programs, however, address alcohol in the context of drug abuse and from the perspec-
tive of treating problem drinkers or alcoholics, rather than preventing workers without
alcohol dependence from drinking and driving (Nathan 1983). Moore and Gerstein
(1981) recommended that worksite health promotion programs expand their focus to
include education on the drinking/driving issue.

A number of important groups-including parents, teachers, youth leaders, peers,
spouses, and other significant people in the lives of at-risk individuals-can be educated
to reinforce avoidance of drinking and driving. They can be reached through the same
avenues as the at-risk population.

Public Education

Education of the general public can be accomplished through media campaigns
employing persuasive communications and sound'principles of information dissemina-
tion. However, media campaigns must compete with more than a billion dollars worth
of advertising a year by the alcohol industry, which is a powerful socializing force,
particularly for adolescents (Atkin and Block 1980). The success of media campaigns,
like that of other approaches to alcohol-related injury control, is likely to be much greater
as part of a more comprehensive approach than as a standalone program (Wallack 1984).

Hochheimer (1981), drawing upon the successful experience of the Stanford Heart
Disease Prevention Program and other such programs, suggested that media campaigns
that provide practical education based on sound communication principles can foster
knowledge and attitude changes in the public. Wallack (1984) noted

an isolated mass media campaign will be of little direct value in changing
rates of alcohol-impaired traffic crashes. On the other hand, ongoing cam-
paigns may be essential to keep drunk-driving high on the public agenda and
to link these problems with broader environmental conditions. Experience
with seatbelts in many foreign countries suggests that mass media campaigns
designed to increase voluntary use were generally unsuccessful, but were
effective in creating a public environment that was more conducive to
accepting subsequent legislation requiring seatbelts. (p. 480)

The experience with safety belt promotion is instructive for other alcohol and safety
behaviors. Mandatory safety belt laws dramatically increase safety belt use (Williams
and Lund 1986), yet nearly half the population does not wear them despite the law.
Vigorous enforcement increases use, but still a substantial proportion do not use safety
belts (Fisher 1980). Public education is essential if we are to obtain a gradual upward
shift in safety belt use. Similarly, a downward shift in the percentage and frequency of


86

BACKGROUND PAPERS

drinking/driving can be facilitated by changes in public awareness of the importance of
not drinking/driving and in the social norms that infiuence this behavior. s

publicity also appears to be an important component of the deterrence approach.
Jonah and Wilson (1983) concluded, "DWI legislation that is not enforced and
publicized seems to be little better than no legislation at all" (p. 464).

Education for Environmental Change

Environmental protection and environmental control of drinking and driig/
driving do not just happen. The process of gaming passage or adoption of legislative acts,
maintaining them in practice, and enforcing them has proven to be an excruciatingly slow
and exacting process that requires educating the decisionmakers who control the
legislative process.

The adoption of public policy options,,such as restricting beverage alcohol sales by
service stations or raising the legal age for driimg alcohol, is an inherently political
process. Because of the active resistance of the alcohol industry (Cahalan 1987), each
initiative must survive on its political merits. Federally mandated requirements for motor
vehicle safety designs and features are similarly buffeted by lobbyists for the transporta-
tion industry and for the public interest. Before passage is likely, legislators must have
evidence of the effectiveness of the initiative, of public support, and of political accept-
ability. The task of education in the larger political process is to inform decisionmakers
so as to facilitate the adoption, implementation, and/or maintenance of policies, prac-
tices, or programs to prevent drinking and driving injuries.

While the public health practice and research communities are now strong lobbying
forces for injury control policy initiatives, citizen advocacy groups such as MADD and
SADD have been given the major share of credit for galvanizing political action with
respect to drinking and driving. Citizen advocacy groups have worked primarily to
introduce stiffer legal penalties and stricter enforcement of drinking and driving laws.
Citizen advocacy has tended to focus both on public education through mass media
(primarily mailed printed materials) to generate support and enthusiasm for the anti-
drunk driving movement and on legislators through lobbying efforts to generate support
for stricter drunk driving penalties. Ross (1985) cautioned that not all of the measures
advanced by citizen activists are equally reasonable and are often presented in such a
way as to preclude scientific analysis.

At the local level, the role of education is to foster adoption of injury control and
environmental protection programs, practices, and policies. Administrators, managers,
and trustees of private or public sector organizations (e.g. schools) are the targets.
Education serves as one part of the promotion and diffusion of injury control and
environmental protection, informing decisionmakers about the use, utility, adoption, and
implementation of specific alcohol prevention programs, or alterations in policies and
practices regarding onsite use of alcohol. Training of workers responsible for implement-
ing these programs is then needed.

Issues

Following are the major issues regarding education for prevention of alcohol-related
MVC injuries.

Personal behavior PLUS environmentulpro~ection. Both are important for decreasing
drinking/driving injury; education is important in achieving both. The incidence of
drinking and driving injuries can be decreased by changes in personal health behavior,
in environmental factors that influence drinking and driving, and in environmental


EDUCATION

protection. Education is a major aspect of the process of changing personal health
behavior and of changing decisionmaker behavior for establishing environmental
change.

Education for health behavior change and environmental protection are compatible
strategies for preventing drinking/driving and reducing injury and should be seen as
complementary rather than competitive. To rely on personal behavior change alone to
protect the public against alcohol-related MVC injuries would be poor public health
practice, as would the sole reliance on environmental control and protection mandated
top-down without adequate public support;

Context and comprehensiveness of education forpersonal behavior change. Successful
prevention of drinking/driving injuries is not likely to occur without changes in current
patterns of driig, particularly among adolescents, young adults, and males. Drinking/
driving cannot be understood outside the context of a society in which drinking/driving
is a socially accepted behavior, where it may be a natural product of our patterns of
driig and dependence on private automobiles for transportation (Ross 1985). And
drinking cannot be understood except by appreciating the dominant socializing influence
of the beverage alcohol industry (Cahalan 1987).

Within this context, specific, short-term alcohol prevention programs are unlikely to
be successful in changing drinking behavior unless they are part of more comprehensive
approaches (Moore and Gerstein 1981; Malfetti 1985; Wallack 1984). The task seems to
be to develop broader and more comprehensive approaches to the prevention and
control of alcohol-related injuries.

Education of individuals to prevent drinking and driving can be delivered through
each of the settings identified by the Federal government for health promotion and
disease prevention: schools, worksites, health care institutions, and communities
(ODPHP 1982). Schools and communities, by virtue of existing structures, may be the
most effective settings for reaching young persons, while health care institutions, com-
munities, and worksites may be more promising for older persons (Moore and Gerstein
1981; Simons-Morton et al. 1989b). Unfortunately, few worksite or health care alcohol
prevention programs exist.

Educational quaZig. Only those educational programs based on sound theoretical
principles (with quality implementation) appear to produce the desired effects (Moore
and Gerstein 1981; Wallack 1984). There is ample evidence that only those media
programs based on sound communication principles can achieve targeted changes in
knowledge and attitudes that can contribute to more moderate social norms regarding
drinking and promote support for public policy initiatives (Wallack 1984). Similarly,
aIcoho1 prevention curricula that are practical and skill-oriented are more likely to be
effective than those that are not (Rundall and Bruvold 1988). The literature on media
campaigns and on the effects of alcohol-prevention curricula suggests that these ap-
proaches are more liiely to be effective in the context of more comprehensive programs
that include environmental supports for behavior change.

Thus, it is essential to promote only the best educational interventions, as some,
especially those based on sound theory, are likely to be more effective than others. In
addition, practices, policies, and legislation that are to be disseminated should be
evaluated and improved upon.

Effective coafitions for inju y control. A number of groups are working vigorously to
advance injury control initiatives: citizen advocacy groups, public health practitioners
and researchers, and governmental agencies. Cooperative mechanisms need to be
developed between cit.&n advocacy groups and the research community (Ross 1985)
and among medical, public health, and traffic-safety communities to alter effectively the
national policy agenda with respect to the control of alcohol-related injuries (NHTSA
1989). Better cooperation and coordination between citizen advocacy groups and public


BACKGROUND PAPERS

health groups in advancing reasonable and scientifically justifiable public policy initia-
tives is desirable.                                       \       m
Consistenr public he&h' mes3cge.r. Clear and simple informational messages about
alcohol and drii@riving need to be established and disseminated. Adolescents, at
least, do not know the number of drii that will impair their abilities (Wii et al.
1986). Transportation safety advocates have unintentionally added to the confusion by
concerning themselves with "drunk drivingW rather than drinking and driving, contriiut-
mg to the misconception that impaired driving occurs only when the driver is inebriated
or legally intoxicated, rather than when the driver has ingested relatively low amounts of
alcohol.

If we are truly interested in reducing alcohol consumption, we should develop
easy-to-understand guidelines about the frequency and amount of driig for those who
drink. Such guidelines, however, are difficult to develop. The effect of alcohol on
behavior is a product of a number of factors, most importantly the number of drinks, but
also the available blood volume (which varies with body size), the availability of food to
impede absorption, drinking experience, and mood. Individuals appear to range in their
sensitivity to the effects of alcohol, making one drink quite intoxicating to some people
yet barely noticeable to others. Further, different alcoholic beverages contain different
amounts of alcohol, making simple messages difficult. The inability to develop clear and
unambiguous messages about safe levels of consumption is an impediment to public
education;

Moore -and Gerstein (1981) noted the diificulty of establishing boundaries around
appropriate drinking practices.

Those whose practices are now well within the boundary may feel outraged
that the government could be so irresponsible as to license a kind of drinking
that seems very reckless to them. Those whose practices are outside the
boundary may feel indignant that the government is discouraging conduct
that seems quite safe to them and may complain that the government is
interfering (p.99).

Perhaps we can agree on a simple public-information message. Some possible alter-
native messages include one, or combinations, of the following statements.

If you drink alcohol:

Drink no more than one to two drinks per day. (Recommended in the U.S.
Dietary Guideliies - USDA/USDHHS 1985)
Drink no more than one or two times per week.
Never drink five or more drii on one occasion.

Never drink more than two drinks on one occasion.
Never drink more than one or two drii before or during engaging in any
high-risk activity such as driving or sports.

Recommendations for Research

Educational Methods

Small-scale studies are needed to investigate the efficacy of various methods and
theory-based programs of education and the means of improving their efficacy. Appro-
priate outcome measures in such studies would include changes in mediating factors for


EDUCATION

89

behavior (knowledge, attitudes, skills) and changes in drinking, drinking/driving, and
safety behaviors.

With respect to school-based and youth-oriented alcohol prevention programs, we
need to address the following research questions:

.  What methods are most efficacious in teaching youths peer-resistance
skills and how to be proponents of moderation with their. peers?

. What methods are most efficacious in training parents, teachers, and
youth leaders to be effective supervisors and role models?

   o  At what grade level should alcohol education begin and what content
   and skills should be taught at each grade?
With respect to settings that are currently underutilized for drinking/driving preven-
tion, such as worksites and health care organizations, we.need to address the following
research questions:

.  What methods are most efficacious in the worksite for'changing
drinking, drinking/driving, and safety behaviors?

o  What methods are most efficacious in educating patients to change
drinking, drinking/driving, and safety behaviors?

o  What methods are most efficacious in educating health care providers
in how to intervene with their patients?

   .  How effective can health care providers be as interveners?
With respect to the promotion of environmental control and protection initiatives, we
need to address the following research questions:

o  By what processes do decision makers make decisions and how can
these processes best be influenced by educational methods?

o  What methods are most effective for achieving adoption,
implementation, and maintenance of environmental controls?

Multicomponent Educational Approaches

Medium-size, population-based studies are needed to test the feasibility and effec-
tiveness of promising, multicomponent educational programs for alcohol-related injury
control. Such studies could be conducted in several schools, worksites, health care
institutions, or communities. Appropriate outcome measures would include changes in
behavior, mediating factors for behavior (knowledge, attitudes, skills), and MVC
injuries.

Demonstration Studies

Large community demonstration studies are needed to test the feasibility and effec-
tiveness of comprehensive broad-based approaches to alcohol-related injury control,
including school and public education along with environmental control of behavior and
environmental protection. Appropriate outcome measures for such studies would
include behavior change, MVC injuries, and MVC mortality.

REFERENCES.

Apsler, R.; Harding, W.; and Goldfein, J. The Review and Assessment of L?esignated Lbiver
   Programr as an Alcohol Cozmfermeasure approach. DOT HS 807 108, Washington, DC:
   Department of Transportation, 1987.

Atkin, C., and Block, M. Content and Effects of Alcohol Advertising. Report I: Overview and
   Summmy of the Project. East Lansing, MI: Michigan State University, 1980.


90

BACKGROUND PAPERS

Baker, S.P.; O'Neill, B.; and Karpf, R.S. The Injmy Fact Book. Lexington, MA: Lexington Books,
    1984.

Baker, S.P. Intervention strategies: Report of the working group, unintentional injuries. In:
   Amber, R-W., and Dull, H.B., eds. Closing the Gap: The Burden of Unnecesmy Illness.
   New York: oxford University Press, 1987. pp.lQO-193.
Bandura, A Social Foundations of Thought and Act&: A Social Cognitive Theory. Englewood
   Cliffi, NJ: Prentice-Hall, 1986.

Bergman, A.B. Use of education in preventing injuries. Pediatric Clinics of North Americu
   29(2):331,-338,1982.

Bigelow, B. 77te NHTSA piogram of Safety Belt Reseamh. SAE Technical Paper Series No.820
   797. Warrendale, PA: Society of Automotive Engineers, 1982
Cahalan, `D. UnderstandingAmerica's DrinkingZ+vbZem San Francisco, CA: Jossey-Bass, 1987.
Coombs, R.H.; Welliih, D.K.; and Fawzy, F.I. Drinking patterns and problems among female
   children and adolescents: A comparison of abstainers, past users, and current users.
   American JoumaZofDmgandAZcohoZAbuse 11:315-348,198s.
Donovan, D.M.; Jesscr, R.; and Jessor, L. Problem drinking in adolescence and young adulthood:
   A follow-up study. JournuZ of Studies on Alcohol 44(1):109-137,1983.
Fell, J. Alcohol Involvement in Trufic Accidents. National Highway Traffic Safety Administration,
   DOT Pub. No. HS-806-269, Washington DC: Supt. of Dot., U.S. Gov. Print. Off., 1982
Fisher, F.B., Jr. Eflectivenessof Safety Belt Usage Laws. Washington DC: NHTSA, US DOT, 1980.
Gerstein, D.R. Alcohol use and consequences. In: Moore, M.H., and Gerstein, D.R., eds.AZcohoZ
   and Public Policy: Beyond the Shadow OfProhibition. Washington DC: National Academy
   Press, 1981.

Glynn, T.J. From family to peer: A review of transitions of influence among drug-using youth.
   JoumaZ of Youth and Adolescence 10:363-383,198l.
Green, L.W. Models of health education and health promotion. In: Matarazzo, J.D., et al., eds.
   Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New
   York: John Wiley, 1984.

Greene, WA., and Simons-Morton, B.G. Introduction to He&h Educution. New York: Macmil-
   lan, 1984.

Hacker, G.k Perspectives. AZcohol Heahh and Research World 10(4):41, 1986.
Hanson, W.B. Effective school-based approaches to drug abuse prevention. EducutionuZ Leuder-
   ship 45(6):9-14,1988.

Hochheimer, J.L. Reducing alcohol abuse: A critical review of educational strategies. In: Moore,
   M-H., and Gerstein, DR., eds. Alcohol and Public Policy: Beyond the Shadow of Prohibi-
   tion. Washington DC: National Academy Press, 1981. pp. 286-335.
Johnston, L.D.; O'Malley, P.M.; and Bachman, J.G. National Trends in Drug Use and Related
   Factors Among High School Shrdents and Young Adults, 19751986. DHHS Pub.
   No.(ADM)87-1535. Rockville, MD: National Institute of Drug Abuse, 1987.
Jonah, B-A, and Wilson, R J. Improving the effectiveness of drinkingdrivingenforcement through
   increased efficiency.Acci&ntAnafysis and Prevention 15:463-481,1983.
Lewis, D.C., and Gordon, AJ. Alcoholism and the general hospital: The Roger Williams Interven-
   tion Program. BuZletin New YorkAcademy of Medicine 59(2):181-197,1983.
Malfetti, J.L. Public information and education sections of the Report of the Presidential Com-
   mission on Drunk Driving: A critique and discussion of research implications. Accident
   AnaZysis and Prevention 17(4):347-353,198s.

Malin, HJ.; Trumble, J.; Koelber, C.T.; and Lubron, B. Alcohol-related highway traffic fatalities
  among young drivers - U.S. Morbidity and MottaZity Weekly Report 31(48):641644,1982
Marshall, KM.; Smith-Donals, L.; Cooke, P.; DeLucas, P.; Blasinsky, M.; and Klitzner, M.
   Determinants of Youth Attihuies and Sk& Towards Which DrinkingJLXving Prevention
   ZVogmms Should be Directed. Vob~me ZZ: An In-depth Review of Twelve Youth DWZ
   Prevention Progruwts. USDOT Pub. No. DTNH 22-84-C-07284. Washington, DC:
    NHrjA 1985.

Miller, P.M., and Nirenberg T.D., eds. Z'revention ofAZcohoZAbuse. New York: Plenum, 1984.
Moore, M.H., and Gerstein, D.R., e&Alcohol and Public Policy: Beyond the Shadow of Prohibi-
   tion. Washington D.C.: National Academy Press, 1981.
Masher, J.F. Server intervention: A guide to implementing local and state programs. Advunces in
   Substance Abuse Supplement 1:233-251,1987.

Mosher, J.F. Alcohol policy and the nation's youth. JournaZofPublic Health Policy9:295-299,198s


EDUCATION

Masher, J-F., and Beauchamp, D.E. Justifying alcohol taxw to public officials. Journal of Public
  Health Policy 4(4):422-439,1983.
Moskowitz, H., and Robinson, C.D. Effects of Low Doses ofAkohol on Lkivin~Related Sh5Us: A
  Review of the Evidence. Pub. No. (DOT) HS807-280, Washington, DC: National Highway
   Traffic Safety Administration, 1988.
Nathan, P. Failures in prevention: Why we can't prevent the devastating effect of alcoholism and
   drug abuse.American Psycho&& 38:459467,1983.
National Highway `Ihftk Safety Administration. Join the Celebrations Boject Graduatkn. U.S.
   DOT HS Pub. No. 807 063, January, 1987.
National Highway Traffic Safety Administratidn. Consensus Report on Impaired Dr@ing. U.S.
   DOT HS 807 390, Wash., D.C., March, 1989.
O'Donnell, M. Research on drinking locations of alcohol impaired drivers: Implications for
   prevention policies. Journal of Public Health Policy 6:510-525,1985.
office of Disease Prevention and Health Promotion. Revention 82. V.S. DHHS, Public Health
   Service, DHHS (PHS) Pub. No. 82-50157, Washington, DC: DHHS, 1982, pp. 2-14.
Gnei, T.P.S., and Jones, R. Alcohol related expectancies: Have they a role in the understanding
   and treatment of problem drinking? Advances in Alcohol and Substance Abuse 6:89-105,
    1986.
Parcel, G.S.; Simons-Morton, B.G.; and Kolbe, LJ. School health promotion: Integrating or-
   ganizational change and student learning strategies. Health Education Quarter@
   15(4):435-450,1988
Pentz, M.A. Community organization and school liaisons: How to get programs started. low&
   of School Health 56(9):382-387,1987.
National Institute on Alcohol Abuse and Alcoholism. Petrakis, P.L., ed. Stih Speciai Repon to the
   U.S. Congress on Alcohol and He& fim The Secretary of Health and Human Services,
   Junuary 1987., DHHS Publication No. (ADM)87-1519. Rockville, MD: The Institute,
    1987.
Prugh, T. Social host liability. Alcohol Health and Research World lq4):3234, 1986a.
Prugh, T. Arena managers project: A team approach. Alcohol Health and Research World
   10(4):30-31,1986b.
Robertson, L.S.; Kelley, A.B.; O'Neill, B.; Wiiom, C-W.; Eiirth, R.S.; and Haddon, W., Jr. A
   controlled study of the effect of television me&ges on safety belt use. American JournuZ
   of Public HeuZth 64( 11): 1071-1080,1974.
Robertson, L.S. Behavioral and environmental interventions for reducing motor vehicle trauma.
   Annual Review of Public Health 7:13-34,1986,
Rose, G. Sick individuals and sick populations. Znternutionul Jo& of Epidemiology 14( 1):32-38,
    1985.
Ross, H.L. Summary of Topic C-Countermeasures. JoumaZ of Studies on Alcohol Supplement
   No. 10:207-209,1985.
Rubin, D.; Hoar, R.; and Klinger, D. Report on Traffic Accident and Iajqv, Z981-7?ze Natioti
   Accident Sampling System. U.S. DOT, NHTSA Contract No. DT'NH22-81-C-07617,
   Annual Report, March 1983.
Rundall, T-G., and Bruvold, W.H. A meta-analysis of school-based smoking and alcohol use
   prevention programs. Heulth Education Quarterly 15(3):317334,1988.
Runyan, C.W., and Earp, J.A.L. Epidemiologic evidence and motor vehicle policy making.
   American Journal of Public Health 75(4):354-357,1985.
Salt& R. Tbe roles of bars and restaurants in preventing alcohol-impaired driving. An evaluation
   of a server intervention. Evaluation and Health Professions lq1):5-27,1987.
Saffer, H., and Grossman, M. Drinking age laws and highway mortality rates: Cause and effect.
   Economic Inquiry XXV:403~17,l987.
Schwnbom, C.A. Health promotion and disease prevention: United States, 1985. Data from the
   National Health Survey Series. Vital& He&h Statistics. Series 10, No.163, DHHS Pub.
   NO. (PHS) 88-1591. Washington, DC: Supt. of Do<s., U.S. &v. Print. Off., 1988.
Simons-Morton, B.G.; Brink, S.G.; Simons-Morton, D.G.; McIntyre, R.; Chapman, M.; Longoria,
   J.; and Parcel, G.S. An ecological approach to the prevention of injuries due to drinking
    and driving. Health Education Quarterly, in press, 1989a.
Simons-Morton, B.G.; Brink, S.G.; Parcel, G.S.; Simons-Morton, D.G.; McIntyre, R.; Longoria,
   J.M.; and Chapman, M. Preventing Acute Alcohol-Reluted Health Roblemr Among
   Adolescents and YoungAdults. Atlanta, GA: Centers for Disease Control, in press, 19896.


92

BACKGROUND PAPERS

Smith, G.S., and Falk, H. Unintentional injuries. In: Amber, R.W., and Duils, H.B., eds. Cbsing
  the Gap: The Burden of Unnecessary Illness. New York: Oxford University Press, 1987.
   pp. 143-163.

Stoudemire, A; Wallack, L; and Hedemark, N. Alcohol dependence and abuse. In: Amber, R.W.,
    and Dull, H.B., eds. Closing the Gap: The Burden of Unnecessq Ilhess. New York:
    Oxford University Press, 1987. pp. 9-18.
Thornberry, O.T.; Wilson, R.W.; and Golden, P.M. Health promotion data for the 199Oobjectives:
    Estimates from the National Health Interview Survey of health promotion and dii
    prevention: United States, 1985.AdvanceData, Vitaland Health Statistim,NCHS No 126,
    September 19,1986.
USDA, USDHHS. N&&ion atui Your He&h: Dietary Gtki@nes forAtnericm 2nd ed USDA
    Home and Garden Bulletin No. 232, Washington, DC: Supt. of Dots., Govt. Print. Off.,
      1985.

Wallack, L. Drinking and driving towards a broader understanding of the role of mass media.
   JoumaI of ALbt!ic He& Policy 5:470-4%,1984.
Williams, AE; Lund, A.=, and Preusser, D.F. Drinking and driving among high school students.
   The InternationaL Joumal of he Addictions 21:643-655,1986.     .,
Williams, A.F., and Lund, AK. Seat belt use and occupant crash protection in the United States.
   American Joumal of public Heaith 76(12):1438-1442,1986.


93

Judicial and Administrative Processes

The Effectiveness of Legal Sanctions in
  Dealing with Drinking Drivers

    James L. Nichols, Ph.D.
National Highway Trafjic Safety Administration

H. Laurence Ross, Ph.D.

National Institute on AIcoholAbuse andAlcoholism University of New Mexico

Introduction

Legal sanctions, whether administered by the courts or by State licensing agencies,
NC central to deterrence-based policies for reducing alcohol-impaired driving. They are
the punishments threatened in support of the law's mandate. Examples are fines, license
actions such as suspension and revocation, jail sentences, and alternatives such as
community service. Deterrence theory posits that sanctions will be effective in modifying
Ixhavior to the extent that they are perceived as being certain, swiftly applied, andsevere.
Thcsc three primary characteristics of penalties, if appropriately perceived, have the
potential to reduce drunk driving.      .
In determining public policy, we would like to know if the different kinds of sanctions,

whrn applied with equal severity, certainty, and swiftness, produce different results. In
adclition, we would like to know if differences in the swiftness, certainty, or severity of a
particular type of sanction produce different results. Our review finds that license actions
appear to be more effective than others, and the certainty and swiftness of punishment
appear to increase impact to a greater extent than severity.

`We Objectives of Sanctions

Criminal sanctions may have several objectives, including general deterrence, specific
deterrence, rehabilitation, incapacitation, and retribution. Restitution and program
financing may also be. objectives of sanctions. Bygelleraldeterrertce, we refer to the effect
of punishing law violators on the drinking and driving behavior of those not sanctioned,
hut who are presumably aware of the punishability of the behavior in question. By specific
deterrence, we refer to the deterrent effect of sanctioning on the specific offenders being
punished. Their experience and the fear of future punishment is expected to reduce their
drinking and driving behavior. R&&i/i&t& refers to changing the violator's motivation
through the experience ofthe sanction, not through fear ofbeingsanctioned in the future.
The rehabilitated driving while intoxicated (DWI) offender no longer wants to drive
drunk, whereas the deterred person refrains from such behavior out of fear of conse-
quences. Incapacitation refers to denying the offender the opportunity to repeat the DWI
offense. Imprisonment accomplishes this during the period of confinement; license
hithdrawal attempts to do this without confinement.


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BACKGROUND PAPERS

Specific deterrence, incapacitation, and rehabilitation effects are frequently inter-
woven and difficult to separate. Their combined impact, which we refer to as individual
reform, is reflected in changes in recidivism of the offenders sanctioned. Recidivism is
usually measured in terms of subsequent DWI offenses or crash involvement.

This review concentrates on determining both the general deterrent and individual
reform (i.e. change in recidivism) impacts that occur as a result of the imposition of
various sanctions.

General Deterrence Versus Individual Reform

The impact of any sanctioning policy on the general driving public is much more
important than its impact on the offenders who are punished. Programs that result in
reduced recidivism by those who are punished are worthwhile to the extent that they
reduce impaired driving by these drivers and perhaps improve their general well-being.
However, without having some impact on the total population of drinking drivers-par-
ticularly those who are not caught-such programs cannot have a major impact on drunk
driving and its consequences.

In any one year, it is estimated that fewer than 5 percent of alcohol-related fatal
crashes involve a driver who was apprehended for DWI the previous year. Thus, even if
the sanctions applied to offenders over a l-year period were lOO-percent effective in
eliminating recidivism among those drivers, the next year's fatal, alcohol-related crashes
would be reduced by less than 5 percent (Nichols and Gundersheimer 1974; Sterling-
Smith 1976). Further, a Minnesota study suggests that if the elimination of recidivism by
known offenders were continued for 8 years, three-fourths of alcohol-related fatal
crashes -those involving drinking drivers not previously known to authorities-would
continue to occur (Lewis 1985). Thus, sanction policies that have a general deterrent
impact are essential for reducing such crashes. The major hope for reducing alcohol-
related fatal crashes lies in policies that affect the total driving population.

Categories of Sanctions

We examine three primary categories of sanctions: confinement in jails, prisons, or
special facilities; license revocation or suspension; and fines. In addition, some evidence
is reviewed regarding the effectiveness of community service.

In the United States, confinement for drunk drivers is traditionally in jails. However,
use of alternative conlinement sites, including the offender's home, is increasing. This is
due in large part to the inability of jails to handle large numbers of drinking drivers.

License actiorzs include both suspension and revocation of the driving permit. Suspen-
sions and revocations can be "hard," prohibiting all driving, or "soft," permitting driving
for limited purposes such as commuting to work. They range in duration from brief
periods (e.g., 30 days) to long periods (e.g., 1 to 5 years) to permanent actions. Suspended
licenses are automatically reinstated at the termination of the suspension, whereas
revoked licenses must be replaced through renewed applications, after the revocation
period has expired.

We groupfines with other officially determined financial penalties such as court costs,
but exclude fees charged for services, such as mandated education, or incidental costs,
such as increased insurance premiums. We do this even though such costs may dwarf
traditional fines. The effects of costs beyond legal penalties are worthy of study and
possible embodiment in the social response to drunk driving, but we do not think of them
as criminal penalties.


JuDIciiiL AND ADMINISTRATIVE PROCESSES

Criminal Versus Administrative Sanctions

95

The judicial or administrative process by which sanctions are imposed is also impor-
tant from a deterrence perspective because it has important implications for all three
characteristiG-swiftness, certainty, and severity-of penalties imposed. Traditionally,
sanctions have been exclusively applied in wurts, using criminal proced~es. Here, the
application of penalties depends on conviction for an offense folloe formal charging
and pleading and is contingent upon a finding of proof beyond a reasonable doubt that
a crime (drunk dritig) was committed. This traditional process is often lengthy and,
because of the stringent standards of proof involved, likely to err in the direction of
leniency. In contrast, the adhinistrutive process requires only that the balance of evi-
dence favor the conclusion that a sanction is merited. It is unconcerned with determining
criminal guilt. The administrative process can thus be relatively swift and certain in
applying sanctions.

in practice, the distinctions between these two processes have often been eroded.
Criminal guilt is most frequently based on a routine plea, rather than on a trial with its
safeguards, delays, and uncertainty. On the other hand, the administrative process can
be slowed and rendered less efficient as those subjected to it demand hearings that may,
in some respects, resemble trials. However, the administrative process generally remains
a swifter and more certain process for applying sanctions, particularly license actions.

The administrative process is employed in the many States that have adopted "ad-
ministrative per se" laws. In these States, administrative license actions are applied to
drivers refusing or failing alcohol breath tests. Refusing or failing the test, not the crime
of drunk driving, is sanctioned in this manner, and offenders may still be subject to a
separate criminal process leading to additional penalties. In those States without admin-
istrative license laws, license suspension and revocation are usually invoked by judges in
their sentences. Even in States where administrative penalties are used, additional
suspensions or revocations can be invoked by judges following criminal convictions.

Thus, license actions can be applied both administratively and criminally. The admin-
istrative process fits license sanctions especially well, because licenses are adminis-
tratively granted in the first place. Although fines are administratively applied in some
areas of the law, this has not yet occurred with regard to drunk driving. The more drastic
nature of confinement and community service appears to limit their application to the
criminal process.

The recent increase in the acceptability and use of administrative license actions has
provided a kind of punishment that fits the demands of swiftness and certainty required
for both specific and general deterrence, The significant increase in the certainty and
swiftness of punishment resulting from the use of administrative process has opened a
new opportunity for controlling alcohol-impaired driving and its consequences.

Evaluation of Sanctions

The bulk of this chapter is concerned with evaluations of various @es and amounts
Of sanctions. These evaluations generally compare different types or severities of sanc-
tions. They do not compare sanction alternatives or variations with no sanctions at ail.
Thus, evaluations of sanctions for drunk drivers concern the effects of marginal changes
in punishment, rather than absolute deterrence. If an increase in the standard fine from
$100 to $500 has little effect, this does not imply that a reduction to zero would yield
similar results, or that fines are worthless in controlling drunk driving. Practically
speaking, these evaluations of marginal changes are sufficient, as there are no serious
Political proposals for abandoning sanctions.


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It is desirable to determine the relative effectiveness of the various categories of
penalties. In addition, within each of the primary sanction categories, it is desirable to
distinguish between penalties of greater or lesser severity, certainty, or-swiftness of
application. However, comparisons between categories present both theoretical and
empirical problems. For example, a judgment of comparative severity between a $1,000
fine and 24 hours in jail would be hard to make and defend. Even comparisons within
sanction categories are difficult to make. While a fine of $1,000 is clearly more severe
than one of $100, it is likely to be much more severe to a person of modest means than
to a person of substantial wealth. As a result of these problems, it is often difficult to
provide more than qualitative (i.e., positive or negative) evidence for the effectiveness
of various sanctions.

Recent concern with the seriousness of the impaired driving problem in the United
States has resulted in numerous sanction-based interventions that, when evaluated, could
ideally enlighten our knowledge and improve practical policy. A major impediment to
this ideal has been that the changes often take the form of complex packages of
interventions. In these circumstances, it is generally impossible to determine which
components may be accounting for positive outcomes. In this chapter, we do the best we
can with available data, characterizing the sanction packages in terms of what we
perceive to be their main thrusts.

Confinement: Jail and Prison Sentences and Their Alternatives

The use of jail or prison sentences as sanctions for drinking drivers has been an
integral part of Scandinavian law for more than 50 years. In the United States, it has been
used much less frequently, but interest in the use of such penalties has increased since
1980. Some theorists have assumed that the severe prison sanctions used in Scandinavia
provide the ultimate weapon for deterring repeat offender, drinkmg drivers. In addition,
some have suggested that such penalties may provide needed "shock value" for first-time
offenders.

It has also been suggested that jail or prison sanctions result in a long-term learning
process whereby the driving public wmes to see drunk driving as a serious and un-
desirable behavior because of the penalties associated with it. The review that follows
presents available research to establish the basis for claiming individual reform and
general deterrent effects resulting from jail or prison sentences.

Individual Reform: Do Offenders Receiving Jail or Prison Sentences Have
Lower Recidivism Than Those Who Do Not?

Reductions in recidivism are often referred to as specific deterrent effects. However,
such reductions may also result from rehabilitation or incapacitation. Therefore, we refer
to reduced recidivism as an indicator of individualrefom. Regardless of the terminology
used, the primary concern is whether the sanction in question reduces recidivism rates
among offenders who receive it.

Voas (1986) reviewed several relevant foreign (Buikhuisen 1972; Dijksterhuis 1974;
Home1 1979, 1981) as well as U.S. studies (Blumenthal and Ross 1973, 1985a, 1986;
Tashima and Peck 1986). He found little evidence of any reduction in recidivism resulting
from jail or prison sentences, particularly in the foreign research.

Three U.S. studies were reviewed that found only negative results. Blumenthal and
Ross (1973) investigated the impact of jail sentences on fust-offense drunk drivers in
Colorado and found no less recidivism for those receiving jail sentences compared to
other sentencing alternatives.

In Washington State, Salzberg and Paulsrude (1983u) and Klmgberg, O'Connell,
Salzberg, Chadwick, and Paulsrude (1984) evaluated the effects of a 1980 law that


JUDICIAL AND ADMINISTRATIVE PROCESSES

97

mandated jail sentences for both first and repeat offenders convicted of DWI. They
reported that people convicted under the new law had higher subsequent crash and DWI
offense rates than people convicted under the previous law and that the mandatory jail
sentence failed to deter subsequent drunk driting.

In California, Tashima and Peck (1986) studied first offenders receiving five different
types of sanctions: license suspensions; jail and probation; jail, prob&tion, and education;
license restrictions only; and license restrictions and education. Offenders receiving jail
and probation had among the worst subsequent conviction and crash records of the five
groups. License suspensions and license suspensions with education were the most
effective sanctions for first-time offenders.

In Ohio, Siegal (1985) evaluated three sentencing alternatives: traditional jail plus
probation, a weekend residential intervention program, and a diverse group of "other"
sanctions. The weekend residential intervention produced the lowest recidivism rates
for multiple offenders, but not for first offenders. The recidivism rates for the jail plus     ,,
probation group were not significantly lower than for the diverse other group. This study
provided evidence that confinement in a special facility, combined with assessment and
referral, can have a positive impact on multiple offenders.

Reduced recidivism rates following mandatory 48-hour jail sentences for first-time
offenders were first reported by Compton (1986) and more recently by Jones, Joksch,
Lacey, and Schmidt (1987). They evaluated the effects of a 1982 Tennessee law by
comparing DWI reconviction rates for offenders convicted in the 3 years after the law
was implemented with those convicted in the 3 years prior to the law. The initial report
by Compton indicated a 40-percent reduction in 24-month rearrest rates following
implementation of the law. The final report (Jones et al. 1987) concluded that the
reduction in recidivism was 11 percent, rather than 40 percent, and that the effect was
temporary, lasting for approximately 3 years, Unlike Siegal's (1985) work, this study
found that the effect of confinement appeared to be greater for first offenders than for
repeat offenders, and greater for older (over age 25) than for younger offenders.

In conclusion, our review of the effect of confinement on recidivism rates found five
studies that reported no reductions in recidivism (Buikhuisen 1972; Home1 1979,198l;
Blumenthal and Ross 1973; Tashima and Peck 1986); one that reported no significant
difference in effect between a special facility and traditional prison (Dijksterhuis 1974);
one that found no effect for traditional confinement but did report reduced recidivism
for multiple offenders confined to a special facility for assessment and referral (Siegal
1985); and one study that found reduced recidivism for first time offenders (Compton
1986; Jones et al. 1987).

General Deterrence: Does Confinement Deter Drivers Who Are Not Caught?

It is important to know whether jail penalties deter drinking drivers who have no
previous arrest or conviction on their record, because they are involved in the majority
of alcohol-related fatal crashes. General deterrent impact is usually measured by surveys
that show changes in drinking and driving behavior or by data analyses that show changes
in alcohol-related fatal crashes or nighttime fatal crashes.

The Scandinavian countries have used jail or prison sentences for more than 50 years.
In Sweden, such penalties have generally not been applied to offenders at lower alcohol
concentrations, and they have been applied with varying degrees of consistency to more
extreme offenders (Voas 1982, Ross et al. 1984). Still, confinement has been used more
commonly in Scandinavia than in the United States, and it has been a more visible part
of their deterrent effort.

In a critical review entitled "The Scandinavian Myth: The Effectiveness of Drinking
and Driving Legislation in Sweden and Norway," Ross (1975) challenged the assumption
that Scandinavia's tough approach for dealing with drinking drivers was responsible for


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BACKGROUND PAPERS

a low rate of alcohol-related fatal crashes. Using time-series analyses, Ross found no
changes in traffic deaths in either Sweden or Norway immediately after drunk driving
penalties were increased in those two countries. Ross reiterated his findings and his
conclusions in subsequent papers (e.g., Ross 1978, 1982) and recommended to the
parliaments of both Norway and Sweden that a reduction in the severity of penalties
would not provide a less effective deterrent. He also evaluated a 1950 Finnish law that
increased prison penalties for drinking drivers involved in injury crashes (Ross 1982).
Although he found a reduction in total and injury crashes following implementation of
the law, Ross rejected the hypothesis that it was due to the law. This was because injury
crashes showed a greater reduction than fatal crashes, which are more highly correlated
with the use of alcohol.

Ross' reviews and evaluations resulted in considerable debate over the impact of laws
modeled on those of Scandinavia, particularly on the use of jail penalties. As a result,
much additional research was conducted and published regarding the impact of such
laws on a variety of variables such as incidence of drinking and driving, rate of apprehen-
sion for drinking drivers, alcohol concentration levels of apprehended and fatally injured
drivers, public knowledge and acceptance of the laws and penalties, and social costs of
penalties as well as reductions in fatal and injury crashes (e.g., Andenaes 1978; Votey
1978; Klette 1978, 1983; Votey and Shapiro 1983, 1985; Snortum 1984; Snortum et al.
1986). In many cases, Scandinavian data were compared with similar U.S. data to assess
the circumstantial evidence for concluding that such laws have a deterrent impact.

Reviews of such studies by Snortum (1984) and by Voas (1982) found convincing
evidence that, compared with the United States and most other western nations, Scan-
dinavian countries had a lower proportion of fatally injured drivers with high alcohol
concentrations; an even lower incidence of drivers on the roadway who had high alcohol
concentrations; and a higher proportion of drivers who were aware of and supported the
laws and the associated penalties.

Applying econometric analyses to the Swedish and Norwegian data, Votey (1978)
found that fatalities were'negatively correlated with convictions for drunk driving and
license withdrawals in Norway and with length of jail sentences in Sweden. Subsequent
analyses by Votey and Shapiro (1983,1985) supported the effectiveness of all three types
of sanctions in use in Sweden (i.e., jail, license withdrawal, and fines). Because of the
stronger negative correlation of fines and license actions with fatal crashes, they sug-
gested that increased reliance be placed on fines and license actions in the future. These
authors found, as did Ross in hi 1982 evaluation of the impact of the Finnish law, that
jail sentences were more negatively associated with serious injury crashes than with fatal
crashes, an unexplained paradox.

Ross (1982, 1985) acknowledged the low rates of drunk driving in Scandinavia but
rejected both the procedures of Votey and Shapiro and the conclusion that imprison-
ment is necessary for deterrence. In his book, Ross (1982) stated that a variety of facts
were consistent with the possibility that the Scandinavian countries had achieved some
marginal deterrence over the long run. However, he maintained, the same deterrent
effect could have been obtained with laws that were less punitive and costly.

In spite of their differences, Ross and Votey and Shapiro agreed on the wisdom of
placing more reliance on licensing and tines. In addition, Klette (1985) concluded that
while the Scandinavian laws had been effective, the use of jail sentences should be
reduced.

As we suggested earlier, in addition to a simple deterrent effect, severe penalties may
be long-term components of general prevention. While simple deterrence results from
the public's fear of a sanction, the longer term, educational component involves the
gradual development of a social norm that drunk driving is wrong, as demonstrated by
the sanctions associated with it. In Scandinavia, jail sentences have been shown to have
some long-term effect. But some evidence implies that emphasis on other penalties


JUD,Gw~ ~0 ADMINISTRATNE PROCESSES

aould have had as great an effect. Further, a clear trend toward reduced emphasis on
sanction severity is indicated by both fewer jail sentences and shorter jail terms. This is
true, to some extent, for all of the Scandinavian nations. In Sweden, Denmark, and
Finland, significantly more emphasis is being placed on the adoption of illegal per se
laws, roadside breath testing, and roadside sobriety checkpoints (Voas 1982). In all three
nations, continuing emphasis is being placed on license withdrawals (primarily admin-
istrative) amI fines based on income levels.

ln the United States, as of 1988, 14 States mandated jail sentences (or community
service) for fast offenders, and 42 States mandated such penalties for repeat offenders.
Sentences for first offenders were often for minimal periods such as 2 days. Sentences
for repeat offenders were usually longer but not as long as those traditionally used in
Scandinavia. Because of factors such as suspended sentences, diversionary programs,
and plea bargaining, many offenders sentenced to jail were never actually confined.

Early evaluations of the general deterrent value of jail sentences in Chicago (Robert-
son et al. 1973); in Yakima, Washington (Grube and Kearney 1980), and in Phoenix,
Arizona (Voas 1975) involved laws or policies that were never fully implemented (Voas
1982). No general deterrent effects were reported in these studies, perhaps as a result
of incomplete implementation. Voas (1975) and Ross (1976) pointed out that the effects
of severe sanctions, such as jail, were often "neutralized" by factors such as reduced
arrests, increased not-guilty pleas, increased requests for jury trials, decreased convic-
tion rates, and increased court backlogs. These have been demonstrated to be very real
handicaps to the use of severe sanctions. However, such factors may not be as over-
whelming when officials or the public have a strong commitment to making such
sanctions work.

Two recent studies were conducted in jurisdictions where jail sentences were regu-
larly administered. In both cases, first offenders were the primary targets of the law.
Falkowski (1984) reported on the efforts of judges in Hennepin County, Minnesota, who
voluntarily implemented a policy of providing Zday jail sentences for first-time DWI
offenders. Initially, the sentences were imposed on 93 percent of convicted offenders.
Even after 2 years, 80 percent of such offenders received jail sentences. Falkowski found
a statistically significant (24l percent) reduction in nighttime fatal crashes after the policy
had been in effect for 2 months. (It is not clear if such a lag was anticipated. If not, it
raises some questions regarding the interpretation of the results of the time-series
analysis.) Falkowski also reported a marked increase in enforcement coincident with the
policy and suggested that the jail policy might not have been successful without the
increase in arrests. However, her analyses suggested that the change in sentencing policy
was the primary cause of the fatality reduction.

In neighboring Ramsey County, which did not implement the jail policy, there was a
similar increase in arrests and a (smaller) decrease in nighttime fatalities. However, the
decrease in fatalities in Ramsey County was not coincident with the implementation of
the policy in Hennepin County.

Subsequent analyses by Clear-y and Rodgers (1986) supported Falkowski's findings.
Even though arrest rates and other program efforts increased significantly throughout
the State, and even though these efforts were accompanied by statewide reductions in
fatal crashes, the reductions observed in Hennepin County were greater (25 percent)
than for the remainder of the State (16 percent). Although there is some question
regarding how the time lag in observed results should be interpreted, the Hennepin
County experience suggested that the Zday jail sentence policy likely had an impact on
fatal crashes.

The most recent study of the general deterrent effect of jail sentences involved the
mandatoryZdayjai1 sentence legislation in Tennessee. This legislation was implemented
in July of 1982 and evaluated by Jones et al. (1987). Nighttime, single vehicle, fatal crashes
showed an upward trend until shortly after implementation of the law. This upward trend

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was followed by a decline in such crashes, which continued for 24 months. This decline
occurred at the same time as daytime crashes we&increasing. Taken at face value, and
considering Tennessee alone, the study suggested that ". . . a reduction in alcohol-related
fatal crashes of up to 15 percent could be attributed to the mandatory jail law." As in
Hennepin County, there was a time lag before the reversal in crash trends occurred. The
evaluators also worried that their findings were tempered by the fact that similar
reductions occurred in two adjoining States, Alabama and Kentucky, that did not
implement mandatory jail sentences. However, they overlooked the fact that both
Alabama and Kentucky implemented DWI legislation and other significant counter-
measures immediately preceding the reductionsin nighttime, singlevehicle, fatal crashes
in those States.

In a recent study by the Insurance Institute for Highway Safety (IIHS), Zador, Lund,
Fields, and Weinberg (1988) evaluated the effectiveness of three different types of laws:
illegal per se, administrative licensing, and mandatory jail or community service laws.
They found that all three kinds of laws reduced fatalities and that administrative licensing
laws had the greatest impact. Laws mandating jail or community service for first
offenders resulted in an estimated 6-percent reduction in late-night fatal crashes, which
are most commonly associated with alcohol. This study supported the idea of a general
deterrent effect for brief mandatory jail sentences for first-time offenders. It covered a
number of States across the Nation.

Can Problem Drinkers Be Deterred?

With regard to individual reform (i.e., reduced recidivism), we have already provided
evidence that suggests that multiple offenders who receive jail sentences do not appear
to be affected by them, but first offenders may be at least temporarily affected. An issue
that has frequently been raised involves the extent to which heavy or "problem" drinkers
who are not caught can be deterred by severe penalties. Generally, theorists have
speculated that moderate or "social" drinkers are most affected by penalties of any kind
and that problem drinkers are unable to modify their behavior. In support of thii theory,
Voas (1982) showed that six times as many drivers had low to moderate BAC levels on
U.S. roadways as on Swedish roadways, but that only three times as many crash-involved
drivers had these moderate levels. The implication was that Sweden, in comparison with
the United States, had significantly reduced the number of social drinking drivers on the
road but not the riskier problem-drinking drivers.

However, Snortum et al. (1986) reported survey results compatible with the idea that
problem drivers had been deterred by jail sentences in Norway. The researchers found
that, while Americans showed only slight inclinations not to drive home after drinking,
Norwegians showed substantial inclinations not to drive. This was true for persons from
high as well as low baseline levels of alcohol consumption.

Data from NHTSA's Fatal Accident Reporting System (FARS) have suggested that
since "tougher" sanctions (including but not limited to jail) were implemented in the
United States, drivers with high BACs have been less frequently involved in fatal crashes
(Nichols 1988). Roadside surveys conducted in Minnesota (Palmer and Tix 1986; Tix
and Palmer 1987) and across the Nation (IIHS 1987u, b) have supported this suggestion.

Thus, while conventional wisdom and some data suggest that, in Scandinavia, primari-
ly social drinkers have been deterred by laws involving the use of prison sentences,
evidence has also shown that drivers with high alcohol concentrations, presumably
problem drinkers, have been deterred in both Scandinavia and the United States.
Snortum et al. (1986) suggested that although many heavy drinkers in Norway may not
have changed their drinking habits, they have found ways to avoid driving after drinking.

Summary of Confinement Effects
The National Institute of Justice (1984) reviewed jail sentencing practices in several


JUDICIAL AND ADMINISTRATIVE PROCESSES

U.S. jurisdictions and concluded that implementation of mandatoryjail sentenceswould
be likely to produce the following results:

   .  Drunk driving arrests would increase.

   .  Court workloads would increase.

   o More defendants would challenge, postpone, or avoid compliance with
   court procedures and decisions.

0 Effects on subsequent recidivism rates would vary from one site to
  another.

   .  Incarceration rates would increase.

   0  Strains would be placed on the correctional system.

   a A variety of special programs and facilities would be required.

   .  Traffic fatalities might decline.
This report also indicated that legislative enactment is not necessary and that adverse
effects can be minimized or eliminated.

In our review, we found only slight evidence that jail sentences reduce recidivism
among offenders who receive them. One study supported the proposition that the use
of special facilities with referral to treatment may reduce recidivism for multiple of-
fenders (Siegal 1985). One U.S. study showed that brief, mandatory jail sentences may
temporarily reduce recidivism for first-time offenders (Jones et al. 1987).

With regard to the much more important general deterrent effects, some evidence
has been provided for a long-term benefit associated with the use of jail sentences in
Scandinavia (Voas 1982; Snortum 1984). However, such benefit might well have been as
great with less severe sanctions (Ross 1982; Voeey and Shapiro 1985). Scandinavian
nations are modifying their approach to be less dependent on jail sentences and more
dependent upon fines, license actions, and random roadside testing procedures. Jail
sentences have not been eliminated, but they have been reduced in duration and their
use has been directed more to persons with highei alcohol concentration levels (Vows
1982; Ross et al. 1984). Treatment is also being more frequently considered as an adjunct
to jail sentences (Winsten 1987).        '

In the United States, jail sentences have frequently resulted in a high cost to the
judicial and correctional systems. In some locations where jail sentences were used, they
produced more innocent pleas and requests forjury trials, fewer convictions, and greater
court backlogs (Voas 1975; Ross 1976). The experience in Hennepin County, Minnesota
provided an example of the difference judicial commitment can make. The courts in
Hennepin County did not become backlogged, jail facilities were not generally overbur-
dened, jury trials did not increase, and fatal crashes did decrease following implemen-
tation of the sanction policy (Falkowski 1984).

Recently, the use of brief, z-day jail sentences has increased in the United States. Four
studies that we reviewed (Falkowski 1984; Cleary and Rodgers 1986; Jones et al. 1987;
arid Zador et al. 1988) found a general deterrent effect of these jail sentences for first
offenders. Several studies have suggested that license withdrawal and substantial fines
may be more effective than mandatory jail sentences (Klette 1985; Votey and Shapiro
1985; Zador et al. 1988). These findings do not necessarily mean that jail should be
eliminated as a sanction. They do suggest that fines and license actions should receive
greater emphasis.

Alternatives to Jail Sentences

In addition to traditional license withdrawals and fines, a number of sanctions are
used specifically as alternatives to jail sentences Most common among these alternatives
have been community service, residential treatment, and house arrest. While residential

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treatment has had an impact on recidivism (Siegal1985), such programs have not been
shown to have a general deterrent effect.

Similarly, there is little evidence that community service or house arrest, when applied
to large numbers of offenders, has deterrent impact. The PresidentiaI Commission on
Drunk Driving recommended the use of 48-hour jail or lo-day community service
sentences for second-offense drunk drivers. Since then, many community service pro-
grams have come into existence. One evaluation of these programs (Stenzel et al. 1987)
was conducted in Baton Rouge, Louisiana where, beginning in 1983, virtually all DWI
offenders were sentenced to community service. This program was accompanied by a
public information campaign that appeared to be successful in increasing public aware-
ness of the program. However, both self-reports and crash data failed to provide any
statistically significant evidence of reduced recidivism for offenders who received this
sanction in 1984, compared with offenders in 1982 who did not.

With regard to general deterrence, analyses of several surrogate measures produced
mixed results, but single vehicle, fatal and injury crashes were somewhat lower following
implementation of the program. It appeared that the percentage of drivers involved in
fatal and serious injury crashes who had been drinking was reduced.

Clearly, more attention should be paid to some of these alternatives to jail, particularly
those that combine restrictions of freedom with treatment for alcohol-related problems.
Even where treatment is not part of the program, the general deterrent impact of house
arrest and special confinement facilities for drunk drivers should be investigated more
thoroughly.

License Suspensions and Revocations

License actions would seem to be an integral and essential part of removing drunk
drivers from the roadway. However, such actions have been applied with extreme
variation from one jurisdiction to another, even within the United States. Recently,
increasing emphasis has been placed on license actions as drunk driving sanctions, both
in foreign countries and in the United States.

In examining the effects of license actions, we came upon a number of important
comparisons, including: discretionary versus mandatory actions; fully imposed versus
suspended, stayed, or conditional actions; license withdrawal versus education or treat-
ment; immediately imposed versus delayed actions; short versus long sentences; and
criminal versus administrative processes. While adequate research on all of these issues
does not exist, most have received some attention, primarily with regard to reductions
in recidivism,

individual Reform: Do License Actions Result in Reduced Recidivism?

As with jail sentences, deterrent, rehabilitation, and incapacitation effects are some-
what confounded in evaluating license suspensions. In this review, we continue to use
the term "individual reform" to refer to reductions in the recidivism rates of offenders
who receive these sanctions, regardless of which component is responsible for the
reductions.
Evidence of individual reform as a consequence of license actions comes primarily
from studies conducted in the United States. In most cases, these evaluations involved
judicially imposed license sanctions. The most recent and complete review of such
studies was conducted by Peck, Sadler, and Perrine (1985) who concluded that

there is no question that license suspensions have a significant effect in
reducing the accident and drunk driving <frequency of convicted DUI of-
fenders . . . the overall consistency of the results from different investigators,
using different quasi-experimental designs, precludes any other conclusion.


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An important issue frequently encountered in these studies is that many offenders
continue to drive during periods of suspension or revocation. The proportion of sus-
pended drivers who continue to drive has been estimated by various studies to range
from 25 to 75 percent (e.g., Hagen 1977, Hagen et al. 1980; ?&berg et al. 1981; Peck et
al. 1985; Ross and Gonzales 1988); This high rate of subsequent driving is related to the
fact that the perceived risk of being identified and prosecuted for driving while sus-
pended is extremely low. In spite of the large number of suspended or revoked drivers
who continue to drive, their crash and violation records during revocation or suspension
are signifi~tly better than those of nonsuspended drivers. This suggests that they drive
fewer miles and more cautiously. Moreover, the low rates of crashes and violations are
maintained after the license actions expire.

The study of discretionary versus mandatory license withdrawal actions provides an
evaluation of the importance of certainty in the administration of such sanctions. Hagen
(1977) reviewed studies conducted in Oregon (Kaestner and Speight 1974) and in
Washington (Paulsrude and Klingberg 1975). These studies were not limited to alcohol-
related offenders. They included persons who had a sufficient number of violations that
driver improvement actions were invoked. Based on these studies, Hagen concluded that
the traffic safety effectiveness of the discretionary use of license suspension was "less
than startling." He contrasted these findings with those of a California study (Epperson
et al. 1975) where the effectiveness of imposing mandatory license suspensions for
multiple driving under the influence (DUI) offenders was "strongly evidenced."

Hagen then examined 6 years of postconviction driving records for multiple DUI
offenders who received mandatory license withdrawals and compared them with the
records of a matched group of offenders not receiving the mandated action because of
dismissals of prior convictions. He found that a significantly smaller proportion of the
license-action group was involved in a subsequent DUI arrest or crash. This effect lasted
for approximately 4 years and was greater for older than for younger offenders.

Blomberg, Preusser, and Ulmer (1987) provided convincing evidence of the impor-
tance of certainty of license actions in reducing recidivism. They evaluated a 1982
Wisconsin law which mandated that all persons convicted of operating while intoxicated
(OWI) would receive 3- to 6-month license suspensions. If a person was convicted of
OWI and did not have such a penalty imposed by the court, the law required that the
Bureau of Driver Licensing impose such a penalty. Virtually 100 percent of first-time
OWI offenders in 1983 had their licenses suspended, compared with 45 percent in the
year prior to the law. These researchers found that the new law group had a l-year, OWI
recidivism rate of 5.4 percent compared with a rate of 7.8 percent for the old law group,
a reduction of 30 percent. A control group of moving violation offenders also showed
reduced recidivism after the law was passed, but it was a smaller reduction. After
controlling for the magnitude of this reduction, the differences in recidivism between
the OWI groups were still significant.

In summary, the research suggests that mandatory license actions are more effective
than discretionary sanctions in reducing recidivism. Certainty of the license action is
likely to be a major factor in producing this effect.

Several studies have evaluated license withdrawals compared with education and
treatment sanctions. When people are given education or treatment sanctions, license
withdrawal actions are often stayed or suspended pending completion of the program.
Thus, these studies also provide an evaluation of fully imposed sanctions compared with
stayed or suspended license actions.

A series of California studies provided the most comprehensive information regard-
ing license actions compared with education and treatment alternatives. Hagen (1977)
and .Hagen, Williams, McConnell, and Fleming (1978) evaluated the effectiveness of
California alcohol treatment programs as an alternative to license actions. They found


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that drivers with mandated loss of license had significantly fewer subsequent crashes and
violations than those who attended rehabilitation programs in lieu of license actions.
                                                            -
A followup study by Sadler and Perrine (1984) compared Cyear subsequent driving

records of these offenders. They found that offenders who received mandated license
suspensions had significantly fewer subsequent arrests andviolations than offenders who
did not receive such sanctions. Offenders who received education or treatment alterna-
tives may have had fewer subsequent alcohol-related violations. Overall, they concluded
that license suspensions were more effective than any known form of alcohol education
or rehabilitation.

Tashima and Peck (1986) found similar results for both first and multiple offenders.
For second-time offenders, license suspension reduced the crash risk to nearly that of
the average driver. The treatment group with a restricted license had a mean crash rate
that was 91 percent higher than that of the suspended group.

Similar results have been found in other States. In North Carolina, a study by Popkm,
Li, Lacey, Stewart, and Wailer (1983) found that first-time DUI offenders who attended
an alcohol/drug education program in lieu of receiving license suspensions had sig-
nificantly higher subsequent DUI conviction and crash rates than those whose licenses
were suspended.

In the State of Washington, Salzberg, Hauser, and Klingberg (1981) compared 5-year
driving records of habitual offenders whose licenses were revoked, offenders whose
revocations were stayed as a result of participation in an alcohol treatment program, and
a control group whose cases were dismissed. Although the groups showed no differences
in subsequent DWI arrests, adjusted data indicated that offenders receiving license
revocations had approximately half as many subsequent moving violations and crashes
as either offenders whose sentences were stayed or offenders whose cases were dis-
missed. Neither drivers whose license revocations were stayed nor drivers who avoided
sanctionsvia dismissal of their charges appeared to have modified their drivingbehavior.

Following more than a decade of evaluations of the effectiveness of various programs
related to the Alcohol Safety Action Projects implemented by the National Highway
Traffic Safety Administration, Nichols et al. (197&, b) and Nichols, Ellingstad, and Reis
(1980) concluded that the majority of education and treatment programs showed little
impact on reducing subsequent alcohol-related arrests or crashes, whereas license
actions had been generally effective. Thus, they recommended that education and
treatment programs should not be used in lieu of license actions, but should be continued
as adjuncts to licensing actions. Mann, Leigh, Vingilis, and DeGenova (1983) reiterated
the concerns of Nichols et al. (197&, b, 1980) regarding the diversion of drunk drivers
to rehabilitation programs in lieu of license actions.

Our review found that persons with stayed or suspended license actions had more
subsequent violations and crashes than persons whose licenses were actually withdrawn,
and that education or treatment programs did not counteract this negative effect. If
education and treatment programs are to be considered (and they should be), their use
should be in addition to license withdrawal.

Relative to the issue of length of license withdrawal, a study in New South Wales,
Australia (Home1 1981) found that license withdrawal longer than 2 months was not
aSsociated with lower DUI reconviction rates. However, among drivers who were not
rearrested for DUI (i.e., good risk drivers), longer periods of disqualification were
associated with fewer non-alcohol-related violations. These reduced violations con-
tinued for up to 18 months after the license was restored. Home1 suggested that 1% to
l&month disqualification periods were optimal.

In California, Sadler and Perrine (1984) provided further evidence that longer
sentences reduce recidivism to a greater extent than shorter sentences. They found that


JUDICIAL AND ADMINISTRATIVE PROCESSES                                        105

offenders who received 3-year license revocations had fewer subsequent total crashes
and convictions than those who received l-year suspensions. This was particularly true
for younger offenders.

Looking only at very brief sentences in the State of Washington, Sabberg and
Pa&rude (198%) found that first-time offenders who received 30-day license suspen-
sions (in addition to other penalties mandated by law) had fewer subsequent moving
violations (though more alcohol-related violations) than fast offenders who received the
other penalties but who avoided the suspension. No impact was apparent on crash
involvement. Their results suggested that short-term suspensions may be ineffective in
reducing DWI recidivism.

The findings of Stewart, Gruenewald, and Roth (1988) were consistent with those of
Salzberg and Pa&rude. These researchers investigated the recidivism rates of offenders
receiving 30-day administrative license suspensions in Louisiana and Mississippi. While
the brief administrative license sanctions appeared to have made drivers more cautious,
they did not decrease DUI recidivism rates.

Our review found no studies that specifically evaluated the effect of immediate versus
de@ed Iicense acfions. Generally, license actions imposed by the courts take place 4 to
6 months after an arrest for DWI whereas administrative sanctions occur within 1 to 2
months following arrest. Evaluation of the effectiveness of license actions resulting from
judicially imposed license actions compared to administratively imposed actions would
be helpful in guiding States currently pursuing administrative licensing laws.

In summary, license actions of reasonable duration have been found to be effective
in reducing crash and violation recidivism rates among offenders who receive them.
Within reason, longer sanctions appear to be more effective than shorter sentences. The
ability of license actions to reduce recidivism has been demonstrated for first offenders
in California, North Carolina, and Wisconsin and for multiple offenders in Washington
and California.

Generally, license actions are superior to remedial education or treatment. Some
characteristics of license actions that appear to increase their effectiveness in reducing
recidivism include making them mandatory; increasing their certainty of application, not
offering remedial programs in lieu of license actions, and providing for suspensions of
reasonable duration, such as 3 months or more. It is also believed, but not yet
demonstrated, that minimizing the time from arrest to license withdrawal adds to its
effectiveness.

General Deterrence: Do License Actions Reduce Drunk Driving and
Alcohol-Related Crashes Among Drivers Who Are Not Caught?

As with jail sentences, it is most important to determine whether the general public
is deterred from drinking and driving by license sanctions. Here, the studies by Votey
and Shapiro (1983,1985) are again relevant. Application of their econometric models
to Sweden's fatality and injury data indicated that, among all sanctions, including jail,
license actions were most highly associated with reductions in fatal crashes.

Few studies have measured the general deterrent impact of judicially imposed license
actions in the United States. This is perhaps due to the irregularity with which such
sanctions are applied. Recently, however, there has been more opportunity to observe
the impact of significant increases in the certainty of license withdrawal actions because
a number of States have begun imposing administrative sanctions. These sanctions have
generally been brief-to-moderate in duration (i.e., 30-90 days), compared with the
maximum duration allowable in criminal law (i.e., 1 year or more).

As of 1988,23 States had administrative licensing laws, most implemented since 1982.
The most frequently reported evidence regarding the general deterrent effect of these


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BACKGROUND PAPERS

laws has not come from formal evaluation studies. Rather, such evidence has come from
observations and reports of significant increases in the number of license actions
imposed, followed by significant (10-U percent) reductions in night-time or alcohol-re-
lated fatal crashes. Such trends have been observed in several States that have passed
administrative license laws (Illinois 1986, Minnesota 1987; Nevada 1986, New Mexico
1988).

Some of these laws have not been adequately evaluated, because they were enacted
as components of comprehensive legislative packages. In Minnesota, Cleary and
Rodgers (1986) determined the overall impact of a legislative package implemented in
1982 and found significant reductions in several fatal crash measures. Improvements in
a previously implemented administrative licensing law constituted a major component
of the legislation evaluated.

Similarly, in North Carolina, Lacey (1987, 1988; Lacey et al. 1984) evaluated the
impact of a legislative package that included administrative license suspension as a
primary component and found significant reductions in several alcohol-related crash
measures, particularly for young drivers.

In Wisconsin, Blomberg et al. (1987) provided more specific evidence for the general
deterrent effect of a combination of judicially and administratively imposed license
sanctions for first-offense drinking drivers. The 1982 law they evaluated provided that
any driver convicted of OWI who did not receive a license suspension or revocation by
the court would have his license suspended administratively. Time-series analyses found
that implementation of the law was associated with a 25-percent decrease in single-
vehicle nighttime crashes, which are likely to be alcohol-related.

One of the evaluations most specific to the general deterrent effects of administrative
licensing actions was conducted by Ross (1987). He evaluated the effectiveness of a New
Mexico administrative licensing law using telephone surveys and time-series analyses of
alcohol-related crash fatalities. Following implementation of the law, telephone surveys
indicated that the perceptitin of risk of apprehension and conviction rose slightly, though
insignificantly; the perception of risk of license withdrawa1, if convicted, rose consider-
ably and significahtly, and there was a temporary reduction in the proportion of persons
who admitted to drinking and driving. More importantly, an interrupted time-series
analysis of a 6-year, monthly series of fatality data indicated a reduction in the alcohol-
related proportion of fatalities from 66 percent prior to the law to 56 percent following
the law, a 15-percent reduction. Because of the absence of effects in some related data
series, Ross urged caution in interpreting the results. Still, the New Mexico experience
supports the wisdom of wider adoption of administrative license withdrawal for drunk
driving.

In New Mexico as in Minnesota, surveys were conducted to measure changes in
perceived risk of apprehension and sanctioning (Rodgers and Cleary 1983). One of the
fmdings of these surveys was that respondents felt license suspensions would discourage
drinking and driving more than any other sanction.

More recently, the Insurance Institute for Highway Safety (Zador et al. 1988)
evaluated the effectiveness of three different types of laws: illegal per se, administrative
per se, and mandatory jail (or community service) laws. This study found that all three
typesof laws affected fatalities, but that the administrative licensing laws had thegreatest
impact. This is consistent with the findingsin Sweden byvoteyand Shapiro (1983,1985).
Zador et al. estimated that administrative licensing laws reduced driver involvement in
late-night fatal crashes by approximately 9 percent. This study provided support for a
general deterrent effect of administrative license laws in several States.

In summary, while most of the evidence for reductions in recidivism comes from
studies of criminally imposed license actions, evidence for a general deterrent effect of
licensing actions comes primarily from studies where such actions have been administra-


JUDICIAL AND AD~W3-RATIVE PROCESSES

107

tively imposed. Administrative license laws have generally been followed by significant
increases in the number of offenders receiving license actions and by small but significant
reductions in alcohol-related fatal crashes (Minnesota 1987, Lacey 1987, 1988; Nevada
1986; Ross 1987; Blomberg et al. 1987; etc.).

Throughout our review, we found evidence that, compared with other sanctions,
license actions have the greatest individual and general deterrent potential (e.g., Home1
1981; Votey and Shapiro 1985; Tashima and Peck 1986, Zador et al:l988): Regardless
of the type of sanction, certainty of action appears to be an important component for
deterrence, particularly general deterrence (e.g., Falkowski 1984; Epperson et al. 1975;
Jones et al. 1987; ROSS 1987; Blomberg et al. 1988; Zador et al. 1988).

With regard to administrative license actions, swiftness of action may also be an
important component since administrative license withdrawals are usually imposed in a
fraction of the time required for criminal sanctions. However, we found no studies that
specifically evaluated this matter.

Fines

Fines have not been well evaluated for their impact on recidivism or their general
deterrent effect despite the fact that such actions are a common element inmost sanction
combinations. The substantial fines imposed by the Scandinavians were associated with
reductions in fatal crashes by Votey and Shapiro (1983,198s). In Australia, Home1 (1979,
1981) found that fines and "goodbehavior bonds," forfeited upon a repeat offense, were
effective in reducing recidivism among DWI offenders. Home1 (1981) reported that
neither long nor short periods of imprisonment were any more effective in reducing
recidivism than were fines or good behavior bonds. He also found that higher fines ($300
or more) were more effective than lower fines in reducing recidivism .

In Sweden, violators receive "day fines." One day fine is one-tenth of 1 percent of the
offender's annual income. The amount of the fme assessed is also associated with the
seriousness of the offense (e.g., the offender's alcohol level). At the upper levels of
severity, the fine can be as high as 80 day fines, which is more than 1 month's income
(Winsten 1987). It would be useful to know if fines based on income levels, such as those
used in Scandinavia, would produce greater general deterrent effects than the fines
commonly used in the United States.

While we do not generally include costs such as insurance premiums as fines, it is
worth noting that in New Jersey, heavy tines combined with substantial insurance
assessments and license reinstatement fees have been credited by State safety officials
with producing a significant reduction in alcohol-related fatal crashes. To date, however,
no research evidence supports that claim.

In addition to their potential for reducing recidivism and alcohol-related crashes,
tines serve another important function in some jurisdictions. They provide a source of
funds for maintaining DWI countermeasure efforts. The State of New York has one of
the most comprehensive program-financing systems in the United States. This system is
based on the use of mandatory minimum tines, which are deposited in a specially
designated DWI program account and redistributed to the counties in response to their
program plans. The redistributed funds help pay for various components of the DWI
control system such as enforcement, prosecution and adjudication, education, and public
information. New York has credited this self-financing system, based on mandatory
minimum fmes, with signilicant reductions in alcohol-related fatal crashes since 1981
(McCartt and Dowling 1985).

Whether the observed reductions in New York can properly be attributed to the
self-financing system is debatable. Nevertheless, this type of system is important from
several perspectives. First, tines have been shown to have both specific and general


108

BACKGROUND PAPERS

deterrent effects. Second, fines provide a mechanism for funding DWI countermeasure
programs. Third, the process of redistributing funds from fines provides a mechanism
for controlling programs and for encouraging activities that have the greatest potential
for reducing alcohol-related crashes.

Conclusions and Recommendations

Based on our review, we conclude that while all sanctions have some potential for
reducing drunk driving and alcohol-related crashes, some have more potential than
others. While it is desirable and beneficial to modify the behavior of the small proportion
of drinking drivers who are caught, the most important function a DWI sanctioncan have
is to effectively deter the many drinking drivers who will never be apprehended. We feel
that swift and sure license actions provide the greatest potential on both counts. While
the limited number of studies conducted in the United States suggests that brief jail
sentences for first offenders can also have a general deterrent effect, such actions are
more costly to implement than license actions.

Fines can also be effective deterrents, particularly the heavier fines used in Scan-
dinavia. This potential, combined with the fact that fines can provide needed income for
DWI countermeasure efforts, suggests that more emphasis should be placed on the use
of tines; Some consideration should also be given to fines based on income levels.

Overall, we would propose a model sanctioning system that would provide income to
fund the program, maximum general deterrence for drinking drivers who have not been
apprehended, and significantly increased emphasis on keeping multiple offenders off
the roadways, at least until there is evidence that their drinking problems have been
effectively addressed.

For first offenders, our model system would provide for mandatory minimum fines or
fines based on income and mandatory minimum hard license suspensions of no less than
90 days, followed by a probationary or restricted license period. Following the hard
suspension period, incentives would be provided to engage in alcohol education, assess-
ment, and referral programs.

To make license actions more effective, greater emphasis would be placed on keeping
suspended and revoked drivers from driving during their license withdrawal period.
More extensive use of license plate confiscation for persons found driving while
suspended would make such violations more visible and thus more enforceable. Repeat
offenders would receive mandatory minimum hard license suspensions of 1 year. These
actions failing, emphasis would be shifted to vehicle confiscation and confiiement.

Incarceration would be used primarily for the most extreme offenders. It would
involve special facilities and would include in-house efforts to assess and refer offenders
to residential treatment programs. Driving privileges would not be restored to such
offenders without medical evidence that their drinking problems had been effectively
addressed.

Significant public information efforts would be directed toward keeping the public
aware of sanctioning efforts and of the certainty of their application.

While much research on sanctions has already been conducted, several issues deserve
additional research attention. These include the deterrent effect of swiftness in applying
sanctions; hard suspensions compared with soft suspensions; mandatory minimum fmes
and fines based on the income level of the offender; alternatives to jail such as special
facilities, house arrest, or community service; adding assessment and treatment to
incarceration for multiple offenders; administrative licensing laws; and the effect of


JUDICIAL AND ADMINISTRATIVE PROCESSES

109

license plate and vehicle confiscation in reducing the number of offenders who drive
while their licenses are suspended or revoked.

REFERENCES

Andcnaes, J. The effects of Scandinavia's drinking-driving laws: Facts and hypotheses. Scun-
   dinavian Shldies in Criminology 6~35-53, 1978.
Blomberg, R.; Preusser, D.; and Ulmer, R. Deterrent Effects of Mandatory License Suspension for
  DWZ Convictions. DOT-HS-807-138. Washington, DC: National Highway Traffic Safety
  Administration,`1987.

Blumenthal, M., and ROSS, H. Two EqerimentaZShidies of Trafic Law: VoL Z, The Effect ofLegal
  Sanctions on DW offenders. Technical Report DOT-HS-800-825. Washington, DC:
   National Highway Traffic Safety Administration, 1973.
Buikhuisen, W. General Deterrence: Research Md 7?ieory. The Netherlands: Groningen Univer-
   sity, Criminological Institute, 1972.

Clcary, J., and Rodgers, A. Anaiysh of rhe Effects of Recent Changes in Minnesota's DKZ Laws,
  Part III: Longihcdina1AnnIysi.s of the Policy Impacts. St. Paul, MN: Research Department,
   Minnesota House of Representatives, 1986.
Compton, R. Preliminary analysis of the effect of Tennessee's mandatory jail sanction on DWI
  recidivism. Research Notes. Washington, DC: National Highway Traffic Safety Admin-
   istration, 1986.

Dijksterhuis, P. The specific preventive effect of penal measures on subjects convicted for drunken
   driving. Blulalkahol 12:181-191, 1974.

Eppcrson, W.; Harano, R.; and Peck, R. Final Reprt to the Legislature of the State of California
  inAccord with Resolution, ChapterlSz 1972 LegislativeSession. Sacramento, CA: Depart-
   ment of Motor Vehicles, 1975.

Falkowski, C. 7he Zmpact of Two-Day /ail Sentences for Drunk Drivers in Hennepin County,
  Minnesota. Final Report on Contract No. DTNH-22-82-05 110. Washington, DC: Nation-
   al Highway Traffic Safety Administration, 1984.
Grubc, J., and Kearney, K. The Yakima County Drinking and DrivingProject:An Evaluation of a
  Mandatory Jail Sentence and a Public AwarenesS Campaign. Pullman, WA: Social Re-
   search Center, Washington State University, 1980.
Hagen, R. Effectiveness of License Suspension for Drivers Convicted of Multiple Driving-Under-
  the-Znflrlence Offenses. Report No. 59. Sacramento, CA: Department of Motor Vehicles,
    1977.

llagen, R.; McConnell, E.; and Williams, R.L. Suspension and Revocation Effects on the DUZ
  Offender. Report No. 75. Sacramento, CA: Department of Motor Vehicles, 1980.
IIagen, R.; Williams, R.; McConnell, E.; and Fleming, C. An Evaluation of Alcohol Abuse
  Treatment as an Alternative to Driver's License Suspension or Revocation. Report NO. 68.
   Sacramento, CA: Department of Motor Vehicles, 1978.
Homel, R. The deterrent effect of penalties on drunk/drivers. In: Johnston, I.R., ed. Proceedings
  of the Seventh International Conference on Alcohol Drugs and Traffic Safety, Canberra,
   Australia: Australian Government Publishing Service, 1979. pp. 536-546.
Homel, R. Penalties and the drunk/driver: A study of one thousand offenders.Australian and New
   Zealand Journal of Criminology 14:225-241, 1981.
Illinois, State of. DUZ Fact Book. Springfield, IL: Office of Secretary of State, 1986.
Insurance Institute for Highway Safety. Drinking and LIriving Down ShrUpry in U.S. During Last
   I3 Years. Washington, DC: the Institute, 1987a.
hSUram Institute for Highway Safety. Drunk driving drops sharply across nation. Status Report
   22(10):4,198!b.

Jones, R.; Joksch, H.; Lacey, J.; and Schmidt, H. "Field Evaluation of Jail Sanctions for DWI."
  Final Report, Mid-America Research Institute, for the National Highway Traffic Safety
   Administration, Washington, DC, 1987.
Kaestner, N., and Speight, L. Oregon Shcdy of Drivers License Suspensions. Salem, OR: Depart-
   ment of Transportation, 1974.

mzttc, H. On the politics of drunken driving in Sweden. Scandinavian Studies in Criminology
   6: 113-l 19, 1978.


110

BACKGROUND PAPERS

Klette, H. Drinking and Driving in Sweden-the Low and Its Effects. Lund, Sweden: Lund
   University, 1983.

Klette, H. Drinking and driving in Sweden-The law and its effects. In: Kaye, S., and Meier, G.W.,
  eds. Alcohol, Drugs and Traffic Safety: Z'roceedings of the Ninth ZnternationaZ Conference
  on AlcohoJ Drugs and Trafic Safety. San Juan, PR, 1985. pp. 757-772.
Klingberg, C.; O'Connell, J.; Sal&erg, P.; Chadwick, J.; and Pa&rude, S. An Evaluation of
  Washington State's I979 Driving WhiZe Intoxicated (DWZ) Laws. Final Report, DOT
  HS-806-838. Washington, DC: National Highway Traffic Safety Administration, 1984.
Lacey, J. Safe Roads Act Update. Chapel Hill, NC: University of North Carolina, Highway Safety
   Research Center, 1987.

Lacey, J. Safe Roads Act Update. Chapel Hill, NC: University of North Carolina, Highway Safety
   Research Center, 1988.

Lacey, J.; Popkin, C.; Stewart, R, and Rodgman, E. Preliminary EvaZuation of the North Carolina
  Safe Roads Act of Z983. Chapel Hill, NC: Highway Safety Research Center, University of
   North Carolina, 1984.

Lewis, R. Estimates of DWZ Recidivism in Minnesota Fatal Crashes. St. Paul, MN: Minnesota
   Criminal Justice System Task Force, 1985.

Mann, R.; Leigh, G.; Vingilis, E.; and DeGenova, K. A critical evaluation of the effectiveness of
  drinking-driving rehabilitation programmes.AccidentAnaZysti and Prevention 15441-461,
    1983.

McCartt, A, and Dowling, A. An Zmpact Evaluation of the New York State Stop-DWZ Program.
  Albany, NY: Institute for Traffic Safety Management and Research, State University of
   New York, 1985.
Minnesota, State of. Cost of DWZ Control. . . And Cost of Lack of Control; Hard Core Problem..
  .iMultipie Offenders; Deterrence of Drinking Drivers, License Revocation and Other Penal-
  ties. Report. St. Paul, MN: Minnesota Department of Public Safety, 1987.
National Institutes of Justice. Mandatory Confinement for Drunk Driving: Zmpacts on the Criminal
   Justice System. Washington, DC: the Institute, 1984.
Nevada, State of. "Nevada's DUI Law Background/Experience/Effect." Informal paper, Depart-
   ment of Motor Vehicles and Public Safety, Carson City, NV, 1986.
New Mexico, State of. "New Mexico Traffic Fatalities, 1982-1987." Informal Report, Traffic Safety
   Bureau, Santa Fe, NM, 1988.

Nichols, J. Recent Trends in the Alcohol-Related Crash Problem in the United States. Washington,
   DC: National Highway Traffic Safety Administration, Office of Alcohol and State
   Programs, 1988.

Nichols, J., and Gundersheimer, A. "A Constraint Upon the Maximum Cost Effectiveness of
  Programs Targeted at Individuals with Poor Driving Records." Unpublished paper,
  National Highway Traffic Safety Administration, Washington, DC, 1974.
Nichols, J.; Ellingstad, V.; and Struckman-Johnson, D. An experimental evaluation of the effec-
  tiveness of short term education and rehabilitation programs for convicted drinking
  drivers. In: Proceedings of NationaZ Council on Alcoholism Annual Forum St. Louis
  Missouri. Washington, DC: National Highway Traffic Safety Administration, 1978.
Nichols, J.; Ellingstad, V.; and Reis, R. The effectiveness of education and treatment programs
  for drinking drivers: A decade of evaluation. In: Proceedings of the 8th International
  Conference on AlcohoJ Drugs, and Traffic Safety, Stockholm, Sweden. Washington, DC:
   National Highway Traffic Safety Administration, 1980.
Nichols, J.; Weinstein, E.; Ellingstad, V.; and Struckman-Johnson, D. The specific deterrent effect
   of ASAP education and rehabilitation programs. Journal of Safety Research 10(4), 1978.
Palmer, J., and Tix, P. Minnesota Alcohol Roadside Survey. St. Paul, MN: Department of Public
   Safety, 1986.

Paulsrude, S., and Klingberg, C. Driver License Suspension: A Paper Tiger? Report No. 32.
  Olympia, WA Research and Technology Division, Department of Motor Vehicles, 1975.
Peck, R.; Sadler, D.; and Perrine, M. The comparative effectiveness of alcohol rehabilitation and
  licensing control actions for drunk driving offenders: A review of the literature. Alcohol,
   Drugs and Driving: Abstracts and Reviews l( 14): 15-39, 1985.
Popkin, C.; Li, L.; Lacey, J.; Stewart, R.; and Waller, P. An Initial EvaZuation of the North Carolina
   Alcohol and Drug Education Trafic Schools: Volume I. Technical Report. Chapel Hill,
   NC: Highway Safety Research Center, University of North Carolina, 1983.


JUDlCih AND ADMINISTRATIVE PROCESSES

Robertson, L.; Rich, R.; and Ross, H.; Jail sententxs for driving while intoxicated in Chicago: A
  judicial policy that failed Luw and Society Review 8:5547,1973.
Rodgers, A, and Clear-y, J. AnaZysis of the Effects of Recent Changes in Minnesota's DWZ Laws,
  Part ZZ: The Peweptions of Minnesota's Drivers. Report. St. Paul, MN: Research Depart-
   ment, House of Representatives, 1983.

Ross, H. The Scandinavian myth: The effectiveness of drinking and driving legislation in Sweden
   and Norway, X& JoumaZ of Legal Studies 4(2), 1975.
Ross, H. The neutralization of severe penalties: Some traffic law studies. L.mv ar;d Society Review
   10(3):403413, 1976.

Ross, H. Scandinavia's drinking-and-driving laws: Do they work? ScMdinavi~ Studies in
   crimlhology, 1978.

mss, H. Deterring the Drinking Driver-Legal Policy and So&Z Control. Lexington, MA: Lex-
   ington Books, Heath, 1982.

Ross, H. Deterring drunken driving: An analysis of current efforts. Journal of Studies on Alcohol
   SuppZement l&122-128,198s.

Ross, H. Administrative license revocation in New Mexico: An evaluation. Law and PoZicy
   9(l):@-16,1987.

Ross, H., and Gonzales, P. The effect of license revocation on drunk-driving offenders. Accident
  Analysis and Prevention 20(5):379-391,1988.

Ross, H.; Klette, H.; and McCleary, R. Liberalization and rationalization of drunk-driving laws in
   Scandinavia. Accident Analysis and Prevention, 16(5/6):471487,1984.
Sadler, D., and Pertine, M. An Evah&on of the California Drunk Driving Countermeasure System
  Vohune 2, The Long-Tenn Trafic Safety Impact of a Pi& AlcoholAbuse Treatment as An
  Ahernativeto License Stqensions. Report No. 90. Sacramento, CA Department of Motor
   Vehicles, 1984.

Saizberg, P., and Klingberg, C. The effectiveness of deferred prosecution for driving while
   intoxicated. Journal of Studies on Alcohol 44:299-306, 1983.
Saizberg, P., and Pauisrude, S. tigal Sanction for Driving WhiZe Intoxicated: Effect of the 1980
   Washington Law on Drunk Driving Recidivism. Research Report No. 51. Olympia, WA:
   Department of Licensing, 1983~.

Sal&erg, P., and Paulsrude, S. Legal Sanctions for Driving While Intoxicated: 7he Effectiveness of
  Short-Temt License Stqension. Research Report No. 50, Olympia, WA: Department of
   Licensing, 19836.

Salzberg, R.,; Hauswer, R.; and Klingberg, CLicense Revocation andAlcohol Treatmentfiograms
  for Habitual Traffic offenders. Report No. 40. Olympia, WA: Research and Technology
   Division, Department of Licensing, 1981.

Siegal, H. Impact of Driver Intervention Program on DW7Recidivism and Problem Drinking. Final
  Report on Contract No. DTNH 2283-C-05150. Washington, DC: National Highway
   Traffic Safety Administration, 1985.

Snortum, J. Alcohol impaired driving in Norway and Sweden: Another look at the "Scandinavian
   Myth." taw and Policy Quartert'y 6(1):5-37, 1984.

Snortum, J.; Hauge, R.; and Berger, D. Deterring alcohol-impaired driving: A comparative analysis
   of compliance in Norway and the United States. Justice Quarterly 3(2):139-165,1986.
Stenzel, W.; Manak, J.; and Murphy, P. An Evaluation of a Community Service Sanction for DWI:
  The Baton Rouge Community Service Work-Program. Report No. DOT HS 807 200.
  Washington, DC: National Highway Traffic Safety Administration, 1987.
Sterling-Smith, R. Psychosocialldentijication of Drivers Responsible for FataZ Vehicular Accidents
  in Boston. Washington, DC National Highway Traffic Safety Administration, 1976.
Stewart, K; Gruenewald, P.; and Roth, T. An evaluation of the specific deterrence effects of
  administrative license revocation. In: Proceedings of the 35th Zntemational Congress on
  Alcohol and hug Dependence, Oslo, Norway, 1988.
Tashima, H., and Peck, R. An Evaluation of the California Drunk Driving Countemwasure System.-
   VoZume 3, An Evaluation of the Specijic Deterrent Effects ofAZtemative Sanctions for First
  and Repeat DW mnders. Sacramento, CA: Department of Motor Vehicles, 1986.
Tn, P., and Palmer, J. Minnesota Alcohol Roadside Srcwey: Sumrmuy of Reports. St. Paul, MN:
   Department of Public Safety, 1987.

Voa~, R. A systems approach to the development and evaluation of countermeasures programs
  for the drinking driver. In: Chafez, M.E., ed. Proceedings of the Fourth AnnualAlcoholi.sm

111


112

BACKGROUND PAPERS

   Conference of the NationaZInstitute ofAkoholAbuse a&Alcoholism. DHEW Publication
  No. (ADM)76-284. Washington, DC: Supt. of Dots., U.S. Govt. Print. Off., 1975.
Voas, R. Drinkingand~vin~Scandinavian Laws, Tough Penaltiesand UnitedStaresAltemtUives.
  Report No. DGT HS-8O6 240. Washington, DC: National Highway Traffic Safety Admin-
   istration, 1982

Voas, R. Evaluation of jail as a penalty for drunk driving. Alcohol, Dnrgs and Drivingz Abstracts
   and zzeviews 2(2):47-70, 1986.

Votey, H. The deterrence of drunken driving in Norway and Sweden: An econometric analysis of
   existing policies. In: Hauge, R., ed. ScMdinavion shldiks in criminolo@ 6:79-99, Oslo,
   Norway: Universititsforlaget, 1978.

Votey, H., and Shapiro, P. Highway accidents in Sweden: Modelling the process of drunken driving
   behavior and control. AccidentAnalysis and Rrvention 15:523-533,1983.
Votey, H.L., and Shapiro, P. Cc&t effectiveness of alternative sanctions. for control of drunken
   driving: The Swedish case. In: Kaye, S., and Meier, G.W., eds. heeding of the Ninth
   International Conference on Alcohol, Bugs, and Trafic Safety, San Juan, Puerto Rico.
   DOT HS806-814. Washington, DC: National Highway Traffic Safety Administration,
    198.5.

Winsten, J. "Drinking and Driving: Scandinavia's Success Story." Transcript of Remarks, Center
   for Health Communications, Harvard University, Cambridge, MA, 1987.
Zador, P.; Lund, A.; Fields, M.; and Weinberg, K Fatal Crash Involvement and Laws Against
  Alcohol-Zmpaired Driving. Washington, DC: Insurance Institute For Highway Safety,
    1988.


113

Judicial and Administrative Processes

Prosecution, Adjudication, and
Sanctioning: A Process Evaluation of
     Post-l 980 Activities

James L. Nichols, Ph.D., Kevin E. Quinlan

National High way Tiafic Safety Administration

Any serious program to reduce alcohol-related crashes must seek to accomplish two
objectives: (1) reduce the recidivism of apprehended offenders by deterring, incapacitat-
ing, or rehabilitating them and (2) deter the general population from driving while
intoxicated (DWI) or impaired. Of these two objectives, the latter is much more
important than the former. The majority of alcohol-related fatal and serious injury
crashes involves drinking drivers who have not been previously apprehended for DWI.
According to the most complete and objective estimates available, nearly 75 percent of
all alcohol-related fatal crashes involve drivers who have never before refused or failed
a chemical test for alcohol (Lewis 1985).

If all the DWI offenders arrested this year were incapacitated, fewer than 5 percent
of next year's alcohol-related fatal crashes would be reduced (Nichols 1988a; Sterling-
Smith 1976). This being the case, a M-percent reduction in recidivism applied to everyone
arrested for DWI would result in a reduction in next year's alcohol-related fatal crashes
of about 2 percent. This is not an insignificant number. Applied nationally, it would
account for an annual reduction of nearly 500 fatalities. Furthermore, many of the repeat
DWIs involved in alcohol-related crashes are chronic offenders who show a complete
disregard for the law and must be dealt with in an effective manner.

However, there is a more important reason to deal with all arrested offenders. What
happens to these people provides the basis for deterring the much greater number of
offenders who have not been caught. On any given weekend night, even in a high
enforcement area, fewer than 1 in 500 drunk drivers are arrested for DWI. In most
jurisdictions, fewer than 1 in 1,000 are apprehended. Over a full year, only about 1 in 20
persons who regularly drive while intoxicated are apprehended. Unless something is
done to deter offenders who have not been arrested, they will continue to drive impaired
and will be involved in approximately 18,000 alcohol-related fatalities each year.

The foundation for deterring these drivers depends on their perception of the like-
lihood of being apprehended and on their perception of what will happen to them if they
are apprehended. They have only the past, publicized performance of the enforcement,
judicial, and licensing systems on which to base their perceptions. That is why the
prosecution, adjudication, and sanctioning components of the driver control system are
so essential to reducing alcohol-related fatal crashes. Not only do they constitute a

NOTE During the period of this writing, Mr. Quinlan was on detail to the National Transportation Safety
bard where he is now employed.


114

mechanism for changing the behavior of known offenders, they also provide a basis for
establishing effective general deterrence.

In the past, the judicial and administrative systems have not korked well, individually
or together, in providing effective and efficient processing and sanctioning of DWI
offenders. There has been very little consistency from one court to another in dealing
with DWI offenders. Prosecutors have had excessive caseloads and little training. Judges
have been overwhelmed and, at least occasionally, disinterested in the DWI problem.
Attorneys have specialized in defending DWI offenders and have created many obstacles
to efficient prosecution, adjudication, and sanctioning During this decade, the public
has become much more interested in the DWI problem than ever before. In fact, for a
short time, driving while intoxicated was one of the more publicized social problems. In
addition to generating media interest in drunk driving, citizen activist groups such as
Mothers Against Drunk Driving (MADD) and Remove Intoxicated Drivers (RID)
demanded the prosecution and sanctioning of drunk drivers to the fullest extent of the
law. As a result, State legislatures passed a myriad of laws, many of H;hich have not been
implemented as intended (Quinlan 1987).

Legislative Changes Since 1980

Some progress was made during the 1980s to deal more effectively with drinking
drivers. Most of the legislative changes are documented in a series of legislative digests
developed by the National Highway Traffic Safety Administration (NHTSA). The most
recent of these digests covers legislation passed through December 1987 (Hatos 1988).
Thousands of DWI bills were considered by the States and hundreds were enacted.
Legislation focused on issues such as reducing or eliminating plea bargaining, increasing
the certainty of license suspensions, encouraging "hard" suspension of driving privileges,
mandating jail or community service, and providing enhanced penalties for repeat
offenders and for those causing injury or death.

By the end of i987,25 States had a mandated minimum license suspension period for
a first DWI conviction; 43 States and the District of Columbia mandated license
suspension after a second DWI conviction (usually for a longer period), and 45 States
mandated suspensions for third or subsequent convictions (Hatos 1988). To counteract
the many delays and inconsistencies that had characterized the courts during the 197Os,
nearly half the States passed laws permitting administrative license withdrawal for
drivers who failed a chemical test for alcohol. Even with these "administrative per se"
laws, however, many States still used restricted and probationary licenses, thus softening
the impact of license sanctions.

In 1982, Congress passed the Alcohol Safety Incentive Grant Program, commonly
called the "Section 408 program". This program provided additional funds to States that
mandated prompt and minimum "hard" suspension periods for all offenders, had illegal
per se laws, mandated 48 consecutive hours of jail or community service for repeat
offenders, and provided evidence of increased enforcement and public information
efforts.

By October 1988, 21 States had adopted such provisions and were qualified for
Section 408 grant funding. Fatalities involving an intoxicated driver declined to a greater
extent (and more rapidly) in the first 10 of these States, compared with nonqualified
States. A second group of 6 qualified States showed somewhat smaller decreases than
the first 10, but still showed lower levels than the nonqualified States (Levy 1987).

The increased seriousness with which the alcohol-impaired offense was being per-
ceived by the legislatures was reflected in the introduction of mandatory minimum jail
sentences for first offenders. By the end of 1987, 14 States mandated minimum jail


JUDICIAL AND ADMINISTRATIVE PROCESSES

115

sentences for first-time DWI convictions, and 42 States mandated jail for second
convictions (Hatos 1988).

Generally, changes in sanctions resulted in progressively more severe sanctions for
more frequent offenders. This reflected some tolerance for lirst offenders but less
tolerance for second and subsequent offenders. By 1988,23 States had habitual offender
laws (Hatos 1988).

Impact of Leg,islative and Other Program Changes
Since 1980

Most States increased DWI arrests from 1980 to 1983, with concomitant increases in
the number and proportion of offenders who were prosecuted, convicted, and sanc-
tioned. A significant increase in public and media attention to the problem was evident
through 1983, as well. After 1983, arrests, convictions, sanctions imposed, and media
attention declined. Meanwhile, however, most States experienced reductions in the
alcohol-related proportion of their fatal crashes until 1985 or 1986, when the proportion
of such crashes began to level-off or rise again (Nichols 1988u). Following are experi-
ences from two States.

Florida

The State of Florida provides an example of how public interest in drunk driving
resulted in legislation and significant increases in enforcement, prosecution, conviction,
and sanctioning of offenders. An evaluation of the Florida experience (Sotter 1986)
indicated that traffic fatalities in Florida increased from 1978 through 1981 along with a
steadily growing public concern over drunken driving. The public perceived that senten-
ces for driving under the influence (DUI) were too light and lacked uniformity and that
a number of loopholes existed. As a result, legislation was passed in 1982 that increased
mandatory minimum lines and license suspension periods for both first and repeat DWI
offenders. In addition, the new law mandated 50 hours of community service for
frost-time offenders.

According to the 1986 report, the 1982 legislation (and the debate that preceded it)
were accompanied by an increase in arrests, convictions, and license actions for DUI.
The average number of days of license revocation for DUI increased from approximately
150 prior to the law to more than 500 by November 1982. The number of permanent
revocations also increased dramatically. Although the provisions of the new law were
not intended to increase the use of confinement, the number of jail sentences increased
by 55 percent from 1981 to 1983.

Repeat offender convictions increased by approximately 20 percent over that same
period. Requests for jury trials remained at less than 3 percent in all counties. Although
chemical test refusals were low, they were higher for repeat offenders than for first
offenders, and conviction rates were lower for repeat offenders who refused such tests.

Followirig the increases in arrests, convictions, and sanctions, nighttime fatalities
began to drop, reaching a low in 1983. It was speculated that the reduction in fatalities
would not have occurred without the significant increase in enforcement by the Florida
Highway Patrol. However, most officials felt that the increased number of convictions,
license actions, and other sanctions contributed to this reduction as well.

Further examination of the Florida experience suggest that the reductions in
nighttime fatal crashes have been maintained. Data from the Fatal Accident Reporting
System (FARS) show that the nighttime proportion of all fatal crashes declined from 63


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BACKGROUND PAPERS

percent in 1982 to 59 percent in 1984 and has remained at approximately that level
through 1987. The proportion of fatal crashes that were single-vehicle, nighttime crashes
dropped from 41 percent in 1982 to 36 percent in 1987 (Nichols 19988b).  +

As in Florida, several States (e.g., New York, New Jersey, Kentucky, Colorado, Utah)
had initial increases in arrests, prosecutions, .and convictions, followed by reductions in
alcohol-related fatal crashes. In most cases, the increases in arrests and convictions were
temporary, although lo- to l5-percent reductions in the alcohol-related proportion of
fatal crashes were usually maintained.

North Carolina

North Carolina provides a somewhat different example in that the number of arrests
and convictions actually decreased. In addition, North Carolina is 1 of more than 20
States that passed administrative license suspension laws to increase the certainty and
swiftness of license sanctions. In June 1983, the legislature enacted the "Safe Roads Act"
(SRA), which made major revisions to the State's drunk driving law. North Carolina
already had a high DWI arrest rate but a very low conviction rate. The legislature
intended to further deter driving whiie intoxicated by imposing more certain and
uniformly severe sanctions. The new law included short-term (administrative) license
suspension for a chemical test refusal or failure; mandatory jail for multiple offenders
and those involved in more serious cases; strict sentencing guidelines; elimination of
lesser included offenses which had been alternatives for plea bargaining; and several
provisions designed to deter young drinking drivers.

A series of reports have described the impact of the North Carolina Safe Roads Act
(Lacey et al. 1984, Lacey 1987,1988). In contrast to the Florida experience, the number
of DWI arrests and the total number of convictions declined following implementation
of the law. However, the proportion of arrested drivers who were convicted increased
significantly (from 59 percent in 1982 to 68 percent in 1986), particularly at BACs of 0.10
and above (from 72 percent in 1982 to 91 percent in 1986).

The courts appeared to follow the intent of the law by nearly always sentencing
persons convicted of more serious levels of DWI (e.g., higher BACs, multiple offenses)
to jail and less serious levels to community service. The number of persons receiving
license suspensions also increased significantly. The administrative suspension law
resulted in immediate (lo-day) license suspensions for virtually all persons refusing or
failing a chemical test. In short, drinking drivers faced a greater certainty of receiving
some sanction once arrested.

Some problems surfaced following implementation of the new procedures. Because
the mandatory jail terms were usually served on weekends, jail overcrowding during
these periods became a problem. In addition, the more complex and lengthy paperwork
associated with processing cases through the court system taxed the manpower resources
of the courts.

In spite of these problems and the reduction in arrests, North Carolina apparently
did achieve some additional certainty in the conviction and sanctioning of arrested drunk
drivers. More importantly, the changes in the way of handling drunk drivers were
followed by a significant decline in the alcohol-related percentage of serious and fatal
crashes, particularly for youthful drivers. Data from North Carolina (and from FARS)
indicated that both the alcohol-related and nighttime proportions of fatal crashes
declined through 1985, after which they remained essentially level. The declines were
somewhat greater than in Florida, ranging from lo-15 percent for nighttime fatal crashes
to 25-35 percent for the alcohol-related proportion of drivers killed.

In North Carolina, the administrative license suspension law, lower BAC levels for
drivers under age 21, provisional licensing for drivers under age 18, raising the minimum


JUDICIAL AND ADMINISTRATIVE PROCESSES

drinking age, and law enforcement efforts aimed at reducing the purchase of alcohol by
minors deserve special mention. This combination appears to have provided a com-
prehensive set of deterrence measures aimed at youthful drivers and centered around
the loss of driving privileges. Most importantly, these measures were accompanied by
50- to 60-percent reductions in the alcohol-related proportion of crashes involving young
drivers. These reductions are of a magnitude not frequently experienced and, according
to the most recent analysis (Lacey 1988), the reductions have been sustained.

117

Other States Enacting Administrative Per Se Laws

As in North Carolina, most States that enacted administrative per se laws were able
to show reductions in alcohol-related fatal crashes following their implementation. Many
have also increased their emphasis on judicially imposed sanctions. Although the
majority of these States also experienced increases in arrest rates (e.g., Oklahoma,
Nevada, Colorado, and Utah), a few did not. North Carolina, Wisconsin, Oregon, and
Indiana provided evidence that, even without increases in arrests, increases in license
actions were accompanied by decreases in the alcohol-related and nighttime proportions
of fatal crashes. Media and public attention were undoubtedly major factors as well.

In some States with administrative per se laws (e.g., Maine, North Carolina, Oregon,
and Wisconsin), the decline in the alcohol-related (or nighttime) proportions of fatal
crashes has leveled out but appears not to have reversed. In other administrative per se
States (e.g., Colorado, Indiana, Mississippi, Missouri, Nevada, Oklahoma, and West
Virginia), initial declines in these indices were followed by slight increases around 1985
or 1986 but by further declines in 1987. In still other such States (e.g., Iowa. Louisiana,
and Utah), initial declines in the alcohol-related or nighttime proportions of fatal crashes
were followed by recent increases that have not been reversed. Finally, in some States
(e.g., Alaska and Wyoming) the enactment of administrative per se laws was followed
by variable patterns in these indices (Nichols 1988b). Overall, a study by Zador, Lund,
Fields, and Weinberg (1988) found that the adoption of administrative per se laws by 18
States resulted in approximately 9 percent fewer alcohol-related fatalities.

Changes in Caseload, Convictions, and Sanctioning

Just how much increase in judicial caseload accompanied the legislative emphasis of
the 198Os? Surprisingly, it does not appear that the increases in arrests, filings, and
convictions were dramatic. In most States, increases in arrests preceded major legisla-
tion. On a national basis, for example, DWI arrests increased by about 13 percent from
1978 to 1980 and by 27 percent from 1980 to 1983. Arrests then declined by about 2
percent from 1983 to 1986 (FBI 1987). While most States passed DWI legislation
throughout the 1980-87 period, the greatest activity for major legislative packages
appears to have been from 1981 to 1983.

A review of DWI arrests from the reports available indicated that, during the years
immediately surrounding major legislation in the various States, changes in the numbers
of drivers arrested for DWI varied from 30-percent decreases (e.g., North Carolina) to
50- to 60-percent increases (e.g., Florida and Minnesota). Using 1980 as a baseline,
increases of 20 to 30 percent in the numbers arrested were typical (e.g., New York, New
Jersey, Utah, Colorado, and California). Arrests began to level off or decline in most
States by 1984.

Changes in the numbers of offenders convicted of DWI varied from 20-percent
decreases to increases of 50 percent (e.g., Kentucky) over baseline levels. Most of the
States appear to have increased the number of convictions by 20-40 percent. Estimated


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BACKGROUND PAPERS

conviction rates generally varied from 70 percent to 90 percent, usually with initial
increases followed by decreases to near baseline levels.     \       v
Following is a sampling of States, from east to west, for which arrest, conviction, or
sanctioning information was found. These data provide an idea of the magnitude and
timing of arrest and caseload changes that occurred after 1980, as well as changes in
sanctioning policies.

Maine implemented major legislation in 1981. Arrests increased 29 percent from 1978
to 1981 (prior to the law) but only 7 percent from 1981 to 1983 (after the law). Arrest
rates returned to prelaw levels by 1984. Over the 6-year period surrounding the legisla-
tion, conviction rates increased from 66 percent to 90 percent of those arrested (Hingson
et al. 1987).

Massachusetfs implemented major legislation in 1982. Hingson et al. (1987) found that
arrests increased by 20 percent in the 3 years prior to the 1982 law and 29 percent after
the law became effective. Convictions increased by 31 percent. The use of jail increased
dramatically from 1980 to 1983 (Massachusetts Senate Report 1984,1986).

New York implemented its "STOP-DWI" legislation in 1981, Arrests increased for 3
successive years following the legislation, then declined slightly. In 1985, there were still
32 percent more arrests and 42 percent more convictions than in 1980. The conviction
rate increased from approximately 82 percent in 1980 to 89 percent in 1985. The use of
jail sentences increased by 56 percent (New York DMV 1985,1986).

In New Jersey, DWI arrests increased by 33 percent from 1980 to 1982, then began to
decline. Convictions showed a similar trend. By 1985, DWI arrests were 15 percent above
their 1980 level. Convictions were only 6-percent higher, having decreased significantly
after 1983. The annual conviction rate varied between 79 and 90 percent of those
arrested, with an average of 85 percent over this period (New Jersey Department of Law
and Public Safety 1986):

Kentucky passed major legislation in 1984. DWI arrests increased the first year
following the law, then declined. By 1986, arrests were only 3 percent above the 1983
level, but convictions were still 56 percent higher than in 1983. The conviction rate
increased from 49 percent in 1983 to 72 percent in 1986 (Kentucky Division of Driver
Licensing, personal communication 1988).

Indiana implemented major legislation in 1982 and 1983. Arrests remained level, but
the number convictions increased by 18 percent after the 1983 legislation. The conviction
rate increased from 63 percent to 77 percent. When no BAC information was available,
the conviction rate was only 48 percent. In contrast, the conviction rate for the more
serious felony DUI charge was 95 percent. The proportion of convicted offenders
receiving license suspensions in Indiana increased from 50 percent before the 1983 law
to 70 percent after the law, but all convicted offenders should have received a court-
ordered license suspension. Similarly, according to Foley et al. (1986), all offenders
should have received an administrative license suspension following the filing of an
affidavit by the arresting officer, but in 20 percent of the arrests, no affidavit was filed.
Approximately 90 percent of the offenders received tines. The proportion of convicted
recidivists who received a jail or community service sentence increased from 70 percent
to 75 percent. The majority of fines and license suspensions was served as sentenced, but
approximately two-thirds of the jail sentences were never served (Foley et al. 1986;
Automotive Transportation Center 1986; Indiana Governor's Task Force 1987).

msconsin implemented new legislation in mid-1982. Arrests decreased by 17 percent
from 1980 to 1982 (prior to the law) and remained approximately level from 1982 to 1983.
However, license suspensions increased by 50 percent from 1980 to 1982 and by another
40 percent in 1983. In 1983, virtually all offenders arrested for Operating While Intoxi-


JUDlCfiL AND ADMlNlSTRATM PROCESSES                                           119

cated (OWI) lost their driving privileges through a combination of judicial and admini-
strative sanctions (Blomberg et al. 1987).

In Minnesota, comprehensive legislation was passed in 1982. DWI arrests increased       -
each year from 1981 through 1984, then declined slightly through 1986. In 1986, arrests
were still 60 percent above their 1980 level. Information on convictions was not available,
btt license revocations increased by 40 percent. However, while the number of admini-
stratively imposed license actions increased by 180 percent, the number of court-
imposed license revocations decreased by 65 percent (Minnesota Department of Public
Safety 1987). As in North Carolina, this suggested that the administratively imposed
license actions may have been substituted for judicially imposed license actions. In
Minnesota, officials have indicated that most first offenders who receive administrative
license revocations are granted restricted driving privileges rather than hard license
suspensions.

Missouri legislation was implemented in 1982 and 1983. DWI arrests increased by 14
percent from 1981 to 1983, decreased by 19 percent from 1983 to 1985 and increased
again by 17 percent in 1986, when they were 7 percent above the 1981 level (Bruce and
Bruce 1988).

,,

Colorado implemented major legislation in 1983. DWI arrests increased by44 percent
from 1980 to 1984, then decreased from 1984 to 1986. Arrests were 21 percent higher in
1986 than in 1980. Convictions for DWI increased by 38 percent from 1981 to 1983
(Colorado Division of Highway Safety 1984, personal communication 1987).

Washington implemented major legislation in 1979. City and county police increased
their DWI arrest activity. Washington State Police first decreased their DWI arrests from
1978 to 1980, then increased such arrests from 1980 to 1981. This pattern is very different
from that in most States such as New York, Florida, Arizona, and California where State
police agencies produced the initial increases in DWI arrests.

After the legislation was implemented in Washington, convictions for DWI increased
by 50 percent and convictions on all alcohol-related driving offenses increased by 21
percent. Overall, a conviction rate of just over 80 percent of those adjudicated was
maintained. A significant shift away from plea bargaining ocurred. The mean daily
population of persons incarcerated for DWI offenses increased by approximately 96
percent from mid-1981 to mid-1983, but there was an increasing tendency for courts to
recommend "no license suspension" for fust DWI offenders. By 1982, nearly half of the
first offenders avoided license suspension (Klingberg et al. 1984).

A More Detailed Look at Changes in DWI Processing

The examples described above give an overview of the types of statewide changes in
caseload and sanctioning policies that the courts experienced during the 1980s. However,
these examples do not provide an adequate view of the effects of legislation on court
processing parameters such as prosecution policies, court congestion, delay of disposi-
tions, records available, and enforcement of sanctions. To get a better idea of these
effects, the California experience is described in more detail, using information from
studies of Los Angeles County (Bloch and Aizenberg 1985), Alameda County (Hepperle
and Klein 1985), Santa Clara County (Lang 1986), and the State as a whole (Perrine 1984;
Helander 1986; Stewart and Laurence 1987). Many of the problems that were identified
by these reports were characteristic of the problems experienced by other States.

Summary of California Legislation
The new laws that became effective in 1982 in California were very similar to laws


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BACKGROUND PAPERS

passed in other States. They provided for (a) an illegal per se offense at 0.10 alcohol
concentration; (b) an attempt to limit judicial discretion; (c) increased fines; (d) poten-
tial jail terms for all offenders and mandatory jail terms for repeat offenders; (e)
increased use of license restrictions; and (f) restricted plea bargaining (Stewart and
Laurence 1987). California did not pass an administrative per se licensing law.

Statewide, DUI arrests increased by 18 percent from 1979 to 1981 (prelaw) and by
another 6 percent from 1981 to 1983, but then declined by approximately 2 percent from
1983 to 1985 (Hepperle and Klein 1985; Lang 1986). The conviction rate for persons
arrested for driving while under the influence increased from 61 percent in 1981 to 68
percent in 1982, an increase of 11 percent. An additional 4 percent of offenders were
convicted of alcohol-related reckless driving (Perrine 1984).

Alameda County

The report by Hepperle and Klein (1985) reviewed the effects of the 1982 law in
Alameda County. It indicated that court processing of DUIs became more complex and
lengthy because of the 1982 law. This finding is parallel to findings in Los Angeles County
and in Florida.

The average time to close a DUI case increased from 48 days (in 1981) to 86 days (in
1983~84), an increase of nearly 80 percent. This occurred because more defendants had
attorneys and waited longer in the process (usually until the pretrial hearing) before
pIeading guilty. Before the law, over half pleaded guilty or no contest at arraignment. By
198384, only 38 percent did so. The percentage of "same day dispositions" declined
from 32 percent (in 1980-81) to 23 percent (in 1983&l), a decrease of 28 percent. Still,
as in most other States, more than 80 percent of the offenders eventually pleaded guilty.
It simply took more court time and effort.

Little evidence was found of plea bargaining, although approximately 16 percent of
arrests failed to result in the filing of a DUI charge. These cases usually involved a BAC
less than 0.13 percent or (asin other States) a test refusal. Only 4 percent of the sampled
cases went to trial, and more than 80 percent of these trials resulted in convictions,
compared with 73 percent in 1980.

Relative to sentencing, the law resulted in higher fines, longer terms of probation, and
frequent use of mandatory DUI school and driver's license restrictions (not full suspen-
sions or revocations). Jail and license suspensions were generally reserved for second or
third offenders, and "straight jail" was less often imposed than "weekend work" and
work furlough. Seventy percent of those sentenced received fines of $500 to $700, not
including the cost of school, treatment, or weekend work. Ninety-five percent of all
sentences included probation, usually with miniial supervision. The use of 90-day
license restrictions increased, but these restrictions seldom resulted in the total loss of
driving privileges. In over half the cases, no license action was taken at all.

Approximately half of ail defendants received jail sentences, but less than a third of
them actually served such sentences. Most did weekend work. This was similar to the
Florida experience, where two-thirds of those sentenced to jail never served their
sentences. In Alameda County, 55 percent of the defendants were repeat offenders. This
is a high proportion, compared with the average of 20-30 percent reported in most States.
An estimated 2.5 percent of those convicted of DUI were rearrested within 2 years. The
report recommended wider use of licensing suspensions (including administrative ac-
tions), vehicle confiscation, and individual treatment.

Los Angeles County

In southern California, Bloch and Aizenberg (1985) evaluated the effects of the 1982
law on the Los Angeles County courts, which processed more than a third of all the DUIs


JUDlcbiie AND ADMINISTRATIVE PROCESSES

in the State. They found that the number of guilty pleas had been risig prior to the law,
hut not as rapidly as the number of filings. Thus, a slow but steady decrease occurred in
the proportion of cases resolved by a guilty plea.

After the 1982 law, the number of guilty pleas dropped signilicantly, while the number
of filings continued to increase, thus lowering the conviction rate even more. Then, in
1983, while the number of guilty pleas remained constant, the number of ftigs dropped.
As a result of these variations, the conviction rate fust decreased from 77 percent in 1981
to 68 percent in 1982, then increased to 73 percent in 1983. Overall, the conviction rate
decreased by 6 percent from 1981 to 1983.

Acquittals and dismissed cases increased by 68 percent and 78 percent, respectively.
However, they constituted less than 4 percent of the dispositions of all filings. Similarly,
while jury and bench trials increased by 55 percent and 7 percent, respectively, they
constituted less than 2 percent of all filings. This was comparable to the 4 percent of
filings resulting in trials in Alameda County and 3 percent in Florida.

Efforts to delay or avoid the effects of sanctions became much more common after
the 1982 law. Continuances, transfers, and failures to appear increased by 78 percent,
ZOO percent, and 23 percent, respectively. As a result, court backlogs increased. The rate
of dispositions to arrests went from 79 percent in 1981 to 72 percent in 1982 and back
up to 77 percent in 1983. In spite of the increase in overall congestion, the report
indicated that the courts were able to function without large-scale disruption or
distortion.

A review of FARS data showed significant reductions in both alcohol-related and
nighttime proportions of fatal crashes from 1982 through 1986 (Nichols 19886). Similarly,
a review of studies by Bloch and Aizenberg indicated reductions in alcohol-related
crashes following the implementation of the law (Bloch 1983,1984, Bloch and Aizenberg
1984; Peck 1983, 1984), although Hilton (1983) cast some doubt that such reductions
were caused by the law. Bloch and Aizenberg speculated that the California law might
have been more successful had it paid more attention to increasing the certainty of
punishment. They also pointed out that no long-term, statewide effort was undertaken
to assist the courts in dealing with their congestion problems.

121

Statewide California Studies

In 1987, Stewart and Laurence completed a statewide study of the California ex-
perience. These researchers provided several additional insights. First, they pointed out
that a survey of prosecutors in 12 counties indicated that nearly all felt that the new illegal
per se law helped reduce plea bargaining and aided in the prosecution of DUI cases.
Still, 90 percent of the convictions were under the older, "presumptive" DUI statute, and
only 5 percent were under the per se statute. An additional 5 percent of convictions were
under both statutes. In addition to the per se law, the practice of plea bargaining was
further restricted by the new law. DUl charges could no longer be reduced to simple
reckless driving, but could be reduced to alcohol-related reckless driving. The latter
charge would be counted as a prior DUI if the offender was rearrested within 5 years.
Prior to the law, the conviction rate was higher for repeat than for first offenders. After
the law, the conviction rates for the two groups were approximately equal.

Despite the public outrage over DUI crashes that resulted in death or injury, felony
DUI cases apparently were not vigorously prosecuted. The Department of Motor
Vehicles (DMV) reported a conviction rate of only 27 percent on felony DUI charges,
compared with a conviction rate of 69 percent for misdemeanor DUI ch,arges (Perrine
1984). This was opposite to the findings in Indiana. Still another study (Helander 1986)
found that less than 20 percent of DUI offenders involved in a fatal or injury crash were
arrested for felony DUI and fewer than 20 percent of those arrested were convicted. In
fact, 35 percent of those arrested for felony DUI showed no record of conviction on any


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charge. Helander indicated that while the law had resulted in an increased conviction
rate for first offenders, it led to a decreased conviction rate for repeat offenders.

                                       \\.      s
  The problem with felony DUI cases apparently involved several aspects of processing,
including the transferring and recording of information. In a study of more than 5,000
convicted first offenders who were enrolled in education or treatment programs, 400
reported that their arrests had involved an injury crash, and 99 reported that their arrests
had involved a fatal crash. A review of DMV records for 245 of the offenders involved
in injury crashes and 60 involved in fatal crashes found that 14-18 percent had no

alcohol-related convictions of any kind on their record. Of the 60 records of drivers who
reported having been involved in a fatal crash, not one showed a fatal crash associated
with DUI or reckless driving.

In most counties, the courts had no information about the number of offenders at
various processing stages in the system. Most counties had no fully computerized
recordkeeping systems. Thus, the court's records were often incomplete, difficult to
decipher, or irretrievable. In addition, problems were found with the accuracy and
completeness of DMV records. Sixty-two percent of fust offenders, reported as dropouts
by treatment programs, were recorded by DMV as having completed the program.
Twenty-three percent did not show a DUI conviction on their records.

Eighty-one percent of repeat offender dropouts were not recorded as such by DMV
(Helander 1986). The failure of agencies, primarily the courts, to transfer information
to the DMV prevented the imposition of mandatory license actions that should have
followed dropout from treatment. Stewart and Laurence pointed to the importance of
the recommendation of the Presidential Commission on Drunk Driving regarding the
need for a comprehensive, statewide tracking and reporting system.

The 1982 law also resulted in more DUI offenders ordered to jail, to treatment, and
to pay higher fines. More license actions were imposed, but they were usually license
restrictions, not actual suspensions or revocations. More offenders received probation
and for longer periods, but few received any offtcial supervision. First offenders who
received probation generally avoided mandatory license actions. In 1984, the typical first
or second offender sanction combination was a line, probation, a restricted license, and
referral to a treatment program. Another frequent pattern for first offenders was a fine,
probation, treatment, and a 2-day jail sentence in lieu of a license restriction. Second
offenders often received a higher fine, probation, and a longer jail sentence than first
offenders (Helander 1986). There was a clear hesitancy to impose any form of hard
license suspension or revocation. This is ironic, since more evidence for the effectiveness
of license sanctions comes from the California DMV than from any other single source
(e.g., Hagen 1977; Peck et al. 1985; Tashima and Peck 1986).

Some of the most important findings covered the enforcement of sanctions. The most
common violation of probation for first offenders was failure to pay the line (15 percent
of first offenders studied). Because of jail overcrowding, fewer than half the offenders
sentenced to jail actually spent time incarcerated. Often months passed before space
was available for an offender to serve even a 2-day sentence. Weekend sentences made
the probIem even more severe. Sometimes offenders would register and be sent home
because the jail was full. Some jurisdictions allowed offenders to participate in super-
vised work programs.

Enforcement of license actions was particularly weak. The 1982 legislation increased
the mandatory penalties for convicted DUI offenders who drove while suspended or
revoked. However, the conviction rate for such offenders fell substantially after the new
law took effect, from 46 percent in 1981 to 26 percent in 1982. Stewart and Laurence
speculated that prosecutors and the courts were resisting the enforcement of licensing
sanctions.

In summary of their statewide review, Stewart and Laurence suggested that while the


JUDICIAL AND ADMINISTRATIVE PROCESSES

123

certainty of some punishment for first offenders occurred as a result of the 1982 law, the
certainty of punishment for repeat offenders actually decreased following implementa-
tion of the new law. As in Florida, the swiftness of punishment decreased following the
new law in California. Furthermore, and perhaps most importantly, license actions were
applied unevenly and enforced weakly. In spite of the convincing evidence for the
effectiveness of license actions in reducing recidivism and in creating general deterrence,
actual suspensions or revocations were most often traded off for treatment, restricted
licenses or, in some cases, Zday jail sentences. In addition, very little emphasis was
placed on enforcing license actions when they were applied. These problems have been
reported in a number of other States (e.g., Massachusetts, North Carolina, and
Washington).

Summary of Changes and Impacts

What can we conclude from the information reported by these States? Did the tougher
laws of the early 1980s make prosecution and adjudication more efficient or more
difficult? Information from several States suggested that illegal per se, improved implied
consent, and perhaps administrative per se laws facilitated prosecution and adjudication.

On the other hand, more severe and mandatory sentences and anti-plea bargaining
laws often increased the difficulty of processing cases. Thii increased difficulty led to
more frequent use of defense lawyers, longer periods from arrest to case disposition and,
in some cases, an increased number of trials requested (although trials accounted for a
very small percentage of all dispositions in most jurisdictions). Furthermore, mandatory
sentences were generally viewed unfavorably by judges who frequently found ways to
circumvent them, particularly with regard to license actions and jail sentences.

Has legislation resulted in greater or lesser certainty of conviction and punishment?
In most cases, the certainty of conviction increased, at least temporarily. Most States
reported increased numbers of persons convicted (largely due to increased arrests) and
increased proportions of those arrested who were convicted. Administrative per se laws
have increased the certainty of at least one punishment. In addition, restrictions on
plea-bargaining made it more likely that offenders would be convicted on an alcohol-re-
lated charge. A 1986 NHTSA study indicated that anti-plea bargaining laws were
effective, but that judicial cooperation was essential.

Some sites experienced sharp increases in conviction rates and, in other sites, already
high convictions rates were maintained. In Fort Smith, Arkansas, a study by Surla, Voas,
Koons, and Reiner (1987) found that the elimination of plea bargaining resulted in a
conviction rate increase from 72 percent (prelaw) to 88 percent (postlaw).

It also appears that more offenders received at least some sanctions, including lines,
license actions, jail, and community service. While this was true of license actions as well
as the other sanctions, many courts (and administrative agencies) appeared to have made
an effort to avoid the use of hard license suspensions.

Was the severity of sanctions increased? While severity varied somewhat, most States
reported increased levels of fmes, use of jail sentences (even for first offenders), and use
of community service. Again, with license actions, the answer was less clear. While more
offenders received some form of license action, this was frequently accomplished by
administrative license actions that were less severe (e.g., 90 days) than the maximum
criminal sanctions (e.g., 1 year) that could have been imposed by the courts. In several
States, courts did not impose license sanctions if they were already being imposed
administratively. Even in States without administrative per se laws, efforts were made to
avoid using hard license suspensions.


124

BACKGROUND PAPERS

Have the existing procedures and laws deterred the drinking driver? Fewer drii
drivers are on the road today than in the 1970s (IIHS 1987; Palmer and Tii 1986; Tii
and Palmer, 1987). Also, fewer drivers are at the higher alcohol concentrations. Most
importantly, nearly every index of alcohol-related crashes has shown lo- to l5-percent
reductions in the problem since 1982. Greater reductions have occurred among young
drinking drivers. Many factors have combined to cause these reductions. Among them
are increased enforcement, publicity, and public interest. However, the evidence regard-
ing the effectiveness of sanctions, combined with the increased application of sanctions
in the 198Os, suggests that the increased prosecution, adjudication, and sanctioning
activities have contributed to these reductions.

What are the most effective sanctions? For the deterrence of first offenders and
would-be offenders (i.e., general deterrent effect), the swift and sure application of
license suspensions has been more effective than any other measure (Nichols and Ross,
this volume), Evidence also shows that signiticantly higher fines have had both specific
and general deterrent effects for first-time offenders (Home1 1981; Tashima and Peck
1986; Votey and Shapiro 1985). In addition, mandatory minimum fines can be used, as
they are in New York State, to provide a funding mechanism for supplying the police,
prosecutors, and the courts with the resources they need to sustain a deterrent effort.
Also, 2-day jail sentences for first offenders can evidently have both specific and general
deterrent effects (Falkowski 1984; Cleat-y and Rogers 1986; Zador et al. 1988; Jones et
al. 1988). However, the use of a jail sanction is considerably more costly than other
sanctions and causes more disruption of the courts.

Finally, for more severe repeat offenders, particularly chronic offenders, neither
existing sanctions nor rehabilitation programs alone have had any significant effect.
Confinement in special facilities, with provisions for assessment and referral, can have
some impact (Siegal 1985). Clearly, more emphasis must be placed on keeping such
offenders off the highways until some medical evidence is provided that their drinking
problems have been addressed.

Has progress been made in deterring repeat offenders or suspended drivers from
continuing to drive? For repeat offenders and those who continue to drive after license
suspensions, there is growing interest in more severe license sanctions, license plate
confiscation, vehicle impoundment or confiscation, and surveillance by special patrols.
However, such actions have been inadequately applied and evaluated. This area deserves
much more attention than it has received.

How can we solve the existing DWI adjudication problems of the judiciary? If we take
advantage of what we have learned from our past experiences and find more effective
ways to communicate these findings to prosecutors, judges, legislators, and other offs-
cials, we should be able to increase the eflectiverress of prosecution and judicial actions.

The remaining problem will then be eficiency. Effective prosecution and sanctioning
efforts will likely continue to have adverse effects on the efficiency of the courts because
of resistance by defendants and defense lawyers. One recourse is to provide the courts
with adequate resources so they can continue to function, taking whatever time is proper
and necessary to carry out their duties. The courts can provide more certainty to the
conviction and sanctioning process given adequate time and resources to do SO,

Remaining Issues and Problems in Processing
Apprehended DWls

In the wake of the legislative changes of the 1980s and the increased arrests that
accompanied these changes in many States, court overload and backlogs have presented


JUDICIAL AND ADMINISTRATIVE PROCESSES                                            125

continued obstacles to effective and efficient prosecution and adjudication of DWI
offenders. While legislation (e.g., illegal per se laws) has been passed to facilitate
prosecution, more severe penalties have frequently resulted in fewer guilty pleas (at least
early in the process) and more involvement by defense lawyers. The result has often been
longer periods from arrest to disposition.

In addition to case overload, inadequate training of persons who are assigned DWI
cases remains a major problem. Prosecutors, judges, probation officers, and other
professionals in the adjudication system frequently have limited understanding of the
drunk driving problem and its complexities. Chief prosecutors consider most law school
graduates inadequately prepared in procedural and trial advocacy skills. Usually no
formal entry training, other than a brief orientation, is provided for newly appointed
assistants. In addition, most lower court judges receive little or no training prior to their
election or appointment to the bench. A few States require continuing education
programs for sitting traffic court judges during their tenure on the bench (Quinlan 1987).
The problems of court overload and inadequate training, combined with the inherent
independence of the judiciary, frequently result in the imposition of either inadequate
or inappropriate sanctions. Little knowledge or consensus exists about sanctioning
policies that would be proper and effective. Knowledge about the effectiveness of various
sanctions has less often been taken into account than have operational impacts. The
result has been a failure to more effectively change the behavior of those offenders who
are apprehended and to more effectively deter offenders who are not caught.
In summary, the problems that remain in the processing of DUI offenders include the
following.

o  Overload and backlogs

o  Inadequate training for prosecutors and judges

o  Inadequate resources to avoid disruption of the system and distortion
of sanctions imposed

o  Plea bargaining (especially to a non-alcohol-related offense)

o  Excessive delays between arrest and disposition

o  Offenders not prosecuted or con&ted on DWI charge

o  Lack of consensus regarding effective sanctioning policies

o  Excessive and inappropriate exceptions to sanctions

o  Diversion into education or treatment in lieu of, rather than in addition
to, other sanctions

o  Failure to deal with offenders who violate terms of sentences

o  Failure to more effectively reduce recidivism

o  Failure to more effectively deter offenders who are not caught

a  Failure to effectively track offenders from arrest to completion of
  sanctions

Many of the reports reviewed for this chapter, as well as a review of the literature on
the effectiveness of sanctions (Nichols and Ross, this volume), emphasized the impor-
tance of swift and sure license suspensions in reducing alcohol-related crashes. In
addition, several studies pointed to the need for followup to ensure that suspensions
were not violated. The use of surveillance patrols, more severe suspensions, license plate
confiscation, vehicle impoundment or confiscation, and confinement have frequently
been proposed for dealing with suspended offenders who continue to drive.

A consensus appears to be growing that every reasonable effort should be made to
impose meaningful, hard license sanctions and to ensure that such penalties are fulfilled.
A review of Missouri's experience with DWI legislation in the 1980s (Bruce and Bruce


126                                                        BACKGROUND PAPERS

1988) pointed out that "nothing seems to be as important to the American driver as that
plastic card evidencing the right' to drive upon the public highways. Defense attorneys
will readily admit that their primary responsibility, and the reason they are retained by
their clients, is to make sure their client keeps his or her license." Polls conducted in
Minnesota (Rodgers and Cleary 1983) and other States indicated that the loss of license
was the most feared penalty among drivers who had not been arrested for DWI. A
problem of driving while suspended does exist. However, additional emphasis should be
placed on resolving that problem, rather than abandoning or circumventing the most
effective sanction known.

A report on Ohio's DWI experience by Katz and Sweeney (1984) suggested that
convicted drunk drivers who continue to drive after their licenses have been suspended
constitute a significant threat to the safety of others and must be dealt with more severely
than in the past. These authors further suggested that "the mandatory surrender of
license plates during suspension periods should be required if the offender is the holder
of plates and consideration should be given to requiring the surrender of license plates
if a vehicle owner permits an unlicensed driver to operate his vehicle."

Many judges have claimed that the use of hardship or occupational licenses is
necessary to avoid loss of employment by the offender. However, studies conducted in
Delaware (Johnson 1986) and in Mississippi (Wells-Parker and Cosby 1987) indicated
that very few offenders lost employment because of lost driving privileges.

NHTSA Recommendations

In 1987, NHTSA implemented a series of State workshops to review the status of the
DWI problem and to explore ways to reduce it. A manual was developed to provide
background in the various areas of DWI prevention and control, In the adjudication
section, recommendations were made regarding the prosecution, adjudication, and
sanctioning of DWI offenders (Quinlan 1987). Following is a summary of those recom-
mendations, many of which dealt with the problem of establishing adequate training and
communication programs.

Prosecution

1. Establish through the District Attorney's training office or the Attorney

General's office, a DWI prosecution assistance center.

2. Develop a State DWI trial manual, or adapt the NHTSA manual.

3. Develop a DWI prosecutor seminar and self-instruction program.

4. Conduct specialized training for junior prosecutors.

5.  Develop case-tracking and prosecutor performance systems.

6.  Pilot test the elimination of plea bargaining in DWI cases.

7. Develop a DWI section to a prosecutors newsletter.

Adjudication

1. Through the State judicial education ofticer, develop a DWI adjudication
support program for judges.

2. Develop a State DWl bench book (or use the NHTSA bench book).

3. Develop a DWI seminar and self-instructional training program.


JUDICIAL AND ADMINISTRATIVE PROCESSES

127

4. Encourage judges to participate in specialized training of DWI adjudication.

5. Develop/implement a DWI case-tracking system at the lowest court level for use
in that court and community. Integrate with a statewide tracking system.

6. Use a standardized psychometric test as the basis for drinker classification and
referral to treatment. Ensure that personnel using the test are adequately
  trained.

Sanctions

1.

2.

3.

4.

5.

6.

Enact and implement administrative per se legislation.
Conduct a review of sanctions which can be applied to DWI offenders.
Develop a State sanctioning policy and grid (or matrix) to aid the courts in
developing packages of sanctions appropriate to DWI offenders.
Implement jail/treatment combinations for multiple offenders in conjunction
with long-term outpatient aftercare and support.
Implement community service programs as an alternative to jail, when jail
crowding is a problem or for certain populations (e.g., youthful offenders).
Provide long-term probation as a means of ensuring compliance with sanctions
and participation in treatment programs or for certain populations (e.g.,
youthful offenders).

7.  Eliminate diversion programs.

Status of Recommendations by the Presidential
Commission on Drunk Driving

In November 1983, the Presidential Commission on Drunk Driving issued its final
report. This report contained a number of recommendations that have direct relevance
to the prosecution, adjudication, and sanctioning of DWI/DUI offenders. Since the
Commission spent considerable time and effort developing its recommendations, it is
appropriate to review them and the status of State programs that relate to them, before
making additional recommendations.

The Commission made recommendations regarding driving while under the influence
in 10 major areas: public awareness, public education, private sector, alcoholic beverage
regulation, systems support, enforcement, prosecution, adjudication, licensing admini-
stration, and education and treatment (Presidential Commission 1983). Following are
the recommendations most relevant to the purposes of this review. Included with the
recommendations is available information on the status of legislation and/or programs
related to these recommendations. This information was not part of the Commission's
recommendations. Much of it comes from NHTSA's Legislative Digest (Hatos 1988)
and was current as of January 1988.

Systems Support

Program Financing

Legislation should be enacted at State and local levels that creates a dedicated
jimding source including offender fines and fees for increased efforts in the


128

BACKGROUND PAPERS

enforcement, adjudication, sanctioning, education, and treatment of DUI
offenders.

The NationalCommission Against Drunk Driving (NCADD) indicated that in 1988
approximately 40 States had user funding for at least some of the components of their
DUI control system. New York provides the best examp1.e of such a system.

The availability of adequate resources for the courts to process DWI cases is essential
for an effective deterrent effort. More cases and more severe penalties, combined with
less plea bargaining and fewer exceptions to sanctions, will result in significantly greater
demands on the court. However, the courts can withstand these pressures if adequate
resources are provided.

Citizen and Public Support

Grassroots citizen advocacy groups should be encouraged Co continue fosieting
awareness of Ihe DU. problem, and to cooperrte with government oficiuls,
prosecutors and judges to &al more effective@ with the alcohol-related crash
problem.

In 1988, these groups were active in nearly every State, but a CatholicUniversity Study
(McCarthy et al. 1987) suggested that the number of new chapters has been declining
since 1983. These groups provided the impetus for the progress made in the 1980s.
Without active citizen concern for this issue, it is unlikely that further progress can be
made.

State and local governments should create task forces of governmental and
nongovernmental leaders lo increase public awareness of the problem and
should apply more efleclively DUI laws.

By 1984, more than 40 States had such task forces. Very few were known to be in
existence in 1988. This is unfortunate, since they provided the blueprints for State action
in the beginning of the decade.

Criminal Justice System Support

Police, prosecurors and courts shouldpublicly assign a high priority to enforcing
DUI statutes.

Most States increased their priority on DUI enforcement, prosecution, and adjudica-
tion in the 1980s. Since 1985, emphasis appears to have waned.

Police, prosecutors, judges, and other related justice system personnel should
participate in entry level and annual inservice trainingprograms established to
improve the detection, prosecution, and adjudication of DUI offenders.

An estimated 36 States had ongoing programs for prosecutors and judges in 1988.
Still, the majority of prosecutors and judges have apparently never received training or
attended seminars regarding the DWI issue.

Prosecutors shouldprovide local enforcement agencies and courts with periodic
legal updares on developments andlor changes in the DUI laws.

No additional information available

The Chief Justice or highest appellate judge in each State should convene an
annual meeting of aN components of the regal system to review the progress and
problems relating lo DUI offenses.

No additional information available.


JUDlCktL AND ADMINISTRATIVE PROCESSES

Tracking and Reporting Systems

129

Police prosecutors and courts should collect and report DUI apprehension,
charging, and sentencing information to the State licensing authority. Convic-
tions on military and Federal lands, including Indian tribal lands, should also
be reported. The State licensing authority must maintain a traffic records system
capable of tracking offenders from arrest to conviction, in&ding sanctions
imposed by judicial and licensing authorities.

From the reports reviewed, it appears that most courts do not have automated
systems. Only a handful of States have attempted to develop a statewide data system and
no known statewide tracking systems exist. Some community-level tracking systems exist
but are not integrated into State systems. This is an important deficiency that should
receive additional emphasis.

Enforcement

Chemical Testing

Each State should establish an "implied consent" statute which provides that
all drivers licensed in the State are deemed to have given their consent to tests
of blood, breath, or urine to determine their alcohol or drug concentration.

As of January 1988, all 50 States had implied consent laws in some form. In 31 States
and the District of Columbia, such laws applied to other drugs as well. If properly
formulated, these laws provide an important incentive for drivers to provide alcohol
concentration information. Such information, in turn, plays a major role in the ability to
successfully prosecute and convict drinking drivers.

One of the most important provisions of an implied consent law is that the penalties
for refusing must be greater than tlzose for either a DWI or an iilegaI per se conviction. In
1988, it was estimated that approximately half the,States had implied consent penalties
that were more severe than penalties for a conviction of DUI or illegal per se.

Other important provisions of an implied consent law are:

(a) that a test refusal can be introduced at a DUI trial as evidence of conscious-
ness of guilt; (b) that offenders who are unconscious or othenvise incapable of
refusal are deemed to have given their consent to a test, the results of which are
admissible in any trial orproceeding (c) that an individual's right to consult
his attorney may not be pennitted to unreasonably delay administration of the
test; (d) that results ofpreliminary breath test devices be admissible in tlte DUI
trial proceedings, and (e) that refusals in sister States shah result in license
suspensions in the State of aiiver residence.

Prosecution

Plea Bargaining

Prosecutors and courts should not reduce DUI charges.

AS of January 1988,13 States either prohibited or limited plea bargaining. While many
prosecutors feel that plea bargaining is essential, it undermines attempts to create
general deterrence. Proven sanctions such as license suspensions often cannot be
imposed if the offense is plea bargained.

Definition of BAC

States should enact a definition of breath alcohol concentmtlon and make it


130

BACKGROUND PAPERS

illegal to dnve or be in control of a motor vehicle with a breath alcohol
concentration above that level.

Ai of January 1988, 14 States plus the District of Columbia defined illegal alcohol
concentrations in terms of breath alcohol (BRAC) as well as blood alcohol (BAC)
concentrations.

lllegal Per Se at 0.10 Alcohol Concentration

L.egi>Iation should be enacted making it illegal per se for a person with an
alcohol concentration of 0.10 or higher within 3 hours of arrest to drive or be in
actual physical control of a motor vehicle.

As of January 1988,44 States plus Puerto Rico had illegal per se laws.

Appellate Action

Prosecutors should initiate appropriate appellate actions to ensure judicial
compliance with statutory mandates governing DUK cases. . . . courts frequently
&ore mandatory sentencing requirements in DUI cases. UXess the prosecutor
is willing to seek an appellate remedy, the practice will continue unchecked.

Adjudication

Mandatory Sentencing

llle sentences recommended upon conviction of driving under the influence
should be mandatory and not subject to suspension orprobation. Specifically,
the recommendations are that:

Ail States establish substantial mandatory minimum fines for DUI offenders,
with correspondingly higher mandatory fines for repeat offenders.

As of January 1988,16 States had mandatory minimum fines for first offenders.

Any person convicted of afirst violation of driving under the influence should
receive a mandatory license suspension for a period of not less than 90 days,
plus assignment of 100 hours of communi@ service or a minimum jail sentence
of 48 consecutive hours.

As of January 1988, 24 States had mandatory minimum license suspension for
first-time offenders; 7 States mandated jail or community service for first offenders, and
an additional 7 States mandated jail without any provisions for community service.

Anyperson convicted of a second violation of driving under tile inji'uence within
5 years should receive a mandatory minimum jail sentence of 10 days and
license revocation for not less than 1 year.

As of January 1988,14 States mandated some period of jail or community service, and
an additional 28 States mandated jail without any provision for community service for
second-time offenders; 43 States and the District of Columbia mandated license suspen-
sions or revocations for second offenders.

Any person convicted of a third or subsequent DUI violation within 5 years
should receive a mandatory minimum jail sentence of 120 days and license
revocation for not less than 3 years.

As of January 1988, 39 States mandated jail for a third offense. Nearly all States
mandated license suspension for a third offense.


JUDICIAL AND ADMINISTRATIVE PROCESSES

131

Sentencing of Suspended Drivers Who Continue to Drive

Stales should enact a statute requiring a man&tory sentence of al least 30 days
for any person convicted of driving with a suspended or revoked license or in
violation of a restriction due lo a DUI conviction.

Few States have effectively implemented such sanctions, alth,ough some appear
interested. Some States have also been considering attacking the problem of driving
while suspended by confacating the license plates or the vehicles of such offenders. The
license plate confiication approach is intended to make driving while suspended a more
visible offense. It has the added advantage of little or no cost.

Felony DUI

Causing death or serious injury to others while driving under the influence
should be classified as a felony.

In 1988, 44 States and the District of Columbia had death-related offenses, often
called vehicular homicide. In 38 States and the District of Columbia, this constituted a
felony charge, and in 6 States it was a misdemeanor.

Court Administration

Spee& trial: DUI cases al the trial levelshould be concluded within 60 days of
arrest. Sentencing should be accomplished within 30 days. The appellate
process should be expedited and concluded within 90 days.

From information reviewed, it appears that few courts have achieved this.

Preconviction Diversion

Preconviclion diversion to alcohol education or alcohol rreatmenr programs
should be eliminated. AJindingon the charge should be rendered andparticipa-
tion in education or treatment programs should then become a condition of
sentencing.

Although most States have eliminated statewide diversion programs, a few States and
courts in several States still regularly divert offenders from sanctions into education or
treatment. Often in such systems, no conviction and no record of an alcohol-related
offense exists.

Presentence Investigation

Before sentencing, a court should obtain and consider upresentence investiga-
tion report detailing the defendant's driving and criminal record and, where
possible, an alcohol problem assessment report. In all cases, an alcohol
problem assessment report should be completed by qualifiedpersonnelprior lo
rhe determination of an education or treatmentplan.

NCADD estimated that 23 States complied as of 1988.

Victim Programs

Any person cdnvicted of driving under the influence who causes personal injur>,
orproperty damage should pay res&ution.
As of 1988, NCADD estimated that 42 States complied.

The U.S. Congress should enact legislarion that eliminates the possibility rhat
a dnrnk aver, judged civilly liable, will be able to escape the penalties of civil
action by filing for bankmp~q.


132

No additional information available.

State and local governments or courts by rule should require victim impact
statements (including oral or written statements by victims or survivors) prior
to sentencing in all cases where death or serious injury results from a DUI
offense.

Licensing Administration

Administrative Per Se License Suspension

States should enact legislation to require prompt suspension of the license of
drivers charged with DUI upon a finding that the driver had a BAC of 0.10 in a
legally requested andproperly administered test. 77zeprompt suspension should
also extend to those who refuse the test (i.e., implied consent), as ~$1 as those
who are tiving in violation of a restricted license.

As of the end of 19&3,24 States plus the District of Columbia had administrative per
se laws, with many variations in the provisions of these laws.

Restricted Licenses

Each State driver's licensing authority should review irs practice of issuing
occupational hardship dn'ver's licenses following suspension or revocah*on and
establislt strict uniform standards relative to issuance and control of such
limited driving privileges. i%ese licenses should be issued only in exceptional
cases. In no event should this be done for repeat offenders.

In fact, most States with mandatory license revocation, whether by the court or by the
administrative process, make extensive use of restricted, occupational, and probationary
licenses. Only about 21 States (i.e., those qualified for 408 incentive grant funds) have
mandatory, minimum hard 1iCense periods during which restricted licenses are not to be
issued.

Provisional License for Young Drivers

States sllould adopt laws providing a provisional license for young beginner
drivers which would be withdrawn for a DUI conviction or an implied consent
refusal.

Education and lkeatment

Assignment Process

Rekabilitation and education programs for individuals convicted of DUZ
should beprovided as a supplement to othersanctions andnot as a replacement
for those sanctions.

Although most States appear to have moved away from diversion programs, some still
make extensive use of them and allow sentencing to treatment programs in lieu of a
conviction or a license or jail sanction.

Presentence investigations, including alcoJzo1 assessments conducted by
qualified personnel, sltould be available to all courts in order to appropriately
classify the defendant's problem with alcohol. Repeat offenders should be
required to undergo medicalscreeningfor alcoholism by a physician trained in
alcoholism, an alcoholism counselor, or by an approved treatment facility,

NCADD estimates that only 23 States require a presentence of a postsentence
investigation. Fewer specify the type of personnel required to administer such tests.


JUDICIAL AND ADMINISTRATIVE PROCESSES

AlcoJtol education programs sltould be used only for those first offenders WJIO
Jlave had no previous exposure to suclt programs. Problem drinkers and repeat
offenders should be referred to more intensive rehabilitation programs.
No additional information available.

AlcoJ~ol treatment and rehabilitalion programs should be available for in-
dividuals judged to need such services. The programs should be tailored to the
individual's needs and the individual sltould be assigned to such programs for
a length of time determined by treatment personnel and enforced by court
probation.

Most States use existing treatment facilities. It is not known how many programs
include treatment tailored to the specific needs of the offenders.

Compliance

  When assignments are not complied with, the COWS or the administrative
licensing agency must take steps to impose furtrter restrictions on driving
privileges or to assessjiutJlerpenalties as spelled out in tlte origirlal sentence.
Evidence from the States suggests that this remains an important problem to be
resolved.
A records reporting system sltould be available to assure lhar individual of-
fenders assigned to education or treacmenf services do in fact comply witJl tJle
  assignments and fo make information on compliance available to motor
  vellicle administration officials at tlte time of appearance for relicensing.

Tracking of individual offenders from arrest through completion of sanctions remains
a goal to be achieved. Software has been developed to aid community-level tracking
systems.

REFERENCES

Automotive Transportation Center. "Do Laws Make a Difference? An Analysis of Indiana's 1983
  Anti-Drunk Driving Law." Report to,the Governor's Task Force to Reduce Drunk
   Driving, Purdue University, West Lafayette, IN, 1986.
Ilruce, T., and Bruce P. The legislative response to the drunk driving dilemma: An empirical
  analysis of its success and failure (in Missouri). St. Louis University Law Journal, in press.
I3loch, S. One year later: A preliminary assessment of the effectiveness of California's new drinking
  and driving laws. Abstracts and Reviews in Alcohol and Driving 4(2):9-20, 1983.
filoch, S., and Aizenberg, R. The effects of tough DUI laws: California's first twenty months.
   Journal of Trafic Safety Education 3 l(2): 1984.
Bloch S., and Aizenberg, R. "The Effects of Tough Drinking and Driving Laws: An Examination
  of the Judicial and Traffic Safety Experience of California. Paper presented at the 1985
  Annual Meeting of the Academy of Criminal Justice Sciences, Las Vegas, NV, March 31,
    1985.

Blomberg, R.; Preusser, D.; and Ulmer, R. Deterrent Effects of Mandatory License Sqxmion for
  DWZ Convictions. DOT HS 807 138, Washington, DC: National Highway Traffic Safety
   Administration, 1987.

Clcary, J., and Rodgers, A.Analysis of the Effects of Recent Changes in Minnesota's DWILaws. St.
   Paul, MN: House of Representatives Research Department, 1986.
Colorado Division of Highway Safety "A Decade of Progress." Denver, CO: the Division, 1984.
Fatkowski, C. "The Impact of Two-Day Jail Sentences for Drunk Drivers in Hennepin County,
  Minnesota." Final Report on Contract No. DTNH-22-82-05110, National Highway Traf-
   fic Safety Administration, Washington, DC, 1984.
Federal Bureau of Investigation. Crime in the United States. Uniform Crime Reports, Washington,
   DC: U.S. Department ofJustice, 1987.

Foley, J.; Doherty, M.; and Habegger, J. Dnmk Driver Recidivist Penalties in Indiana for 1985.
  Report to the Governor's Task Force to Reduce Drunk Driving. West Lafayette, IN:
  Automotive Transportation Center, Purdue University, 1986.

133


134

BACKGROUND PAPERS

Hagen, R. Effectiveness of License Suspe?uion for Drivers Convicted of Multiple Driving-Under-
  i'he-Injluence offenses. Report No. 59, Sacramento, CA: Department of Motor Vehicles,
    1977.

Helander, C. lXe California DUI Countermeasure SystemAn Evaluation of System Processingand
  Deficiencies. Sacramento, CA: California Department of Motor Vehicles, 1986.
Hepperle, W., and Klein, D. DUIAdjudication Evaluation Project. Alameda County, CA: Office
   of Court Services, 1985.

Hatos, S. DWI legislation. In: I?ze 1987-88 Alcohol Highway Safety Workhop Series Reference
   Manual, Washington, DC: National Highway Traffic Safety Administration, 1987.
Hatos, S. .!qi.&ive Digest. Washington, DC: National Highway Traffic Safety Administration,
      1988.

Hilton, M. The Effectiveness of Recent Changes in California Law ar Drinking Driving Counter-
  meauues: An Interrupted Time-Series Analysir. Berkeley, CA: Alcohol Research Group,
    1983.

Hingson, R.; Heeren, T.; Kovenock, D.; Mangione, T.; Meyers, A; Morelock, S.; Lederman, R.;
   and Scotch, N. Effects of Maine's 1981 and Massachusetts' 1982driving-under-the-influ-
  ence legislation. American Journal of Public Health 77(5):593-597, 1987.
Homel, R. Penalties and the drunk/driver: Astudy of one thousand offenders.Au.wczZi# and New
   Zealand Journal of Criminology 14:225-241,1981.
Insurance Institute for Highway Safety. Drinking and Driving Down Sharply in U.S. During Last
   13 Years. Washington, DC: the Institute, 1987.
Indiana Governor's Task Force. The Governor's Task Force to Reduce Drunk Driving 1987
  Progress Report. Indianapolis, IN: the Task Force, 1987.
Johnson, D. The Effect of Administrative License Revocation on Employment. Washington, DC:
  Office of Alcohol and State Programs, National Highway Traffic Safety Administration,
    1986.

Jones, R.; Joksch, H.; Laccy, J.; and Schmidt, H. "Field Evaluation of Jail Sanctions for DWI."
  Final Report, Mid-America Research Institute, for the National Highway Traffic Safety
   Administration, Washington, DC, 1987.

Katz, L., and Sweeney, R. Ohio's new drunk driving law: A halfhearted experiment in deterrence.
   Case Western Reserve Law Review 34(2/3), 1984.
Kiingberg, C.; O'Connell, P.; Saizberg, P.; Chadwick, J.; and Paulsrude, P. An Evaluation of
  Washington State's 1979 Driving While Intoxicated (Dwr) Laws. NHTSA Report DOT HS
   806 838, Washington, DC: NHTSA, 1984.

Lacey, J.; Popkin, C.; Stewart, R.; and Rodgman, E. Beliminq Evaluation of the North Carolina
  Safe Roads Act of 1983. Chapel Hill, NC: Highway Safety Research Center, University of
   North Carolina, 1984.

Lacey, J. Safe RoadrAcf Updare. Chapel Hill, NC: Highway Safety Research Center, University of
   North Carolina, 1987.

Lacey, J. Safe Roads Act Update. Chapel Hill, NC: Highway Safety Research Center, University of
   North Carolina, 1988.

Lang, K. Santa Clara County Driving Under the injluence Arrest Data Analysb. Santa Clara, CA:
   Santa Clara County Alcohol Bureau, 1986.

Levy, P. "Analysis of Proportion of Drivers Intoxicated in 408 and non-408 States." Unpublished
  report. Office of Alcohol and State Programs, National Highway Traffic Safety Admin-
   istration, Washington, DC, 1987.

Lewis, R. Estimates of DWI Recidivism in Minnesota Fatal Crashes. St. Paul, MN: Minnesota
   Criminal Justice System Task Force, 1985.

Massachusetts Senate Committee of Post Audit and Oversight Drunk Driving in Massachusetts:
   1984 Stafzis Report. Boston, MAz the Committee, 1984.
Massachusetts Senate Committee of Post Audit and Oversight. The Stafe's Drank Driving Law:
  AppraisingPegomzance. Boston, MAI the Committee, 1986.
Minnesota Department of Public Safety. Cost of DWI Control; Cost of Lack of ControL..Deterrence
  of Drinking Dn'vers; License Revocation and Other Penaities. St. Paul, MN: MDPS, 1987.
National Highway Traffic Safety Administration. Dm Charge Reduction Study. Washington, DC:
   the Administration, 1986.

New Jersey Department of Public Safety. State Comnubion on Drunk Driving: Second Annual
  Report. Trenton, NJ: Department of Law and Public Safety, 1986.
New York State Department of Motor Vehicles. An Impact Evaluation of the New York State


JUD[CW AND ADMINISTRATIVE PROCESSES                                         135

STOP-DWI Program. Albany, NY: The Institute for Traffic Safety Management and
Research, 1985.

NW York State Department of Motor Vehicles. STOP-DWI: The First Four Years, An Evaluation
  Update. Albany, NY: The Institute for Traffic Safety Management and Research, 1986.
Nichols, J. Recent Trena!s in the Alcohol-Related Crash lkblem in the United States. Washington,
   DC Office of Alcohol and State Programs, National Highway Traffic Safety Administra-
   tion, 1988u.

Nichols, J. "A Review of Trends of Alcohol-Related and Nighttime Fatal Crash Data From 1982
  Through 1987." An internal, unpublished analysis, National Highway Traffic Safety Ad-
   ministration, Washington, DC, 1988b.

Palmer, J., and Tii P. Minnesota Alcohol Roadside Survey. St. Paul, MN: Department of Public
   Safety, 1986.

Peck, R. The Trajic Safery Impact of Cahfomia `s New Dmnk DrivingLaw (AB541):An Evaluation
  of the First Nine Months of Er@ence. Sacramento, CA: California Department of Motor
   Vehicles, 1983.

Peck, R. "Effects of California's New DUI Laws." Paper presented at the California Association
   for Safety Education Conference, Stateline, NV, 1984.
Peck, R.; Sadler, D.; and Pet-tine, M. The comparative effectiveness of alcohol rehabilitation and
   licensing control actions for drunk driving offenders: A review of the literature. Alcohol,
   Drugs and Driving: Abstracts and Reviews l( 14):15-39,1985.
Perrin, M. Analysis of DUI Processing From Arrest Through Post Commun ication Counter-
   measures. Sacramento, CA State of California, Department of Motor Vehicles, 1984.
Presidential Commission on Drunk Driving. Final Reprt. Available from National Commission
   Against Drunk Driving, Washington, DC, 1983.
Quinlan, K. DWI prosecution, adjudication and sanctioning. In: The Z987-88 Alcohol Highway
   Safety Workshop Series Reference Manual. Washington, DC: National Highway Traffic
   Safety Administration, 1987.

Rodgers, A, and Cleary, J. Analysis of the Effects of Recent Changes in Minnesota's DWI Laws,
  Part ZZ: The Perceptions of Minnesota's Drivers. Report. St. Paul, MN: Research Depart-
   ment, House of Representatives, 1983.

Siegal, H. Impact of Driver Intervention Program on DWI Recidivism and Problem Drinking.
   Washington, DC: National Highway Traffic Safety Administration, 1985.
Sotter, R. Impact of DUI Legistion in the State of Florida. Tallahassee, FL: Bureau of Public
   Safety Management, 1986.

Sterling-Smith, R. PsychologicalIdentijication ojDrivers ResponsibleforFatal VehicularAccidents
  in Boston. Washington DC National Highway Trafftc Safety Administration, 1976.
Stewart, K, and Laurence, S. Senate Concurrenf Resolution Number 27 Report: A Review of the
   Implementation and Effectiveness of Drinking and Driving Legislation. Sacramento, CA:
   Office of Traffic Safety,1987.

Surla, L; Voas, R.; Koons, S.; and Reiner, G.An Evaluation of the Elimination of Plea Bargaining
  for DWI wen&rs. Washington, DC: National Highway Traffic Safety Administration,
    1986.

Tashima, H., and Peck, R.An Evakation ofthe Califomiakutk Driving Countermeasure System:
   Vohme 3, An Evaluation of the Specific Deterrent Effects ofAlternative Sanctions for First
  and Repeat DUI Offenders. Sacramento, CA: Department of Motor Vehicles, 1986.
Ti, P., and Palmer, J. Minnesota Alcohol Roadside Swvey: Summary of Reports. St. Paul, MN:
   Department of Public Safety, 1987.

Votey, H.L., and Shapiro, P. Cost effectiveness of alternative sanctions for control of drunken
  driving: The Swedish case. In: Kaye, S., and Meier, G-W., eds. Proceedings of the Ninth
  International Conference on Akoho,! Drugs, and Trafic Safety, San Juan, Puerto Rico,
   DOT HS-806-814. Washington, DC: National Highway Traffic Safety Administration,
    1985.

Wells-Parker, E., and Co&y, P. Impact of driver's license suspension on employment stability of
  drunken drivers. Social Research Report Series, 87(3); Social Science Research Center,
   Mississippi State University, 1987.

ador, P.; Lund, A; Fields, M.; and Weinberg, K. Fatal Crash Involvement and Laws Against
  Alcohol-Zmpaired Driving. Washington, DC: Insurance Institute For Highway Safety,
    1988.


136

Law Enforcement

Issues in the Enforcement of Impaired
Driving Laws in the United States

     Robert B. Voas, Ph.D.
Environmental Research Institute of Michigan (ERkf)

John H. Lacey, Ph.D.

The Universiy of North Carolina Highway Safety Research Center

In our best year, 1983, 1.9 million drivers were arrested for driving while impaired
(DWI) in the United States. This number represented approximately 1 percent of the
Nation's total licensed drivers. This was a significant increase over the 197Os, when only
about one-half of 1 percent of licensed drivers were arrested for DWI each year. Still, it
is not enough. Speaking a decade ago, Borkenstein (1975) noted that

Roadside surveys of the occurrence of alcohol in the driving public have
shown that when enforcement is at the current level of 2 arrests per officer
per year, and with automobile density what it is in the average congested city
today, there are about 2,000 violations for each arrest. A "violation" is a trip
from one point to another with a blood alcohol concentration of .lO percent
or higher; thus, in a typical community of 1 million population, with 1,000
patrol officers making two arrests per man per year, there will be 2,ooO arrests
and 4 million violations.

Since Borkenstein made that statement, the percentage of licensed drivers arrested
for DWI has doubled and, therefore, the ratio of violations to arrests may now be down
to 1,000 to one. Indeed, two studies suggested that where intensive enforcement is
applied, the violation-to-arrest ratio can be reduced to approximately 300 to one (Beitel
et al. 1975; Hause et al. 1982). These higher arrest rates, which are not typical of the
enforcement level of the country as a whole, have been shown to produce small reduc-
tions in alcohol-related accidents (Voas and Hause 1987).

DWI arrests nationally rose significantly from 1979 to 1983; the proportion of highway
fatalities that were alcohol-related dropped 10 to 15 percent from 1982 to 1986. The
extent to which this increase in arrests contributed to the subsequent decrease in
alcohol-related fatalities is difficult to determine. The increase probably contributed as
one element in a larger complex of factors that included citizen activist programs, new
alcohol legislation, and increased public interest in health and safety (Howland 1988).
Regardless, a doubling of the total number of arrests has had, at best, a modest effect
on the alcohol-related casualty rate.

Luckily, deterrence of drunk driving is not determined by the absolute number of
arrests but by the public's perception of the probability of being arrested (Ross 1984).
While it may be generally true that the more arrests made, the more the public will be
deterred, there is no precise relationship between the number of arrests and the extent
of deterrence. In some cases, highly publicized programs result in a higher perceived


LAW ENFORCEMENT

137

level of enforcement than is produced by simply raising the number of arrests without
publicity.

An example of this phenomenon was reported by Williams and Lund (1984). These
researchers conducted a telephone survey of drivers in Fairfax County, Virginia and
Montgomery County, Maryland. Fairfax County consistently had the highest arrest rate
per licensed driver, but Montgomery Country police regularly used roadside sobriety
checkpoints. Citizens of both Fairfax and Montgomery counties stated that they were
more likely to be arrested in Montgomery County, apparently because of the higher
visible use of checkpoints.

The extent to which an enforcement program succeeds in convincing potential
drinking drivers that their probability of apprehension is high is important. Highly visible
enforcement offers the possibility that programs can be implemented that, while not
greatly increasing the total number of DWI arrests, will reduce alcohol-related crashes.

Development of the Traditional Behavioral
Enforcement System in the United States

The drunk driving problem was first recognized in scientific literature in 1904,
approximately 5 years after the first highway safety fatality in the United States. The
United States and Norway were among the first industrialized nations to make impaired
driving a criminal offense. In 1910, New York adopted an impaired driving law, and in
1911, the State of California followed suit. This early criminalization of drunk driving set
it apart from other traffic infractions. For example, higher penalties were provided for
the offense, including incarceration and substantial periods of license suspension. By
1924, the State of Connecticut was jailing 254 drivers per year for DWI. Thus, from the
early years of this century, the United States has treated this offense as seriously as any
nation in the world. The system of enforcement that emerged can be described by the
four-step process outlined in figure 1.    '

The first step in this process is to identify vehicles in the traffic flow that are being
driven by impaired operators. This is done based on either the vehicle being involved in
a crash or the officer on patrol observing unusual, aberrant, or illegal behavior. Once
stopped, the second step is performed. The driver is interviewed to determine whether
he or she has been drinking and shows signs of intoxication. Common symptoms used
for this purpose are bloodshot eyes, flushed appearance, slurred speech, odor of alcohol,
and so forth. If this initial interview indicates that the individual may be impaired, the
officer normally takes a third step, which is to invite the driver out of the vehicle to
perform a set of sobriety tests (e.g., walking a straight line, touching the nose with eyes
closed) which, alongwith the aberrant driving, become the basisof the officer's testimony
to support the charge of "driving while impaired".

The term "drunk driving" presented considerable problems in adjudicating the DWI
offense because of its lack of objective definition. The popular conception of a drunk
individual involved highly aberrant behavior (e.g., staggering gait, incoherence). How-
ever, it soon became evident that individuals could be at increased risk of crash
involvement without displaying such symptoms. Efforts were made to strengthen initial
legislation by substituting such terms as "under the influence of alcohol" and, more
recently, "impaired by alcohol." However, with no objective measure of driving skill
available for testing individuals charged with drunk driving, much was left to the
interpretation of the jury, which was prone to find that the behaviors described were
similar to their own party behaviors and were not commonly accepted as being risky.

Just before the Second World War, a new factor was added to the enforcement

k.                                                 -.                                 /


FIGURE 1

STAGES IN THE DWI ENFORCEMENT PROCESS

A.  TRADITIONAL U.S. "BEHAVIORAL BASED" ENFORCEMENT

Vehicle
Selection

Determination
   Of
Alcohol Use

o Accident        o Behavioral Cues
o Moving Violations   (odor of alcohol
o Erratic Driving    slurred speech,
             etc.)
              0 Passive sensor

o Field or Behavioral
sobriety tests
0 Preliminary
breath tests

B. SCANDINAVIAN "CHEMISTRY BASED" ENFORCEMENT

Vehicle
Selection

Determination
   of
Alcohol Use

Test
for
Impairment

o Checkpoints       0 Passive Sensors

0 Preliminary
Breath Tests

o Breath Test
o Blood Test
o Urine Test

I                     I

fines (22 states


LAW ENFORCEMENT                                                    139

process-the use of chemical tests for alcohol to determine impairment. Initially, these
test results were added to the total evidence presented to support the testimony of the
police officer. Once the courts began to accept thii new scientific evidence, State
legislatures moved to enact laws that specifically provided for chemical testing. In 1939,
Indiana became the frost State to provide for a chemical test; Maine, New York, and
Oregon soon followed.

-

This legislation was significant in that it established the principal that chemical test
data provided competent evidence of impairment. In addition, these laws established
specific alcohol concentrations (AC) as presumptive evidence of intoxication. Estab-
lishing such a presumption required the defense to provide other competent evidence
to rebut the chemical test data or lose its case. The initially prescribed levels followed
the recommendations of the American Medical Association (AMA), which proposed
that an individual with an AC of 0.15 or greater was presumed to be under the influence,
while an AC between 0.05 and 0.15 was competent evidence of impairment when
supported by other, verbal testimony. Finally, the AMA recommendation held that an
AC below 0.05 was presumptive evidence that the individual was not under the influence.

Since the Second World War, most States have lowered this presumptive level to 0.10,
and several States have lowered it to 0.08 Recently, the National Safety Council
Committee on Alcohol and Drugs recommended that the presumption that an individual
is not impaired when the AC is below 0.05 be stricken from DWI legislation, since recent
evidence shows that the performance of a substantial number of individuals is impaired
at ACs below 0.05 (Moskowitz and Robinson 1988).

Thus, with the passage of these laws, a fourth step was added to the enforcement
system illustrated in figure 1. Once police officers obtain sufficient evidence from
sobriety tests to convince them that individuals are impaired under the State's DWI law,
they will charge the drivers with the offense, take the individuals into custody, and
transport them to the police station for a chemical test.

Robert Borkenstein's development of an inexpensive breath test device, the
Breathalyzer", provided a means for police departments to rapidly test individuals for
their AC. The use of breath testing in the United States avoided many of the problems
experienced in the foreign countries that continued to rely on blood tests that required
a police surgeon to come to the station and draw blood. The Borkenstein Breathalyrer"
and those breath test instruments that succeeded it have provided a reliable means of
collecting highly accurate breath test data. States have established control systems for
approving and calibrating these units and for training and supervising breath test
operators in each police department.

The success of the chemical test in achieving convictions for impaired driving raised
the issue of whether the State could require drivers to submit to this test. In a landmark
decision, the Supreme Court decided in Schmetier v California that the police had the
authority to take a blood sample forcibly, under limited circumstances. The Court held
with respect to the Fifth Amendment that this did not constitute self-incrimination, since
the evidence gathered was not testimonial but physical in character. Secondly, the Court
determined that the forcible taking of a blood sample did not violate the Fourth
Amendment prohibition against unreasonable searches and seizures since there was full
probable cause to suspect the driver of driving under the influence (see Laurence 1988
for a discussion of constitutional issues related to DWI enforcement and adjudication.)

This decision opened the way for States to pass laws providing for the forcible taking
of blood samples from arrested drivers. However, neither police departments nor
legislatures wanted a system in which people would be held down and needles inserted
in their arms as part of the arrest process. Therefore, acompromise was developed under
which the State passed legislation providing that operating a vehicle on the State's
highways implied consent for giviug a sample for a chemical test in the event of a DWI
arrest. If the driver, having been arrested, refused to provide a sample, then the Motor


140

BACKGROUND PAPERS

Vehicle Administrator was empowered to suspend the driver's permit for a some stated
period.

It required almost two decades for all States to adopt this implied consent procedure.
To achieve adoption by the final hold-out States, it was necessary to increase the
safeguards in the breath testing process. As the breath test became a more important
element in the drunk driving litigation process and as implied consent statutes gave less
opportunity for the driver to refuse testing, States added legislation to require that breath
test devices be equipped with safeguards that would prevent the operator from making
errors in the testing process. As a result, units were developed that automatically stepped
through the process of calibrating and checking the instrument, collecting a breath
sample, and providing printed output so that the possibility of error was minimized.

The four-step process provides a reasonably effective enforcement system. However,
the seriousness of the drunk driving offense, with its potential for a jail sentence and a
lengthy driving suspension, resulted in a number of pressures being applied to the lower
courts that reduced their overall effectiveness with DWI offenses. Those charged with
DWI hired lawyers to argue their cases, increasing the procedural paperwork for police
officers. Each step of the enforcement process had to be documented to demonstrate
probable cause for the stop and the DWI charge and to show that the breath test was
conducted according to State regulations by qualified personnel. The bureaucratic
procedures became very onerous for the police, frequently requiring 2 to 4 hours for
each arrest and thereby discouraging DWI enforcement.

Because of the serious penalties, many offenders insisted upon full legal recourse,
and court dockets frequently became overloaded. Significant backlogs were created,
particularly when defendants demanded jury trials. The court and the prosecution were
often motivated to seek plea bargains in which the individual charged with DWI pleaded
to a lesser offense in return for having the drunk driving charge dropped. When the police
saw this, some were discouraged from making DWI arrests.

The traditional behavioral enforcement system provides wide discretion to the in-
dividual oflicer in determining which vehicles to stop and, once the vehicle is stopped,
whether to proceed with the investigation of the DWI offense. Thus, the officers'
attitudes, detection skills, and motivation are extremely important to effective enforce-
ment. In studies of police officers' attitudes toward DWI enforcement, most officers
admitted to occasions when they did not pursue investigations where they were fairly
sure the driver was impaired. One of the primary reasons given for failure to follow
through was the length and bureaucratic nature of the paperwork involved. Arrests were
less likely to be made toward the end of an officer's daily tour because completing the
arrest would require staying overtime.

Officers were also likely to consider the significance of drunk driving compared with
the fairness of penalties for thii offense in making their arrest decision. Where they
believed the penalties were inappropriately severe, they were more prone not to pursue
arrests of marginally impaired drivers. Arrests were frequently avoided by allowing a
passenger to take over the driving or, in the case of teenaged drivers, driving the
individual home (Oates 1974).

With the founding of the Department of Transportation, the new Highway Safety
Bureau (soon to be the National Highway Traffic Safety Administration) attempted to
overcome some of these problems by establishing 35 demonstration programs called
Alcohol Safety Action Projects (ASAPS). These projects were designed to provide an
integrated approach to the drinking/driving problem (NHTSA 1979). Courts,
prosecutors, and the police received additional funds and participated in a coordinated
program to increase DWl arrests by simplifying police paperwork and by increasing the
speed of prosecution and adjudication.

These projects generally succeeded in increasing (usually doubling) the number of


IAW ENFORCEMENT                                                         141

arrests for DWI (Levy et al. 1978). Within the enforcement activity, the arrest increases
were primarily achieved through special DWI-emphasis patrols that operated on
weekend evenings. These patrols usually consisted of 2 to 10 vehicles, depending on the
size of the community. They normally made as many arrests in a year, on the two or three
weekend evenings when they were active, as the full police force had made annually prior
to the ASAP programs. While the ASAP programs came to an end by 1975, this
dedicated patrol procedure has continued to be a feature of most communities in which
DWI enforcement is emphasized.

Aside from sponsoring the ASAP demonstrations, the Federal Government at-
tempted to assist DWI law enforcement by developing more scientific and objective
procedures for identifying drinking drivers. A program to determine which vehicle
maneuvers were most likely to indicate an intoxicated driver was funded by NHTSA and
resulted in a set of driving "symptoms" graded by the probability that the driver would
be at 0.10 AC or greater (Harris et al. 1979). A second research effort was directed at
developing a standardized set of field sobriety tests for use by police officers. The sobriety
tests commonly in use, up until the last decade, were highly influenced by individual
officers' preferences. NHTSA sponsored a review of the literature and the development
of a standardized set of three tests: lateral gaze nystagmus, body sway, and divided
attention. The availability of these tests, particularly the gaze nystagmus test, has
increased the capability of police officers to estimate the probable alcohol content of the
suspected driver (Tharp et al. 1981).

By the latter part of the 197Os, the traditional behavioral system for detecting and
apprehending drinking drivers had been significantly improved. This was evidenced by
the fact that close to 1 million drivers were being arrested each year for this offense. It
is probable that even more arrests would have been made had it been possible for the
courts to handle the increase in case load.

The Chemistry-Based Enforcement System

The behavioral system of enforcement just described, which developed in the United
States, was fairly typical of most industrialized nations. The U.S. system had some
advantage in that it was based on breath rather than blood alcohol measurement. This
simplified the enforcement process by not requiring the presence of a physician to collect
blood. While this system was developing and maturing in the United States, the Scan-
dinavian countries developed a significantly different approach to the enforcement of
DWI laws.

In 1936, Norway passed legislation that provided that being in charge of a vehicle and
having a blood alcohol concentration in excess of 0.50 was an offense. This was the first
of the so-called "illegal per se" laws. Similar laws were later adopted by the other
Scandinavian countries. The significance of the illegal per se approach is that it circum-
vents the issue of behavioral interpretation, since the offense has only two relevant
criteria- being in charge of a vehicle and having an AC over a given limit.

Once these laws were in place, the police departments in the Scandinavian countries
began to use field breath test devices. These consisted of tubes through which the suspect
blew. Any alcohol in the breath would cause a chemical reaction in the dichromate
crystals in the tube and produce a color change, from yellow to green. The length of the
stain provided a rough measure of alcohol concentration. These legal and chemical test
changes, when combined with the traditionally severe sanctions provided in Scan-
dinavian laws, became known as the "Scandinavian model" (Ross 1975; Andenaes 1988).

The British Government implemented elements of this system in the Road Safety Act
of 1967. Because of the wide publicity elicited in the British press while this new


142

BACKGROUND PAPERS

legislation was being debated, the law produced one of the most dramatic examples of
.changed drinking driving behavior resulting from DWI legislation (Ross 1973, 1988).
The success of the British Road Safety Act stimulated other nations, such as Canada,
the United States, and Australia, to attempt similar programs. The implementation of
the system in Canada had a much smaller effect because of limitations on the authority
of police officers to require field tests. In Britain, roadside breath tests could be required
of anyone in an accident or guilty of a driving infraction. In Canada, the officers could
test only when there was cause to believe the individual was impaired.

In the United States, the success of the British Road Safety Act increased interest in
roadside breath testing of drivers. Implementation of roadside testing was held back
because of a challenge to the accuracy of the tube-type testers (Prouty and O'Neilll971)
and the question of whether roadside breath tests could be administered without reason
to believe that a DWI offense had been committed.

The first problem was overcome through the development of miniature, electronic
test devices using fuel cell or semi-conductor sensors. By the mid-1970s a small fuel cell
test device the "Alco-Sensor"ry became available and was sold to police departments
throughout the country. This device permitted roadside breath tests with substantially
the same accuracy as could be obtained with the evidential breath test devices in the
police station. It also appeared to increase the number of arrests. In Minnesota, in early
1980, the State purchased a large number of roadside breath testers and distributed them
to State and local police departments. A time-series analysis performed by Cleary and
Rodgers (1986) suggested that this distribution produced a permanent increase in arrests
by Minnesota police agencies.

The second issue, regarding the authority of the officer to require a preliminary breath
test in the absence of probable cause, has not been resolved by the Federal courts. Most
police departments use field breath test devices only after the field investigation has been
completed and the officer has decided that the driver is impaired and is about to charge
him with the DWI offense. The field test device is then used toverifjr the officer's decision
and to avoid transporting an individual who later turns out to be below the legal limit to
the police station for the evidential test.

Rarely, if at all, are these devices used during the second step of the investigation
where the officer attempts to determine if the individual has been drinking heavily.
Because these devices are not used earlier in the arrest process, many impaired drivers
avoid detection because they fail to give thz signs typically observed by police. Field
studies (Taubenslag and Taubenslag 1954, Vingilis et al. 1982; Jones and Lund 1985)
have demonstrated that police officers miss at least half the impaired drivers with whom
they come in contact. This is not surprising, since studies of the ability of physicians to
identify drivers with ACs over 0.10 indicate that even they fail to detect half the
individuals who would be legally impaired for driving (National Safety Council 1976,
page 11).

Of all the nations that adapted modifications of this Scandinavian system, the state of
New South Wales, Australia has recently made the most rigorous application of what
Voas (1982) has labeled the "chemistry-based" enforcement program. In New South
Wales and in Tazmania, laws were passed authorizing random breath testing of all drivers
using the roads, and the police were provided with funds to establish a policy of vigorous
use of sobriety checkpoints.

During 1982, the first year of the New South Wales "Staysafe Program," Home1 (1%)
reported that nearly 1 million breath tests were made on a driving populationof 3 million,
or nearly one in three licensed drivers, and monthly fatalities decreased by an average
of 23 percent compared with the previous 6 years. Other data (Ross 1988) suggested that
this change has been relatively permanent. As Ross noted, the evidence clearly supports
the deterrence theory, since surveys of the driving publicindicate that they are well aware
of the law and the police enforcement practices. Moreover, it appears that a fair amount


LAW ENFORCEMENT

143

of this information is reaching drivers through their own experience of being tested or
through friends who have been tested at checkpoints.

The chemistry-based enforcement system implemented in New South Wales,
Australia is in sharp contrast to the more behavioral approach used in America. Rather
than selecting vehicles from the traffic flow based on aberrant or illegal behavior, the
chemistry-based system makes extensive use of roadside checkpoints. A breath test is
then conducted on every driver stopped. This makes it unlikely that drinking drivers can
drive in a manner that will avoid observation and testing by the police. Once the field
test for alcohol indicates that the driver has an illegal alcohol concentration, the
individual is charged and taken to the police station for an evidential test.
While checkpoints have been used as an occasional feature of the enforcement

programs in a number of communities throughout the United States, no jurisdiction has
adopted this method as a principal feature of its enforcement activities. More wide-
spread use of checkpoints has been constrained by questions regarding the consti-
tutionality of the procedure and the manpower required to conduct checkpoints.

A series of Federal court decisions (Ifft 1983) have established a "balancing" proce-
dure that permits the police to conduct checkpoints under certain highly controlled
procedures where the State can demonstrate that this technique is required to protect
citizens against the hazards posed by the drunk driver. The procedures required by the
court are somewhat limiting. Survey sites must be preselected on the basis of drunk
driving incidents and surveyed for safety. A plan must be developed in advance and
approved by the highest authority in the police department. Checkpoints must be
manned by a number of police officers, with their vehicles, to provide a signifmant "show
of force" to reassure drivers that they are not being singled out for investigation. The
procedure for selecting vehicles from the traffic flow must prevent individual officer
discretion in order to avoid arbitrary or biased selection procedures.

Because of these rather elaborate requirements, checkpoints in the United States
' have been relatively expensive operations, Considerable controversy has arisen as to
whether they are cost effective. In part, this controversy depends on the objectives of
checkpoints. Some police departments hpld that deterrence is accomplished by simply
stopping and interviewing a large number of motorists, regardless of the number of
arrests made. Other departments stress making DWI arrests in checkpoint operations.

Those departments that emphasize driver contacts and the creation of deterrence as
the principal role of checkpoints generally employ very brief interviews (lo-l.5 seconds)
and only rarely use prearrest breath-testing devices. Such brief interviews make it
unlikely that the officer can detect any but the most highly impaired drivers. Other
departments conduct somewhat longer interviews (resulting in fewer drivers contacted),
but make greater use of prearrest test devices, with a resulting higher arrest rate. Voas,
Rhodenizer, and Lynn (1985) demonstrated that a checkpoint can produce more DWI
arrests per hour than traditional patrol procedures.

The use of prearrest breath-test devices at checkpoints has been limited by the
continuing issue as to whether a test can be required without probable cause, or at least
"reason-to-believe" that the driver is impaired by alcohol. In an effort to overcome this
limitation, passive sensors have been developed (Voas 1983; Jones 1986, Jones and Lund
1985). These handheld units pump mixed environmental and expired air from in front
of the driver's face into the sensor and can be made sufticiently sensitive to reliably detect,
those individuals who are over the legal limit (Jones and Lund 1985).

Legal analysis of these devices (Fields and Henricko 1986) suggested that they are
not limited by the provisions of the Fourth Amendment prohibition against warrantless
searches and could be used without establishing probable cause that an offense had been
committed. This should make it possible for police to use such devices at sobriety
checkpoints. When this is done, a drinking driver can be detected in lo-15 seconds (Voas


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BACKGROUND PAPERS

and Layfield 1983). Passive sensors are currently being tested by a number of police
departments but the courts have not yet ruled on their constitutionality. -

Current Status of DWI Enforcement in the
United States

Beginning in 1980, a new element entered the DWI enforcement picture. This was
the emergence of citizens' activist groups, such as Mothers Against Drunk Driving
(MADD) and Remove Intoxicated Drivers (RID). These groups succeeded in calling
public attention to the drunk driving problem and in motivating legislators to pass
substantial DWI legislation. Most of the legislation dealt with increasing penalties and
making them mandatory, or with prohibiting plea bargaining. The general effect of this
type of legislation, with respect to enforcement, was to increase the efforts of defendants
to avoid conviction, thereby putting increased stress on the quality of the evidence
provided by the police officer in court. This increased pressure on the police investiga-
tion was counterbalanced somewhat by the adoption of illegal per se laws in 45 States.
These laws made it an offense to be at an illegal AC while in control of a vehicle.

An illegal per se law reduces the requirement on the police officer to present evidence
of impairment, though it does not eliminate it entirely. It is still necessary to show
probable cause for administering the evidential breath test in the frst place. In addition,
despite the per se law, many courts continue to accept arguments regarding the behavior
of the defendant.

A second significant element in the new wave of legislation was the passage of
"administrative per se" laws that empowered motor vehicle departments to suspend the
licenses of drivers not only for refusal to take a chemical test but also for failing a test.
Many of these laws permit the police officer to seize the driving permit at the time of
arrest and substitute a notice of hearing, which serves as a temporary license. The license
is then forwarded to the motor vehicle administrator. The suspension takes place unless
the hearing determines that the police officer did not have probable cause to require a
chemical test or that the chemical test procedure was faulty.

Administrative per se laws provided an additional incentive for the police to make
arrests by ensuring that arrests for drunk driving will result in an immediate consequence
and that the efforts of the police will not be invalidated by plea bargaining or some other
limitation in judicial procedures. At the same time, such laws add somewhat to the
paperwork required at the time of arrest.

This wave of legislation also produced an increase in the number of States that
specifically provided for the use of prearrest breath tests at the roadside by police
officers. However, most police forces continue to use these devices as they had before,
only at the end of the investigation.

Perhaps the most significant effect of this wave of legislation and the public attention
given to drunk driving was the fact that it reminded police departments and individual
police officers of the extent of public support for rigorous DWI enforcement. This public
support also resulted in additional funds for many police departments for DWI enforce-
ment and political support to pursue drunk driving arrests more rigorously.

Currently, the traditional behavioral system of enforcement (shown in the upper
portion of figure 1) remains the primary method of apprehending drinking drivers in the
United States. Considerable technology has been applied to thii system since its initia-
tion early in the century, particularly in the area of breath testing. However, the system
remains basically dependent upon the experience andjudgment of the off&xx in selecting
the vehicles to be stopped and identifying drinking drivers, because breath test technol-


LAW ENFORCEMENT                                                      145

ogy is not applied until near the end of the investigative process. The chemistry-based
system shown in the Iower portion of figure 1 is not used in this country except for partial
application in occasional checkpoints conducted in some jurisdictions.

Total arrests peaked in 1983 and have decreased slightly since then. The number of
arrests seems unlikely to increase unless considerable additional funding becomes
available to police departments to augment their traditional behavioral system or to
pursue more extensive use of sobriety checkpoints.

Evaluation of Enforcement Efforts in the United States

While considerable effort has gone into the enforcement of drunk driving laws in the
United States, and significant sums have been spent on equipment and overtime pay-
ments to special DWI patrols, relatively little rigorous scientific evaluation of these
efforts has occurred (Jonah and Wilson 1983). Several factors mitigate against such
evaluations. First, most enforcement efforts are implemented as part of a package of
DWI legislative programs, making it diflicult to separate the effect of the increased
enforcement effort from other changes in the DWI control system.

Second, the public appears to accept relatively superficial evaluations and shows little
appreciation of the need for rigorous scientific evaluation. Many enforcement programs
are evaluated on the basis of a change in the number of DWI arrests. This is a completely
inadequate basis for such evaluations, since the estimated arrest rate is 1 for every 1,000
offenses. Doubling such a rate can hardly have much impact in and of itself. Further,
changes in the arrest rate are subject to differing interpretations. Increases in arrests are
often cited as evidence that the increased enforcement is achieving its goal. Decreases
in arrests are sometimes also cited as evidence that the enforcement process is achieving
its goal, because (so the reasoning goes) fewer drunk drivers are on the road. Thus, this
measure of enforcement effectiveness is completely circular and useless for the purposes
of research, except as an intervening variable when an effort is made to determine the
actual reduction in alcohol-related crashes.

The alcohol-related crash criterion is a difficult one to apply because AC data are
principally available only for fatally injured drivers. Other AC data are available only for
that small proportion of less severe crashes in which a DWI arrest is made, a clearly
biased statistic. To obtain a more objective measure of enforcement impact, crash series,
such as single vehicle crashes occurring late at night, are frequently used. Such crashes
are more likely to involve a drinking driver than multivehicle crashes occurring during
daylight hours. In many communities, relevant crash records are too poorly kept or the
numbers of crashes are too few to provide a good basis for evaluating enforcement
programs. A better, but much more costly, measure is to use voluntary roadside surveys
in which the drivers are asked to voluntarily provide a breath sample for research
purposes. These surveys provide a measure of the number of drivers who are impaired
during those times when most drinking and driving occurs, an important measure of the
impact of an enforcement program.

Two studies have shown changes in the average alcohol concentrations of drivers
using the roadways as a result of enforcement programs. The first of these, Levy et al.
(1978), evaluated the changes in roadside surveys at 19 of the 35 Alcohol Safety Action
Projects. They found a statistically significant reduction in the number of drivers with
illegal ACs in roadside surveys conducted after the projects were initiated, compared
with results obtained before program implementation. These results, however, were
undoubtedly influenced by elements of the ASAPs in addition to the increased enforce-
ment of DWI laws.

A demonstration of impact more specifically traceable to increased enforcement was


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reported by Voas and Hause (1987) in a study of a special enforcement program in the
city of Stockton, CaIifornia. Over a 3-year period, they reported a drop of as much as
one-third in the number of drivers above theO.10 legal limit. This drop in,impaired drivers
was accompanied by a significant reduction in nighttime crashes, compared to four other
similar cities in the central valley of California. The reduced level of alcohol-related
crashes was maintained during the 3 years of enforcement activity, but tended to
disappear when the special enforcement project came to an end. Several other scientific
evaluations of enforcement programs that have found positive results are available in the
literature (e.g., Klein 1982; Lacey et al. 1986).

Overall, the studies of traditional enforcement programs in the United States have
tended to be similar to those covered in Ross' (1984) international review of DWf
programs. Short-term reductions in drinking driving crashes were obtained in some
cases, particularly where enforcement was accompanied by considerable publicity.
However, the changes tended to be transitory, maybe because the police failed to fully
utilize the Rowers provided to them by the law (as in the case of the British Road Safety
Act) or because, after an initial intensification, enforcement efforts returned to previous
levels (as in Stockton). Finally, as Borkenstein (1975) hypothesized, it may be necessary
to keep changing enforcement procedures to make them "new" and newsworthy and to
attract the attention of the public.

Few chemistry-based checkpoint systems in the United States have been scientifically
evaluated. Voas, Rhodenizer, and Lynn (1985) reported on a year-long enforcement
program in which checkpoints were implemented every weekend within the city of
Charlottesville, Virginia. Their evaluation indicated that the police apprehended fox
DWl approximately 1 percent of the drivers stopped at the checkpoint. In addition,
another 1 percent of the drivers were arrested for driving without a license. Random
digit dialing telephone surveys indicated that approximately one-fourth of the nighttime
drivers in Charlottesville came into direct contact with a checkpoint and that more than
90 percent of all drivers were aware of the checkpoint program. Comparison of the
nighttime and alcohol-related crash rates in Charlottesville with those of a similar
community that did not employ checkpoints revealed that this procedure reduced such
crashes by approximately 15 percent. A similar reduction was apparent when crash rates
for Charlottesville were compared with those for the State of Virginia as a whole.

Additional evidence for the impact of checkpoint procedures was obtained by Wil-
liams and Lund (19&J), who conducted a random digit dialing survey and compared the
attitudes and knowledge of the driving public in those communities that used checkpoints
with communities that did not use checkpoints. Where checkpoints were used, drivers
reported higher levels of deterrence to drinking and driving than citizens of counties
where they were not used. These studies provide some evidence for the effectiveness of
the chemistry-based enforcement system. A full evaluation of the chemistry-based
enforcement system awaits an adequate application of this technique in the United
States.

Eight Issues for Future Enforcement Programs

This summary of the status of DWl enforcement in the United States suggests that it
is having a significant general (but unmeasured) impact on deterrence to drunk driving.
However, little additional effectiveness can be expected unless new resources are
committed to, or new technology and procedures are employed in, the enforcement
effort. Among the issues that are currently being debated and the proposals for new
enforcement methodology being considered, the following 10 items should provide the
subject matter for recommendations to be made in the Surgeon General's Report.


LAW ENFORCEMENT

Issue I: Increasing the use of sobriety checkpoints

147

As noted, the Federal courts have provided for the use of sobriety checkpoints under
certain constraints (Ifft 1983); however, the legality of thii procedure under the Federal
constitution does not necessarily mean that it meets the requirements of each of the 50
State constitutions. As of this date, the Supreme Courts of 18 of the 50 States have made
favorable decisions regarding checkpoints, while the Supreme Courts of 9 other States
have made unfavorable decisions. These unfavorable decisions, however, frequently
resulted from the consideration of checkpoint programs that did not meet Federal
guidelines. Where there is full compliance with the Federal guidelines, it is probable that
most States will find that checkpoint procedures meet the appropriate constitutional
tests.

Perhaps more significant than constitutional issues is the acceptability to the public
of checkpoint programs. Police administrators tend to be highly sensitive to public    j
opinion. While police departments are often interested in new and novel procedures,
police organizations tend to be basically conservative. Most public surveys show sig-
nificant support for use of the checkpoint procedure. Voas, Rhodenizer, and Lynn
(1985) found that the public in Charlottesville, where checkpoints were regularly con-
ducted, were more in favor of checkpoints than the public in the comparison community
which had not experienced a checkpoint program. Most available evidence suggests that
police departments will be supported by the public if they implement checkpoint
programs. Nevertheless, the concern with public relations remains a major drawback to
checkpoint programs in the minds of many police administrators.

A third problem in mounting checkpoint operations is the issue of cost effectiveness.
The Federal court specifications for checkpoint operations require the assembly of a
number of police vehicles and the use of a minimum of four to six officers. (In contrast,
a checkpoint can be conducted in New South Wales, Australia by a single officer). This
requirement for a relatively large force presents personnel and cost problems for many
localities. Some jurisdictions have addressed this problem by combining resources from
State, county, and local police. Others have used overtime or diverted officers from other
duties.

Depending on the procedures used and the policies implemented, a checkpoint may
result in relatively few arrests or, alternatively, in more arrests per man hour than would
be achieved in an equal amount of traditional enforcement activity. In any case, the
impact of a checkpoint should not be assessed on the basis of the number of arrests
produced. As demonstrated by Williams and Lund (19&t), the impact of sobriety
checkpoints on the general driving population is more important in creating deterrence
than the number of arrests made by traditional enforcement procedures.

States and communities could be encouraged to promote checkpoint operations. This
could be done both by influencing police policy and by providing additional funds for
checkpoint equipment and operations. At issue is whether this procedure, which is a
basic part of the chemistry-based enforcement system, would be cost effective in increas-
ing deterrence to drunk driving. Evidence from Scandinavia and Australia suggests that
it may be the most cost-effective procedure.

Issue 2: Using portable breath tests earlier in the DW enforcement
process

Portable breath test devices, about the size of a cigarette package, have been available
to the police for over a decade. Twenty-six of the 50 States have passed legislation
specifically authorizing their use. However, they are rarely used early in the investigative
procedure. This occurs partly because of the general assumption made by police
departments that the preliminary breath tester (PBT) cannot be used prior to obtaining


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reason to believe that the individual has been driving while impaired. Thus, the devices
are used only after the officer has completed his investigation. They are used only to
verify the officer's decision, with the result that many over-the-limit drivers who did not
appear to be intoxicated escape detection.

The prearrest breath test is clearly a search in'the constitutional sense because the
suspect is required to blow through a mouthpiece and provide an active breath sample.
The Federal courts, however, have been willing to accept a compromise or a balancing
test when the need of the State to protect its citizens is sufficiently great and the intrusion
provided by the search is sufficiently smaIl to make the search reasonable. Some
constitutional experts believe that the act of blowing into a mouthpiece is such a smaIl
intrusion that it would meet this test. They predict that the Federal courts would find it
acceptable to administer a breath test to motorists in accidents or to motorists guilty of
driving offenses without requiring specific evidence that they are imp,aired by alcohol.

Should the courts find that the PBT does not meet constitutional standards without
probable cause to suspect a DWI offense, then the passive sensing technology is available
for use early in the arrest process. These devices, while somewhat less accurate than the
PBT, would almost certainly pass constitutional tests since most experts agree that the
passive sensor does not involve a search within the meaning of the Fourth Amendment
(Fields and Henrico 1986). The use of such sensors on all individuals stopped at sobriety
checkpoints or all individuals stopped for speeding or other traffic infractions would
result in a significant increase in DWI arrests, since current evidence indicates that police
engaged in these enforcement activities fail to detect half or more of the intoxicated
drivers with whom they come in contact.

States and localities could encourage the use of PBTs and passive sensors through
their influence on police policies and by providing funding for the purchase of this type
of equipment. The important issue, however, is not providing additionaI equipment, but
more significantly, encouraging police ofticers to use this technology at the beginning,
rather than at the end, of their DWI investigation procedure.

Issue 3: Expanding DW7 enforcement through new legislation

Borkenstein (1975) noted that a typical community with a population of 1 milIion will
have 1,000 patrol officers. This same hypothetical city, would have approximateIy325,OOO
hazardous moving violations per year. He proposed that, to increase deterrence to
impaired driving, every driver stopped for such a hazardous moving offense should be
tested for alcohol. If such a driver were found to have an AC over a minimum level (e.g.,
O.OS), he would be given a special aggrevated-by-alcohol traffic citation. The offense of
speeding might carry a line of $20.00 or $30.00, but the offense of speeding while
aggrevated-by-alcohol would carry a higher fine (e.g., $50.00) and would also result in a
notation on the driving record that an alcohol-related offense had occurred. Drivers with
ACs over the per se limit could also be charged with the DWI offense.

The principal issue that arises in this procedure is the Fourth Amendment limitation
on conducting searches without probable cause. The proposal to test all individuals guilty
of serious driving infractions is similar to the British Road Safety Act of 1%7. Enforce-
ment would require court acceptance of a driving infraction as meeting the requirements
for permitting a "search" such as the use of a prearrest breath test device. If the courts
determined that such a search was not permitted without specific evidence that the
individual was impaired, passive sensors could be used to obtain evidence of drinking,
followed by the use of a PBT. This procedure would likely result in a significant increase
in the number of drivers arrested for DWI and an increase in the number of drivers
receiving an alcohol-related offense citation on their driving records.

Another type of program directed at increasing the number of drinking drivers
apprehended is the "Roadside License Suspension" program used in several Canadian


LAW ENFORCEMENT                                                     149

provinces. This legislation has two forms. In the first, as practiced in New Brunswick,
Ontario, Manitoba, and Saskatchewan, the driver can be required to take a roadside
breath test if the officer has reason to believe the driver is impaired. If the result is over
0.05, the officer can suspend the individual's driving permit for periods varying from 6
to 24 hours.

Another approach, used in Alberta, British Columbia, and the Yukon Territories,
places the testing decision on the driver. Relevant to this approach, the British Columbia
Motor Vehicle Act (Section 214) states that (a) if a police officer believes a driver's ability
is affected by alcohol (or other drug), he may request the driver to surrender his license;
and (b) the period of suspension is 24 hours unless the driver voluntarily submits to a
test that determines an AC not exceeding 50 mg percent.

Thus, the suspected offender has the choice of submitting to the test to demonstrate
that he is not over the 0.05 limit or of surrendering his driving license to the police officer,
finding other means to get home, and returning to the police station the next morning to
retrieve his driving license.

One potential problem with such lesser offenses is that they can be used inap-
propriately to avoid the paperwork and hassle involved in the prosecution of more
serious drunk driving offenses. If the offense of a traffic violation aggrevated-by-alcohol
were created with lower penalty levels, it might well be used as an opportunity for plea
bargaining with individuals apprehended with illegal ACs being allowed to plea down to
this lesser offense. Police oflicers might also use the short-term suspensions to avoid the
paperwork involved in bringing more serious charges in the first place. The basic issue
is whether the enactment of such a law would increase the deterrence of drunk driving.

Issue 4: Expanding oficerparticipation in alcohol enforcement

As noted earlier, the ASAP program popularized the use of special, dedicated DWI
enforcement teams. This system was intended to stimulate the apprehension of impaired
drivers by all members of the traffic patrol by offering the opportunity to earn overtime
pay on the special patrols. Sometimes this opportunity was extended only to those
officers who achieved a high arrest rate on their normal duty hours. To a certain extent,
this general concept worked as intended. However, in the long run, it tended to establish
a policy of allowing a few highly motivated officers to specialize in DWI, while permitting
the large majority of traffic officers to make few, if any, DWI arrests. The fact that a two-
or three-man special enforcement team active on Friday and Saturday nights could make
as many arrests as the rest of the traffic department was more an indication of the lack
of attention to drunk driving by the average officer on patrol than an indication of the
level of skill of the special patrol members.

It will be difficult to greatly increase arrest rates as long as the pursuit of the drunk
driver is seen as a specialist activity for a few officers. Expanding the role of the rest of
the traffic department in DWI enforcement activities would not only increase the number
of arrests but would also broaden the impact on the driver, since individuals would be
investigated for impairment, not only on Friday and Saturday nights, but throughout the
week.

States and localities should be able to increase the number of arrests by the regular
traffic patrols through training and by providing the officers with prearrest breath testers
or passive sensors; With a passive sensor backed up by an active preliminary breath tester
to use in the field, the traffic officer need not be an expert in conducting sobriety tests
or in detecting evidence of impairment from the appearance of the driver. Using these
devices, he can identify individuals who are over the limit and bring them in for evidential
tests.

With police management emphasizing the importance of drunk driving enforcement,


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BACKGROUND PAPERS

all officers who are trained and equipped with passive sensors and PBTs should be able
to contribute substantially to the drinking driving enforcement effort within a com-
munity. The principal issue here is whether the State and locality should fund police
departments to train officers, purchase passive sensors and PBTs, and encourage police
administrators to make DWI enforcement a high-priority activity for all offtcers engaged
in traffic patrol activities.

Issue 5: Lowering AC limits for private vehicles

Of the 50 States, 41 currently have per se limits at 0.10, while 2 others have 0.08 limits.
The National Safety Council Committee on Alcohol and Drugs has taken the position
that all individuals at 0.08 AC are impaired. The American Medical Association has gone
even further, recommending that the National limit be 0.05 AC. Considerable contro-
versy exists regarding the desirability of lowering the AC limit from O.iO, which is the
current standard in the United States. The fast issue is whether, in fact, ACs below this
level increase the probability of accident involvement. The second issue is whether
lowering the illegal AC level reduces the number of high AC drivers on the road or the
number of alcohol-related accidents. The third issue is whether lower AC levels can be
enforced, and, if so, what such enforcement costs.

With regard to the first issue, laboratory and epidemiological studies have indicated
that increases in impairment and crash risk begin at low AC levels (Moskowitz and
Robinson 1988). Hurst (1973) found that no matter how experienced with alcohol, any
individual is at higher risk for involvement in a crash at any AC level over zero. This
provides a basis for arguing that the AC limit should be zero, since any level above that
will increase the probability of crash involvement. On the other hand, an attempt to
eliminate all driving with any positive AC is beyond the resources and capability of the
criminal justice system, as shown by the Nation's experience with prohibition.

With respect to the second issue, no adequate scientific studies demonstrate the
effectiveness of lower AC levels per se. Data from Scandinavia (where the AC limit is
0.05) indicate that the number of high AC drivers on the roadways is clearly lower than
in the United States, Canada, and the Netherlands, where the AC limits are 0.10,0.08,
and 0.08, respectively (Snortum 1984). However, many other differences between these
nations could contribute to these differences, and it is not possible to determine the
relative role of the AC limit compared to the differences in enforcement policy and
procedure, the penalties for the offense, and the general cultural attitudes toward alcohol
use and drinking and driving.

Overall, no reliable research evidence clearly demonstrates that lowering the AC
alone produces a reduction in alcohol-related accidents. Rarely in real lie is a single
countermeasure feature implemented so that it can be evaluated on its own without the
interacting effect of other changes in the law or in enforcement. A change in the AC level
would probably also be accompanied by a change in enforcement, since enforcing lower
AC limits may well require different enforcement techniques.

Relative to the issue of enforcing a lower AC limit, some police forces are currently
experiencing considerable success in apprehending drivers at lower ACs with traditional
patrols. In North Carolina, approximately 10 to 15 percent of all drivers arrested are
below 0.10. A significant number of arrests below the 0.10 level are also made by other
police departments, such as in the District of Columbia. A serendipitous impact of
lowering the AC limit is to increase the probability of conviction for those at 0.10 and
higher, since many prosecutors provide for a buffer zone at the legal limit, whatever it
may be. In many cities, for example, the prosecutors operating under the current 0.10
law only move those cases where the measured AC is 0.12 or 0.13 and above, because of
the difficulty in obtaining convictions where the AC is near the legal limit. Moving the


LAW ENFORCEMENT

151

legal AC limit to 0.08 could lower this buffer zone and increase convictions for those
with 0.10 ACs.

If the legal limit is reduced to 0.05 or 0.08, greater reliance will probably have to be
placed on the chemistry-based system shown in the lower portion of figure 1. The use of
checkpoints and passive sensors will likely be increased, since the individuals who are at
these levels are less likely to present the signs of impairment on which the police normally
rely.

Whatever final decision is made regarding lowering the AC limit, it is important to
repeal the section of many State laws that provides that an AC below 0.05 is presumptive
evidence that the individual isnor intoxicated. More recent studies of the effect of alcohol
on performance (Moskowitz and Robinson 1988) clearly demonstrated that some
individuals are impaired below that level. Further, a number of individuals with low ACs
may also have consumed drugs so that the combination of alcohol and drugs produce an
impairing effect. This provision could make an AC below 0.05 an obstacle to prosecution
of these cases. Further, a number of States have established zero AC limits in which any
measurable AC (generally 0.01 to 0.02) is an offense for teenage drivers who are not
permitted, under law, to drink. The presumption that an individual below 0.05 is not
impaired is in clear conflict with this type of legislation.

Issue 6: Suspending driverk licenses

Historically, the suspension of the driving privilege has been the most salient penalty
for a conviction of driving-while-impaired. The laws of the States varied in their proce-
dures for administering the license suspension penalty. In some cases, this became a
province of the court with the court seizing the license and, perhaps, substituting a limited
driving permit. Usually, the court would forward an order to the Motor Vehicle Admin-
istrator to suspend the license. Because the driving public feared the loss of license and
saw that as a significant penalty, it became the basis for considerable plea bargaining, to
such an extent that in the early 197Os, license suspension occurred only irregularly, and
many defendants got off with only fines.

Studies conducted principally in the States of California, Washington, and North
Carolina (Popkin et al. 1983; Salzberg and Klingberg 1983; Sadler and Perrine 1984; Peck
et al. 1985) demonstrated that while as many as one-half to two-thirds of those who
receive suspensions continue to drive, suspended drivers were involved in fewer total
accidents and fewer non-alcohol related accidents than individuals who retained their
licenses in return for attending education or treatment programs.

Partly as a result of this evidence and partly as a result of the public concern and
attention to the DWI problem stimulated by citizen activist groups such as MADD and
RID, administrative suspension laws, which bypassed the courts, were enacted during
the late 1970s and early 1980s. The lead was taken by the State of Minnesota, which
enacted so-called administrative per se legislation in 1976. This legislation operated in
conjunction with the implied consent law, so that the driver was not only to lose his license
if he refused a chemical test, but also if he failed such a test. This administrative
withdrawal procedure was adjudicated to be constitutional, provided the offender had
the opportunity to have a hearing to determine that there was probable cause for his
arrest and that the chemical test had been properly conducted (Reeder 1981).

An important feature of a number of these laws was that the police officer was allowed
to pick up the license on the spot, upon either refusal or failure of the test, and replace
the license with a hearing notice. The license was then returned to the Motor Vehicle
Administrator by the police officer. In this way, an initial penalty for drunk driving was
administered on the spot, a feature that could enhance the deterrence to DWI by
reducing the time between offense and punishment and that has been shown to increase
the motivation of police officers in some States.


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BACKGROUND PAPERS

Zador et al. (1988) conducted a study of the impact of per se legislation and the
administrative per se laws and found evidence that the administrative per se law
contributed to some of the national reduction in alcohol-related accidents that occurred
between 1982 and 1986. The issue of the effectiveness of administrative license revoca-
tion as a penalty lies beyond the scope of this paper. However, this law is significant to
the DWI enforcement effort in that it places an additional requirement on police officers
but, also, provides them with a potentially motivating element in that they can be assured
that the offender is receiving a significant penalty. Too often iu the past, when the
application of sanctions has been dependent upon litigation, plea bargaining, and other
delaying tactics, the offender has received minor punishment or none at all. Currently,
23 States have administrative per se laws. The success of this procedure suggests that it
would be desirable for the remaining States to enact similar legislation.

Issue 7: Enforcing driver's license suspensions

Suspension or revocation of the driver's license is considered to be the single most
effective DWI sanction for reducing subsequent traffic offenses and accidents. However,
this sanction comes under attack from practitioners and citizens groups alike because
of compelling evidence that a majority of DWI offenders continue to drive to some
degree during the period of their license revocation or suspension (Sadler and Perrine
1984).

Despite these indications that many offenders continue to drive while under suspen-
sion or revocation, there is evidence that those under suspension, as a group, have
significantly lower rates of rearrest for DWI and of crash involvement (Popkin et al. 1983;
Peck et al. 1985). However, those who do continue to drive (even if they are driving more
safely than otherwise) are flaunting the sanction imposed on them and should be arrested
and punished. The problem has been that driving with a suspended or revoked license
has been a relatively invisible offense. In other words, it generally does not come to a
police officer's attention unless some other violation of the law is detected. Even when
it is detected and a citation for driving without a license is issued, the court frequently
does not convict because of the inability of the prosecutor to demonstrate that the driver
received legal notice of his or her suspension. This occurs because the notices frequently
go through the mail, and there is no acceptable evidence that they were received.

The State of Virginia, among others, has attempted to use police in surveillance of
the residences of suspended drivers in an effort to apprehend those who continue to
drive. This procedure has yet to be adequately evaluated, but obviously involves fairly
high costs in police manhours. Another traditional approach to dealing with this problem
is to increase the penalties for driving while suspended by providing for vehicle impound-
ment or jail time for suspended drivers. The effectiveness of these more salient penalties
procedures is unknown, but their deterrent effect is most probably highly dependent
upon the effectiveness of the enforcement system in apprehending suspended drivers.

In urban areas with large numbers of automobiles, there is simply no way in which the
police can, without some technological assistance, determine whether the individual
operating a vehicle is properly licensed. One aid employed by the State of Minnesota
and in certain other jurisdictions, such as New Philadelphia, Ohio, is to confiscate the
vehicle tags of the drivers who are convicted of driving without a license or convicted of
DWI and replace them with distinctive plates that call attention to the vehicle. This
provides a means for identifying those vehicles that may be driven by a suspended driver.
Several States are currently placing more emphasis on this approach.

A more technological approach to the identification of vehicles driven by suspended
drivers is the use of the so-called TAGS system, which has been evaluated by the
Insurance Institute for Highway Safety (Miller 1978). In that system, police officers are
provided with a keyboard on which to enter vehicle tag numbers at random. These


LAW ENFORCEMENT                                                      153

numbers are transmitted to a central data file that checks to determine if the tag belongs
to a vehicle that has been stolen, if the driver is wanted for other criminal offenses, or if
the vehicle is owned and driven by a suspended driver. If a match occurs, a signal is sent
to the patrol vehicle so that it can stop the car and interview the suspected driver. Using
this TAGS system in Maryland, Miller found that 9.6 offenders were identified per officer
hour compared to only .5 offenders per officer hour using traditional patrol methods.

The sobriety checkpoint also offers a method of enforcing the laws-against driving
while suspended. In the CharIottesviIle checkpoint program (Voas et al. 1985), 1 percent
of the drivers stopped were given citations for driving without a proper license, equal to
the number arrested for DWI. (For a full discussion of the technical problems in
enforcing license suspension, see Voas 1988).

It is clear that if suspension of driver's licenses is to be the principal penalty for drunk
driving, and if a large number of drivers are to be arrested each year, it will be important
to enforce this restriction effectively. Approximately one-half of the drivers suspended
do not reapply for licenses when they are eligible, apparently because of the high cost of
automobile insurance to offenders. Therefore, between 500,030 and 1 million drivers
come off the rolls of State driving license registers each year, but these dangerous
individuals continue to drive. This places them outside the normallicense control system.
An efficient enforcement procedure that can deal with this problem needs to be
developed.

Issue 8: Managhg license penalties automatically

One function of sanctions is to incapacitate the offender and prevent a repetition of
the offense by making it impossible to commit the same crime. Incarceration is the classic
method for ensuring that an offender will not repeat his offense, at least during the prison
term. In DWI adjudication, jail terms are generally far too short to have any significant
effect through incapacitation. The offender is soon released and able to operate his
automobile. Suspension of the driving license is intended to continue the incapacitation
for a significant period, usually several months to a year or more. However, this type of
incapacitation is only partially effective.because it is difficult to enforce. A recently
developed alternative to traditional enforcement methods, which will incapacitate the
individual from repeating his offense, is the alcohol safety interlock. The concept for a
device that would be mounted on the car and test the operator's performance or AC was
first proposed in the Secretary of Transportation's report, AIcohoI and Highway Safety,
in 1968 (U.S. DOT, 1968). In 1970, Voas reviewed this concept, describing the oppor-
tunities and the problems posed by what he dubbed as "Alcohol Safety Interlock
Systems" (Voas 1970)

The idea of an in-vehicle system that can determine the impairment of the driver and
prevent vehicle operation is such a parsimonious and attractive approach to the solution
of the DWI problem that this concept has long enjoyed considerable support among
safety specialists and politicians. As a result, the Federal Government undertook a
decade of research directed at developing an interlock system (Compton 1988). This
research was primarily directed at using performance tests as a method for identifying
the impaired driver. This is attractive because performance tests can detect drivers
impaired by drugs as well as alcohol. However, the first commercially developed devices
have all been based on the measurement of breath alcohol using simple semiconductor
sensors.

Currently, at least 10 States have passed legislation authorizing the testing of these
devices, and individual courts in a number of other States have established demonstra-
tion programs. To this date, however, there has not been a sufficient number of these
devices in the field to provide an adequate scientific test of their effectiveness. Slightly
over 200 units are currently authorized in two experimental counties in California in an


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BACKGROUND PAPERS

evaluation program that is being supervised by the Office of Highway Safety of the State
of California. In another year or two, this program should provide scientific evaluation
of these devices.

While these devices control only the driving in the vehicles in which they are placed
and therefore do not control driving by offenders in other vehicles, they offer the
potential for taking over much of the supervision problem. Since the systems are
predicated upon the offender paying for their cost and the monitoring being done by
.commercial companies, these systems relieve the State of considerable expense. They
will free the police to use their time in enforcing basic drinking driving and other
hazardous driving laws. The principal concern of the highway safety community is that
these devices will be implemented widely before they are fully evaluated and will be
substituted by the courts for the full suspension penalty, which has been proven to be
effective.

Conclusion

The issues listed above provide an important agenda for consideration in action
programs and research studies. The first half of this decade has brought considerable
progress in the reduction of alcohol-related accidents as a portion of total fatal accidents.
It has provided the Erst evidence in history that it is possible to ameliorate the drinking
driving problem through the criminal justice system. The recent leveling off of DWI
arrests and alcohol-related fatalities suggest that new initiatives are needed if the
progress seen during the first half of thii decade is to be continued.

REFERENCES

Andenaes, J. The Scandinavian Experience. In: Laurence, M.D.; Snortum, J.R.; and Zimring, F-E.,
  eds. Social C&r01 of the Drinking Dn'ver. Chicago: University of Chicago Press, 1988.
   pp. 43-63.

Beitel, GA.; Sharp, M.C.; and Glauz, W.D. Probability of arrest while driving under the influence
  of alcohol. JournaZofStudies on Alcohol 36(1):109-l 15, 1975.
Borkenstein, R.F. Problems of enforcement, adjudication and sanctioning. In: Israelstam, S., and
  Lambert, S., eds. Alcoholhugs and Trajjic Safety. Proceedings of the Sixth International
  Conference on Alcohol, Drugs and Traffic Safety. Toronto, Ontario: Addiction Research
   Foundation of Ontario, 197.5.

Cleat-y, J., and Rodgers, A. Analysis of the Effects of Recent Changes in Minnesota's DWI Laws:
  Pan III Longitudinal Analysis of Policy Impacts. St. Paul, MN: Research Department,
   Minnesota House of Representatives, 1986.

Compton, R.P. Potential for Application of Ignition Interlock Desices to Prohibit Operation of
  Motor Vehicles by Intoxicated Individuals. Washington, DC: National Highway Traffic
   Safety Administration., 1988.

Department of Transportation. AZcohol and Highway Safety. Report to the U.S. Congress.
  Washington, DC: Supt. of Dots., U.S. Govt. Print. Off., 1968.
Fields, M., and Henricko, AR. Passive Alcohol Sensors-Constitutional Implications. The
  Prosecutor 20( 1):45-50, 1986.

Harris, D.H.; Hewlett, J.B.; and Ridgeway, R-G., fir& Defection of&kg while InfoaiCUfed.
  Project Interim Report: Identification of V&al Cues and Development of Detection
  Methods. NHTSA Report No. DOT HS 805-051. Washington, DC: NHTSA, 1979.
  Available from NTIS, Springfield, VA 22161

Hause, J.; Voas, R.; and Chavez, E. Conducting voluntary roadside surveys: The Stockton
  experience. In: Valverius, M-R., ed. Proceedings of the Satellire Conference to the 8th
  International Conference on Alcohol Drug, and Trafic Safety, 104-13. Stockholm: The
   Swedish Council for Information on Alcohol and Other Drugs, 1982.


LAW ENFORCEMENT

155

Homei, R. Policing the Drinking Driver: Random Breath Testing Md the Process of Deterrence.
  Sydney, Australia: Federal Office of Road Safety, 1986.
Howland, J. Social norms and drunk driving countermeasures. In: Graham, Ed. Preventing
  Automobile Injwy; New Findings from Evaluation Research, Dover, MAz Auburn House,
   1988. pp. 163-180.

Hurst, P. Epidemiological aspects of alcohol in driver crashes and citations. Journal of Sufeq
   Research 5(3(:130-148,1973.

Ifft, R.k Curbing the drunk driver under the fourth amendment: The constitutionality of
   roadblock seizures. Georgetown Law Journal 71:1457X& 1983.
Jonah, B.k, and Wilson, RJ. Improving the effectivenessof drinkingdrivingenforcement through
  increased efficiency. Accident Analysis & Prevention. 15(6):463-482,1983.
Jones, I.S. The Development and Evaluation of a Passive Alcohol Sensor. Washington, DC:
   Insurance Institute for Highway Safety, 1986.
Jones, IS., and Lund, AK. Detection of alcohol-impaired drivers using passive alcohol sensor.
  Journal of Police Science and Administration 145(2): 153-f&),1985.
Klein, T. The Effect of Changes in DWI Legislation in the State of Mqband. NHTSA Technical
   Report. Washington, DC: NHTSA, 1982.

Laccy, J.H.; Steward, J.R.; Marchetti, L.M.; Popkin, C.L.; Murphy, P.V.; Lucke, R.E.; and Jones,
  R.K. Enforcement and Public Infotmution Strategies foT DWI General Deterrence: Arrest
  DrunkDriving-The Clear-water and Large, Florida Eqerience. NHTSA Report No. DOT
   HS 807066. Washington, DC: NHTSA, 1986.
Laurence, M.D. The legal context in the United States. In: Laurence, M.D.; Snorturn, J.R.; and
  Zimring, F.E., eds.Social Control of the Drinking Driver. Chicago: University of Chicago
   Press, 1988. pp. 136-168.

Levy, P.; Voas, R.B.; Johnson, P.; and Klein T. Evaluation of the AsAPs. JoumalSafety Research
   10(4):162-176, 1978.

Miller, G. Summary Report on Project TAGS-An Eqxriment in Mass Screening of License Plates
  to Zdentiji, Motor Vehicle Law Violators. Washington, DC: Insurance Institute for Highway
   Safety, 1978.

Moskowitz, H., and C. Robinson. Effects of Low Doses of Alcohol on Driving Reiated Sk&: A
  Review of the Evidence. NHTSA Report, DOT HS 807-280. Washington, DC: NHTSA,
    1988.

National Highway Traffic Safety Administration. Summury of Nutionul AZcohoZ Safety Action
  Frojecfs. Washington, DC: Supt. of Dots., US Govt. Print. Off., 1979.
National Safety Council. Alcoholand the Impaired Driver. Chicago: National Safety Council, 1976.
Oates, J.F., Jr. Factors InfluencingArrestsforAkohol-Related Traffic ~olations. National Highway
  Traffic Safety Administration, Technical Report, DOT-HS-801~230. Washington, DC:
   NHTSA, 1974.

Peck, R.C.; Sadler, D.D.; and Perrine, M.W., The Comparative Effectiveness of Alcohol
  Rehabilitation and Licensing Control Actions for Drunk Driving Offenders: A Review of
  the Literature.Alcohol, Drugs, and Drivtitg;Abstracts and Reviews 1(4);15-40, 1985.
Popkin, C.L.; Li, L.R; Iacey, J.H; Stewart, J.R.; and Wailer, P.F.AnInitiuZEvaluation oftheNorth
  Carolina Alcohol and Drug Education Traffic SchooLs. Volume 1: Technical Report.
  Chapel Hill, NC: University of North Carolina Highway Safety Research Center, 1983.
Prouty, R.W., and O'Neill, B. An Evaluation of Some Quantitative Breath Screening Tests for
  Alcohol. Technical Report. Washington, DC: Insurance Institute for Highway Safety,
    1971.

Reeder, R.H. Analytical Study of the Legal and OperationalAspects of the Minnesota Law Entitled
   "Chemical Test for Intoxication. " NHTSA Report No. DOT-HS-806-170. Washington,
   DC:NHTSA, 1981.

Ross, H.L. Law, science and accidents: The British Road Safety Act of 1%7. The Journalof Legal
   Studies 2(1):1-78, 1973.

Ross, H.L. The Scandinavian myth: The effectiveness of drinking-and-driving legislation in Sweden
   and Norway. The Journal of Legal Studies 4(2):285-310,1975.
Ross, H.L. Deterring the Drinking Driver: Legal Policy and Social Control. Lexington, MA:
   Lexington Books, 1984.

Ross, H.L. Deterrence-based policies in Britain, Canada and Australia. In: Lawrence, M.D.;
  Snortum, J.R., and Zimring, F.E., eds. Social Control of the Drinking Driver. Chicago:
   University of Chicago Press, 1988. pp. 64-78.


156

Sadler, D.D., and Perrine, M.W. An EvaIuation of the California Dmnk Driving Countermeasure
  System: Volwne 2 The Long-Term Trajjic Safep Impact of a PilotAlcoholAblcse Treatment
   as an Alternarive to License Suspensions. Report No. 90. Sacramento, CA: California
   Department of Motor Vehicles., 1984.

Salzberg, P.M.; and Kiingberg, C.L The effectiveness of deferred prosecution for driving while
   intoxicated. Journal of Studies on AkohoI 44:299-306,1983.
Snortum, J.R. Alcohol impaired driving in Norway and Sweden: Another look at "the Scadinavian
   Myth." Law and Policy 6(1):5-37,1984.

Taubenslag, W.N., and Taubenslag, MJ. Selective Trafic Enforcement Program (STEP): Fort
   Lauderdale, Pasco Services, Inc. Final Report. Washington, DC: NHTSA, 1975.
Tharp, V.; Bums, M.; and Moskowitz, H. Development of Field Test of Psychophysical Test for
   DWArrest. Technical Report no. DOT-HS805-864. Washington, DC: NHTSA, 1981.
Vingilis, E.R.; Adlaf, E.M.; and Chung, L. Comparison of age and sex characteristics of police-
   suspected impaired drivers and roadside-surveyed impaired drivers.AccidenrAnufyrfi and
   Prevention 14:4X-30,1982

Voas, R.B. "CarsThat Drunks Can't Drive." Paper presented at the annual meeting of the Human
   Factors Society, San Francisco, 1970.

Voas, R.B. Selective enforcement during prime-time drinking-driving hours: A proposal for
   increasing deterrence without increasing enforcement costs. Abstracts and Reviews in
   Alcohol and Driving 4(3):3-21, 1982.

Voas, R.B. Laboratory and field tests of a passive alcohol sensing system. Abstracts and Reviews
   in Alcohol and Driving 4(3):3-Z& 1983.

Voas, R.B. Emerging technologies for controlling the drunk driver. In: Laurence, M.D., Snortum,
  J.R.; Zimring, F.E., eds. Social Control of the Drinking Driver. Chicago: University of
   Chicago Press, 1988.

Voas, R.B., and Hause, J.M. Deterring the drunken driver: the Stockton experience. Accident
  Analysis and Prevention 19(2):81-90, 1987.
Voas, R.B., and Layfield, WA. Creating general deterrence: Can passive sensing help? The Police
   Chief 50:56-61, 1983.

Voas, R.B.; Rhodenizer, AE.; and Lynn, C. Evaluation of Char-lottesvilZe Checkpoint Operations.
   Technical Report, DOT Contract DTNH-22-83-C-05088. Washington, DC NHTSA,
    1985.

Williams, A-F., and Lund, A-K Deterrent effect of roadblocks on drinking and driving- Traffic
   Safeq Evaluation Research Review 3:7-18,1984.

Zador, P.R.; Lund, A-K-; Fields, M.; and Weinberg, K.; Alcohol-Impaired Driving Luws and Fatal
   Crash Involvement. Washington, DC: Insurance Institute for Highway Safety, 1988.


157

Transportation and Alcohol Service Policies

Transportation Alternatives for Drinkers

    Robert Apsler, Ph.D.
Department of Psychiatry, Harvard Medical School

Drunk driving persists at stubbornly high rates despite continuing efforts to reduce
its occurrence (Reed 1981; NHTSA 1985; National Commission Against Drunk Driving
1987). One of the most compelling explanations for this phenomenon is the observation
that alcohol and automobiles have become such integral features of our society that
drunk driving is virtually inevitable (Gusfield 1981; Mosher 1985; Ross 1987). If substan-
tial reductions in drunk driving are to occur, dramatic changes must take place. Either
drivers must sharply curtail their drinking, or ways must be found to stop intoxicated
individuals from driving.

This chapter focuses on a class of prevention strategies that take the latter approach.
These strategies share a philosophy of attempting to provide drinkers with safe transpor-
tation while requiring as little modification as possible in drinking practices. There is, of
course, nothing new about informal efforts to find safe transportation for intoxicated
individuals. Surely, efforts to help intoxicated individuals get home safely began long
before the invention of the automobile. Today, incidents of hosts, fellow drinkers, sober
associates, and police assisting intoxicated individuals in obtaining safe transportation
have become part of our drinking lore, even though they have received little study. In
contrast to these informal interventions, formal programs designed either to provide safe
transport for individuals or to encourage informal actions appear to have originated only
in the last few years. Unfortunately, they too have received almost no attention from
researchers. These efforts to implement transportation alternatives for intoxicated
drivers can be divided into two groups: (1) those in which the individuals participating
in the drinking activity supply both vehicles and drivers- the designated driver tactic,
and (2) those where neither vehicles nor drivers are typically provided by the individuals
taking part in the drinking activity- the safe rides tactic.

Designated Drivers

With a simple and inexpensive tactic, groups of drinkers can assure themselves that
a sober driver will be available when needed. Before drinking commences, they deter-
mine the number of drivers necessary to transport the entire group. Then, that number
of individuals in the group remain sober and drive all of the others. This tactic, the use
of "designated drivers," has been championed by a diverse array of sources and is
currently receiving wide dissemination through the mass media.

The tactic of drinkers designating individuals to remain sober and do the driving has
great appeal. First, the tactic can be used in any settingwhere people drive together after
drinking. For example, it can be employed in private homes, bars, sporting events, and
restaurants. Second, underage youths can adopt the tactic without requiring the
authority or approval of adults. Third, no cost need be associated with exercising the
tactic. In fact, designated drivers save money by drinking nonalcoholic beverages. Even


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BACKGROUND PAPERS

when incentives are offered to designated drivers by drinking establishments, the cost of
the incentives tends to be inconsequential. Fourth, if light drinkers or abstainers are
unavailable, only the designated drivers need change their drinking behavior for the
tactic to be successful. Other group members are free to drink in whatever way they
choose.

Surprisingly, virtually no research has been done on the designated driver tactic.
Nevertheless, even the sparse information that does exist reveals both the great potential
and some important limitations of the tactic. The potential for widespread use of the
designated driver tactic is apparent from the results of a 1987 Gallop Poll (Gallup 1987).
Nearly all Americans (91 percent) who participated in social events where alcohol was
available wanted the people with whom they associated to employ the designated driver
tactic. Furthermore, results from another item in the survey suggested that ample
numbers of individuals are willing to serve as designated drivers. Nationally, 78 percent
of the individuals who visit settings where alcohol is served indicated that they would be
willing, on occasion, to serve as a designated driver. Interestingly, drinkers were more
inclined than nondrinkers to serve as designated drivers (84 percent versus 67 percent,
respectively). Although the Gallop Poll indicated that most people approve of the
designated driver concept, the question remains as to whether their favorable disposition
translates into practice. How often and under what circumstances do groups of drinkers
designate some of their members to remain sober and do the driving?

Informal Designated Drivers

One of the advantages of the designated driver tactic is that formal programs are not
necessary. Any group of individuals in any drinking environment can designate someone
to remain sober and do the driving. Unfortunately, information about these "informal"
designated drivers is even more scarce than about those who participate in formal
programs. It consists of responses to a few survey items included in studies directed
primarily at other aspects of the drinking/driving problem. For example, as part of an
unpublished telephone survey that Wayne Harding and I conducted in 1987, people
living in a Boston suburb were asked about the designated driver tactic. Respondents
were randomly selected from a list of licensed drivers and then screened to produce a
sample of 502 individuals who reported having used alcohol and having driven (not
necessarily together) in each of the 2 past years.

To estimate use of the designated driver tactic, we asked respondents, "During the
last 12 months, how many times were you part of a group of drinkers in which someone
didn't drink so they could drive others in the group ?" Over half (53 percent) of the entire
sample indicated that they had been part of such a group. Eighty-four percent of the
individuals who had been in such a group reported that it happened 12 or less times
during the past 12 months (nearly half said 3 or fewer times). Another item asked how
groups made the decision to use the designated driver tactic. Only 3 percent of the
respondents reported that they had been in a group that was "encouraged by a bar or
restaurant" to designate someone to remain sober and do the driving. This low figure
fits with the finding reported below that formal programs produce few designated
drivers. All other respondents reported that their groups made the decision to designate
a sober driver on their own.

Snortum, Hauge, and Berger (1986) also conducted surveys bearing on use of the
designated driver tactic for reducing drunk driving. They estimated that 12 percent of
American groups of drinkers always appoint one person to remain sober to drive, while
42 percent of such groups never designate a driver to remain sober. In sharp contrast,
76 percent of Norwegian groups were estimated to always employ the designated driver


Tf&4NSPORTATlON AND ALCOHOL SEFMCE POLICIES

159

tactic, while only 4 percent never used it. Unfortunately, the findings were clouded by a
58-percent response rate in their U.S. sample and an unknown response rate in Norway.

Survey of Formal Designated Driver Programs

In 1985, the National Highway Traffic Safety Administration funded a study specifi-
cally aimed at answering questions concerning designated drivers (Apsler et al. 1987).
The major focus of the project became the examination of formal designated driver
programs (DDPs) - systematic efforts by drinking establishments or organizations to
actively promote the designated driver tactic. A "snowball" approach was employed in
an effort to locate as many DDPs as possible throughout the United States. As various
individuals and organizations were contacted, they identified some DDPs and suggested
other individuals who might know of more. Ultimately, these sources produced the    ,,
names of 431 alleged DDPs. To verify the existence of some programs and to learn more
about them, we then began telephoning a geographically diverse sample of the programs
that had been praised most highly by our sources. Telephone conversations were held
with spokespersons from 37 operational and 3 defunct DDPs. Four of the 37 programs
were also visited by the investigators.

A second series of phone calls was made to membership organizations, such as
fraternal clubs, veterans organizations, and fraternities and sororities. Some of these
organizations are notorious for the heavy drinking that takes place, yet virtually none
appeared on the list of DDPs identified through the snowball survey. Fii-four mem-
bership organizations randomly selected from seven major U.S. cities were contacted,
resulting in five DDPs with whom extended conversations were held.

Characteristics of DDPs

The formal DDPs that were contacted tended to be similar in many ways, despite
assorted variations. For example, most DDPs operated whenever the drinking estab-
lishment was open, though a few restricted the hours, and two operated onlyon holidays.
All respondents claimed that the cost of operation for their DDP was minimal and
inconsequential. All DDPs utilized some form of in-house publicity, such as posters,
table tents, employee buttons, and promotion by the server or doorman. When publicity
occurred in the mass media, it tended to be donated or consisted of news items. Over
half of the DDPs stated that they had eligibility requirements for participation, usually
in the form of a minimum group size that ranged from two to six people. One program
also specified a maximum group size of six people, reasoning that larger groups would
not fit in one automobile. Nearly all DDPs required that the designated driver abstain
from alcohol, though some permitted the driver to have up to two drinks. All but two
DDPs gave incentives to designated drivers, usually in the form of free nonalcoholic
drinks. A few DDPs offered free food, and others gave coupons that could be redeemed
in the future for free food or drinks. In many establishments, a patron wanting to obtain
the incentive for becoming a designated driver had to approach the server and make the
request. However, in roughly a third of the DDPs, one of the staff was expected to
approach eligible parties with an explicit request that someone be designated as the
sober driver. Once selected, the designated driver often received some form of iden-
tification, such as a button or hand-stamp.

The Number of Designated Drivers

It appears that few individuals are participating in the DDPs offered by drinking
establishments. Precise figures were unavailable, since few establishments kept reliable
records of the numbers of designated drivers, and none recorded the number of eligible


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BACKGROUND PAPERS

groups served. Nevertheless, estimates offered by drinking establishments provide at
least a ballpark indication of the numbers involved. The majority of drinking estab-
lishments reported serving 20 or fewer designated drivers per week. A'much more
meaningful figure is, of course, the percentage of eligible groups in which someone
served as a designated driver. Here the figures are even more tenuous, since only a few
respondents made a guess at the number of eligible groups served by their establishment.
Typically, less than 10 percent of the eligible groups participated in a DDP.

Limited Appeal of the Designated Driver Tactic

The vast majority of Americans approve of the designated driver tactic and are willing,
on occasion, to serve as a designated driver. Yet existing evidence indicates that relatively
few groups of drinkers in the United States actually employ the tactic. Part of the
explanation may be that there are many circumstances in which serving as a designated
driver is unappealing and/or impractical.

Who Will Abstain if Everyone Wants to Drink?

Individuals' willingness to serve as a designated driver is probably associated with
their perception of how necessary drinking is for enjoying an activity. At sporting events,
for example, beer drinking may be at least as important for some people (especially young
males) as the contest. In such settings where drinking, particularly heavy drinking, is a
central part of the experience, remaining sober may be seen by many individuals as too
great a sacrifice. In principle, taking turns can make serving as the designated driver
more palatable. But if group membership is fluid, equitable sharing of this role becomes
difficult.

The designated driver tactic is likely to be unappealing in numerous other circum-
stances. For instance, when two people go out for drinks, will one of them drink alone?
Social activities intended to bring together people who do not know each other well are
another example in which drinkers might be reluctant to forego alcohol, since drinking
is viewed by many as a social lubricant that facilitates meeting strangers. People who
generally feel that alcohol helps them relax and become more outgoing may be unlikely
to accept the handicap of not drinking. Problem drinkers are also poor candidates for
the role of designated driver. Even people willing to remain sober may resist serving as
a designated driver out of reluctance to transport a bunch of drunks. Who wants a car
full of potentially belligerent individuals? Who will clean up the mess and get rid of the
smell if someone vomits?

Logistical Problems

Even when individuals are willing to remain sober, they may often be reluctant to serve
as a designated driver for logistical reasons. The designated driver tactic is most
attractive only when the starting points of group members are geographically close and
also when their ultimate destinations after drinking are near each other. It is un-
reasonable to expect one individual to drive long distances to pick up and drop off other
group members. A compromise is for everyone to drive to a central location from which
the designated driver ferries the group to and from the location where drinking occurs.
This compromise does reduce the number of miles driven by the intoxicated members
of the group. However, if intoxicated group members use the availability of a designated
driver as justification for drinking more than they usually would, then their risk of a crash
could be even greater than if they had drunk less and driven the entire distance
themselves.


TRANSPORTATION AND ALCOHOL SERVICE POLICIES

The Need for Planning

This last example points to another limitation of the designated driver concept: the
need for organization and planning in advance of the activity. Once individuals have
arrived in their own cars at the drinking location, it is probably too late in most
circumstances to employ the designated driver tactic. Although it would still be possible
for the drinkers to leave their cars at the drinking location and. ride home with the
designated driver, most people are probably reluctant to do so. Clearly, it is better to
determine in advance who will attend an activity that will include drinking, how many
vehicles will be needed, and who will drive. Timing is another critical aspect of the
planning issue. The designated driver tactic requires all members of a group to arrive
and depart at the same times. This extensive planning seems practical mainly in struc-
tured activities, such as staged events or regular social functions.

161

Other Disadvantages of the Designated Driver Tactic       /

Resistance From Servers

Alcohol servers in the drinking establishments we visited explained that they receive
smaller tips from groups with designated drivers. The nonalcoholic beverages that
designated drivers drink are usually free, or if purchased, they cost much less than
alcoholic beverages. Consequently, alcohol servers, who rely on tips for much of their
income, suffer economically when they serve designated drivers, unless drinking estab-
lishments make arrangements to compensate them for lost tips. Obviously, without a
subsidy, servers may be reluctant to encourage patrons to adopt the designated driver
tactic, and we found no establishment that provided such a subsidy.

Reliance on an Honor System

In many drinking situations, the success of the designated driver tactic depends
entirely on the commitment of both the.designated driver and other members of the
group. Even when alcohol servers and hosts encourage use of the tactic, they can do little
to ensure either that designated drivers begin sober, remain sober, or that they do the
driving. Servers typically must rely on buttons or hand-stamps to identify designated
drivers, and these devices can easily be hidden by someone determined to obtain
alcoholic beverages. Similarly, servers or hosts have no way to guarantee that the
designated driver drives all members of the group. We did find rare instances in our
study of DDPs when doormen would occasionally follow patrons into the parking lot to
make certain that an apparently sober individual got behind the wheel. Nevertheless,
even such extreme efforts can easily be circumvented.

Determination of "Sober"

While most formal DDPs do not serve alcohol to designated drivers, individuals
employing the designated driver tactic informally are free to determine the degree of
sobriety that the designated driver must maintain. A potential danger is that some groups
will be mistakenly complacent as long as the designated driver is less intoxicated than
the others, even if not completely sober.

Excludes the Solitary Drinker

By definition, the designated driver tactic works with a group of individuals- not with
a single individual. Consequently, the tactic cannot help provide safe transportation for
the solitary drinker.


162

Safe Rides

Another transportation-based approach for reducing alcohol-related automobile
crashes is to provide both vehicles and drivers for intoxicated individuals who would
otherwise drive themselves or ride with an intoxicated driver. This approach is usually
referred to as "safe rides." Formal safe ride programs (SRPs) encompass a wide variety
of transportation alternatives, such as taxicabs, limousines, tow trucks, buses, and
automobiles, while the informal provision of safe rides generally relies on taxicabs and
automobiles. Typically, when transportation is needed by an intoxicated person, either
that person or someone else, such as a server or host, obtains transportation from outside
the drinking environment. In some instances, contact is made directly with a company
that provides the transportation, such as a taxicab company, while in others a wm-
munications service is contacted, and it, in turn, makes arrangements for transportation.

The safe rides tactic is a theoretically perfect solution to the drinking/driving problem.
A primary attraction from a drinker's standpoint is that no modification of drinking
behavior is necessary. No one need remain sober or even moderate his or her alcohol
consumption, and still all drinkers can be transported home without endangering either
themselves or others. In addition, the safe rides tactic works with solitary drinkers. Unlike
the designated driver tactic, the safe rides tactic does not depend on the existence of
groups of individuals.

The safe rides tactic appears to receive the same high level of approval that was found
for the designated driver tactic. Caudill, Kaufman Kantor, and Ungerleider (1988)
interviewed 1,522 patrons as they entered bars and nightclubs in Sacramento and San
Jose, California. The survey was conducted to obtain baseline data for a study of SRPs.
Nearly all of their respondents (% percent) believed that the availability of SRPs would
be useful; 63 percent of the respondents selected the number "10" on a l-10 scale of
usefulness. In addition, 79 percent of all respondents reported that they might use such
a service if it were available. An even larger percentage of heavy drinkers, 87 percent,
indicated that they might take advantage of a safe rides service. On the other hand, they
also found that a large number of respondents (38 percent) had not heard about SRPs,
and few had actually used one. Seven percent of all respondents and 12 percent of heavy
drinkers reported that they had used the services of a SRP sometime in the past.

Informal Safe Rides

As in the case of the designated driver tactic, formal programs are not necessary for
the safe rides tactic to be used. Intoxicated individuals do not need a SRP to use taxicabs
or receive rides from sober friends in order to avoid drunk driving. However, this
informal use of the safe rides tactic has received almost no attention from researchers.
One exception is an ethnographic study of bar settings conducted by Gusfield, Rasmus-
sen, and Kotarba (1984). They recount observing incidents in four drinking settings
where bartenders would sometimes call a taxicab for intoxicated patrons wanting to
avoid driving. The likelihood of bartenders assisting patrons in avoiding drunk driving
depended largely on the relationship between patron and bartender. Furthermore, the
authors noted considerable variation both among and within drinking establishments in
bartenders' efforts to help patrons obtain a safe ride.

Hernandez and Rabotis (1987) study of interventions in drunk driving situations also
provides information about the informal use of safe rides. They questioned 247 college
student volunteers from an introductory sociology class to learn about incidents in which
someone had tried to stop them from driving after drinking. Ninety-seven of the students
reported experiencing such an incident. Most of the 89 reported interventions in which


TRANSPORTATION AND ALCOHOL SERVICE POLICIES                                     163

someone drove the respondent home occurred at parties (49 percent), and a somewhat
smaller portion (33 percent) occurred at friends' homes. Many fewer instances of
respondents being driven home took place at either bars (12 percent) or restaurants
(6 percent). The results of these two studies substantiate informal use of the safe rides
tactic but obviously leave a great many questions unanswered.

Survey of Formal Safe Ride Programs

In 1986, the National Highway Traffic Safety Administration funded a survey of SRPs
(Harding, Apsler, and Goldfein, 1988u, b) that followed the same procedure described
above for our earlier study of the designated driver tactic. First, leads on 515 SRPs across
the country were obtained using a snowball survey. After information for 325 programs
were verified, detailed data were collected on 52 programs (see Harding, Apsler, and
Goldfein 1987 for a directory that summarizes key features of the 325 programs). Twelve
of the 52 safe ride programs were then visited by the investigators.

Characteristics of SRPs

We found SRPs existing in communities ranging from small towns to large cities. They
were operated by numerous types of organizations, including cab and bus companies,
charitable organizations, trade associations, hospitals, government agencies, and non-
profit organizations set up specifically for this purpose. Many operated year-round, often
providing service every day of the week. Safe ride programs advertised themselves both
through the local media and with signs in drinking establishments and other locations.
Programs run by transportation companies typically used their own dispatchers and
drivers, while other programs used various combinations of paid and volunteer staff.
Often, SRPs were staffed largely by volunteers and operated in conjunction with a
transportation company that provided the vehicles and drivers.

Even though nearly all programs provided their service at no cost to riders, the
average annual cost of the year-round programs was under $12,000. Most programs
obtained funding from a wide variety of sources, the most common of which were
donations in the form of free advertising from the media, member fees paid by drinking
establishments and/or corporations, donations from alcohol distributors, and fundrais-
ing activities.

Most programs accepted requests for rides either from drinkers or someone calling
for the drinker, while some took calls only from drinkers and others only from alcohol
servers. Many programs screened riders to make sure they fit their requirements, such
as whether the rider was intoxicated, drove his/her own vehicle to the drinking site,
intended to go directly home, and whether the origin and destination fit within the
program's operating range.

The Number of Riders

As was the case with DDPs, reports of the number of riders transported by SRPs must
be interpreted with caution. For instance, some programs could only make estimates,
and others could not separate the number of requests received from the number of rides
provided. Nevertheless, about half of the programs reported delivering roughly 400 or
more rides per year, and about a quarter delivered 1,000 or more rides per year.
Unfortunately, almost no ride programs gave estimates for the size of the target popula-
tion. Since SRPs tend to cover entire communities or large sections of major cities, the
number of eligible intoxicated drivers within their operating boundaries could be quite
large.


BACKGROUND PAPERS

Disadvantages of Ride Programs

Cars Are Usually Left Behind

Only a small percentage of SRPs (about 15 percent of those we contacted) transport
drivers' cars or provide free transportation the next day to help drivers retrieve their
vehicles. Obviously, some drivers may forgo a ride home knowing that they must leave
their car behind. They may be concerned that returning home without the car will
incriminate them; they may fear that their car will be stolen and/or vandalized if left
overnight; or they may simply want to avoid the inconvenience of retrieving their car.

Determination of Level of Intoxication

With rare exceptions, SRPs rely on either the drinker or someone else at the driig
site to determine whether the drier is too intoxicated to drive safely. Intoxicated
individuals are notoriously incapable of accurately judging their level of intoxication, and
research shows that even people who often observe intoxicated drivers, such as alcohol
servers, tend to be poor judges of level of intoxication (Langenbucher and Nathan 1983).
As a result, it may be the more cautious drivers who tend to seek out rides for themselves,
while observers, such as servers, may tend to single out only the most obviously intoxi-
cated individuals for a safe ride home. Various devices, such as "Know-Your-Limit"
cards and breathtesting machines, could easily be made available to patrons wanting
assistance in judging their level of intoxication. Even so, it might still be only the more
cautious individuals who would use these devices.

Potential for Abuse

People who are not intoxicated can easily take advantage of many SRPs, as can
intoxicated individuals who do not have cars. In an effort to minimize abuse, some RSPs
screen clients. For example, some take requests for rides only from servers as one way
of insuring that riders are intoxicated, and some ask to see driver's licenses and keys as
at least partial assurance that the rider would otherwise drive. However, no information
exists about the prevalence of inappropriate use of SRPs. Staff in some programs also
reported efforts to screen out individuals who made frequent requests for rides. Unfor-
tunately, those individuals (often referred to by program staff as "alcoholics") may be
the ones who present the greatest danger on the roads.

A Special Case: Transportation to and From Drinking
Locations

A rare variation of SRP transports drinkers in both directions-first bringing them
to drinking locations and then taking them home from those locations. This "round trip"
version of safe rides overcomes several important limitations of the "home-only'
programs. For instance, the question of what to do about drinkers' cars disappears, since
people do not drive their cars to the drinking locations. In addition, these SRPs make
no attempt to determine level of intoxication, so the issue of abuse of the program
disappears - anyone, intoxicated or not, can use these programs,

In those situations where the "round trip" SRP is practical, safe rides can become a
nearly perfect solution to the drunk driving problem. The most common examples are
special buses or trains that transport people to and from a scheduled event, such as a
sporting event. Another variation occurs in Boston, where the mass transit system is kept


TRANSPORTATION AND ALCOHOL SERVICE POLICIES

running later than usual on New Year's Eve to help transport the thousands of people
attending events held in the downtown area. The problem with these versions of the safe
rides tactic is that many drinkers may drive themselves home from the points where
buses, trains, or subways deposit them. Another example of round-trip SRPs is the
increasing popularity of limousine service on high school prom nights in some com-
munities. If door-to-door service is provided, then there is obviously no driving after
drinking.

The major obstacles to wider use of round-trip SRPs based on mass transit are the
same ones that prevent wider use of mass transit in general. Given the widespread
ownership of automobiles in most locations and the existence of an extensive highway
system, mass transit cannot compete with automobiles bn convenience and cost. Round-
trip SRPs are a realistic option when (1) a large number of individuals live in relatively
dense areas, and (2) they travel to drinking sites located in a relatively small geographical
area. These conditions are typical of some college towns. Dormitories might be clustered
in one area and fraternities and sororities in another, while many of the favorite drinking
establishments congregate in one section of the nearby town. However, now that the legal     '
drinking age has been raised across the country, most undergraduates cannot legally
drink in drinking establishments. Consequently, there may no longer be sufficient traffic
between campuses and drinking establishments to make round-trip programs practical.

The Costs of Expanding Safe Ride Programs

If SRPs are to be more effective, they must transport more riders. Yet, it is not clear
whether the existing sources of funds and/or volunteers could keep pace with a significant
increase in the use of SRPs. The key, of course, is determining how much the ridership
would increase if efforts were made to expand the role of SRPs. The answer to that
question depends largely on the nature of the population of potential riders that is chosen
as a target. For example, SRPs could transport anyone who wants a ride, or they could
be restricted to intoxicated individuals. If riders must be intoxicated, then a level of
intoxication should be chosen. The commonly used BAC of 0.10 percent is an obvious
candidate, though a much lower level, such as the 0.05 percent BAC recommended by
the American Medical Association (Council on Scientific Affairs 1986) must be con-
sidered. Will potential riders have to prove that they would drive if they are refused use
the safe ride program? Will passengers trying to avoid riding with an intoxicated driver
be transported, as is usually the case with existing SRPs? Will underage drinkers be
transported? The maximum length of rides and permissible destinations of trips are
other factors that markedly impact cost estimates. At present, little is known about how
the number of eligible individuals would vary with the selection of different target
populations. Nor is there information on the percentage of eligible people who might be
persuaded to take advantage of SRPs.

At least two other types of costs must be considered in planning for broader use of
safe rides programs. First, drinking establishments might have to increase their parking
facilities to hold the cars that accumulate as their intoxicated drivers receive alternative
transportation home. Second, the cost of transportation back to the drinking site at a
later time for drivers to retrieve their cars must be included in the overall equation. These
costs can be built directly into the SRPs by having them transport cars along with their
drivers. For example, a few SRPs transport riders' cars with tow trucks or provide a
second, sober driver.

On the other side of the cost issue is the question of who would pay for an expanded
system of SRPs in the event that existing funding sources could not cover the costs. There
are several possibilities. Additional expenses could be borne by those who obtain rides,
or .the costs could be spread across a larger population, such as all drinking estab-

165


166

BACKGROUND PAPERS

lishments, all drinkers, or even across all taxpayers. Cost sharing, say between riders and
drinking establishments, is another option.

Finally, an effort to markedly expand SRPs will almost certainly depend heavily on
taxicabs. Consequently, it will have to contend with the 50-percent drop in the number
of taxicabs and the 4Opercent decline in taxicab operators that occurred over a recent
M-year period (Gilbert et al. 1984). On a more positive note, Teal (1985) reported on
developments in the taxicab industry that may improve its financial health.

Conclusions

The designated driver and safe rides tactics comprise a class of transportation
alternatives that help reduce the number of intoxicated drivers on our roads. Both tactics
enjoy broad support from potential users and can be employed in virtuaily any drinking
setting. Safe rides programs make even fewer demands on drinkers than the designated
driver tactic and can be successful without advance planning. Hundreds of designated
driver and safe rides programs have been established in a broad array of settings. They
cost little to operate in their present forms and receive broad support from drinkers,
drinking establishments, community organizations, activist groups, and the alcohol
beverage industry. Yet, two key questions remain: (1) Just how much impact have the
designated driver and safe rides tactics had so far in reducing numbers of intoxicated
drivers? (2) What is their potential for making a further reduction?

Formal DDPs, according to reports of the programs themselves, produce relatively
few designated drivers. While some people employ the designated driver tactic on their
own, they may do so infrequently. Based on scanty results, the main effect of publicity
about the designated driver tactic may be to encourage drinkers to ride with abstainers
or light drinkers when such individuals happen to be available and willing to transport
others. The most important disadvantages of the designated driver tactic are probably
the need for planning and the existence of many circumstances where the tactic is
unappealing to drinkers and/or Iogistically impractical.

Nationally, SRPs transport thousands of individuals each year. However, riders' levels
of intoxication have not yet been documented, nor has the number who would have either
driven or obtained a ride from an intoxicated driver in the absence of SRPs been verified.
Furthermore, little is known about the numbers of eligible riders and the feasibility of
markedly expanding the scope of SRPs. One likely obstacle to increasing ridership is the
requirement in many SRPs that riders leave their cars at the drinking site.

The policy implications of existing data are that the designated driver and safe rides
tactics should continue to be encouraged and supported with the clear understanding
that these strategies are limited in what they can be expected to accomplish. Until
additional research shows otherwise, it appears that these strategies are unlikely to fulfill
what, at first glance, appears to be their enormous potential for reducing the numbers
of intoxicated drivers.

Of the two strategies, the designated driver tactic is the more questionable. At present,
the only prudent position is to remain extremely skeptical about the impact that it can
have. In those circumstances when use of the tactic is both appealing and practical, it
can be completely effective in eliminating intoxicated drivers from the roads. Research
is necessary to determine how often those circumstances exist and to explore the
possibilities for increasing the frequency with which they occur. Safe rides programs,
especially when coupled with servers and hosts assuming the responsibility for detecting
intoxication and ensuring the use of alternative transportation, can be extremely effec-
tive. Here, too, research is necessary to determine just how effective SRPs are in practice
and how serious are the obstacles to their wider use.


T~SPORTATION AND ALCOHOL SERVICE POLICIES

167

Use of the designated driver and safe rides tactics could be increased by addressing
some of the problems discussed above. For example, participation in the designated
driver tactic could be bolstered by stressing the need for planning and encouraging
drinking establishments to provide incentives for groups of driers who arrive in a single
car and also participate in a DDP. More people would probably take advantage of SRPs
if their cars were transported. Employers could help by following the lead of those who
distribute coupons for a free ride to their employees, thereby making it increasingly
difficult for them to justify driving while intoxicated.

Motivation Is a Key Factor

Ultimately, however, the prospects for expanded use of the two strategies may depend
less on their specific characteristics than on the level of motivation among drinkers to
avoid drunk driving. Both strategies are primarily procedures that can be employed by
drinkers who are already motivated to avoid drunk driving. While publicity about DDPs
and SRPs may reinforce concern with drunk driving and may trigger action when
presented during drinking ictivities, it probably contributes relatively little to overall
motivation.

Results from surveys cited earlier are consistent with thii line of reasoning. For
example, Snortum, Hauge, and Berger (1986) attribute the much greater use of transpor-
tation alternatives in Norway than in the United States to national differences in attitudes
toward drinking and driving. They make no mention of differences between the two
countries in either publicity about transportation alternatives or in availability of these
services. Similarly, the discrepancy between American's widespread approval of both
the designated driver and safe rides tactics and their infrequent use of the tactic points
to lack of motivation as a likely explanation.

More Research Is Essential

The tentative conclusions presented here are largely speculative due to the paucity
of data. Thus, the one clear message that emerges from the area of transportation
alternatives for intoxicated drivers is the need for additional research. The scarcity of
research is surprising given the central role that alternative transportation will have to
play if drunk driving is to be substantially reduced. Drinking practices appear to be
relatively immune to change. Consequently, the success of efforts to motivate people to
avoid drunk driving will depend heavily on the availability of attractive and practical
alternatives to driving.

REFERENCES

Apsler, R.; Harding, W.M.; and Goldfein, J. The review and assessment of designated driver
  programs as an alcohol countermeasure approach. Technical Report DOT HS 807 108.
  Washington, DC: National Highway Traffic Safety Administration, 1987.
Caudill, B.D.; Kaufman Kantor, G.; and Ungerleider, S. "Safe Rides: A Controlled Investigation
  in Two Major California Cities." Paper presented at American Psychological Association
   Annual Conference, Atlanta, 1988.

Gxmcil on Scientific Affairs. Alcohol and the driver. Journal of the American MedicalAssociation
   255(4):522-527, 1986.

Gallup, G., Jr. Designated drier program: Who holds the key to safety?Alcohoftim &Addicrion
   12:16,1987.

Gilbert, G.; Burby, RJ.; and Feibel, C.E. Taxicab operating characteristics in the United StateS.
  Tranportation 12(2):173-182, 1984.

Gusfield, J.R. Kinking-Driving and the Symboiic Order. Chicago: University of Chicago Press,
    1981.

Gusfield, J.R.; Rasmussen, P.; and Kotarba, J.A. The social control of drinking-driving: An
  ethnographic study of bar settings. Law & Policy 6(1):4%6,1984.


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BACKGROUND PAPERS

Harding, W.M.; Apsler, R.; and Goldfein, J. A Directory ofRide Service &ograms. Interim Report
  DOT-HS-807-146. Washington, DC: National Highway Traffic Safety Administration,
    1987.

Harding, W.M.; Apsler, R.; and Goldfein, J. ~AssessmenrofRideSeniceProgramsar MAlcohol
  Cowrtmmeanue. Technical Report DOT HS 807 290. Washington, DC: National High-
  way Traffic Safety Administration, 198&z.

Harding, W.M.; Apsler, R.; Goldfein, J.A Users'Guide toRia% ServiceProgra??zs. Technical Report
  DOT HS 807 291. Washington, DC: National Highway Safety Traffic Administration,
    1988b.

Hemandez, A.C.R., and Rabow, J. Passive and assertive student interventionsin public and private
  drunken driving situations. Journal of Studies on Alcoholism 48(3)5X59-271,1987.
Langenbucher, J.W., and Nathan, P.E. Psychology, public policy, and the evidence for alcohol
  intoxicationAmerica hychobgkt 38(10):1070-1077,1983.
Mosher, J.F. Alcohol policy and the presidentialcommission ondrunkdriving: The pathsnot taken.
  Accident Analysir & Prevention 17(3):239-250,1985.
National Commission Against Drunk Driving. Progress Repott on Rec~mmendatiom Proposed by
  the Presidential Commission on Drrurk tiving. DOT HS 807.. 043. Washington, DC:
  National Highway Traffic Safety Administration, 1987.
National Highway Traffic Safety Administration. Alcohol and Highway Safety 1984: A Review oj
  the Stole of the Knowledge. DOT HS 806 569. Washington, DC: National Highway Traffic
   Safety Administration, 1985.

Reed, D.S. Reducing the costs of drinking and driving. In: Moore, M.H., and Gerstein, D.R., ed.
  Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC: National
  Academy Press, 1981, pp.336-387.

Ross, HI,. Brewers view drunk driving: A critique.AccidentAnalysir & Prevention 19(6):475-477,
    1987.

Snortum, J.R.; Hauge, R.; and Berger, D.E. Deterring alcohol-impaired driving: A comparative
  analysis of compliance in Norway and the United States. Justice Quarterly 3(2):139-165,
    1986.

Teal, R.F. Private enterprise in public transportation: The case of the taxi industry. Trunsportution
   Quarter& 39(2):235-252 1985.


Transportation and Alcohol Service Policies

Server Intervention and Responsible
  Beverage Service Programs

    Robert F. Salk, Ph.D.
Prevention Research Center Berkeley, California

The recent rise in alcohol-impaired automobile crashes, injuries, and fatalities after
a dip in those rates over the past few years reminds us how intractable this problem is.
School-based education and mass media programs, intensified law enforcement, and
court-ordered treatment programs have no doubt changed the normative climate
regarding drinking and driving, and yet something about the phenomenon limits the
effectiveness of these attempts to change individual attitudes and behavior.

Recognizing that people's ability to alter their habits depends greatly on situational
influences, prevention specialists have turned their attention to reducing the risk of
alcohol-impaired driving through modification of the drinking environment itself. Alter-
ing those contexts can, in conjunction with the educational approaches, reduce risk to a
far greater degree than would either strategy alone.

Server intervention refers to a broad set of strategies to create safer drinkingenviron-
ments that first, reduce the risk of intoxication and,second, reduce the risk that intoxi-
cated persons will harm themselves or others. These strategies include specialized
training for servers and managers, but could also comprise raising the prices of alcoholic
beverages, promoting food, and altering decor to foster safe drinking. Since approxi-
mately half of those driving while intoxicated (DWI) come from a place licensed to sell
alcoholic beverages (O'Donnell 1985), it seems natural to look at ways to intervene in
those places to prevent the problem.

In a series of articles, Mosher (1979,1983,1984u) has laid out a conceptual framework
for server intervention that addresses environmental reforms at two basic levels: the legal
environment and the specific environment of the licensed establishment. The broad goal
of server intervention is to work in a coordinated fashion at both levels to achieve
consistent and effective prevention.

The first and most encompassing level, the legal environment, includes dram shop
(civil) liability law, State and local Alcoholic Beverage Control (ABC) codes, and
criminal statutes that affect serving practices. Dram shop (liquor liability) laws are those
that hold commercial servers (and sometimes social hosts) liable if they serve obviously
intoxicated or underage persons who subsequently cause harm to others or themselves.
Mosher (19&k) as argued that current liability laws are vague and pay little attention to
their potential in preventing alcohol-related deaths and injuries, and has coauthored a
model dram-shop law that would correct these deficiencies (Colman et al. 1985). ABC

NOTE: preparation of this article was supported by the National Institute on Alcohol Abuse and Alcoholism
Research Center grant AA06282 to the Prevention Research Center, Pacific Institute for Research and
Evaluation. The material is this caapter is taken from a larger paper appearing in Health Education Quarterly.


170

BACKGROUND PAPERS

statutes and regulations also, of course, determine how, when, and where alcoholic
beverages may be served, but there again, little heed is paid to prevention. Indeed, many
view these provisions as "quaint but outdated remnants of a past era" when the primary
concern wasivith controlling vice and other criminal activity (Mosher 1984b). Criminal
statutes constitute a third facet of the legal environment, usually drafted to state explicitly
what is often contained in ABC codes and dram shop laws (e.g., laws prohibiting sale to
minors or obviously intoxicated persons).

The level that has received more attention is the environment of the establishment
itself. The earliest server intervention programs concentrated primarily on training
servers to recognize intoxication and refuse service to any customer who appeared
intoxicated. `As they gained experience with such programs, howeve? many trainers felt
that server training alone was not sufficient to prevent intoxication.  First, interven-
tion took place after the onset of intoxication, and second, servers seemed unable to
carry out their new responsibilities unless management and management policies were
solidly behind the prevention effort. Thus, more comprehensive programs were
developed to include review and modification of management policies and operations,
in addition to training for employees. Reflecting the evolution, one now hears more about
"responsible beverage service" than server intervention per se.

The review and revision of management policies are not limited to those prohibiting
alcohol sales to minors and obviously intoxicated customers. They also focus on the
availability and promotion of nonalcoholic beverages and food, standards for customer
behavior, minimum staffing levels, transportation for intoxicated customers, and full
management support for servers who limit their customers' consumption.

Server training is necessary because most new policies require the server to accom-
modate to several major changes. Servers must redefine their role with respect to the
customer and learn a new set of skills for monitoring and controlling customers' driig.
In addition to concrete knowledge and skills, however, training must help servers
understand the program goals, modify their own attitudes about alcohol and its service,
and overcome any fear or anxiety they may have about their new duties.

Research to Date

In the last couple of years, a handful of server intervention studies have been
conducted. Although their aims and methods differ, each has tried to estimate the impact
of server training or server intervention on either the server's behavior or the customer's
consumption of alcohol. Very little (if any) systematic research has yet been conducted
regarding specific components of a program, or how the program can be delivered for
maximum impact and efficiency.

One of the first evaluations of server intervention, the Navy Server Study (Saltz 1987),
sought simply to determine whether the concept of server interveition had potential
merit as a prevention strategy. Two similar Navy Clubs for enlisted personnel were
selected, with one serving as a program site and the other as a comparison. The test site
employed approximately 50 people who had direct contact with customers. It took in

1  For a brief history of Server Intervention programs and evaluation, see Saltz, RF. Server Intervention:
Conceptual overview and current developments.dkohol, Drugs, andDriving Abstracts andReviews 1(4):1-14,
1985.

2  One may compare the proceedings from the 1984 and 1987 Responsible Beverage Service Forums
sponsored by the Responsible Hospitality Institute of Springfield, MA. The proceedings from the latter
meeting of program and research specialists revealed a much greater concern for management systems to
support server training.


T&W3PORTATlON AND ALCOHOL SERVICE POLICIES

over half a million dollars from alcohol sales in 1985 (ivhen the data were collected), and
would get as many as 800 customers on a busy night. The program itself involved extensive
consultation with the club manager, producing several changes in club policies and
practices, and an l&hour training course for all staff.
The policy changes included promoting nonalcoholic beverages and food, overtly
delaying service of an alcoholic beverage if it would put the patron at or above the legal
limit for intoxication, and discontinuing the sale of beer in pitchers. Food service, which
had previously been segregated from the bar area, was installed in the barroom, and
money incentives were provided for servers and cooks to promote food sales. In addition,
where servers had been free to serve customers anywhere in the building, the new
program assigned them to specific sections of optimal size so that customers' consump-
tion could be monitored. The food and beverage menus were expanded and drink prices
raised marginally to cover the program costs.

The training course, broken into five modules and spread out over as many weeks,
covered the reasons for change, alcohol's effects on the body, monitoring customers'
consumption to know when they had reached the limit, and techniques to pace service
and refuse it when necessary. Group discussions and visual presentations were used
throughout the l&hour program, with role-play exercises dominating the last two
sessions.

Data to measure the program's impact came from interviews with randomly selected
customers, structured observations of selected customers' consumption, and archival
data of alcohol and food sales provided by the clubs. The project did not measure
changes in server behavior, primarily because the researchers could not agree on a
method, but also because the prime question was the program's effect on patron
consumption. Data were collected for 2 months prior to program implementation and 2
months following.

Results have been reported from the interview data. Customers were interviewed on
Thursday, Friday, and Saturday nights for 3 to 5 minutes. Questions included arrival time,
mode of transportation, consumption of speciftc foods and beverages, frequency of
patronage, age, height, and weight. The primary dependent measure was whether the
patrons were over their "limit" as defined by a drink-counting system introduced in the
training (a limit based on the number of drinks, the duration of time drinking, and the
patron's weight category). Thii limit, incidentally, corresponds very closely to the BAC
estimate derived from a formula given in Segal and Sisson (1985). A logistic regression
analysis that statistically controlled for intervening variables showed that the risk of
intoxication, which was as high as 32 percent for males at the test site, was cut in half (to
15 percent) after the program was implemented. For females, the rate dropped from 5
percent to 2 percent. Figure 1 shows the cumulative distributions of BAC levels (pre-
and post-program) at the experimental site. Note, for example, that the BAC for the 70th
percentile dropped from approximately 0.12 percent to 0.07 percent.

While the Navy study accomplished its goal of showing the potential for server
intervention, many questions remained about the generalizability of its fmdii, the
relative effectiveness of the training and policy changes, and the need for such extensive
consultation and training to achieve the results. The servers'behavior was not monitored,
the evaluation only assessed the short-term impact, af3d no one knows how the Navy Club
setting may differ from commercial establishments.

A second study, reported by Russ and Geller (1987; Geller et al. 1987), concerned

171

3  While some wonder whether the Navy Club was a more controlled environment, it was not unusual to
see fistfights break out on the premises, along with the usual attempts by underage patrons to obtain an
alcoholic beverage. The club was also under constant pressure lo produce the profit necessary to keep various
other recreational base operations funded.


172

BACKGROUND PAPERS

60

Cumulative w
Percent

           50

30

20

10

6

10  11  12  13  14  15  16  17
Total Alcohol Drinks

22 23 24 25 >25

Figure 1. Experimental site interview data, pre versus post-training

one of the commercially available server training programs, TIPS (Training for Inter-
vention Procedures by Servers of Alcohol) (Chafetz 1984). This program comprises a
6-hour course that includes video vignettes, group discussion, and role-playing, with an
emphasis on identifying signs of impairment, pacing service, checking patrons' age, and
promoting alternatives to alcoholic beverages. The trainees must then score at least
70-percent correct on a 40-question written test to become certified servers.

The authors recruited 17 trainees from two commercial establishments, ending up
with about half the employees having been trained. Research assistants, posing as
customers, entered the establishments 24 times before and 25 times after the training
and attempted to order and consume a drink every 20 minutes over a 2-hour period. If
the training were effective, the server should intervene in some way to slow down or
terminate the "pseudopatron's" consumption. Russ and Geller counted the type and
number of interventions for each drink ordered (up to the maximum of 6 drinks) and
compared the type and frequency of intervention for the trained staff (n = 17) and the
untrained staff (n = 9) against the pretraining baseline (type and frequency of interven-
tions) with all staff (n = 24). They found that while the untrained staff intervened no more
frequently than at baseline (about 0.75 interventions), the trained staff intervened more
frequently (3.24 interventions). Interventions included the offer of food or water, check-
ing ID, delaying service, commenting on the quantity or speed of the customer's alcohol
consumption, and making a driving-related comment.

A second measure of the program's impact was the pseudopatron's BAC taken after
the 2-hour drinking period. Whereas those served by the untrained staff had BACs as


TRANSPORTATION AND ALCOHOL SERVICE POLICIES

173

high as baseline (mean of 0.103, with four of nine pseudopatrons above the legal limit),
none of those served by the trained staff was over the legal liiit (mean of 0.059 BAC).

These results were obtained without the benefit of policy changes at the management
level or having all staff at an establishment working together to make the program a
success. It would certain be interesting to compare these findings with those obtained
when all of an establishment's staff was trained at once.

In contrast to the Navy Server Project, the TIPS evaluation addressed training per se
rather than training as part of a broader program. Its advantages include a direct measure
of the server's behavior and its impact on the pseudopatron's BAC but, as with the Navy
study, it has a few weaknesses as well. It, too, measured program impact in the short
term, collecting baseline and posttraining data over an 11-week period. Though the
trained servers were more likely to intervene, the interventions themselves were fairly
mild. For instance, onIy 10 of the 55 interventions involved delay of service, and half of
those were during the first three drinks, with no server delaying service of the sixth drink.
The modal intervention was the offer of food or water, which accounted for about a third
of the interventions. Eleven of the I3 interventions occurring on the sixth drink were
either offers of food and water, or comments about the pseudopatron's consumption or
driving. At no time was service refused.

The mildness of the interventions was reinforced by the few examples given of how
they were coded. The pseudopatrons were accompanied by a confederate who activated
a small tape recorder when the server and pseudopatron interacted. Two research
assistants, blind to the pre- or post-training condition, independently coded the inter-
ventions. "Delay of service" could mean that the server offered to refill the confederate's
nonalcoholic beverage without offering to get the pseudopatron another alcoholic drink.
Since the confederate ordered only one drink during the 2-hour period, it's hard to
interpret the significance of the "delay." A "driving-related comment" could be asking
who was driving or suggesting that a nondrinking partner drive carefully. These inter-
ventions do not seem capable of having a major impact on driving while intoxicated.
What, then, of the pseudopatron's BAC? Here again, interpretation is complicated.
The pseudopatrons were instructed to order a drink every 20 minutes for 2 hours. If the
server intervened, they were to react in's manner similar to their normal drinking
behavior. If offered food, for example, the pseudopatrons were told to accept it if they
were hungry. This leaves the BAC measure to be a result of the interaction of the server's
behavior and the pseudopatron's (unmeasured) inclination to accept the offer or heed
the comment, whatever the case may be. As an example, two pseudopatrons could enter
the same establishment, one could accept the offer of food while the other wasn't hungry.
They would then presumably exit with different BACs despite identical "interventions"
by the server. If the pseudopatron's behavior is not consistent, the generalizability of the
results is uncertain.

While we know the mean level of intervention increased for 17 trainees, we cannot
tell from the reported data whether the increase in intervention was widespread among
the trainees, or whether, say, 2 or 3 trainees were especially active and accounted for all
the interventions while the other 14 or 15 remained unaffected by the training.

Finally, individual trainees were not compared pre- and post-training, since the
baseline data did not identify servers. Since the pool of trainees was basically self-
selected, we don't know the degree to which the serving practices between the trained
and untrained servers were different even before the training.

The National Highway Traffic Safety Administration (NHTSA) has sponsored two
demonstration and evaluation studies of sewer intervention. The first, called TEAM
(Techniques of Effective Alcohol Management), represented a collaborative effort of
NHTSA and several other organizations, and focused on alcohol service at seven
selected arenas associated with the National Basketball Association (NHTSA 1986). The


174

BACKGROUND PAPERS

program called for policy review and revision, followed by a Chour training covering the
drinking and driving problem, liability law, alcohol's effects, recognizing impairment,
policies and practices, and dealing with alcohol and drug related incidents. All arena
employees were included in the training, not just those who served beverages.
The TEAM evaluation report is hard toassess because the evaluation activities were
directed toward program development. The program was constantly changing as dif-
ferent data were collected at subsets of the seven participating arenas. The program was
evaluated through a combination of a followup review of arena management policies (at
five sites), surveys of staff and patron attitudes and reported behavior (at seven and three
sites, respectively), and a review of sales data from two sites. The study showed that the
program did result in policy revisions at the participating arenas, and that alcohol
consumption (especially beer) declined in two sites while food and nonalcoholic
beverage sales increased. 4 Through data collected from the staff and patrons, the
researchers also concluded that management support was critical to the success of the
program, and furthermore, that the support had to be visible for the-staff to carry out
their own responsibilities.

The TEAM evaluation is best thought of as an informal summary of loosely organized
quantitative and qualitative data, much of which was apparently collected after the
programs were in place. It provides many suggestions to program designers and trainers,
but should not be considered a formal impact evaluation. The authors of the report, in
fact, state that a formal evaluation design was inappropriate for their purposes and
needlessly constraining.

NHTSA also sponsored a study conducted by M&night (1987) that involved the
development and delivery of a responsible beverage service program to 32 estab-
lishments in Louisiana and Michigan. In this study, a 3-hour training was given to servers
and managers, with 3 additional hours for the managers alone; 245 people were trained
in all. A specially selected group of 10 establishments in each State was used for
comparison, along with 24 establishments that were invited to participate but did not.

The emphasis of the training was on prevention, providing the servers with strategies
to prevent customers from becoming intoxicated. If service is performed responsibly, it
should not be necessary to refuse service to anyone. The server's trainiig used videotapes
followed by discussion of the material shown in the tapes, The training covered the
concept of server liability, the moral and legal responsibility to prevent intoxicated
patrons from driving, and the physiological effects of alcohol. The course then moved to
prevention, including checking ID, serving food and nonalcoholic beverages, providing
activities, and observing patrons for signs of impairment. The final module for servers
covered intervention-what to do when customers became intoxicated-and included
such tactics as delaying service, providing alternative transportation, and refusing serv-
ice. The servers were expected to know when intervention was needed, but the managers
were expected to carry it out.

The extra 3 hours for managers covered intervention skills and strategies (with
role-play exercises) and a section on responsible alcohol service business practices,
where managers were encouraged to formulate policies relevant to their own
establishments.

The program's effectiveness was measured via pre-post differences in scores on a
lo-item knowledge test and a stt of 10 items measuring opinions about the service of
alcohol. The knowledge test comprised different, but equivalent, items for the pre and
post-tests, while the opinion scale remained the same for both administrations. In a

4  The report does not offer consistent data on these changes, nor are there significant tests. Given the
lack of comparison sites, it would be difficult to attribute changes in the test sites to the TEAM program
alone.


TRANSPORTATION AND ALCOHOL SERVICE POLICIES

175

separate set of items, servers were also asked about the frequency with which they
engaged in several different types of activities related to prevention (e.g., offering coffee,
inquiring as to who is driving, refusing service). Managers were given a checklist of
beverage service policies (e.g., closing hours, availability of snacks) to indicate which
they employed at their establishment. The same forms were given to servers and
managers 4 months after the training.

Research assistants were used in this study, also, to pose as customers, but here they
were to feign intoxication when entering the establishment to see if they would be served
a drink despite their condition. The pseudopatrons were trained to maximize the
consistency of their behavior, which included staggering to their table, missing the chair
or stool when sitting, slurred speech, and exhibiting difficulty in handling the money to
pay for the drink. After 15 minutes, the pseudopatron would leave the establishment and
record details of the encounter, whether any intervention had taken place, and whether
any customers were intoxicated or drinking despite appearing underage. All estab-
lishments were visited four times by four different assistants before and after the training.

The results of the Louisiana and Michigan programs differed somewhat. Knowledge
scores increased in both States, with Louisiana trainees (n = 120) improving their scores
from a mean of 6.35 to 7.65, and Michigan scores (n = 95) improving from a mean of 6.24
to 8.23. The Michigan score change was (statistically) significantly greater than the other
State's. The trainees' opinions became more favorable, too, after the training, with the
Michigan trainees starting out with more favorable opinions than the Louisiana trainees.

A self-report, serving practices questionnaire was completed by 55 percent of the
Louisiana servers and only 29 percent of the Michigan servers. Apparently, many of the
servers had quit working at their original establishments, and some had been promoted
to managers. Both sets of servers reported a statistically significant increase in respon-
sible serving practices. The manager's reports on serving policies showed a significant
change in policies in Michigan but not Louisiana.

Table 1 summarizes the level of intervention by servers confronted by the "intoxi-
cated" pseudopatron. One can see that `in the best of circumstances (the Michigan
treatment post period), the pseudopatrons were served 72 percent of the time with no
intervention of any kind. On the other hand, outright refusal of service jumped from 3

Table 1. Distribution of server action by experimental group, site, and period
                (in percents)

Server action

    Louisiana          Michigan
Treatment   Control     Treatment   Control
Pre  Post   Pre   Post    Pre Post Pre Post
N=62 N=62 N=127 N=126    N=63 N=61 N-141 N=135

Service, no intervention   92   90   93   85    87   72   86   86
Service, status         3    3    4    2      3    7    6    5
Service, alternative      3    3    3   10      3    0    3    4
Service, slow           2    0    0    0      3    2    3    0
Service, transport       0    0    0    0      0    0    0    1
Service, final          0    0    0    0      0    3    1    0
No service           0    3    0    2     3   16    2    4

Source: M&night 1987.


176

BACKGROUND PAPERS

Table 2. Mean intervention level by experimental group, site, and period for
   collapsed intervention score

Louisiana           Michigan

Time  Treatment Control   Both  Treatment Control   Both Total

Pre     .08     .07     .07     .16      .16     .16    .l2

Post     .l3      .17     .16     A4      .18     26    21
Diff     .05      .lO     .09     23      .02.     .lO    .16

Source: McKnight 1987.

to 16 percent in the same group of establishments. While the Louisiana treatment group
was more likely to refuse service after the training, so was the control group.

To test the outcomes for statistical significance, the author collapsed the intervention
levels into "service without intervention, " "service with some form of intervention," and
"no service," with scores of 0, 1, and 2, respectively. Table 2 shows the resulting
differences across sites and conditions. An analysis of variance (ANOVA) showed that
the program produced in a significant increase in interventions in Michigan, but not
Louisiana. Unaccountably, the Louisiana control group's increase in intervention was
greater than the treatment group, primarily in their suggesting alternatives.

M&night concluded that the program can improve knowledge and attitudes and can
produce a small increase in interventions, but, depending on situational variables,
changes in management policy may be small and limited, and finally, the type of
establishment influences the program's chance of success. In particular, the program
seems to be most successful in places with a smaller volume of sales, or that serve affluent
clientele.

The latest reported evaluation of a responsible beverage service program was con-
ducted by researchers of the Addiction Research Foundation in Toronto, Canada
(Glicksman and Single 1988; Simpson et al. 1986). Here, manager and complementary
server training courses were given in four different types of establishments in Thunder
Bay, Ontario, with four other sites used for comparison. Managers and owners were
trained to implement specific policies of which servers were aware and which would
reinforce the desired serving practices. Training for servers included such topics as
serving and the law, health, preventing intoxication, and managing intoxicated persons.
The training emphasized clear and concise steps for servers to take. The program also
set a limit on the number of drinks a customer could have.

A 35-item true/false test was used along with three open-ended items to assess
changes in trainees knowledge of appropriate serving practices. A t-test showed sig-
nificant increases in both portions of the test, with true/false scores improving from 24.1
to 30.2, and the open-ended items from 1.3 to 5.3 (out of a perfect score of 11).

The study also adapted and expanded on the pseudopatron approach used in the
Geller and M&night studies by devising seven alternative scripts for the pseudopatrons,
covering different situations that would require intervention, as follows:

Being too "young" to be served
Ordering too many drinks at once
Ordering too often
Displaying drunken behavior and disorderly conduct


T~NSPORTATION AND ALCOHOL SERVICE POLICIES

Displaying drunken behavior but quiet conduct
Preparing to drive home when obviously intoxicated
Ordering drinks when intoxicated

The research team also constructed a 1Zpoint scale of server responses to these
incidents, ranging from a -6 for unsolicited service of more alcohol (when service should
be denied) to + 6 for calling the manager over. Intermediate scores were assigned for
responses that fell in between-for example, a -1 for ignoring the customer and a +2
for commenting on the pseudopatron's behavior. If the server's actions involved more
than one response, the scores were added together.

Pre- and post-measures of knowledge about alcohol and good serving practices
showed a significant improvement among those who had been trained, and measures of
receptivity to the training were also positive. ANOVA was conducted with three pairs
of matched bars (the fourth pair had to be eliminated because of untrained staff in the
experimental site) using a 2 X 2 repeated measures design using time (pre versus post
intervention) and group (experimental versus comparison). The dependent variable was     '
the server's response scores (with a constant added to make all scores positive). As with
the Navy Server study, results showed both a time effect and an interaction of time and
group. The mean score of the comparison sites increased slightly from about 16.3 to 16.9,
while the experimental sites' mean score rose from about 15 to over 21 (see figure 2). It
seems clear that the trained servers had moved toward more appropriate responses to
the problematic scenes acted out by the pseudopatrons.

22 r

21 -

20 -

19 -

18 -

17 -

16 -

Experimental

Comparison

I                I                I

Pretest    Posttest

  Time

177

Figure 2. Server behavior- interaction of time by group

Source: Gliksman and Single 1988.


178                                                    BACKGROUND PAPERS

As with the other evaluations, only short-term effects were measured, and again, one
cannot tell from the report how widespread the interventions were across trainees. Since
the server could respond in several ways, it is theoretically possible with an additive score
for a few servers to have exceptionally high scores while others remained unchanged,
resulting in an overall gain in the mean intervention score.

In summarizing the existing research, we should point out that these studies differed
in their aims. The TEAM study did not employ a strict evaluation design partly because
the researchers felt it was not appropriate for program development, but also because
they wished to remain open to any opportunities to get a "feel" of how the program was
working. The Navy study was trying to measure the impact of a comprehensive program
that included more than server training on customer consumption, and thus, did not
focus on the servers' intervention so much as on whether the overall program both
reduced customer demand and limited the supply of alcohol.

The TIPS evaluation and the M&night study, on the other hand,,were explicitly
concerned with whether the server training had increased the likelihood of intervention
by the server directly. It is unclear why the TIPS program would have seemed somewhat
successful despite having only some of the servers trained and no particular management
support, while the M&night program had a limited impact in only one of the two States.
Perhaps the difference was due to the different definitions of "intervention." For the
TIPS study, mild forms (comments, offering food and water, etc.) were weighted alike,
whereas for M&night's analysis, mild forms were scored lower than refusals. On the
other hand, the TIPS pseudopatrons did not necessarily show overt signs of intoxication
as did the other study's staff. One might guess that refusal of service to obviously
intoxicated customers would be one of the easier objectives to achieve in the training.

Research Recommendations

Obviously, we have only just begun to explore this promising avenue for prevention.
The studies summarized above were designed to assess the potential for server interven-
tion. There are, of course, a host of specific questions remaining regarding the proper
emphasis for such prevention strategies and questions regarding the social and legal
environments that may encourage the intensity and growth of responsible beverage
service. Among these research questions are the following:

o  Trainingcuniculum. How much emphasis is needed on "affective" topics versus
specific skills in intervention? Which modes of training (e.g., lecture, videotape,
group discussion, role play) are best suited for each topic in the curriculum?
How long must the training be? Who should be trained? What kind of followup
training is required and how often should it be offered?

o  Establishments. What program modifications are necessary for very large or
small businesses? Should the program be tailored for different clientele (e.g.,
upscale versus casual).

o  Management policies. Which policies and practices should be considered the
minimum necessary to create an environment conducive to the prevention aims
of the training'? Which specific practices pose the largest risks for intoxication
(e.g., happy hours or other promotions)? What is the impact of patron educa-
  tion?

o Social and legal environment. What role does dram shop liability play in en-
couraging effective programs? What is necessary for insurance companies to
offer meaningful discounts to businesses that participate in responsible
beverage service programs?


TRANSPORTATION AND ALCOHOL SEFIVICE POLICIES

Summary

179

It should be clear that much remains to be done to refine the design and implemen-
tation of server intervention or responsible beverage service programs. While current
results are somewhat mixed, there does seem to be an opportunity to reduce the risk of
intoxication, or at least the level of intoxication, among customers at licensed
establishments.

Obviously, research and evaluation of server intervention or responsible beverage
service is in its infancy. While we now have reason to believe that server intervention can
reduce intoxication and subsequent alcohol-impaired driving, the results are mixed,
especially regarding the size of that impact. When results differ, we naturally turn to
questions about the nature of the programs being evaluated and how they were imple-
mented. Further research can take the materials that were developed in the programs
designed to date, compare their features, and begin a systematic exploration of which
features should be kept and which discarded, which methods are best suited for deliver-
ing those elements, and what situational and environmental influences help or hinder an
effective program's implementation.

REFERENCES

Chafe&, M.E. Training in intervention procedures: A prevention program. Abstracts: Review of
   Alcohol Md Driving 5: 17-19,1984.

Colman, V.; Well, B.; and Mosher, J.M. Preventing alcohol-related injuries: Dram shop liability in
   a public health perspective. Western StateLaw Review 12:417-517, 1985.
Geiler, E.S.; Russ, N.W.; and Delphos, WA, Doesserver intervention make a difference?AZcohol
   Health and Research World 11(4):6469,1987.
Gliksman, L., and Single, E." A Field Evaluation of a Server Intervention Program: Accommodat-
   ing Reality." Paper presented at the Canadian Evaluation Society Meetings, Montreal,
   Canada, May, 1988.

M&night, A.J. Development and Field Test of a Respkible Alcohol Service Progrant Voiume I:
   Research Findings. Report No. DOT HS 807 221, Washington, DC: National Highway
  Traffic Safety Administration, Department of Transportation, 1987.
Mosher, J.M. Dram shop liability and the prevention of alcohol-related problems. Jomal of
   Studies on Alcohol 40:773-798, 1979.

Mosher, J.M. Senter intervention: a new approach for preventing drinking driving. Accident
   Analysis and Prevention 15:483-497,1983.

Mosher, J.M. Server Intervention: Present Status and Fuhue Prospects. Berkeley, CA: Prevention
   Research Center, 19840.

Mosher, J.M. Legal Liabilities of Licensed Alcoholic Beverage Establtihments: Recent Develop-
   ments and Policy Zmplications. Berkeley, CA: Prevention Research Center, 1984b.
Mosher, J.M. The impact of legal provisions on barroom behavior: Toward an alcohol-problems
   prevention policy. Alcohol 1:205-211, 1984.c.

National Highway Traffic Safety Administration. TEAM: Techniques ofEffectiveA&ohofManage-
   ment: Findings from the First Year. Washington, DC: National Highway Traffic Safety
   Administration, Department of Transportation, 1986.
O'Donnell, M. Research on drinking locations of alcohol-impaired drivers: Implication for preven-
   tion policies. Journal of Public Hen&h Policy 6:510-52.5, 1985.
Russ, N.W., and Geller, E.S. Training bar personnel to prevent drunken driving: A field evaluation.
   American Journal ofPublic Health 77:952-954,1987.
Saltz, R.F. The roles of bars and restaurants in preventing alcohol-impaired driving: An evaluation
   of server intervention. Evaizuztion and the Health Professions lO( 1):5-27, 1987.
Segal, R., and S&on, B. Medical complications associated with alcohol use and alcoholism. In:
   Bratter, T.E., and Forrest, G., eds. Alcohol&m and Substance Abuse. New York: Free
   Press, 1985.

Simpson, R.; Stanghetta, P.; Brunet, S.; Single, E.; Solomon, R.; and Van de duet, W. A Guide to
   the Responsible Service ofAlcohol. Toronto: Addiction Research Foundation, 1986.


180

Injury Control

Injury and Disability Prevention and
  Alcohol-Related Crashes

      Julian A. Waller, M.D., M.P.H.
Depa&rmnt of Medicine, University of Vermont, Burlington, Vermont

This chapter is built around four assumptions. First, contrary to the general impres-
sion of the public, and even of many working in the field of highway safety, about 80
percent of the people fatally injured in alcohol-related crashes are individuals who
themselves had been drinking and are either drivers, impaired passengers of alcohol-
impaired drivers, or impaired pedestrians (Waller 1985). About two-thirds of injuries in
alcohol-related highway crashes also involve such individuals.

The image of the innocent victim who is run down by a drunken driver who escapes
all injury himself has great emotional impact but only limited support from the real world.
We have a responsibility to be fully aware that injury to the innocent is not the largest
aspect of the problem.

Second, the tendency over the years has been to see issues involving alcohol and injury
primarily as a safety problem, rather than a public health concern. As work over the past
two decades has shown, reinforced by the recent National Academy of Sciences report
I+lryirr America, injury is the primary cause of lost productive years of life in the United
States, and alcohol abuse is an important contributor to that toll (National Research
Council Committee on Trauma Research 1985).

A very substantial proportion-probably a majority- of persons who get into trouble
with alcohol on the highway are not typical social drinkers, but rather problem drinkers
or alcoholics. The safety issue is only part of a much larger public health problem.

In looking at the safety aspect, we must constantly be aware of this broader perspec-
tive. For example, an important effect of increasing the age for alcohol consumption to
21 was the reduction in the highway crash toll among teenagers. But, although at least
some short-term data suggest otherwise (Vingilii and Smart 1981), it may be that the
most important long-term result of such legislation will be to reduce a wide range of
alcohol-related problems among teenagers and the onslaught of teenage and young adult
alcoholics that we began to see when the drinking age was lowered to 18.

Third, during the late 196Os, Dr. William Haddon developed a matrix of highway crash
analysis in which human, vehicular, and environmental factors interact during the
precrash, crash, and postcrash phases to determine the occurrence, initial severity, and
ultimate outcome of these events. He subsequently described generic interventions
relevant to these phases in his brilliant paper, "On the Escape of Tigers" (Haddon 1970).
In talking about injury prevention and amelioration, this chapter utilizes Haddon's basic
approach, with an awareness of all three types of factors across all three phases of crash
events.

Finally, this review is clearly not alone in discussing components of Haddon's nine
cells. Therefore, this examination is quite selective, focusing on aspects that will not be
considered by others or that will be considered in a different context.


INJURY CONTROL                                                          181

Behavioral Issues in the Precrash Phase

How do we alter behavior to prevent the occurrence of crashes? All the other panels
are concerned with one or another aspect of this area. This chapter focuses particularly
on three aspects. One is the characteristics of the populations we are trying to reach.

As data expand, it is becoming increasingly clear that many people begin to be
impaired at blood alcohol concentrations (BACs) below 0.05 gm/dl. But the data about
who gets into trouble are equally clear. Over three-quarters of alcohol-related fatalities,
and almost as high a proportion of alcohol-related injury crashes, involve drivers or
pedestrians with BACs of 0.10 gm/dl or higher. Usually the BAC is much higher,
averaging 0.16 gm/dl (NHTSA 1986).

My own work and that of others has focused on two groups of heavy drinkers, namely,
teenage and young adult males, and problem drinkers and alcoholics. A new group
causing increasing concern is teenage and young adult females who are drinking more
and driving more, at least in part as aspects of their new independence (Fell 1987).

This discussion, however, focuses on a different issue, namely, the interdependence
of lifestyle components. Studies show that those teenagers most likely to drive after
drinking are also the ones most likely not to use seatbelts, to drive recklessly, to have less
exercise, to prefer more fat in their diet, to have had premarital sexual experience, and
to have done so without benefit of contraceptives (Jessor 1987; Maron et al. 1986). We
know that heavy drinkers tend also to be heavy smokers, a fact not lost on the tobacco
and alcohol beverage manufacturers, which often are divisions of single companies and
thus are able to consolidate marketing strategies. A recent study by the Internal Revenue
Service shows that individuals most likely to cheat seriously on their taxes are also more
likely to be taking chances in other aspects of their lives, including speeding, drunken
driving, adultery, and risky investments and sports (Goleman 1988).

This is precisely why it is so important to take a broader public health viewpoint.
Specific behavioral interventions often show at least partial success. But such interven-
tions all tend to bog down on the fact that they have minimal effect on those hard core
segments of the population that are most `overrepresented in whatever behavioral aspect
they are trying to change.

The problem, simply stated, is that we are just beginning to learn which behaviors
interact, and how, so as to create that entity we called lifestyle. We know relatively little
about how lifestyles are either transmitted or altered between generations or within
generations, and whether it is possible to alter selectively one aspect of lifestyle, even if
it creates dissonance with other aspects. Frankly, we need such information if we are to
do more than simply nibble around the edges of behavioral modification. Alcohol-
related behavior is far too intimately and intricately tied to other life beliefs and behaviors
to permit us to expect success with simplistic approaches to modifying behavior, espe-
cially as it relates only to the activity of driving.

The foregoing and subsequent comments may sound like a plea for more research,
and on one level they are. But the ultimate goal is to achieve intervention programs that
work. In addition to basic research, we need to try out interventions in such a way that
they can be adequately evaluated to answer the following questions, among others
(Wailer 1980).

o  Does the program alter behavior, morbidity, or mortality overall? Are any other
activities or events going on in the community that may explain any changes
observed? For example, the rise of activities by MADD, SADD, RID, and other
groups concerned with alcohol and highway safety coincided with the end of
the baby boom, and it appears that at least a part of the reduction in alcohol-
related crashes can be attributed to the reduction in young males, rather than


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BACKGROUND PAPERS

to specific anti-alcohol activities. This is not a criticism of the activities per se,
but rather of the method of determining effect.             . .

o Is the programmore or less successful with some segments of the population,
or under some circumstances, than with others?

.  What proportion of the total problem do-those segments account for?

.  What factors seem to explain the population or circumstance differences? Are
the factors intrinsic to the population or &cum- stances itself, to the way the
intervention was carried out, or to both?

o  Can the program be modified in a way more likely to reach the hard to reach,
for example, by addressing more specifically those unique aspects of knowledge,
attitudes, and practices that make them a more difficult target?

a  Given the availability of other nonbehavioral options for injury control, is the
cost-effectiveness of the program sufficient to warrant its continuation, or are
other options preferable?

The methods for answering these questions must be built into the initial design of the
intervention rather than being tacked on as an afterthought. This requires early involve-
ment of someone with skills and knowledge in process and outcome components of
program evaluation. It has been said that knowledge without action is futile; but action
without knowledge is fatal. We need sound use of both.

The third concern is about alcohol-impaired pedestrians, who account for 7 percent
of all alcohol-related highway fatalities (NHTSA 1986) but a substantially higher propor-
tion of those in urban areas. Most attention in the efforts to reduce the alcohol-related
highway tolI has been paid to the impaired driver, as indeed it should. But we must not
overlook the pedestrian. Efforts to educate people about alcohol-related risks should
also mention the risks to this group of road users.

An excellent study by Blomberg et al. (1979) in New Orleans showed that, unfor-
tunately, it is not possible to identify high-risk locations where impaired pedestrians are
more likely to be found. Nonetheless, some efforts aimed at high-risk populations may
be of use, Efforts to provide alcohol in controlled settings on campuses, for example,
may reduce the likelihood that college students will travel as either drivers or pedestrians
after becoming impaired off campus. But apparently no evaluation of such activities has
taken place. Clearly, more needs to be done in both the research and program areas.

Vehicular Issues in the Precrash Phase

There is a tendency to assign ail responsibility for a crash to the driver or the
pedestrian if alcohol is present. But, as Patricia Wailer cogently notes (Haight et al.
1976).

The fact that the human error involved in accidents is frequently related to
information failure (including recognition errors) strongly suggests that the
demands of the driving situation are more than the driver can handle. There
is considerable need to recognize that the human being varies in his perfor-
mance and that on the whole it can be assumed that he probably does about
as well as he can be expected to, given the circumstances. Accident inves-
tigations should be conducted in which the human element is taken as a given
and the vehicle and environment are analyzed to determine the extent to
which they need to be modified so that the human can function satisfactorily.
Thus, simply because a vehicle is performing up to the manufacturer's
standards does not mean that the vehicle performance is satisfactory. Per-
haps the manufacturer's standards need to be modified and the vehicle
performance enhanced. Simply because the roadway signing meets the
criteria set down in a highway design handbook does not mean that the


INJURY CONTROL                                                       183

signing is adequate. The criteria often used call for signs that can be readily
viewed by drivers with 20/30 vision. Furthermore, the standards must be met
only by the signs when they are new. Most highway signs remain iu place for
years, and many legally licensed drivers cannot meet a vision criterion of
20/30. Under such circumstances, when the driver fails to read the sign in
time to make a decision, is it a driver failure? Most humari factors experts
would not agree, yet accident causation studiespersist inperpetuatingthemyth
that dnvers are somehow supposed to be able to compensate under any
conditions for. the shortcomings (legalizedfaikres?) of the vehicles and driving
environment. (p. 48-49)

Ample evidence exists that vehicle design or other characteristics contribute to the
occurrence of highway crashes.

a

Perhaps the most obvious example involves the motorcycle, which combines
special problems with stability and handling, reduced conspicuousness so that   . .
other drivers are less able to avoid it and, once in a crash, reduced survivability
for the occupants. Recent work from California and New York indicates that
special training and licensing requirements for motorcycle drivers are inade-
quate to compensate for these problems (Insurance Institute for Highway
Safety). In 1986, fully 54 percent of motorcycle fatalities had been drinking
(NHTSA 1986), but whether the unique features of the motorcycle exacerbate
the effects of the alcohol impairment is not known. In other words, if a driver
has a crash at a given BAC it is not known to what extent the vehicle handling
characteristics versus the driver's handling capabilities contribute to the crash.

o  One modification of motorcycle design that has aided crash avoidance has been
linking the ignition switch to lights so that motorcycles always operate with their
lights on during the daytime, thus increasing their visibility. The addition of
reflectors to bicycles also improves the nighttime visibility of these vehicles, thus
giving a car driver impaired by alcohol additional time to react.

o Issues of vehicle handling characteristics also are relevant to the crashes of
certain utility vehicles that have. a propensity to roll over in crashes (Reinfurt et
al. 1982). When faced with the rollover data, persons representing the automo-
tive industry on a related lawsuit countered that the overrepresentation of
rollovers did not reflect the vehicle characteristics per se, but rather the sorts
of people who drive these vehicles, for example, the fact that such vehicles are
often driven by the young.' As seen in figure 1, the propensity to rollover is
associated with age. Both the young driver and the "older" driver are at higher
risk of rollover in crashes for two of the three models examined. If the issue were
solely driver characteristics, one would expect to see overrepresentation only
of young drivers, but not of those who have reached the "senile" years of 35 or
  older!

o  But it is also known that the automotive industry- as does any industry- tries
to target its buying audience by selective placement and design of advertise-
ments to highlight vehicle characteristics that are likely to attract certain buyers.
It is unlikely that many 45-year-old business executives drove around during the
1960s and 1970s in VW bugs, or currently use pickup trucks as their transpor-
tation of choice. It is equally unlikely that many 19-year-old laborers ?? college
students are in the market for a Mercedes or Volvo or Lincoln Continental, and
advertisements for these vehicles that appear to be aimed at these audiences
are seldom, if ever, seen.

o  How does all this relate to alcohol? A study from the General Motors research
staff shows a strong correlation between "Youth Sport," "High Sport," "Sixties

1

Comments about the Reinfurt et al. paper by Kent Joscelyn and others during post-presentation question
and answer period at AAAM meeting, 1982.


184

BACKGROUND PAPERS

%

40 -

30 -

64 Jeep CJ-5

10 -

+-----I, Ford Bronco

A.. . . . . . . . A  Chev.  Blazer

- All Utility
          Vehicles

.   I      I      I      I            I
   <20     20-24   25-29    30-34             >34

                                 DRIVER AGE

Figure 1. Utility vehicle rollover percentages by driver age for single vehicle
     crashes.

Generation," and "Wild West/Cool Bravado" vehicles and likelihood of involve-
ment or death in an alcohol-related crash, and either negative or no association
for "Sedate, Self-restrained" or "Domestic Economy" vehicles (Angell and Von
Buseck 1985). The authors of this research were not able to divulge which
vehicles lit into such categories. The question, of course, is to what extent do
handling characteristics of the vehicles involved make driving easier, more
difficult, or have no effect for drivers with alcohol in their systems?

o  Issues related to braking provide an additional vehicular example. Recent
improvements of braking systems in more expensive vehicle models through the
use of computers are aimed at a longstanding problem of brakes that lock up
and permit the vehicle to skid. In considering the anticipation or early iden-
tification of a skid situation, Olsen (1978) has noted that suspension systems in
many U.S. vehicles are sufficiently "soft" so the driver may realize he is begin-
ning to skid when there is barely time, or it is already too late, to make an
appropriate response.

o  Given the fact that alcohol alters perception, judgment, and slows response


INJURY CONTROL

185

time, "soft" suspension and standard brake systems can only add to the demands
of the driving task for a person who is already impaired. The recent installation
of elevated rear brake lights is an important improvement to quickly alert drivers
to potential danger and should especially benefit those with modest impairment
by alcohol.

o  Side and rear view vision systems have been faulted in many vehicles, especially
trucks, and in 1972 an estimated 900,000 crashes per year were attributed to
inadequate vision on trucks, with 500,000 of those believed to result from poor
but correctable mirror design (Reiss et al, 1972). Alcohol severely affects vision,
including narrowing of visual fields. Inadequacies of vehicle vision systems,
therefore, are likely to be even more of a problem for the alcohol-impaired
driver than for the average driver.

o  Trucks present their own set of difficulties. In 1986, almost 5,100 medium or
heavy trucks (over 10,000 lbs) were involved in crashes, in which 4,881 persons
died. Only 16 percent of the fatalities were truck occupants (NHTSA 1986).   '
Crash rates for trucks exceed those of other vehicles on all types of roads,
including freeways, and when trucks account for 25 percent of traffic volume on
an expressway system, a 3-percent increase in truck traftic produces a 23-per-
cent increase in crash frequency per mile (U.S. Bureau of Public Roads 1963).
Overwhelmingly, such crashes are more serious because the energy loadings are
  greater.

o  Other drivers find it particularly difficult to maneuver in the presence of large
trucks, not only because they are behemoths, but because they often are
traveling faster or slower than the traffic flow, may be poorly visible at night,
create aerodynamic turbulence and, in bad weather, may obscure the vision of
other drivers by splashing their windshields. Each of these characteristics adds
to the alcohol impairments of the driver. Therefore, the very presence of more
trucks on the roads quite likely exacerbates the problem of alcohol-related
crashes. Add to this the safety effects of deregulation and of increases in truck
size and double trailers that have been approved at the Federal level and it is
clear why we have a serious problem.

Roadway Issues in the Preinjury Phase

The earlier quote by Patricia Waller is relevant to issues of highway design and
construction as well as to vehicles. It is not enough to know that individuals crashed
because they were impaired by alcohol, The question also is, if they were so impaired,
why did they crash where they did and not at an earlier location along their path? The
answer often is that only at this location did the driving task become too demanding.

Much is already known about the types of roadway characteristics that increase
demands on the driver and are associated with more crashes. In addition, some recent
work has pinpointed the interreration between some of these factors and alcohol
impairment. Here are a few examples.

0  Several studies done for the Insurance Institute for Highway Safety pinpointed
roadway characteristics that are overrepresented in single vehicle crashes. One
study in Georgia showed that such crashes are most likely to occur at or near
curves of greater than 6 degrees, especially if associated with grades of 2 percent
or more (Wright and Robertson 1976). These data, however, are not specific to
drivers using alcohol, and it is reasonable to assume - but currently not known
- that a person with a BAC of 0.10 gm/dl might be at greater risk at somewhat
less demanding locations, e.g., curves of 4 degrees or greater with or without an
associated grade.

o  Presumably, the higher the BAC the less demanding the roadway that will prove


186

BACKGROUND PAPERS

excessive. However, since the Georgia study examined single vehicle crashes,
which commonly involve alcohol, it may also be that unimpaired individuals tend
not to crash until the road is much more demanding and, in fact, the combination
of a 6-degree curve and 2-percent grade is a good measure of the point at which
the demand becomes too great for the typical driver impaired by alcohol. This
can only be determined, however, by a BAC-specific analysis of crash
environment.

o  Increasing the speed with which a traffic light changes from green to red is
associated with an increase in intersection crashes, whereas slowing the change
cycle reduces the crash rate (Zador et al. 1985). A change of 20 percent, from
lo-percent slower than that recommended in traffic management manuals to
lo-percent faster, is associated with a fourfold difference in crash rate. Again,
impaired drivers are uniquely likely to be affected by such changes because they
have slower reaction times, especially for situations that involve making choices.

a  A report from the National Transportation Safety Board (1980) identified the
State of Utah as having two to three times as many crashes per day of wet
weather as do the surrounding States. It does not seem reasonable to assume
that Utah has more careless or alcohol-impaired drivers than these other States.
In fact, given its large Mormon population, one would anticipate less alcohol
use. The difference appears to be attributable to the Utah roads, which are built
with a dense aggregate so that water doesn't drain off readily and vehicles can
hydroplane easily.

While this situation has been documented for Utah, it is not known how often
such differences in roadway construction contribute in extremely subtle ways to
the occurrence of crashes, or to those involving alcohol. Police investigations
simply take the roadway construction as an immutable fact and, if drivers skid,
they assume it must have been something they did wrong, rather than consider-
ing the possibility that something may also have been wrong with the way the
road was built.

o  Two cases provide information about the effect of roadway characteristics on
drivers at different BACs. One study indicated that drivers at BACs of 0.05
gm/dl, and, to a lesser extent at 0.10 gm/dl, are less likely to wander off the sides
of roads or across the center line if the painted stripes are 6 or 8 inches wide
instead of the usual four inches (Nedas et al. 1982). Test areas of roadway with
wider side and center stripes had significantly fewer crashes than did standard
  roads.

o  Other work shows that putting reflectors on signs or on pedestrians permits
drivers with moderate BACs to recognize these features from a further distance
(Hazlett and Allen 1969). Since the inadequacies of road sign placement, size,
readability, and information presented have been well documented, such
greater visibility and consequently longer time for the impaired driver to react
can only be helpful (Tamburri 1969). Studies of wrong-way driving by alcohol-
impaired drivers about 20 years ago identified problems of poor signage and
inadequate separation of some on- and off-ramps on freeways and resulted in
important and successful corrective actions (Alcohol and Highway Safety 1968).

The Missing Link in Alcohol-Related
Crash Avoidance Research

Excellent information has existed for at least the past two decades about the relative
risk of crashing that a driver faces at given BACs (Jones and Joscelyn 1978; Haight et al.
1976). Information is also available about the crash contribution, and sometimes even
the relative crash risk, of certain vehicular or roadway characteristics. What is not known
is how the three sets of data interact. To date, no study has specifically examined the


INJURY CONTROL                                                       187

interaction of alcohol, roadway, and vehicular characteristics in crashes without making
the methodologic error of assuming that the roadway and vehicular aspects were
functioning optimally if they were working as designed and constructed. The fact that
they may have been designed or constructed so as to increase crash risk has been
considered irrelevant by prior researchers.

Again quoting Patricia Wailer on this issue (Haight et al. 1976),

It is a serious error to consider the vehicle and environment as noncon-
tributory simply because they meet the currently established standards. Most
drivers also meet the currently established standards. After all, driver licens-
ing programs exist precisely to see that this is the case. Critics may quickly
point out that our licensing standards are not adequate, but cannot the same
criticism be made with equal validity of the standards concerning vehicles
and roadways? Why are these standards somehow sacrosanct while the
standards used to license drivers are so readily the object of criticism? If the
driver in a crash holds a valid license, then the argument can be made that
he, too, has met existing standards and can be held no more culpable than
the inadequate signing that is nonetheless legal. (p. 31)

Such unnecessary additions to the demands on the driver or the pedestrian, of course,
create a problem not only for the person impaired by alcohol, but also for the elderly,
those just learning to drive, persons unfamiliar with the specific road, and all the rest of
us at times when traffic is particularly heavy, weather is bad, or when, for whatever
reason, we happen to be functioning at less than our personal optimum capacity. If the
goal is truly the prevention of crashes, rather than simply the excoriation of those who
consume alcohol, we will look to all possible options in crash prevention, especially if
they have the wider benefits described above.

Human Issues During the Crash Phase

A common axiom says, "Drunks don't get hurt when they fall because they are so
relaxed." Unfortunately, this assumption not only is inaccurate; it is the exact opposite
of what occurs. Both laboratory and epidemiologic evidence has been growing rapidly
documenting that, especially at lower levels of kinetic impact, persons who have con-
sumed alcohol are more likely to be injured, to have severe injury, to die, and to die
before definitive treatment can be brought to bear (Waller 1985). The reason is that
alcohol adversely affects both the internal function of individual cells and the functioning
of organ systems to make it easier for them to become injured and more difficult for them
to respond properly to injuries that do occur. Clearly, this myth of invulnerability for
alcohol-impaired persons needs to be dispelled.

Vehicular Issues During the Crash Phase

The past two decades have seen considerable attention to, and correction of, vehicular
components that increase crash severity. Examples include laws requiring seatbelt use
and the move toward wider availability of airbags, collapsible steering columns designed
to absorb damaging kinetic energy before it reaches the driver's chest, development of
high-penetration windshields, dashboard construction that is less hazardous on impact,
removal of pedestrian-spearing hood ornaments and tail tins, and attempts to alter the
front design of vehicles to reduce pedestrian damage on impact.

Some major hiatuses still exist, however. Attempts to reduce the effects of side
impacts on vehicle occupants are as yet unsuccessful. Most States have not reinstated
laws requiring use of helmets by motorcyclists, despite the documented savings of life,
limb, and money that accompanied initial passage of such laws and the loss of such
savings where these laws were repealed.


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BACKGROUND PAPERS

Unfortunately, with both helmet and seatbelt laws, among those least likely to obey
the law are persons under the influence of alcohol (e.g., Jessor 1987; Maron et al. 1986).
Research has shown that excessive nonuse of seatbelts is to be found as often among
persons entering bars as among those leaving and, therefore, greater nonuse is not an
acute effect of the alcohol per se but rather appears to reflect underlying lifestyle issues
(Preusser et al. 1986). Despite this relatively greater tendency toward nonuse, however,
persons using alcohol more often wear helmets and seatbelts where the law rquires them
than where use is voluntary, indicating that this high-risk group may be harder to reach,
but not impossible to reach.

Another major hiatus is the faihue to improve truck de&n or construction to reduce
crash severity. It has been known for years, for example, that sides and rear ends of trucks
can be constructed to prevent underride by automobiles during crashes and, conse-
quently, to avoid decapitation of automobile occupants. But the trucking industry, to
date, has successfully avoided regulations that would require this small addition to truck
weight (Minahan and O'Day 1977). The industry may have gained, but public safety has
lost. In similar fashion, energy-absorbing features universally found in automobiles are
often not required by NHTSA in pickup trucks or various recreational vehicles, which
are probably the vehicles preferred by high-risk young, heavy-drinking males.

Roadway Issues During the Crash Phase

The past two decades have seen both substantial progress and continuing problems
in roadway safety. Energy-absorbing construction of guardrails, bridges, and under-
passes, and of light- and sign-posts has become far more common, especially on primary
roads built for higher speeds. These changes reflect the decades-old data indicating that
such design and construction reduce crash severity. Little of this, however, has been
applied to secondary roads, and in many places trees, rock outcroppings, and telephone
poles remain - or in some cases continue to be planted or placed- dangerously close to
the roadway, even for roads that have posted speed limits of 50 mph or higher.

One continuing problem is that even the best energy-absorbing devices that were
designed for one generation of vehicles may be inappropriate for subsequent generations
of vehicles that might follow during the expected lifetime of these devices. For example,
devices built to deal effectively with crashes of the large and mid-size cars that preceded
the 1973 oil embargo are no longer adequate for the large population of compact and
subcompact automobiles, especially as these share the roadways with more and larger
trucks.

Again, the Missing Link

Alcohol increases injury severity, especially at lower rates of energy exchange. AU the
vehicular and roadway research and designs for alteration of energy transfer to date have
been based on a presumption of normal tissue response. It is not known to what extent,
if at all, assumptions need to be altered in considering the reduction of injury for
alcohol-impaired persons or, as well, for the elderly, rather than just for unimpaired
young individuals.

Issues During the Postcrash Phase

Only hvo issues during the postcrash phase are considered, namely, the acute manage-
ment of injured persons who have consumed alcohol, and the application of rehabilita-
tion concepts. Treatment of underlying alcoholism postinjury is also an extremely
important issue, but it is being considered by another panel.

Before turning to alcohol-specific issues of acute management, a brief comment
should be made about the general status of trauma care systems in the United States.


INJURY CONTROL

189

Over the past two and a half decades, substantial improvements have occurred in the
trauma care system. Modified hearses and police cars to transport the injured have been
replaced by modular, well-equipped ambulances. The SO-hour or beyond emergency
medical technician (EMT) training has replaced the &hour standard Red Cross course.
Ambulance-to-hospital radio communication has become commonplace. Emergency
department nurses and many physicians are being trained in advanced life support, and
the whole specialty of emergency medicine has developed.

What is still missing is the widespread regionalization of such improvements, espe-
cially as they involve cooperation between ambulance services, between ambulances and
hospitals and, most assuredly, between hospitals themselves. A tremendous economic
power struggle is taking place in many States concerned with designating specific
hospitals as trauma centers because they are better equipped and better staffed, while
neighboring hospitals perceive them as likely to "steal" lucrative cases. Until we see a
system of regionalization of trauma care in every State of the Nation, instead of the
current spotty distribution of such systems, we will not be able to say that this Nation's
acute care system is beginning to be adequate.

We turn now to alcohol-specific issues in acute care. As long ago as 1928, Bogen
documented the need to determine whether a person had consumed alcohol in order to
provide effective emergency care. It is becoming increasingly apparent that the com-
petent physician must determine if the individual is likely, not only to be acutely under
the influence of alcohol, but also to be an alcoholic.

Acutely alcohol-impaired patients are more likely to have cardiac arrhythmia that
may be lie-threatening either at the crash site or shortly after arrival in the emergency
department. They may have greater respiratory distress both because of the acute effects
of alcohol and because they are likely to be smokers. Alcohol may cause severe hypoten-
sion. The presence of alcohol may, on the one hand, cause serious masking of symptoms
of intra-abdominal injuries because of clouded sensorium and, on the other hand, result
in overdiagnosis of the severity of head injury because alcohol-related altered conscious-
ness is confused with trauma-related effects.

If patients are alcoholics, their wounds are more likely to become infected, because
alcohol depresses immune response. But, at the same time, sudden fever may not be a
sign of infection, but rather of impending delirium tremens, which carries a 25-percent
mortality rate.

Many physicians have been concerned about their legal liability if they do a blood
alcohol determination without specific patient approval. It is becoming increasingly
obvious, however, for all of the above reasons, that the physician who does not obtain a
BAC for clinical management is courting a suit for malpractice if problems occur that
might have been foreseeable had the BAC been known.

Lastly, attention must be turned to the subject of rehabilitation. The whole field of
rehabilitation medicine developed as a result of the progressively higher survival rates
of severely injured soldiers that was achieved during World War II and the Korean
Conflict. The years since have seen tremendous advances in basic research in this field
as well as in the design and development of new techniques, skills, equipment, and
prostheses and the formation of rehabilitation teams.

Unfortunately, as was pointed out in the National Research Council (1985) report,
Zujury in America, much of what is known is not being applied. Patients may not be
referred to a physiatrist, or the referral may be sufficiently delayed so that disability is
unnecessarily prolonged or may even have become permanent. Complete rehabilitation
centers are few and far between, and many physicians do not know how to access them.
This is especially true for the services needed for severe head injury, which is a more
common outcome in the presence of alcohol. The plea of this chapter, therefore, is not
so much for new research, but rather for the wider application of what is already ~IIOWLL


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BACKGROUND PAPERS

Summary

Alcohol contributes not only to the occurrence of crashes but also to the initial severity
of injuries, problems in treatment, and ultimate outcome. The exact relationship of
alcohol use and abuse and other lifestyle issues is just beginning to be examined, and the
dearth of knowledge remains an important obstacle to achieving behavioral change for
drivers and pedestrians who drink.

Characteristics of the vehicle'and the road environment also contribute to crash
occurrence and crash severity. Because littIe research, either qualitative or quantitative,
has examined the interaction of vehicular and road environment characteristics in
crashes at various blood alcohol concentrations, the exact relationship remains conjec-
ture, and potential improvements in injury and disability prevention may be missed.
Specifically, the following are recommended:

.  Research needs to be carried out and the results used to intervene in the
interaction between alcohol use practices and other aspects of lifestyle.

o Persons knowledgable in evaluation concepts and methods must be utilized
early in the design of intervention programs, and evaluation should be an
integral part of all such programs.

0  Research should be undertaken into the interaction between different BACs,
vehicle handling characteristics, and aspects of road design, construction, and
maintenance to determine which vehicular and roadway aspects exacerbate the
effects of impairment caused by BACs below 0.10 gm/dl, and to set vehicle and
road standards that will take this knowledge into consideration. Similar re-
search is needed to determine quantitatively the relation between BAC and
vehicle and roadway features relevant to injury severity, and to apply such
knowledge for injury reduction standards.

0 Motorcycle helmet laws need to be reinstated in those States where they were
  rescinded..

0  Federal crash and injury prevention standards currently applicable to
automobiles should be extended to pickup trucks and recreational xhicles.
Rear and side guards on trucks should be mandated to prevent other vehicles
from underriding medium and large trucks in two-vehicle crashes.

0 All necessary steps must be undertaken, including legislation if nxzary, to
ensure that regionalization of adequate trauma systems is achiexd throughout
  the Nation.

o Physicians must be educated through hospital quality assurance m and
other means about the need to determine BAC and to screen for &&ism as
part of the proper management of the trauma patient. Sii -onal
methods should be used to get physicians to seek prompt and Lzpriate
assistance for the rehabilitative aspects of trauma care.

REFERENCES

,Q&ol and Highway Safety. Report to the U.S. Congress. Washington, DC: L'L ant of
   Transportarion, 1968.

Angel& L.S., and Von Buseck, C.R. Anexploratorystudyofvehicle type inalab%-zcrashes.
  In: Evans, L., and Schwing, R.C., eds. Human Behavior and Traffic Q@- X&u York:
   Plenum Press, 1985. pp. 285-328.

Blomberg, R.D.; Preusser, D.F.; Hale,k; and Ulmer, R.G.A Comparison ofk.ktil
  in Pedestrians and Pedeshian Casualties. Final Report on Contraa DTT-Z%&XMfj.
  Norwalk, (=T: Dunlap and Assoc. East, 1979.

Bogen, E. Drunkenness.American Journal of Medical Science 176:153-167,2X
Fell, J.C. Alcohol involvement rates in fatal crashes: A focus on young drive axe izze tiers.


INJURY CONTROL

191

  In: Proceedings of 3Ist Annual Conference, American Association for Automotive
  Medicine. New Orleans, m the Association, Sept. 28-30, 1987. pp. I-30.
Goleman, D. The Tax Cheats: Selfish to the Bottom Line. NY 7IIs, April 1 l:Al, D2,1988.
Haddon, W., Jr. On the escape of tigers: An ecologic note. Technological Review 72:44-53,197O.
Haight, F.k; Joksch, H.C.; O'Day, J.; and Wailer, P.F. Review of Methods for StudyingPre-Crash
  Factors. Report HSRC-PR38. Chapel Hill, NC: Highway Safety Research Center, Univer-
   sity of North Carolina, 1976. pp. 31,48-49.

Hdett, R-D., and Allen, MJ. The ability to see a pedestrian at night: The effects of clothing,
  reflectorization and driver intoxication. American Jountal of Optometry and Archives of rhe
   American Academy of Optometry 45:246-258,1%9.
Insurance Institute for Highway Safety. Two Studies Question V&e of Motorcycle Licensing
  ProgTam. Status Report 23(8):1,2,6. Washington, D.C.: the Institute, August 13, 1988.
Jessor, R. Risky driving and adolescent problem behavior: An extension of problem-behavior
  theory. Alcohol, Drugs, and Driving 3(3-4): l-l 1, July-Dec., 1987.
Jones, R.K., and Joscelyn, KB. Alcohol and Highway Safev 1978. A Review of the State of
  Knowledge. Report DOTHS-803 764. Ann Arbor, MI: Highway Safety Research Institute,
   University of Michigan, 1978.

Maron, D J.; Telch, M J.; Killen, J.D.; et al. Correlates of seatbelt use by adolescents: Implications
   for health promotion. Preventive Medicine 15614623, 1986.
Minahan, DJ.; and O'Day, J. Fatal Car-into-Ttuck/Trailer Underruie CoUi.rions. HSRI Research
  Review 8(3) Nov./Dee. 19771-16. Ann Arbor, MI: Highway Safety Research Institute,
   University of Michigan.

National Highway Traffic Safety Administration. Fatal Accident Reporting System 1986.
   Washington, DC: U.S. Department of Transportation, 1986.
National Research Council Committee on Trauma Research.Injwy in America. Washington, DC:
   National Academy Press, 1985.

National Transportation Safety Board. Special Study: Fatal Highway Accidents on Wet Pavement
  - The Magnitude, Location, and Characteristics. Report NTSB-HSS-80-1. Washington,
   DC: the Board, 1980.

Nedas, N.D.; Balcar, G.P.; and Macy, R.P. Road markings as an alcohol countermeasure for
  highway safety: Field study of standard and wide edgelines. Transportation Research
   Record 847:43-46,1982.

Olsen, R.k The driver as cause or victim in vehicle skidding accidents. Accident Analysti and
   Prevention, lCk61-68, 1978.

Preusser, D.F.; Williams, AF.; and Lund, AK Seatbelt use among New York bar patrons.Jountal
   of Public Health Policy 7:470479, 1986.

Reinfurt, D.W.; Li, LX.; Popkin, C.L.; O'Neill, B.; Burchman, P.F.; and Wells, J.K Rollover and
  serious driver injury differences among various utilityvehicles, pickup trucks and passenger
   car group&In: Proceedings of 26thAnnual Conference, American Association forAutomo-
   five Medicine. Ottawa, Ontario, Canada: the Association, Ott 44297-312, 1982.
Reiss, M.L.; Lunenfeld, H.; and Morton, G.W. Field of view Requirements Directly Behind Trucks
   and Buses. Contract DOT-HS-112-1- 162. Deer Park, NY: AIL, Division of Cutler-Ham-
   mer, 1972.

Tamburri, T.N. Wrong- Way DrivingAccidentsAre Reduced. Highway Research Record 292:24-50.
   Washington, DC: Highway Research Board, 1969.
U.S. Bureau of Public Roads. Traffic Control and Road Elements. Washington, DC: the Bureau,
    1%3.

Vingilis, E., and Smart, R. Effects of raising the legal drinking age in Ontario. Britain Journal of
   Addictions 76:415-424, 1981.

Wailer, J.A. A systems model for safety program evaluation. Accident Analysis and Prevention
   121-5, March 1980.

Wailer, J.A. Injury Control. Lexington, m Lexington Books, 1985. pp. 125-128.
Wailer, J.k Research needs and opportunities concerning human-environmental interactions in
  crashes involving alcohol. Joumal of Studies on Alcohol Supplement 10:54-60, 1985.
Wright, P.H., and Robertson, L.S. Priorities for roadside hazard modification. TraJic Engineering
   46(8):24-30, 1976.

Zador, P.; et al. The effect of signal timing on traffic flow and crashes at signalized intersections.
   Transportation Research Review. lOlfk1-8, 1985.


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


YOUTH AND OTHER SPECIAL POPULATIONS                                          193

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.

REFERENCES

Albert, W., and Simpson, R. Evaluating an educational program for the prevention of impaired
   driving among grade 11 students. Journal of Drug Education 15(1):57-71,198s.
American Academy of Pediatrics Committee on Adolescence. Alcohol use and abuse: A pediatric
   concern. Pediatrics 79(3):450-453, 1987.

Anastas, R. SADD Chapter Handbook and CumUum Guide. Marlboro, MA: Students Against
   Driving Drunk, 1983.

Atkin, C.; Neuendorf, K, and McDermott, S. The role of alcohol advertising in excessive and
   hazardous drinking. Joumal of DrugEducation 13:313-326,1983.
Atkin, C.; Hocking, J.; and Block, M. Teenage drinking: Does advertising make a difference?
   Journal of Communications 34: 157-167, 1984.

Bachman, J.; Johnston, L.; and O'Malley, P. Monitoringthe Future: Questionnaire Responvesfiom
   the Nation's High School Seniors. Ann Arbor, MI: Institute for Social Research, 1987.
Barmark, J., and Payne, D. The Lackland accident countermeasures experiment. In: Proceedings
   of the 40th Annual Meeting of the Highway Research Board, Volume 45, Washington, DC,
   1961. pp. 221-232.

Bergeron, J., and Joly, P. Young drivers' attitudes and drunk driving habits as a function of their


YOUTH AND OTHER SPECIAL POPUIATIONS                                           203

  accident involvement and violation record. In: Benjamin, T., ed. Young tivers Impaired
  by Alcohol and Other Drugs. London: Royal Society of Medicine Services, 1986.
Biddle, B.; Biddle, B.; Bank, J.; and Martin, M. Social determinants of adolescent drinking. Journal
   of Studies on Alcohol 41(3):215-241,198O.

Blanc, H. Problem drinking in delinquent and nondelinquent adolescent males. llte American
   Journal of Lhqs and Alcohol 9(2):221-232,1983.
Boyd, N.R., and Huffian, W. The relationship between adult maturity and drinking-driving
  involvement among young adults. JournaZ of Safety Resemch 15( 1): 16, 1984.
Cameron, T. Drinking and driving among American youth: Beliefs and behaviors. Drug and
   Alcohol Dependence 10: 1 l-33,1982.

Chambers, J., and Morehouse, E. A cooperative model for preventing drug and alcohol abuse.
  National Association of Secondary School Principah'BulZetin January:8187,1983.
Coate, D., and Grossman, M. "Effects of Alcohol Beverage Prices and Legal Drinking Ages on
   Youth Alcohol Use: Results from the Second National Health and Nutrition Examination
  Survey." Unpublished manuscript. New York: National Bureau of Economic Research,
    1985.

DeMarsh, J., and Kumpfer, K Family oriented interventions for the prevention of chemical
  dependency in children and adolescents. Journal of Children in Contemporasy Society 18(1
   and 2): 117-182, 1985.

Department of Transportation. Communications Strategies on Alcohol and Highway Safety,
  Volume ZZ, by Grey Advertising. Report No. DOT HS-803-714. Washington, DC: the
   Department, 1975.

Department of Transportation. Fatal Accident Reporting System 1986 Summary Report.
   Washington, DC: The Department, 1987.

Department of Transportation. Norms and Attitudes Related to AlcohoI Usage and Driving: A
  Review of the Rekvant Literature, Volume III and ZV, by Pawlowski, W. DTNH 22-81-
   07385. Washington, DC: the Department, 1982.
DiBlasio, F. Predriving riders and drinking drivers. Journal of Studies on Alcohol 49(1):11-15,
    1988.

Douglass, R. Youth, alcohol, and traffic accidents: Current status. Recent Developments in
   AlcohoZisnq Vohune I. New York: Plenum Press, 1983.
Drummond, AE., Cave, T.C.; and Healy, DJ. The risk of accident involvement by time of
  week-an assessment of the effects of zero BAC legislation and the potential of driving
   curfews. In: Benjamin, T., ed. Young Drivers Impaired by Alcohol and Other Drugs.
   London: Royal Society of Medicine Services, 1987.
Elliot, D. Self-reported driving while under the influence of alcohol/drugs and the risk of al-
   cohol/drug-related accidents. Alcohol, Drugs, and Driving 3(3-4):314%, 1987.
Farquhar, J.; Maccoby, N.; Wood, P.; Alexander, J.; Breitrose, H.; Brown, P.; Haskell, W.;
   McAlister, A; Meyer, A; Nash, J.; and Stern, M. Community education for cardiovascular
   health. Lancet June:1192-1195, 1977.

Farris, R.; Malone, T.; and Lilliefors, H. A Comparison of Alcohol-Znvolvement in Exposed and
  Injured drivers: Phases Z a& II. (Report No. DOT-HS-4-06954). Washington, DC:
   National Highway Traffic Safety Administration, 1976.
Farrow, J. Young driver risk taking: A description of dangerous driving situations among 16- to
   19-year-old drivers. International Journal of the Addictions 22(12): 1255-1267, 1987.
Fell, J. "Effectivenessof Raising the Drinking Age to21." Paper presented to the 14th International
   Forum on Traffic Records Systems, San Diego, CA, July, 1988.
Finley, B. Drinking and driving behaviors in grades l-10 in one rural high school. Current ZsslCRF in
  Alcohol and Drug Nursing:\ Research, Education, and Clinical Practice. Washington, DC,
   May, 1983.

Forney, M.; Forney, P.; Davis, H.; Van Hoose, J.; Gafferty, T.; and Allen, H. "Factors Affecting
  Knowledge, Attitude, and Behavior Toward the Use of Alcohol Among Middle School
  Students." Paper presented to the American Educational Research Association Annual
   Conference, April, 1984.

Frankena, M.; Cohen, M.; Daniel, T.; Ehrlich, L.; Greenspun, N.; and Kelman, D. Alcohol
  advertising, consumption and abuse. In: Federal Trade Commission. Recommendations
  of the Stafl of the Federal Trade Commission: Omnibus Petition for Regulation of Unfair
  and Deceptive Alcohol Beverage Marketing Practices (Docket Number 209-46).
   Washington, DC: Federal Trade Commission, 1985.


204                                                     BACKGROUND PAPERS

Goodstadt, M. Shaping drinking practices through education. In: von Wartburg, J.; Magnenat, P.;
   Muller, R.; and Wyss, S., eds. C'nts in Alcohol Research and the Revenfion ofArcoho1
   hblems. Beme, Switzerland: Hans Huber Publishers, 1985.
Goodstadt, M. School-based drug education in North America: What iswrong? What can be done?
   Journal of School Health 56(7):278-281,1986.
Gottfredson, D. "Changing School Structures to Benefit High-Risk Youths" Paper presented at
   the National Center on Effective Secondary School's Symposium on Structural Change in
   Secondary Education, Madison, WI, May, 1987.
Hagge, R., and Marsh, W. The Traffic Safev Impact of Proti&ui kenring. Sacramento, CA:
   California Department of Motor Vehicles, 1986.
Hawkins, J.D., and Lishner, D.M. Schooling and delinquency. In: Johnson, E.H., ed. Handbook
   on Crime ami Winquency Prevention. Westport, CT.: Greenwood Press, in press.
Hetherington, R.; Dickinson, J.; Cipywnyk, K; and Hay, D. Attitudesand knowledge about alcohol
   among Saskatchewan adolescents. Canadian Journal of Public Heahh 70(4):247-259,
     1979.

Hingson, R.; Heeren, T.; and Morelock, S. Preliminary effects of Maine's 1982 0.02 law to reduce
  teenage driving after drinking. In: Benjamin, T., ed. Young Drivers Impaired by AIcohoi
  and Other tigs. London: Royal Society of Medicine Services, 1986.
Hingson, R.; Heeren, T.; and Morelock, S. Effects of Maine's 1983 -02 law to reduce teenage
  driving after drinking. Alcohol, L%ugs, and Driving, in press.
Hingson, R.; Howland, J.; Morelock, S.; and Heeren, T. Legal interventions to reduce drunken
  driving and related fatalities among youthful drivers.AZcohol Dmgs, Md Dn'ving 4(2):87-
   98,1988.

Hingson, R.; Scotch, N.; Mangione, T.; Meyers, A.; Glantz, L.; Heeren, T.; Liu, N.; Muscatel, M.;
  and Pierce, G. Impact of legislation raising the legal drinking age in Massachusetts from
   18 to 20. American Journal of Public Health 73: 163-170, 1983.
Hoadley, J.; Fuchs, B.; and Holder, H.The effects of alcohol beverage restrictionson consumption:
  AZ-year longitudinal anatysis.Aimetican JournalofDrugandAlcohoIAbzue 10~375401,
    1984.

Huba, G.; Wingard, J.; and Bentler, P. Applications of a theory of drug use to prevention programs.
  Joumai of Drug Education lo(l):2538,198O.

Insurance Institute for Highway Safety. Srnrus Report 19(3): 1-3, 1984.
Jayet, M. Penal policy for preventing young drivers from drinking: Scope, limits, and principles. In:
  Benjamin, T.; ed. Young Drivers Impaired by Alcohol and Other Drugs. London: Royal
   Society of Medicine Services, 1986.

Jessor, R. Risky driving and adolescent problem behavior: An extension of problem-behavior
   theory. Alcohol, Drugs, and Driving 3(3-4): l-12,1987.
Jessor, R., and Jessor, S. Problem Behavior and Psychosocial Development: A Longitudinal Study
   of Your/t. New York: Academic Press, 1977.

Klitzner, M. An assessment of the research on school-based prevention programs. In: Report to
  Congress on the Nature and Effectiveness of Federd State, and Local Drug Preven-
  tion/Education Z+ogra.mr. Washington, DC U.S. Department of Education, 1987.
Klitzner, M., and Bell, C. "Youth Drug and Alcohol Abuse Prevention: Why We Can't Answer
   the Question, `What Works?"' Paper presented to the 115th Annual Meeting of the
   American Public Health Association, New Orleans, LA, October, 1987.
Klitzner, M., and Schonberg, K Concerns regarding the indirect assessment for drug abuse among
   adolescents. Journal of DeverOpmetttal and Behavioral Pediatrics 9( 1):30-31, 1988.
Klitzner, M.; Gruenewald, P.; Rossiter, C.; Bamberger, E.; and Roth, T. Students Against Driving
  Drunk: A National Study -Final Report. Vienna, Vk Pacific Institute for Research and
   Evaluation, 1987.

Klitzner, M.; Vegega, M.; and Gruenewald, P. An empirical examination of the assumptions
  underlying youth drinking/driving prevention programs. EvaIuarionandProgram Pkznning
   11:219-235,1988.

Koningsberg, D.; Weinhouse, B.; and Wechsler, J. Teenagers and alcohol: Holiday hazard,
  year-round tragedy. L.&es Home Journal lOO(12): 1983.
Kraus, A; Steele, R.; Ghent, W.; and Thompson, M. Predriving identification of young drivers
  with high risk of accidents. Journal of Safety Research 255.56, 1970.
Krohn, M.; Akers, R.; Radosevich, M.; and Lanze-Kaduce, L. Norm qualities and adolescent
  driving and drug behavior. Journal of Drug Issues Fal1:349-359,1982


YOUTH AND OTHER SPECIAL POPULATIONS                                           205

Leventhal, H., and Cleary, P. The smoking problem: A review of the research and theory in
  behavioral risk modification. Psychological Bulletin 88:370-405,1980.
Lewis, C. "Preventing Traffic Casualties Among Youth: What Is Our Knowledge Base?" Paper
  presented to the International Symposium on Youth at Risk for Traffic Accidents, Santa
   Monica, CA, May 1987.

Lightsey, M., and Sweeney, M. Life problems experienced from drinking: Factors associated with
  level of problem drinking among youthful DWI offenders. Journal of Alcohol and Drug
  Educarion 30(3):6582,1985.

Lowman, C. Facts for planning, no. 3: U.S. teenage alcohol use in unsupetvised social settings.
  Alcohol Heahh and Resemch World 6(2): 1981.
McKnight, A; Hyle, P.; and Aibrecht, L Youth License Conbol Hemonstralion Project. NTIS No.
  DOT-H!+806 616. Washington, DC: National Highway Traffic Safety Administration,
    1983.

M&night, J., and McPherson, K Evaluation of peer intervention training for high school alcohol
  safety education.AccidentAn and Prevention 18(4):339-347,1986.
McPherson, K.; M&night, A; and Weidman, J. SupplementalDriver Safety Program Development:
  Final Report, Volume I, Developmental Research and Evaluation. Washington, DC:
  National Highway Transportation Safety Administration, 1983.
Milgram, G. Societal attitudes toward youthful drinking. Journal of Drug E&cation 12(4), 1982.
Morehouse, E. The student assistance program: An alcohol and drug abuse prevention model. In:
  Amowitz, E., ed. fievenrion Strategies in Memal Heahh. New York: PRODIST, 1982
Moskcnvitz, J. Preventing adolescent substance abuse through drug education. In: Glynn, T.;
  Leukefeld, C.; and Ludford, J., eds. Preventing Adolescent Drug Abuse: Intervention
  S@&e@es. National Institute on Drug Abuse Research Monograph No. 47, DHHS Pub.
  No. (ADM)83-1280. Washington, DC: Supt. of Dots., U.S. Govt. Print. Off., 1983.
Moskowitz, J. The primary prevention of alcohol problems: A critical review of the research
  literature. Journal of Studies on Alcohol 50( 1):54-88, 1989.
Moskowitz, J. School Dnrg and Alcohol Policy: A Prehminary Model Relating Policy Implementa-
  rion ro School Problem. Berkeley, CA Pacific Institute for Research and Evaiua-
   tion/`Prevention Research Center, 1987.

Nataanen, R., and Summala, H. Road User Behavior and Traffic Accidents. Amsterdam and New
   York: North Holland/American Eisevier, 1976.
Nusbaumer, M., and Zusman, M. Autos, alcohol, and adolescents: Forgotten concerns and
  overlooked linkages. Journal of Drug Education 1 l(2): 167-178,198l.
O'Day, J. Drinking involvement and age ofyoung drivers in fatal accidents. Hit Laboratory Reports
   October:13-14, 1970.

Omstein, S., and Hannens, D. Alcohol control laws and the consumption of distilled spirits and
  beer. Journal of Consumer Research 12:200-213,198s.
Pacific Institute for Research and Evaluation. The Introduction of Effective Systemwide Strategies
  to Combat Youth Drug and Alcohol Abuse: Assessment Report. Vienna, VA Pacific
   Institute for Research and Evaluation, in press.
Paulson, J. Accidental injuries. In: Behrman, R., and Vaughan, V., eds. Nelson Handbook of
  Pediatrics. Philadelphia, PA Saunders Company, 1983.
Peiz, D., and Schuman, S. Are young drivers really more dangerous after controlling for exposure
  and experience? Journal of Safety Research 368-79, 1971.
Perrine, M.; Waller, J.; and Harris, LAkoholandHighway Safety: Behavioraland MedicaiAspecls.
  Burlington, VT: University of Vermont, 1971.
Polich. J.; Ellickson, P.; Reuter, P.; and Kahan, J. Strategies for ControllingAdolescent Drug Use.
   Santa Monica, CA Rand Corporation, 1984.

Preusser, D.; Williams, A; and Zador, P. The effects of curfew laws on motor vehicle crashes. Law
   end Policy 6115128.1984.

Puska, P.; Nissinen, A.; Tuomilehto, J.; Salonen, J.; Koskela, K; McAiister, A; Kottke, T.;
  Maccoby, N.; and Farquhar, J. The community-based strategy to prevent coronary heart
  disease: Conclusions from the ten years of the North Karelia Project. Annual Review of
   Public Health 6: 147-193,1985.

Robertson, L. Patterns of teenage driver involvement in fatal motor vehicle crashes: Implications
  for policy choice. Journal of Heahh Politics, Policy und Law 6(2):303-314, 1981.
Robertson, L, and Zador, P. Driver education and fatal crash involvement of teenage drivers.
  American Journal of Public Health 73:959-%5,1978.


206

BACKGROUND PAPERS

Robertson, L.S. Crash involvement of teenaged driverswhen driver education is eliminated from
   high school. American Journal of Public Health 70:599603,1980.
Ross, H. Deterring drunken driving: An analysis of current efforts. Journal of Studies on Alcohol
   Supplement 10:122-128, 1985.

Ross, H. Deleting the Drinking Dkfm: Legal Policy and Social Conb-ol. Lexington, MA: Lexington
   Books, 1984.

Saffer, H., and Grossman, M. Effecfi of Beer Prices.and Legal DrinkingAges on Youth Motor
  Vehicle Fa&itzks. Unpublished manuscript. New York: National Bureau of Economic
   Research, 1985.

Schweitzer, S.; Intriligator, M.; and Salehi, H. Alcoholism, an econometric model of its causes, its
   effects, and its control. In: Grant, M.; Plant, M.; and Williams, A., eds. Economics and
  Alcohol Consumption and Control. London: Croom Helm, 1983.
Stoles, P., and Fine, E. Substance abuse patterns among youthful drinking drivers. Alcoholism
   Clinical and Eqxrimental Research 5(l), 1981.
Simpson, H.; Mayhew, D.; and Warren, R. Epidemiology of road accidents involving young adults:
  Alcohol, drugs, and other factors. Drug and Alcohol Lkpendence 10:3563, 1982.
Strickland, D. Advertising exposure, alcohol consumption, and misuse of alcohol. In: Grant, M.;
   Plant, M.; and Williams, k, eds. Economics and Alcohol Consumption and Controls.
   London: Croom Helm, 1983.

Summala, H. Young driver accidents: Risk taking or failure of skills. Alcohol Drugs, and Driving
   3(3-4):79-91, 1987.

URSA/Pacificon. Campaign Strategy Repoti for the IVUAA I%blic information Campaign. Rock-
   ville, MD: National Institute on Alcohol Abuse and Alcoholism, 1980.
Vegega, M, "Deterring Drinking-Driving Among Youth: Some Research Needs." Paper
  presented at the annual convention of the American Psychological Association, Toronto,
   Canada, 1984.

Vegega, M., and Klitzner, M. Drinking and driving among youth: Astudy of situational risk factors.
   Health Education Quarterly, in press.

Vegega, M., and IUitzner, M. What have we learned about youth anti-drinking-driving programs?
   Evaluation and Program Planning 11:203-217,1988.
Vejnoska, I. Putting the brakes on teenage drunk driving. Police Chief 49(12), 1982
Wagenaar, k Alcohol, Young Lkivers, and Traffic Accidents: Effects of Minimum Age Laws.
   Lexington,, MA Lexington Books, 198%.

Wagenaar, A. "Youth Drinking and Driving: One Effective Countermeasure." Paper presented
  at the Drinking and Driving Symposium, American Association for Advancement of
   Science Meetings, Detroit, MI, May 31, 19836.

Wagenaar, A Preventing highway crashes by raising the legal minimum age for drinking: An
  empirical confirmation. Journal of Safety Research 13:57-71.19826.
Wagenaar, A. Aggregate beer and wine consumption: Effects of changes in the minimum legal
  drinking age and a mandatory beverage container deposit law in Michigan. Journal of
   Alcohol Studies 43:469-4%,1982a.

Watts, R., and Rabow, J. Alcohol availability and alcohol-related problems in 213 California cities.
   Alcoholism: CLinical and Experimental Research 7( 1):47-58,1983.
Williams, A; Lund, A; and Preusser, D. Teenage driver licensing in relation to state laws.Accident
   Analysis and fievention 17(2):135-145,1985.

Williams, A.; Lund, A.; and Preusser, D. Drinking and driving among high school students.
   International Journal of the Addictions 21(6):643-655,1986.
Williams, A. Effective and ineffective policies for reducing injuries associated with youthful drivers.
   Alcohol Drugs, and Driving 3(3-4):109-l 17,1987.
W&man, F. Current status of research demonstration programs in the primary prevention of
  alcohol problems. In: Prevention, Intervention, and Treatment: Concerns and Models.
   Washington, DC: Supt. of Dots., U.S. Govt. Print. Off., 1982.
Zylman, R. Youth, alcohol, and collision involvement. Jozunal ofsafety Research 5(2), 1973.


207

Youth and Other Special Populations

Motor Vehicle Crashes and Alcohol
Among American Indians and
      Alaska Natives

Philip A. May, Ph.D.

University of New Mexico

The American Indian population, made up of well over 300 tribes, now numbers more
than 1.5 million or over 0.6 percent of the U.S. population. Throughout the recent past,
it has been a rapidly growing population that has consistently had a birth rate twice that
of the rest of the U.S. population (IHS 1988; May 1988; Broudy and May 1983). Because
of this high fertility, the median age of the Indian population was 22.9 in 1980, compared
to 30.3 for the overaIl U.S. population. The median age of the population living on
reservation was 19 years in 1980 (U.S. Congress 1986). The young age composition has
definite implications for the study of both motor vehicle injuries and alcohol.

Some other general considerations of the U.S. Indian population are also vital here.
While Indians and Alaska Natives live in every State of the Union, most live in 32
"reservation States" (see exhibit l), the vast majority (over 1 million) in Western States
(IHS 1988). Many Indians live in rural areas (46 percent) or other urbanized settings
such as small towns (32 percent), while 22percent live in central cities. In 1980,37 percent
lived on reservations or in Indian communities. Many who live in cities or off reservations
are characterized as highly mobile (U.S: Congress 1986). Average economic indicators
for Indians as a group remain poor. The 1980 Census indicated unemployment rates
twice the national average, and the median family income for Indians was about half the
average for the entire U.S. population (U.S. Congress 1986; U.S. Bureau of Census
1984q b). Finally, educational attainment of many Indians remains lower than the
national averages (Brod and McQuiston 1983).

Overview of Accident Statistics

When reviewing accident data for Indians, one must first consider accidents as they
affect the overall Indian population and then move to specific considerations of gender,
age, and local and regional data, Only recently have accidents fallen to second place
among causes of mortality. Accidents were the leading cause of death throughout the
195Os, 196Os, and 1970s for Indians and Alaska Natives in the 32 reservation States (IHS
1988). In 1983-85? accidents caused 3,218 deaths or 16 percent of all mortality (see table
1). Of these deaths, 1,753 or 54.5 percent were caused by motor vehicles. When measured
by crude rates, accidents are the fourth leading cause of death among other U.S.
residents. Motor vehicle accidents take a higher toll among Indian males than females,
and this is even more true of other accidents.

Table 2 presents age-adjusted death rates that allow comparisons between Indians
and other groups in the United States. When age-adjusted rates are considered, accident


208

BACKGROUND PAPERS

Exhibit 1

Indian Health Service (IHS) reservation States numbered L?4 from 1969 to 1974. Prior
to that, IHS calculated rates on SO-percent samples of U.S. records. Since 1974, eight
more States have heen added. The current 32 stateslisted by administrative area and the
year added for the most recent additions are:
Nashville Area:  Alabama (added in 1984),.Connecticut (added in 1983), Florida,
         Louisiana, Maine (added in 1979), Mississippi, New York
        (added in 1979), North Carolina, Pennsylvania (added in 1979),
         Rhode Island (added in 1983).
Bemidji Area:   Michigan, Minnesota, Wisconsin
Oklahoma Area:  Oklahoma, Texas (added in 1983), Kansas
Aberdeen Area:   Iowa, Nebraska, North Dakota, South Dakota.
Billings Area:    Montana, Wyoming
Albuquerque Area: Colorado, New Mexico
Navajo Area:    Main Navajo reservation (parts of Arizona,NewMexico and Utah)
Phoenix Area:   Arizona (most), Nevada, Utah
Tucson Area:    Southern Ariina (Papago reservation)
Portland Area:   Idaho, Oregon, Washington
Alaska Area:     Alaska

mortality becomes the third leading cause of death for aU Indians and Alaska Natives.
The rate of 42.2 per 100,000 for motor vehicle accidents is 2.3 times the rate for alI races
combined. Other accidents, which in the distant and relatively recent past have played
a major role in mortality among Indians (Kunitz 1983) and particularly Alaska Natives
(Boyd et al. 1968), are 2.2 times higher than U.S. averages.

The trend in accident mortality rates for Indians and Alaska Natives has been down
over the years that accurate, Indian-specific rates have been kept, but the exact mag-
nitude of this drop is difficult to determine . Many procedural changes have affected the
calculation of Indian mortality rates, confusing the interpretation of trends. Some of
these changes include: alterations in census enumeration methodologies for American
Indians and Alaska Natives; changes in methodologies for estimating the Indian popula-
tion (which was necessary to correct suspected undercounts;); debate over whether tribal
enrollment or resident population figures were the most appropriate for use as denom-
inators; and, most importantly, the addition of Indians from States such as Pennsylvania,
Rhode Island, and Connecticut to Indian Health Service "reservation States" (see U.S.
Congress 1986, pp. 59-82; IHS 1988; Passe11 1976; PasseII and Berman 1986, May 1988).

Taken at face value the Indian Health Service (IHS) rates indicate that accident
mortality has fallen dramatically. The age-adjusted rate of motor vehicle accident
mortality declined from a high of 106.2 in 1956 to 42.6 in 1985 (IHS 19@3), a drop of 59.8
percent. However, a more realistic trend figure might be obtained by using m-year
figures from 1956 through 1976, when the major reshaping of the II-IS denominator
began. From 1956 to 1976, the Indian rate of motor vehicle accident death dropped from
106.2 to 74.5 or 29.8 percent. This is quite comparable to the overall U.S. drop of 14.7
percent from 1956 to 1976 or 34.0 percent from 1956 to 1985. Therefore, it is safe to
conclude that the American Indian rates have dropped, probably in a magnitude similar
to or slightly greater than the drop for the overall U.S. population. 1 One  positive
reason for this drop could certainly be the upgrading of emergency medical services
begun in the middle 1970s on many reservations.

1  Indian vital statistics in many areas tend to parallel U.S. statistics, although some rates usually remain
higher. For example, most tribes experienced a baby boom similar to the total U.S. population, only the birth
rates were substantially higher and the peak was several years later (see Broudyand May 1983). Also, motor
vehicle accident rates were reduced in 1974 on the Navajo reservation when the oil embargo forced the
lowering of the national speed limit (Katz and May 1979).


YOUTH AND OTHER SPECIAL POPULATIONS

209

Table I. Leading causes of death for American Indian and Alaska Natives by
   frequency, gender, and rates per 100,000, 1983-85

          Males                    Females
              Mortality                Mortality
Causes of death     Number   rate   Causes of death      Number rate

All causes        11,894
Diseases of the heart   2,727
Accidents        2,385
Motor vehicle     1,263
Other accidents    1,122
Malignant neoplasms   1,424
Chronic liver disease
and cirrhosis       520
Suicide             485
Cerebrovascular diseases 456
Homicide            453
Pneumonia and influenza  387
Diabetes mellitus       284
Chronic obstructive
pulmonary diseases
and allied conditions   254
Certain conditions
originating in the
perinatal period      216
All other causes      2,303

568.4
130.3
114.0
60.4
53.6
68.0

24.8
23.2
21.8
21.6
18.5
13.6

12.1

10.3

All causes
Diseases of the heart
Malignant neoplasms
Accidents
Motor vehicle
Other accidents
Cerebrovascular diseases
Chronic liver disease
and cirrhosis
Diabetes mellitus
Pneumonia and influenza
Certain conditions
originating in the
perinatal period
Nephritis, nephrotic,
and nephrosis
Homicide
All other causes

8,216   382.2
1,958   91.1
1,301   60.5
833   38.7
490   22.8
343   16.0
513   23.9

404   18.8
392   18.2
295   33.7

171    8.0

151
144
2,054

7.0
6.7

Source: Indian Health Service, Chart Book Series, 1988.

The greater magnitude of the rate of inotor vehicle accident death warrants further
discussion here. The overall aggregated data for 1983-85 indicate that Indians and Alaska
Natives die twice (2.3 times) as frequently from motor vehicle crashes. But since these
are overall figures that include both males and females, eastern and western Indians,
Alaska Natives and Indians, rural and urban Indians, and a great diversity of tribes with
differing social and cultural traditions, it is imperative to examine data that are more
specific to local, tribal, and gender variations.

Table 3 gives age- and gender-specific data for U.S. Indians and Alaska Natives.
Indian males' rates of motor vehicle accident mortality are substantially higher than
Indian females, in each age category. Further, Indian males age 15 to 85 years and older
die three times more frequently than Indian females in motor vehicle crashes. Both
Indian males and Indian females have higher rates of death at virtually every age category
than all races combined, the exception being Indian women 75 and over.

This higher rate of accidental death for Indian males, when expressed in years of
potential life lost or life expectancy, is dramatic. Among the Navajo in 1972-74, motor
vehicle deaths reduced the male life expectancy at birth by5.2 years, and other accidents
reduced male longevity by another 3.1 years (Carr and Lee 1978). For Navajo females,
the respective figures were 2.7 years and less than 1 year (Carr and Lee 1978). The
comparable figures for the U.S. population at this time were reductions of less than 1
year for motor vehicle and other accidents for both males and females (Tsai et al. 1978).

An examination of geographical and cultural variations in unintentional injury death
rates (table 4) reveals three items that need to be emphasized. First, the highest rates of


210                                                       BACKGROUND PAPERS

Table 2. Age-adjusted mortality rates (per 100,000 population) for American
   Indians and Alaska Natives in reservation States, 1983-1985, and
   U.S. populations, 1985

Indians         United States     Ratio of
and Alaska                AlI   Indians to
Natives   All races   White   other all US races

All causes         ~ 542.7
Major cardiovascular disease 174.6
Diseases of heart       141.6
Cerebrovascular diseases 26.8
Atherosclerosis         2.5
Hypertension          1.0
Malignant neoplasms       84.9
Accidents             77.7
Motor vehicle         42.6
AII other            35.1
Chronic liver disease
and cirrhosis          29.2
Diabetes mellitus         22.9
Pneumonia and influenza    17.9
Homicide             14.3
Suicide               14.1
Chronic obstructive
pulmonary diseases
and allied conditions     11.5
Tuberculosis, all forms       1.6

546.1     523.1   697.8     1.0
224.0     216.9   273.4     0.8
180.5     176.1   210.4     0.8
32.3     30.1   49.4     0.8
4.0      4.0    3.9     0.6
1.8      1.4    4.7     0.6
133.6     130.7   155.7     0.6
34.7     34.1   39.7     2.2
18.8      19.1   17.4     2.3
16.0     15.0   22.3     2.2

9.6      8.9    14.4     3.0
9.6      8.6   17.7     2.4
13.4      12.8   16.8     1.3
8.3      5.4   24.4     1.7
11.5      12.3    6.7     1.2

18.7     19.2   13.8     0.6
0.5      0.3    1.8     3.2

Source: Indian Health S&vice. Chart Book Series, 1988.

motor vehicle accident deaths occur in the West (Rocky Mountain, Plains, and Upper
Midwest). Indians in the Billings, Aberdeen, Tucson, and Navajo areas have the highest
rates, which are 6.7, 5.4, 4.9, and 4.6 times, respectively, that of the general U.S.
population. Alaska has the lowest rate.

Second, Alaska Natives, while they have lower rates of motor vehicle mortality, have
much higher rates of other accident mortality such as from water transport, firearm
incidents, and air transport. Third, females, particularly those living in Alaska and the
West, are at increased risk for motor vehicle and other injury-related death. In summary,
even though the overall age-adjusted death rates for accidents among Indians seem to
have improved dramatically over the years and are now only 2.2 to 2.3 times the national
averages, many tribes, cultures, and subcultures, particularly in the West, still have
&maIjdy I&her accident mortality rates. The reasons for this are sociocultural (May
1982) as well as geographical and envirqnmental.

Local Mortality Data From the West

Isolated State data confirm, in another way, the extremely high accident mortality
rates for western Indians. From 1982 through 1986 in Montana, the Indian crude rate of
death from motor vehicle accidents was 79.7 per lOO,fKKl, while the non-Indian rate was


YOUTH AND OTHER SPECIAL POPULATIONS

211

Table 3. Age-and gender-specific motor vehicle accident death rates (per
   100,000 population) for American Indians and Alaska Natives in
    reservation States, 1983-85, and U.S. all races, 1984

       MALE             FEMALE

American Indian U.S.  Ratio American Indian -U.S.    Ratio
    and     all Indian to     and      au    Indian to
Alaska Native races U.S. all  Alaska Native races   U.S. all
(1983-1985) (1984) races   (1983-1985) (1984)     races

Under 1 year     19.5      43 4.5       12.0      4.6       2.6
1 to 4 years     23.8      8.0 3.0       18.8      5.7      3.3
5 to 14 years      9.9      8.3 1.2       7.9      4.9       1.6
15 to 24 years     87.7     54.9 1.6      31.9     18.3       1.7
25 to 34 years     99.1     37.0 2.7      30.7     10.7      2.9 /
3.5 to 44 years     78.4     25.2 3.1       29.4      9.2       3.2
45 to 54years     71.0     22.4 3.2       25.7      8.8      2.9
55 to 64 years     59.0     21.9 2.7       22.1      10.1      2.2
65 to 74 years     57.0     24.9 2.3       15.2     12.7       1.2
75 to 84 years     89.4     42.0 2.1       14.4     20.0      0.7
Over 84 years     71.9     53.3 1.3       9.5     13.5      0.7

Source: Indian Health Service, Chart Book Series, 1988.

26.5 (calculated from data in the State of Montana, 1983-88). Even though these wey
not age-adjusted, one can conclude that the Indian rate was approximately 2.5 to 3
times the non-Indian rate in the same State. In New Mexico, similar trends are found. In
both 1976-78 and 1984-86, the age-adjusted motor vehicle accident death rates for
Indians were considerably higher than for the other three major ethnic groups (see table
5). Indian rates in both periods were 2.5 to 5.2 times higher than the other groups, even
though the rates for all groups decreased with time. The rate of decrease was 35.5 percent
for Indians, which was a more substaritial reduction than among Hispanics and blacks,
but not as desirable as the decline among non-Hispanic whites. Among Indian and
non-Indian populations in the same State, Indians have higher rates of motor vehicle
accident death.

Even in the same county, Indians and non-Indians have differential rates of motor
vehicle accident death. For example, in Montana in 1974, a colleague of mine and I
calculated crude accidental death rates for both Indians and non-Indians on a county-by-
county basis. This was facilitated by the fact that reservation boundaries cross several
counties, and each county therefore has a substantial number of both Indian and
non-Indian residents living in a similar natural ecology. Of the 17 counties characterized
by this situation, Indians had higher rates of accidental death (motor vehicle and other)
in 11. The overall mortality rate for Indians in these counties was 253 per 100,000
compared to 70 per 100,000 for non-Indians (May and Morigeau 1976).

Morbidity Statistics

Accidents among Indians put a great burden on the health care system as measured
by hospital discharge data. In fiscal year 1987, injuries and poisonings was the leading
diagnostic category for Indian and Alaska Native males at IHS and contract hospitals,

2  Actually3.6 times, but since the rates are not age-adjusted, too specific acomparison is not appropriate.


Table 4. Age-adjusted death rates (per 100,000 population) by type of Injury, sex, and area for Indians and Alaska Natives, 1980-82

Type of injury

  EASTERN                     WESTERN                    FAR WEST
Nashville Oklahoma Aberdeen Bemidji Billings Albuquerque Navajo   Phoenix  Tucson Portland Alaska

Male

Motor vehicle traffic

Ratio to U.S. all races
Other unintentional injury
Ratio to U.S. all races

Female

Motor vehicle traffic

Ratio to U.S. all races
Other unintentional injury
Ratio to U.S. all races
Total (both sexes)
Motor vehicle traffic

Ratio to U.S. all races
Other unintentional injury
Ratio to U.S. all races

74.4     64.5    160.4    109.9    204.7    104.3    156.8    120.7    162.8    99.5     42.5

2.3     2.0     4.9     3.4     6.3     3.2     4.8     3.7     5.0     3.0     1.3

84.5     36.7    103.0     79.7    149.8     85.6    114.3    106.5    59.7    76.6    277.1

3.1     1.3     3.7     2.9     5.4     3.1      4.2     3.9     2.2     2.8     10.1

22.2     27.8     77.2

2.0     2.5     6.8

4.2     6.7     30.8

0.5     0.7     3.4

46.6

4.1

28.3

3.1

87.2     48.0     51.2     54.1     55.0     49.0    86.7

7.7     4.3     4.5     4.8     4.9     4.3     9.5

35.2     17.6     20.1     24.8     19.2     27.1     11.0

3.9     1.9     2.2     2.7     2.1     3.0     1.0

48.2     45.8    116.8     77.6    145.0     74.8    101.3    85.9    106.2    74.0    27.0

2.2     2.1     5.4     3.6     6.7     3.4     4.6     3.9     4.9     3.4     1.2

42.7     21.1     65.5     53.1     91.1     49.6     64.4    63.9    37.5    51.6    183.5

2.4     1.2     2.3     3.0     5.1     2.8     3.6     3.6     2.1     2.9     10.2

Source: U.S. Congress, Indian Health Care, 1986.


YOUTH AND OTHER SPECIAL POPULATIONS

Table 5. Age-adjusted and crude mortality motor vehicle accident rates (per
   100,000 population) for New Mexico ethnic groups 197878 and
     1984-86

213

Crude
rate

   Age-adjusted rates          Percent
     Ratio            change
Total I&Other Male   Female  1976-86

1976 through 1978
Indian
Hispanic
White non-Hispanic
Black

1984 through 1986
Indian
Hispanic
White non-Hispanic
Black

125.5   350.4     -
44.6   51.2    2.9
39.1   42.6    3.5
23.5   29.2    5.2

85.9   97.0      -     1483
36.3   38.8    2.5      58.6
24.9   25.2    3.8      35.6
23.7   27.7    3.5      43.7

243.5     67.9 -
85.7     22.8 -
61.4     26.2 -
39.7     19.4 -

52.0  -35.5

19.8   -24.2
14.9 a.8
10.3    - 5.1

Source: New Mtico Selected He&h Statistics, 1978 and 1986

accounting for 18.7 percent of ail inpatient stays. Among females, the same category was
the fourth most frequent inpatient diagnosis, accounting for 6.8 percent of all stays.
Within these statistics, motor vehicle-related injuries are the largest category in most
areas of the country, rivaled and/or surpassed only in certain age groups by falls (IHS
1988; unpublished IHS program statistics.).

Available Literature and Explanatory Themes

All the above material raises some interesting questions about why Indians and Alaska
Natives are plagued by high rates of accidental death and injury. Realizing that the word
"accident" is both unpopular and also inaccurate because vehicle crashes have objective,
recognizable, and predictable precursors, it is now expedient to examine the research
literature.

Few major studies are available on motor vehicle accidents among Indians or Alaska
Natives. However, some studies have examin ed all types of accidents combined and also
violent death. Most of these articles include motor vehicle accidents as one of a number
of variables. Schmitt et al. (1966) studied accidental deaths among Indians in British
Columbia (Canada) . In this study, motor vehicle deaths accounted for 24 percent of all
Indian accident deaths as opposed to 35 percent for non-Indians. Drownings and burns
were the most common causes of death.

Boyd et al. (1968) studied accident mortality in Alaska in 1958-62 and found drowning
(water transport) as the leading cause of death (62.7 per 100,000) and motor vehicle
accidents as the third leading cause, behind fires. Brown et al. (1970) also studied all
types of accidents, but used clinic records to examine both morbidity and mortality
among the Navajo. Motor vehicle accident deaths accounted for 48 percent of Navajo
accident mortality in the late 1960s and 19.3 percent of the injuries. Factors related to
motor vehicle crashes were unlicensed drivers, alcohol use, lack of driver education, lax
enforcement of laws, and poor roads.

Omran and Laughlin (1972) also studied injury morbidity and mortality among the


214

Navajo, but focused only on clinic records from an earlier period (1950s and early 1960s)
from a remote, central portion of the reservation. All the studies cited above are rather
descriptive and in many ways serve to place the motor vehicle accident experience in a
historical context (e.g., in relation to horse and wagon-induced injuries) and in the
broader context of all injuries (cuts, falls, etc.).

A more recent study of all types of injury was undertaken by Leon Robertson for the
Indian Health Service (1985). Using national IHS chic data and existing literature,
Robertson reviewed the nature of injury morbidity and mortality as they related to
magnitude in all areas served by IHS. Also, there was an attempt to identify individual
risk factors that relate to injury. Such high-risk diagnoses are venereal diseases, diabetes,
etc. While this was an interesting attempt to identify a general population at risk, the
epidemiological and public health implications of this study were limited by a lack of
focus on local and specific conditions and socio-cultural variables.  i

Four major articles/works have been published about the Papago of Southern
Arizona. Each work examined the total range of injuries from clinic records in various
modern and traditional communities. Hackenberg and Gallagher (1972) found that
injury rates were twice as high in the more modern villages and explained this as a
function of social change correlating with wage labor, Protestant religion, and higher
education. Change produced stress that, coupled with alcohol use, produced more
injury.

Stull(l972,1973) also studied Papago clinic records and found that the highest injury
rates were typical of modern individuals in progressive communities, but that rates of
accident and injury were lower for traditional individuals in progressive communities
and lowest for traditional people in traditional communities. In a later article, Stull
(1977) modified this argument to say that injuries were more prevalent in modern settings
"simply because the environment and associated lifestyle place individuals at a greater
risk for injury." Alcohol was also mentioned as a contributing factor to injury.

One other article that explored the theme of modernization and social stress was
written by James Wills (1969), w h o worked among the Oglala Sioux of Pine Ridge, South
Dakota. Wills states that a comprehensive, baseline self-report survey showed that
accident and injury were higher among fullblood Indians. Further, one half of those
individuals involved in vehicular accidents had been arrested at least once for drinking
and were also prone to other social and legal problems. The bulk of this study, however,
was concerned with brief psychological autopsies of three male Sioux drivers killed in
motor vehicle crashes. These drivers were characterized as having problems of adjust-
ment, low self-esteem, failure to achieve, and feelings of a lack of control over their own
lives.

Another study among the Navajo focused solely on motor vehicle accidents. Using
police data from three States and from tribal police, this project produced three
documents - one monograph (Katz and May 1979) and two article/pamphlets (May and
Katz 1979u, b) -that described and analyzed the multivariate nature and epidemiologic
features of both Indian and non-Indian fatal (n = 500) and nonfatal crashes (n = 2,347).
Data were collected on both the Navajo reservation and roads leading to it in 1973-75
Some of the key findings regarding fatal crashes in this study include:

o  Mortality rates per 100 million miles traveled (which control for driving ex-
posure) were higher for Navajos (12.6 per 100 million) than for the State of
Arizona (5.0), New Mexico (6.1), or the U.S. population (3.8).

o  Of all the fatal Indian crashes, 51 percent were single vehicle, 29 percent were
multiple vehicle, and 20 percent were pedestrian.

o  In fatal single vehicle crashes, Navajos were significantly more likely than
non-Indians to be driving a pickup truck, have an invalid license, be younger,
and have been drinking.


YOUTH AND OTHER SPECIAL POPULATIONS

215

o  When comparing Navajo fatal single versus multiple vehicle crashes, single
vehicle drivers were significantly more likely to have been drinking (41 percent
versus 28 percent), less likely to have a valid license, were younger, and single
vehicle fatalities were more likely to happen at any time of day and in the
daylight.

o  Regarding multiple vehicle crashes, the only signifitit difference between
Navajo and non-Indian experience was that Navajos were more likely to be
driving a pickup.

No differences were found between fatal Indian .and non-Indian crashes regarding
number of persons in the vehicle, condition of vehicle, or environmental conditions
(weather, light, hour of day, weekend, or season).

In nonfatal crashes, weather, road, and environment were more important. Therefore,
this study pointed heavily, but not exclusively, to the individual characteristics (e.g.,
youth, alcohol, license) of the Indian driver. Local belief at the time of the study
maintained that the roads, environmental conditions, vehicles in poor condition, and
driving greater distances were the major determinants of serious crashes. In the study,
however, the rates per hundred million miles traveled and other comparisons did not
support these beliefs, but rather showed that most fatal crashes were related to driver
characteristics.

In addition to the specific findings of the Katz and May (1979) Navajo studies, general
conclusions were reached as to why Indians have a higher rate of motor vehicle death
than others in the United States or surrounding areas.

First of all rurality is a key factor. As Waller (1967) and Wailer et al. (1964)
have shown, accidents in rural areas produce four times the amount of death
than urban accidents of similar severity. Since the Navajo reservation is
possibly the most remote area in the U.S. with a very sparse population
(150,000 to an area the size of West Virginia), high rates of death are to be
expected. The U.S. in general is about 70 percent urban and had a rate of
death of 4.20 per 100 million miles traveled in 1973. One would, then, expect
the total rate for the Navajo reservation (approximately lo-20 percent urban)
to be approximately 12 per 100 million overall and 16 or higher on many
roads. Thus lack of access to medical care due to remoteness and time and
distance to medical care influence the fatalities greatly. . . .

A second major factor in the high rates is the age of the population. Young
persons in the U.S. are frequently involved in and killed in accidents. To a
similar extent Navajo under 30 years of age are also highly involved in
accidents, particularly, single car accidents. The difference, which has the
effect of raising Navajo rates, is the sheer number of people who are under
30 years old. While only 50 percent of the U.S. population is under 30, 70
percent of the Navajo population is under 30. Thus, unless age specific rates
are calculated, crude rates and rates per 100 million miles will be higher for
the Navajo population. The preponderance of young Navajo results in a high
risk population.

A third factor in the high rates is alcohol and the drinking patterns. Younger
persons are more likely to be experimenters with alcohol in the U.S. in
general and this is also true with the Navajo. Most Navajo who drink are
under 45 years of age (Levy and Kunitz 1974) and the modal drinking style
of those who do is sporadic, binge drinking (Ferguson 1968). This style of
drinking, coupled with prohibition, is a factor in high accident rates. Under
prohibition, with most cultural and ethnic groups, drinking styles emphasize
hurried drinking and intoxication (see May 1976). The Navajo are no excep-
tion and drinking in border areas such as Gallup, Farmington, Flagstaff, etc.,


216                                                        BACKGROUND PAPERS

takes this form. After drinking, however, a long drive or walk home of 10 to
over 100 miles becomes a more difficult task, especially on two-lane roads.
Thus, the higher rates of motor vehicle and pedestrian accidents and alcohol
relatedness among the Navajo are influenced by alcohol and particularly the
laws of prohibition on the reservation.

A final variable in explaining high accident rates is culture. As many authors
have pointed out, cultural variables are important in many areas of deviance
or "social pathology" (Levy and Kunitz 1974), and for accidents this is true
(Hackenberg and Gallagher 1972; Selzer and Viokur 1974). Nevertheless
the nature of Navajo acculturation and assimilation should not be ignored.
Acculturation and assimilation of cultural items are slow processes and are
never uniform. Presently in Navajo society, acculturation has occurred in that
the motor vehicle (particularly the pickup truck) has been adopted and is
used with great vigor. Assimilation, on the other hand, the internalizing of
values from another culture, is a much slower process and has not occurred
among many Navajo with regard to motor vehicle use. The Navajo use
pickups in a fashion which is strongly based in traditional values. One very
prominent value surrounding accidents is fatalism. . . . Related to this is a
lack of adoption of safe or defensive driving, many people disregard licensing
procedures and laws, and seat belts are rarely used. This is not to deny that
overall U.S. and European populations could be accused of these behaviors,
but the degree is different. Due to differences in culture and world view,
fewer Navajo have adopted safe practices for motor vehicles than some other
groups in the U.S. population. (Katz and May 1979)

Alcohol Involvement

Because of drunk-Indian stereotypes and other folk beliefs about the West, a strong
relationship between alcohol and motor vehicle accidents among Indians has been
assumed by many (see May and Smith 1988; May 1982). The fact is, however, that there
is little concrete evidence in print to document the true extent of alcohol involvement in
motor vehicle accidents involving Indians and Alaska Natives. There is, however, enough
evidence to generalize here.

First of all, a little known fact is that Indian drinking behavior is highly variable from
one tribe to the next. In some tribes, more youth and adults drink than the general
population but in others, fewer individuals drink. For example, among the Navajo in 1970
only 31 percent of adults drank at all, and many individuals in the over-40 age categories
were abstainers (Levy and Kunitz 1974). By 1985, some increase had been registered in
Navajo drinking prevalence, which was then believed to be as high as 52 percent, but the
prevalence was still lower than the 67 percent reported in the overall U.S. population
(May and Smith 1988). The point here is that Indian drinking patterns arehighlyvariable
from one tribe to the next, and drinking styles are also unique and may not always
conform to popular notions put forth by mainstream stereotypes. Particular drinking
styles, however, are important to consider when studying and intervening with the
unintentional injury complex.

Going back to earlier accident studies, Schmitt et al. (1966) in British Columbia used
hospital insurance data to find that 28 percent of the 300 accidental (of all types) native
deaths in their study were alcohol-related. Further, they found that among those over 20
years of age, 39 percent of the male accident deaths and 49 percent of the female deaths
were alcohol-related. Alcohol intoxication, they concluded, was an important factor in
native driving and transport accidents.


YOUTH AND OTHER SPECIAL POPULATIONS

217

Other studies dealing with all types of accidents have found and/or speculated upon
a native alcohol and injury relationship. Boyd et al. (1968) found that 12 percent of all
motor vehicle accidents and drownings in Alaska were alcohol-related. Wii (1969)
found a significant correlation between Sioux accident victims and alcohol arrest. Brown
et al. (1970) listed alcohol as the most influential factor in Navajo motor vehicle
accidents, but provided no data. Omran and Laughlin (1972) reported that of 10 motor
vehicle accident deaths studied among the Navajo, 5 were alcohol-related. Among the
Papago, both Hackenberg and Gallagher (1972) and Stull(l973,1977) related alcohol
consumption to modernization and acculturation stress, and these in turn combined to
increase injury rates. Katz and May (1979) found that police records baked alcohol to
41 percent of the Indian drivers in single vehicle crashes, 46 percent  of multiple
vehicle crashes, and driver or pedestrians in 44 percent 4 of pedestrian fatalities.

With all of these studies, however, the role of alcohol was, no doubt, underestimated,
for police reports in the 197Os, hospital and clinic records, and death records seldom  .,
reported the true magnitude of the problem (Zylman and Bacon 1968). Further, police
data might be biased in that Indians might be tested more frequently than others as
Westermeyer and Brantner (1972) found, or recording of alcohol involvement on Indians
may be more common or acceptable in terms of societal norms. For example, in the
Navajo studies (Katz and May 1979), the Indian alcohol involvement was 2.8 times higher
in single vehicle crashes, 1.7 times higher in multiplevehicle crashes, and 1.3 times higher
in pedestrian fatalities than non-Indian events. Maybe this was the actual magnitude, but
underreporting and selective reporting of all alcohol involvement must be considered as
a possibility with all these studies.

Some investigators used more accurate or valid data sources. In an intensive autopsy
study of sudden death in British Columbia, 43 of the subjects were Native (Cutler and
Morrison 1971). Of the accidents, suicides, and homicides of these Indians, 54.8 percent
involved BACs at or above to the legal intoxication limit (0.08) in Canada. The authors
concluded that the "high rate of Indian sudden death is primarily the result of occasional,
but intense intoxication in high risk situations" (Cutler and Morrison 1971).

In another study of sudden death, `the Kenora (Ontario) Planning Council found,
through inquiry of knowledgeable parties, that alcohol was a factor in more than 70
percent of the nearly 200 sudden Indian deaths, including even 50 percent of the victims
of homicide. This report concluded that the 70 percent may be an underestimate. In
Manitoba, Trott et al. (1981) found sudden death to be more common among Native
Indians, with 52.5 to 54.3 percent of the accidental deaths alcohol- and/or drug-related.
These data, however, included many non-Indians as well as Indians. Jarvis and Boldt
(1982) studied the deaths of Alberta Province Indians in a prospective fashion, using
interviewers in 35 native communities. Alcohol was involved in 70.6 percent of all motor
vehicle accident deaths as reported by informants immediately following a death. The
four Canadian studies have increased our knowledge considerably, but the question
remains, what about Indians in the United States?

In New Mexico, the medical investigator system and the State laboratories are
centralized in both authority and in operation. Blood and breath testing are strictly
overseen by these centralized bureaus, so the quality of information is good. Since more
than 8 percent of the State is populated by American Indians, and several counties are
heavily Indian, one might closely examine the alcohol and accident situation among
Indians using routine data. Realizing the real risk of committing the ecological correla-
tion fallacy in examining county data without linking it to individuals (Robinson 1950),

3  Includes data on all drivers of both vehicles, so that if one or the other or both were cited as intoxicated,
it was counted as an alcohol-related crash.

4  The pedestrian involvement included 22 percent of the drivers (excluding the 255percent hit-and-run
who maywell have been intoxicated) and 22 percent of the pedestrians.


218

Table 6. Motor vehicle accidents and alcohol in three selected counties in
    New Mexico, 1982-84

          Percent Indian      Alcohol involvement (percent)
County      (major tribe)       Fatal accidents    Severe accidents*

A          66 (Navajo)           78.0            33.1

B          33 (Navajo)           78.0            28.8

C          27 (Pueblo)           73.7            24.2

Entire State      8                 63.7            21.2

*Severe accidents are those that involve injury or death.
Source: New Mexico Traffic Safety Bureau 1984 and New Medco vital Statistics, 1984.

table 6 shows that serious accidents are slightly more alcohol-related in those counties
with a substantial Indian population. County A, which is 66 percent Indian, is probabl!
the best comparison. In the 3 years covered, 1982 through 1984,78 percent of all fatal
accidents and 33 percent of all serious accidents were alcohol-involved as measured by
blood or breath alcohol.

One final statistic from New Mexico is also available. Several studies, particularly in
Canada, referred to one particular Indian pattern or style of drinking-binge drinking-
that is characterized by rapid consumption and leads to high blood alcohol levels.
Autopsy data examining alcohol levels in blood and vitreous fluid samples from 253
accidental deaths in New Mexico indicated that Indian crash victims had high blood-
alcohol levels. The 68 Indian crash victims autopsied in 1986 who were positive for
alcohol had a mean blood alcohol level of 0.201, compared to 0.183 for Hispanic positives
and 0.126 for comparable non-Hispanic whites `(Guerin, in process).

Solutions and Partial Solutions

Given all the data that indicate that alcohol and driving are tragically linked in
American Indian populations, with more severe consequences than among other groups
in the United States, a comprehensive, multivariate prevention strategy must be planned
and launched. Because the available information is not as complete as public health
professionals might desire, more research to further specify the relationship between
alcohol, injury, and Indians is needed in the future. However, current knowledge is
clearly adequate for a solid beginning in prevention and intervention.

Below, general trends and/or ideas in prevention are highlighted, using as a guide the
usual scheme of primary, secondary, and tertiary levels of prevention. Primary preven-
tion attacks root causes of a problem in its basic environmental, social, cultural, and
political structure. Secondary prevention is directed at eliminating the onset of a problem
and/or taking action in the early stages of manifestation. Tertiary prevention seeks to
provide curative and remedial action to deal with and minimize the illness, injury, and
other negative outcomes of a major health problem.

5  The legal intoxication level in New Mexico is 0.10.


YOUTH AND OTHER SPECIAL POPULATIONS

Primary Prevention

219

The so&I, economic, and educational status of many American Indians can undoubt-
edlybe improved to the overall benefit of many tribes and individuals alike (Dozier 1966).
As several authors have pointed out, many Indian groups are undergoing epidemiologic
transition (Omran 1971; Kunitz 1983; Broudy and May 1983), and this movement from
traditional to modern is related to the high accident rates now prevalent, particularly on
Western reservations (Hackenberg and Gallagher 1972; Stulll972,1977,1973; Omran
and Laughlin 1972). As Omran and Laughlin (1972) pointed out, people in transition
"exhibit many insecurities and inabilities to cope with their changing way of life," and
this results in the accident and violence complex among particular segments of Indian
societies. Therefore, assisting Indian groups and individuals in their efforts at economic,
social and educational enhancement will ultimately benefit many areas, including alcohol
abuse and accident and violence rates.

In the Native American Adolescent Injury Prevention Program (unpublished data)   :
run in the rural areas of New Mexico, rural Indian youth were found to have the lowest
scores on social psychological scales, such as locus of control and self-esteem, that are
predictive of accident susceptibility. However, these scores are highly influenced by the
educational level of the parents of the Indian children (see also Liban and Smart 1982).
Indian children from families of high educational attainment not only score better on
social psychological scales, but they aIso report less substance abuse and risk-taking
behavior common to accidents. Therefore, broad social enhancement, such as education,
which may strengthen the family, also enhances the individual in ways that should reduce
the accident rate over an extended period (Mail 1985; Dozier 1966).

Other primary prevention is being, and can be further, pursued. The HIS, Office of
Environmental Health, is now working at national, State, and local levels to improve
roads, encourage seatbelt use, and promote injury control and state-of-the-art highway
safety all over the Indian lands of the Nation. It appears likely that some of this road
improFment has already begun to reduce the accident fatality rates in some reservation
areas.

A final area of primary prevention concerns tribal and community law and policy.
Tribes have great lega power to control alcohol policy, taxation, and enforcement on
their reservations and communities. More than 60 percent have retained prohibition but
are reluctant to enforce strong penalties to support it (May 1975,1976,1977; May and
Smith 1988). Tribes need to strictly examine and change alcohol and social policies so
that they influence new norms and guidelines of behavior regarding alcohol and sub-
stance use, particularly for the minority who abuse alcohol. Whether the policy adopted
is a more strict, comprehensive, and effective approach to prohibition, or whether it is
legalization that is comprehensive and specific in its prescriptive qualities, a new, more
explicit set of policies is needed to guide behavior (see May and Smith 1988; May 1986).

Secondary Prevention

Alcohol and heahh education with youth must continue and be further expanded.
Recent years have seen a great increase in this area, but more has yet to be done. Youth
need to be educated, not only about alcohol abuse, but also taught in a social learning
mode that emphasizes self-esteem enhancement, values clarification, coping, and prob-
lem-solving skills (Bach and Bornstein 1981; Winfree and Griffiths 1983; May 1986).

6  For example, the motorvehicle accident death rate for the Crow and Northern Cheyenne Indians appears
to have declined in 19f31-8.5 (IHS unpublished statistics) from what it was in 1959-75 (see May 1976). Some
of this reduction may be due to the construction of Interstate Highway 25 from Crow Agency to Billings,
Montana, for the old road was a notoriously narrow, hilly, winding, and dangerous stretch of more than 60
miles.


220

BACKGROUND PAPERS

Health education with adult Indians should take a different approach. Most adult
Indians are well aware of the health implications of alcohol abuse but could benefit
greatly from education and exposure to public health principles and the possibilities of
public policy for alcohol-abuse and accident prevention (May and Smith 1988).

A continuing and open forum on alcohol policy needs to be pursued, and widespread
public education will feed this. Policies, laws, and ~paigns that are specific to accident
and alcohol abuse hold great promise for a tribe. Positive action in this area is now
beginning with safety campaigns, but routiniig the dialog and concern regarding these
issues is necessary. Recently, for example, the Navajo Tribe took a major step in this
direction by passing a mandatory seatbelt law for theii reservation, the largest in the
United States (Landon 1988). The enforcement of such laws and the perception of sure
and swift penalties must be emphasized as well (Ross 1982).

Safety programs such as infant car-seat purchase and rental have been promoted by
the IHS and a number of tribes. Generally, these programs seem to be well received, for
most Indians are particularly responsive to child health and weifare issues. The
programs, however, need to be expanded to all babies of all tribes. Targeting youth in
safety programs may produce a whole new generation of Indian seatbelt users. Currently,
surveys of the New Mexico Native American Adolescent Injury Prevention Program
(unpublished data) indicate that young Indian males have the lowest seatbelt use of any
group in New Mexico. But these data also indicate that increasing seatbelt use is the most
common and significant change in behavior of the injury prevention program.

Tertiary Prevention

Until the middle 197Os, few reservations had any emergency medical resources such
as ambulances and trained and employed emergency medical technicians. Now, most
reservations and many rural Indian communities have some level of emergency medical
services, and these small programs may well have had an influence on the drop in Indian
motor vehicle crash fatality rates registered since 1976. However, these services greatly
need to be continually upgraded, improved, and expanded so that more accident victims
can be saved and/or their injuries minimized, and the high disability rate of Indians can
be lowered. Further, emergency room capabilities need to be enhanced, so that accident
victims receive state-of-the-art trauma care whenever possible. New Mexico has only one
level-one trauma center and some western States have none.

The most desirable tertiary prevention would be improved interdiction of drunk
drivers before they cause crashes and expanded alcohol treatment capabilities. Tribal,
Bureau of Indian Affairs, local sheriff, and police forces in Indian country are notoriously
understaffed and in need of further assistance of all kinds. Increasing their training and,
particularly, their manpower and resources should be a priority. Further, if the laws and
policies regarding alcohol and driving under the influence (primary and secondary
prevention) were improved so that the police efforts were facilitated, then enforcement
would be greatly aided. For example, on many "dry" reservations, bootlegging is so
common and institutionalized that the tribal police can tell you who sells and how much
it costs, and can even estimate their income. But to eliminate the practice would require
considerably more manpower, time, and new, stronger,
currently exist on reservations and in most western States. yd more explicit laws than

Alcohol treatment programs in Indian country are characterized by too few resources
and capabilities of all kinds (manpower, money, level of training for the counselors, and

7  On the Naajo reservation, for example, the maximum penally for bootlegging is 6 months in jail and a
SXlOfine.Policereport, however, that tochargeapersonwith bootleggingtakesanumberofofficermanpower
days to build a case, search, collect evidence, and bring it to court. Seldom, however, is any major jail time
spent by the accused, and the maximum fine for conviction ($500) is little more than an overhead expense in
the cost of doing a profitable business.


YOUTH AND OTHER SPECIAL POPULATIONS

221

treatment regimens). A total upgrading and new commitment is needed in this arena, so
that all first-time driving-under-the-influence offenders can be screened and placed in
an appropriate treatment modality (May 1986).

Conclusion

In summary, then, the problem of alcohol abuse and accidents exists in many Indian
communities. It takes a tremendously large toll in terms of injury and lives lost. Since it
has multiple causes and related factors, its solution must also be multivariate. Any
program designed to reduce alcohol-related motor vehicle accidents among Indians
must be comprehensive and must address both general conditions and specific preven-
tion and intervention tasks.

REFERENCES

Bach, P.J., and Bornstein, P.H. A social learning rationaleand suggestions for behavioral treatment
   with American Indian alcohol abusers.Addictive Behaviors 6:75&U, 1981.
Boyd, D.L.; Maynard, J.E.; and Holmes, L.M. Accident mortality in Alaska.Archives ofEnviron-
   mental Health 17: 10 1 - 106, 1968.

Brod, R.L., and McQuiston, J.M. American Indian adult education and literacy: The first national
   survey. Journal ofAmerican Indian Education l:l-16, 1983.
Broudy, D.W., and May, PA. Demographic and epidemiologic transition among the Navajo
   Indians. Social Biology 30:1-16, 1983.

Brown, R.C.; Gurunanjappa, B.S.; Hawk;RJ.; and Bitsuie, D. The epidemiology of accidents
   among the Navajo Indians. Public Health Reports 85881-888, 1970.
Carr, B., and Lee, ES. Navajo tribal mortality: A life table analysis of the leading causes of death.
   Social Biology 25:279-287, 1978.

Cutler, R., and Morrison, N. Sudden Death: A Study of Charactetitics of Victims and Events
   Leading to Sudded Death in British Cohanbia Wth Primary Emphasis on ApparentAlcohol
   Involvement and Indian Sudden Deaths. Vancouver, BC: Alcoholism Foundation of
   British Columbia, 1971.

Dozier, E.P. Problem drinking among American Indians: The role of so&cultural deprivation.
   Quarterly Journal of Studies on Alcohol 27:72-87, 1966.
Ferguson, EN. Navajo drinking: Some tentative hypotheses. Human Organization 27159-167,
    1968.

Guerin, P.E. "Alcohol Related Traffic Fatalities in New Mexico." MA. thesis, Department of
   Sociology, University of New Mexico, in process,
Hackenberg, R.A., and Gallagher, M.M. The costs of cultural change: Accident injury and
   modernization among the Papago Indians. Human Organization 31(2):211-226, 1972.
Indian Health Service. Chart Book Series, 1988 edition. Washington, DC: Supt. of Dots., U.S.
   Govt. Print. Off., 1988.

Jarvis, G.K, and Boldt, M. Death styles among Canada's Indians. Social Science and Medicine
   16( 14): 1345-52, 1982.

Katz, P.S., and May, PA. Motor VehicleAccidents on the Navajo Reservation: Z973-1975. Window
   Rock, AZ: The Navajo Health Authority, 1979.
Kenora Social Planning Council. WWe People Sleep: Sudden Deaths in the Kenora Area. Kenora,
   Ontario: Grand Treaty Council, No. 3, 1973.
Kunitz, SJ. Disease Change and the Role of Medicine: The Navajo E@?rience. Berkeley, CA:
   University of California Press, 1983.

Landon, S. Navajos pass reservation seat belt law. Albuquerque Journal July 31, 1988.
Levy, J.E., and Kunitz, SJ. Indian Drinking. New York: Wiley Interscience, 1974.
Liban, C.B., and Smart, R.G. Drinking and drug use among Ontario Indian students. Drug and
   Alcohol Dependence 9:161-171,1982.

Mail, P.D. Closing the circle: A prevention model for Indian communities with alcohol problems.
   ZHS Primary Care Provider 10~2-5, 1985.


222

BACKGROUND PAPERS

May, PA Arrests, alcohol and alcohol legalization among an American Indian tribe. PZuins
   Anu'tropoZogist 20(68):129-134, 1975.

May, PA. "Alcohol Legalization and Native Americans: A Sociological Inquiry". Ph.D. disserta-
   tion, University of Montana, 1976.

May, PA. Alcohol beverage control: A survey of tribal alcohol statutes. American Indian Luw
   Review 5:217-228,1977.

May, P.A Substance abuse and American Indians: Prevalence and susceptibility. Infern~bnaZ
   Journal of the Addictions 17: 11851209, 1982.
May, PA Alcohol and drug misuse prevention programs for American Indians: Needs and
   opportunities. Journal of Studies on Alcohol 47(3):187-195,1986.
May, PA. The health status of Indian children: Problems and prevention in early life. In: Manson,
   S., and Dinges, N., eds. Health and Behavior: A Research Agenda for American Indians
   andAlaska Natives. Denver, CO: University of Colorado Health Sciences University Press,
    1988.

May, P.A, and Morigeau, G. Unpublished statistics, University of Montana, 1976.
May, P.A, and Katz, P.S. Motor Vehicle Accidents on the Navajo Reservation, 1973-1975: Health
   Planning Swnmary. Window Rock, Arizona: Navajo Health Authority, 1979a.
May, P.A, and Katz, P.S. Motor Vehicle Accidents on the Navajo Reservation, 1973-1975: Public
   Information Pamphlet. Window Rock, Arizona: Navajo Health Authority, 1979b.
May, P.A., and Smith, M.B. Some Navajo Indian opinions about alcohol abuse and prohibition: A
   survey and recommendations for policy. Journal of Stidies on Alcohol 49:324-334, 1988.
Native American Adolescent Injury Prevention Program. Unpublished program data. Health and
   Environment Department, Public Health Division. A SPRANS-funded project. Santa Fe,
    NM.

New Mexico Traffic Safety Bureau. Diving While Znroticured in New Mexico. Santa Fe: Depart-
   ment of Transportation, 1984.

Omran, AR. The epidemiologic transition. Milbank Memorial Fund Quarterly 49509-538, 1971.
Omran A.R., and Laughlin, B. An epidemiologic study of accidents among the Navajo Indians.
   Journal of Esyptian MedicalAssociation 55: l-22, 1972.
Passcll, J.S., Provisional evaluation of the 1970 Census count of American Indians. Demography
   13(3):397-409,1976.

Passell, J.S., and Berman, PA. Quality of 1980 census data for American Indians. Social BioZogv
   33(3-4):163-182, 1986.

Robertson, L.S. "Epidemiological Assessment of the Contributing Factors of Injury Mortality and
   Morbidity Among Native Americans." Manuscript. New Haven, CT: Yale University,
    1985.

Robinson, W.S. Ecological correlations and the behavior of individuals. American Sociological
   Review 15(3):351-357, 1950.

Ross, H.L. Deterring the Drinking Driver. Lexington, MA Heath, 1982.
Schmitt, N.; Hole, L.W.; and Barclay, W.S. Accidental deaths among British Columbia Indians.
   Canadian Medical Association Journal 94228234, 1966.
Seizer, M., and Vinokur, A. Life events, subjective stress, and traffic accidents.American Journal
   of Psychiahy 13 1903906, 1974.

State of Montana. Montana VifuZSfutistics, 1982edition. Helena, MT: State Department of Health
   and Environmental Sciences, 1983.

State of Montana.Monrana I'imlSrarisrics, 1983 edition. Helena, MT: State Department of Health
   and Environmental Sciences, 1984.

State of Montana.Montana VTtaZStatistics, 1984edition. Helena, MT: State Department ofHealth
   and Environmental Sciences, 1985.

State of Montana.Montana ViralSWstics, 1985 edition. Helena, MT: State Department of Health
   and Environmental Sciences, 1986.

State of Montana.Monrana VitalStatistics, 1986edition. Helena, MT: State Department of Health
   and Environmental Sciences, 1988.

State of New Mexico. NewMexico Selected Health Statistics, 1978Annual Report. Santa Fe: Health
   and Environment, 1980.

State of New Mexico. New M&co Selected Health Statistics, 1986AnnuaZReport. Santa Fe: Health
   and Environment, 1988.

Stull, D.D. Victims of modernization: Accident rates and Papago Indian adjustment. Human
   Organization 31(2):227-240, 1972.


YOUTH AND OTHER SPECIAL POPULATIONS                                            223

Stull, D.D. "Modernization and Symptoms of Stress: Attitudes, Accidents and Alcohol Use Among
   Urban Papago Indians." Ph.D. dissertation, University of Colorado, 1973.
Stull, D.D. New data on accident victim rates among Papago Indians: The urban case. Human
   Organization 36(4):395-398, 1977.

Tsai, S.P.; Lee, E.S.; and Hardy;RJ. The effect of a reduction in leading causes of death: Potential
   gains in life expectancy. American Journal of Public Health 68(10):9&i-971, 1978.
Trott, L.; Barnes, G.; and Dumoff, R. Ethnicity and other demographic characteristics as predic-
   tors of sudden drug-related deaths. Journal of Studies on Alcohol 42:564-78, 1981.
U.S. Bureau of Census. American Indian Areas and Alaska Native Kllages, 1980. Supplementary
   Report (PCXO-51-13). Washington, DC: Supt. of Dots., U.S. Govt. Print. Off., 19%.
U.S. Bureau of Census. A Statistical Profile of the American Zndian Population: 1980 Census.
   Census Fact Sheet. Washington DC: Supt. of Dots., U.S. Govt. Print. Off., 19846.
U.S. Congress, Office of Technology Assessment. Indian Health Care. OTA-H-290. Washington,
   DC: Supt. of Dots., U.S. Govt. Print. Off., 1986.
Wager, J.A Control of accidents in rural areas. Journal of the American Medical Association
   201(3):94-98, 1967.

Waller, J.; Curran, R.; and Noyes, F. Traffic deaths: A preliminary study of urban and rural   '

   fatalities in California. California Medicine 101:272-276, 1964.
Westermeyer, J., and Brantner, J. Violent death and alcohol use among the Chippewa in Min-
   nesota. Minnesota Medicine 55:749-752, 1972.
Wills, J.E. Psychological problems of the Sioux Indians resulting in the accident phenomena. Pine
   Ridge Research Bulletin 84963, 1969.

Winfree, L. T., and Grifiiths, C.T. Youth at risk: Marijuana use among Native American and
   Caucasian youths. International Journal of the Addictions 18:53-70, 1983.
Zylman, R., and Bacon, S.D. Police records and accidents involving alcohol. Qrlartedy Journal of
   Studies onAlcohol Supplement 4: 178-211, 1968.


Youth and Other Special Populations

Drunk Driving Among Blacks
   and Hispanics

   Jan M. Howard, Ph.D., Elsie D. Taylor,
H. Laurence Ross, Ph.D., and Mary L. Ganikos, Ph.D.

Prevention Research Branch, National InshMe on Alcohol Abuse a&d Alcoholism

Blacks comprise about 12 percent of the U.S. population, and Hispanics about 8
percent (Bureau of Census 1987). Research suggests that problem drinking and asso-
ciated mortality rates are higher in these two minority groups than in the general public
(Herd 1985; NIAAA 198&z). Yet, few studies have investigated the issue of drunk driving
among blacks and Hispanics. This chapter summarizes relevant characteristics of these
two groups, their drinking practices, and available information on their drunk driving
behavior.

Demographic Characteristics

Such factors as age, socioeconomic status, and rural/urban distribution may have
significant effects on overall consumption patterns and drinking and driving behavior.
Thus, the alcohol problems noted among blacks and Hispanics may be partially a
function of their particular demographic profiles.

On average, the black and Hispanic populations tend to be younger than whites and
underrepresented among persons 65 years of age and older (Bureau of Census 1987).
For both blacks and Hispanics, socioeconomic status (as measured by income and
education) is significantly lower than that for whites (Bureau of Census 1987). Among
civilians age 16 and older, 54 percent of blacks are employed, versus 59 percent of
Hispanics and 62 percent ofwhites (Bureau of Census 1987). Compared to whites, blacks
and Hispanics are much less likely to live in rural areas (Bureau of Census 1984) where
driving is a necessity.

The Hispanic population in the United States is a very heterogeneous group, with
diverse national and sociocultural backgrounds (NIAAA 1987). According to the 1980
census, approximately 60 percent of the U.S. Hispanic population is of Mexican origin;
15 percent are considered Puerto Rican, 6 percent Cuban, and the remaining 20 percent
are linked to other countries, including those in Central and South America (NIAAA
1982a; NHTSA 1987; DHHS 19866). The black population of the United States is ah.0
heterogeneous, reflecting different cultural, regional, and socioeconomic perspectives.

Consumption Patterns

Blacks

The data on drinking practices among blacks are somewhat inconsistent and difficult
to interpret. Blacks are at high risk for alcohol-related medical problems, especially liver


YOUTH AND OTHER SPECIAL POPULATIONS

225

cirrhosis and esophageal cancer (NIAAA 1987), and their cirrhosis mortality rate is
nearly twice that for whites (Herd 1985). Yet, blacks of both sexes report higher
abstention rates than whites; and among drinkers, black men are less likely than white
men to drink heavily (NIAAA 1987). Among female drinkers, the pattern is reversed;
black women are more likely than white women to drink heavily (NIAAA 1987).

The relationship between age and drinking practices appears to differ by race.
Alcohol consumption among white males age 18-29 is high, with a decline after age 30
(NIAAA 1987). Consumption among blacks, however, is relatively low in the 18-29 age
group, rises dramatically among those in their 3Os, and declines after age 39 (NIAAA
1987; NIAAA 1982b). According to a recent report prepared for the National Highway
Traffic Safety Administration (NHTSA), black males in younger age groups "are at
substantially less risk for high rates of heavy drinking than younger whites" (NHTSA
1987). Moreover, studies of adolescents consistently show lower rates of problem
drinking and related arrests among blacks than whites (DHHS 19%). On the other
hand, data suggest that blacks enter alcohol treatment programs at younger ages than
whites, the peak age for blacks being35-44 compared to 45-54 for whites (NIAAA 1987).

The relationship between income level and drinking practices also appears to vary by
race. For white men, increased income has been associated with increased heavy
drinking (NIAAA 1987; Herd 1985). For black men, the reverse is true; increased income
has been associated with decreased heavy consumption (NIAAA 1987; Herd 1985).'
With respect to women, however, the two races are similar: increased income is as-
sociated with more frequent (as opposed to heavy) drinking (NIAAA 1987).

Drinking practices among blacks may differ by geographic region. In the Northeast,
for example, the proportion of blacks in alcohol treatment is reported to be two to three
times higher than their proportion of the regional population (NIAAA 1987; DHHS
1986u). But in the interior South, the number of blacks in treatment is generally
proportional to their representation in the population (NIAAA 1987; DHHS 198&z).

Hispanics

Compared to the general U.S. population, Hispanics in the aggregate have relatively
high rates of heavy drinking and alcohol problems (DHHS 19866). Yet, differences can
be observed within the Hispanic population. As an example, Hispanic men in this country
have relatively high rates of alcohol use and abuse (NIAAA 1987) as well as cirrhosis
mortality (NIAAA 1982a), while Hispanic women show high rates of abstention
(NIAAA 1987). As is true for whites in general, consumption for both sexes seems to
increase with increased income and educational levels (NIAAA 1987; Wilson and
Williams 1983). With respect to age-related drinking problems, Hispanics are more
similar to blacks than to whites. Whereas drinking problems among whites decline
abruptly from their 20s to 3Os, for Hispanics (and blacks) problems increase from their
20s to 30s and then decline gradually in their 40s (NHTSA 1987). First-generation
American-born Hispanic men tend to drink more heavily than Hispanic-American men
born abroad (NIAAA 1987).

Mexican Americans appear to consume more alcohol and report more drinking
problems than the other Hispanic groups (Caetano 1988). The rate of "frequent high
maximum" drinking is relatively large for Mexican-American women as well as men
(Caetano 1988). Both sexes, however, also show high rates of abstention (NIAAA 1987;
Caetano 1988). Compared to the other Hispanic females, Puerto Rican women have the
lowest abstention rate, but data suggest that they are largely moderate drinkers withvery
few heavy drinkers among them (NIAAA 1987).

1  Yet data from the 1983 National Health Interview Surveyshowsimilar income effects for black and white
males (Wilson and Williams 1983).


226

BACKGROUND PAPERS

Among Hispanic-American men born abroad, Mexican Americans have a low rate
of abstention and a rate of heavy drinking six times that of any other national subgroup
(NIAAA 1987). Conversely, Mexican-American women born abroad have a relatively
high rate of abstention and virtually no heavy drinking (NIAAA 1987).

Drunk Driving Behavior

One of the barriers to obtaining information on drunk driving among racial and ethnic
minorities is the failure of the records system to collect appropriate data. Depending on
the purpose for which drunk-driving information is gathered, ascertaining race and
ethnicity may be deemed unimportant. Political and legal considerations may further
limit the availability of relevant data. Drunk driving is a criminal and civil offense that
can have severe personal consequences for the driver involved, Moreover, the stig-
matization of individuals accused of drunk driving can also taint the groups to which they
belong. Under these circumstances, government authorities may be reluctant to collect
pertinent information on specific ethnic groups, or they may decline to release data that
has been collected.

The use of death certificates to determine the proportion of traffic fatalities at-
tributable to drunk driving grossly underestimates the contribution of alcohol to such
deaths (Dufour et al. 1985). The physician who completes the death certificate may not
be the one who provided medical care to the patient and would not necessarily be aware
of alcohol involvement (Dufour et al. 1985). Another problem is that some physicians
do not recognize the importance of death certificate data for advancing medical and
scientific knowledge and fail to record complete information (Dufour et al. 1985). And
even when they have the full picture, they may wish to protect the deceased person's
family from the stigma and financial liability associated with an alcohol-induced
accident.

A more appropriate national data system for investigating alcohol involvement in
traffic fatalities is the Fatal Accident Reporting System (FARS), which contains detailed
information on the driver, vehicle, and environmental characteristics associated with
each traffic death (Dufour et al. 1984). *Unfortunately, FARS does not include data on
the race of persons involved in these fatal accidents. Death certificates indicate the race
of the deceased, but not FARS. Thus, to generate statistics on racial differences in
alcohol-related traffic deaths in the United States, FARS has been linked with the
Multiple Cause of Death (MCD) data system, which is based on death certificates
(Dufour et al. 1984).

This linkage makes it possible to investigate the effects of race on alcohol-related
traffic fatalities for the country as a whole. With respect to Hispanics, however, missing
data are still a problem, because the majority of States do not currently include the
category "Hispanic" on their death certificates. Beginning in 1989, 10 States will pilot
test a new death certificate that does contain a Hispanic category, and it is hoped that
by 1990, all 50 States will collect such information (personal communication M. Dufour,
NIAA4, January 1989).

Despite these various limitations, important relationships have been observed be-
tween race or ethnicity and drunk driving. Blacks and Hispanics both appear to be at
high risk for alcohol-related driving problems.

2  A FARS accident is one that involves a motorvehicle moving on a roadway customarily open to the public
and resulting in the death of a person (occupant or nonoccupant of thevehicle) within 30 days of the accident
(Dufour et al. 1984).


YOUTH AND OTHER SPECIAL POPULATIONS                                            227

Blacks

The report prepared for NHTSA concluded that blacks are at greater risk than whites
for traffic accidents due to drinking (NHTSA 1987). Germane to thii conclusion is the
Grand Rapids, Michigan study which showed that nonwhite drivers were involved in
proportionally more collisions than whites (Zyhnan 1972; Hyman 1968~). Among those
experiencing collisions, a greater proportion of nonwhites than whites had been drinking,
and the BAC levels for nonwhites were considerably higher than those of whites (Zylman
1972; Hyman 196&r; Cosper and Mozersky 1968). According to Hyman's analysis, the
higher accident vulnerability of the nonwhite males extended across every BAC and
educational category. Even in the control group (who were not involved in accidents),
nonwhites were overrepresented in the high BAC categories.

Linkages between FARS and the Multiple Cause Mortality records were effected for
2,700 Oklahoma residents who died in motor vehicle accidents in the late 1970s (Dufour
et al. 1984). This facilitated the investigation of relationships between race and alcohol
involvement in these deaths. Results indicated that 46 percent of the black deaths and
41 percent of the white deaths were alcohol-related. Alcohol involvement was deter-
mined by BAC testing for 91 percent of the blacks and 78 percent of the whites. In the
remaining cases, it was determined by the judgment of the investigating officer. A much
stronger relationship between race and alcohol involvement in fatalities was reported by
Waller and his colleagues (1969). They found that 76 percent of black drivers killed in
traffic crashes in California had been drinking, compared to only 56 percent of whites.
Moreover, 53 percent of the blacks had BACs above a level of 0.15 percent compared
to only 34 percent of the whites.

As recently as 1973, the drunk-driving arrest rate for black adults in the United States
was nearly twice as high as that for whites, but since then the two rates have converged
(Herd 1985). Thus, in 1981 the DUI arrest rate among persons 18 years of age and older
was 951 per 100,000 population for blacks and 917 for whites (Caetano 1984). And for
persons under 18 years of age, the blacks actually showed a much lower DUI arrest rate
than the whites-6.5 arrests per 100,000 population for blacks compared to 47.7 for
whites (Caetano 1984).

Further data on arrests come from studies in specific localities. In a 1968 report, black
males in Columbus, Ohio were twice as likely to be arrested for driving while intoxicated
as were other men in the 20-64 age range (Hyman 1968b). But over the 1972-75 period,
Rabow and Watts (1982) found no significant correlation between the percentage of
black households in 51 California counties and arrest rates for misdemeanor or felony
drunk driving.

A recent analysis of recidivism patterns in Mississippi (Wells-Parker et al. 1988;
Anderson personal communication 1988) suggests that blacks in that particular State
are at higher risk of being rearrested for drunk driving than whites. The study found that
61 percent of black offenders under age 25 and 50 percent over age 25 were rearrested
for DUI during the 6- to 9-year tracking period beginning in 1976. Recidivism rates for
whites in the same age groups were 46 percent and 41 percent, respectively. When the
investigators controlled for other offender characteristics such as age, level of education,
and severity of drinking problem, the blacks were approximately 1.4 times more likely to
recidivate than the whites.

For reasons that are unclear, limited survey data indicate that blacks are less likely to
report driving while drunk than are whites (MAAA 1987; Herd 1985). Among men, the
reported rate for whites is more than two and a half times higher than that for blacks.
And among women, the white rate is more than five times higher than the black rate


228

BACKGROUND PAPERS

(Herd 1985). 3 The possible influence of differential car ownership on these relation-
ships has not been discussed.

Hispanics

Caetano's analysis of FBI statistics for 1981 indicated that among persons 18 years of
age and older, the arrest rate for driving under the influence was more than twice as high
for Hispanics as non-Hispanics (Caetano 1984). Specifically, the rate per 100,000
population was 1,712.2 for Hispanics and 742.6 for.non-Hispanics. Yet, the DUI arrest
rate among persons younger than 18 years of age was only slightly higher for Hispanics
than non-Hispanics (39.8 per 100,000 population compared to342 (Caetano 1984)). An
examination of lotal arrests for Hispanics and non-Hispanics in the 18-plus age range
showed that 19 percent of the Hispanic arrests were for driving under the influence,
compared to 17 percent of the non-Hispanic arrests (Caetano 1984).
                                                   I
Studies of California populations support Caetano's finding that Hispanic arrests for

drunk driving are relatively high. Hyman (1968b) reported an overrepresentation of
Spanish surnames among persons arrested for drunk driving in Santa Clara County.
After controlling for urbanization and income, Rabow and Watts found a significant
correlation (.42) between misdemeanor arrests for drunk driving and the percentage of
Spanish Americans in 51 California counties (Rabow and Watts 1982). However, there
was no significant correlation for felony drunk-driving arrests. Consistent with these
findings are three other California studies summarized by Caetano (DHHS 1986Ir). All
showed an overrepresentation of Hispanics among arrestees for drunk driving (also see
NIAAA 1982u).

In addition, several studies indicated that Hispanics are disproportionately involved
in alcohol-induced crashes. During the 197Os, May and Baker (1974) found an over-
representation of Hispanic drivers in alcohol-related traffic accidents in New Mexico,
and Alcocer reported that the rate of traffic accidents resulting in injuries or fatalities
was higher for Hispanic than non-Hispanic neighborhoods of Los Angeles (DHHS
1986b). Moreover, a higher proportion of the Hispanics than non-Hispanics who had
been arrested- for DWI in Hyman's Santa Clara study had been involved in accidents
(Hyman 1968b; Hyman et al. 1972). The BAC levels also tended to be higher for the
Hispanic than non-Hispanic arrestees (Hyman 1968b).

Interpretation

Drunk driving can be measured directly through roadside surveys, including breath-
alcohol tests of drivers. It is indirectly measured by crashes ("accidents"), especially fatal
crashes, which are strongly correlated with drunk driving, and by arrests, although the
latter is a weaker index because of its sensitivity to the level of police activity. In general,
the available evidence suggests that black and Hispanic drivers are more likely than
members of other groups to be impaired by alcohol.

Roadside survey data obtained in the Grand Rapids study (Zylman 1972; Hyman
1968~~; Cosper and Mozersky 1968) revealed that blacks were more likely than whites to
drive with high BACs and to have crashes. The study stands alone, as more recent
roadside surveys have failed to gather racial and ethnic data. Unfortunately, the Grand
Rapids study cannot be considered recent, but its conclusion of black overinvolvement
in drunk driving is supported by independent studies of involvement in fatal crashes

3  Data from Cosper and Mozershys study of Grand Rapids and "Greentown" respondents are consistent
with these patterns (Cosper and Mozersky 1968).


YOUTH AND OTHER SPECIAL POPULATIONS                                            229

(Dufour et al. 1984, Waller et al. 1%9). These latter studies show that when blacks have
fatal crashes, they are more likely than whites to have alcohol in their blood. However,
these investigations do not in themselves demonstrate a higher fatal crash rate for blacks
on a per capita basis. The studies using arrest (Herd 1985; Caetano 1984, Hyman 1%8b;
Rabow and Watts 1982) and rearrest (Wells-Parker et al. 1988) data have produced
inconsistent findings in the matter of black overinvolvement, perhaps related to the
weakness of the criterion variable (arrests).

Since 1965, both whites and blacks have shown dramatic increases in DUI arrest rates
among persons 18 years of age and older, but whites have shown the greater change over
time, thereby closing the gap between the races (see figure 1). Although the reasons for
these patterns are unclear, several other trends suggest that increased law enforcement
(DHHS 1986a) is the explanation rather than increased drunk driving. The mileage-
based highway mortality rate has been declining over time (National Safety Council 1986)
as has the proportion of fatal crashes in which alcohol is implicated (NHTSA 1988), and
roadside surveys are finding proportionately fewer alcohol-impaired drivers than in
earlier years (Wolfe 1986).

900  -

600  -

too  -

600  -

so0 -

                     A 6kk
                     0 wtr
200  -
,#

I%5       IOX)       1973       1980

        YEAR OF ARREST

Figure 1. U.S. arrest rates for driving under the influence: Persons 18 years and
    over, by race, 1965-1982

Source: This figure was reproduced from Herd (DHHS 19841, page 101). The data sources
for arrest rateswere the Uniform Crime Reports and Current Population Reports. The 1981 arrest
rates portrayed here are lower than those reported by Caetano (1984) because the two authors
used somewhat different estimates of the relevant 1981 populations. However, in both cases the
arrest rates for blacks and whites were quite similar.


230

BACKGROUND PAPERS

Concerning the drinking and driving of Hispanics, no roadside survey-based studies
are available. However, several studies reported overinvolvement of Hispanics in
alcohol-related crashes (DHHS 1986b; Hyman 196%; Hyman et al. 1972), and large
excesses of drunk-driving arrests are reported in the literature (Caetano 1984; Hyman
196%; Rabow and Watts 1982). The consistency of these findings leads to the conclusion
that Hispanics are unusually likely to engage in drinking and driving.

One possible interpretation of the findings concerning arrests of Hispanics, and also
blacks, is that police are disproportionately likely to arrest minority-group members
(DHHS 1986b). If so, the reported overinvolvement of minorities in drunk drivingwould
be misleading (see Morales cited in DHHS 19863). However, the only study on the issue
(Hyman et al. 1972) reported that a higher proportion of Hispanic than non-Hispanic
drunk drivers are arrested as a consequence of accidents rather than moving violations,
a fact inconsistent with the idea that the excess of arrests stems from police bias. Studies
showing excess alcohol-related crashes for minorities may have to contend with different
proportions of blood-alcohol testing (Dufour et al. 1984), which again could produce
misleading conclusions. However, the finding that fewer of the majority group are tested
suggests that their relative rate of impaired driving may be overestimated (assuming that
testing is first done on those most reasonably suspected of drinking, and that the rate is
calculated on the basis of the population tested). Thus, the estimate of excessive
involvement of the minority is likely to be conservative rather than overstated.

If the conclusion of minority overrepresentation in drunk driving is valid and not
merely a measurement artifact, it requires further explanation. Two straightforward
interpretations are that minority status is related to more heavy drinking and to more
frequent driving. However, the latter possibility (excessive driving exposure) could
potentially explain only population-based indexes, like ordinary arrest rates. A third
possible interpretation is that minority-group members, though neither dispropor-
tionately drinking nor driving, are more likely to combine these behaviors.

The first explanation, heavier drinking, is clearly supported for Hispanics, though not
so clearly for blacks. Why Hispanics, in particular, should be disproportionately heavy
drinkers may be explicable on cultural grounds. The "machismo" (manliness) attitude
of Hispanic men (Ames and Mora 1988) may contribute to their higher rates of
alcohol-related arrests and accidents by leading to an increase in risk-taking behavior.
Relevant also is the "cruising" practiced by Hispanic men (and occasionally women) in
the Southwest. This cultural practice involves driving slowly while drinking alcoholic
beverages and flirting with the opposite sex. It is facilitated by a social network that
encourages and sanctions the simultaneous use of automobiles and alcohol. It also makes
these men more visible to police and more vulnerable to arrest (J. Cuellar, Prevention
Research Center, Berkeley, CA, personal communication October 1988).

The second explanation - that minorities drive more than other people- has no
empirical support. Rather, minority-group family automobile ownership and individual
driving appear to be lower, and mileage less, at least among blacks (Cosper and
Mozersky 1968; Hyman 196%). The relatively high urbanization of both blacks and
Hispanics may reduce their need and opportunity to drive. Thus, the excess of minority
arrests for drunk driving would seem to be conservatively stated.

Zylman's (1972) suggestion that black overrepresentation in accidents may be due to
residing (and hence driving) in congested areas must be regarded as merely speculative.
A related speculation, also not yet empirically grounded, is that minority-groupmembers
have less access to transportation alternatives when drinking; these could include formal
alternatives such as mass transit and taxis, or informal ones such as the practice of
accepting designated drivers in drinking groups.

Indirect support for the third explanation, mixing drinking and driving, comes from
the Grand Rapids study finding that, compared with others, blacks offer a larger estimate
of the safe number of drinks that can be consumed before driving (Cosper and Mozersky


YOUTH AND OTHER SPECIAL POPULATIONS                                          231

1968). Moreover, the suggestion has been made that minority-group members may
disproportionately drink in locations away from home, such as bars and parking lots,
presenting the inducement to drive while impaired. However, a recent national survey
found only equivocal support for this idea (Caetano and Herd 1987). In any event, the
need to use automobiles for nearly all social purposes is so fundamental in American life
that such differences would probably be only marginal in their effect.
Both blacks and Hispanics are disproportionately youthful groups, which leads to the

suggestion that their overinvolvement in drunk driving may merely reflect their
demographic characteristics. However, among young people in both groups, the dii-
ferences from the majority in arrest rates are either reduced or reversed (Caetano 1984),
a finding that contradicts the demographic explanation.

A commonly offered explanation of minority involvement in drunk driving hinges on
the low socioeconomic status of blacks and Hispanics in America. However, controls for
occupation, education, and income, although possibly successful in reducing the linkage
between minority status and indexes of drunk driving, do not seem to eliminate the
relationship (Zylman 1972; Hyman 1968~; Rabow and Watts 1982).

In brief, the excess involvement of minorities in drunk driving seems to be real and
not a statistical artifact. It is not merely the reflection of age or class differences related
to race and ethnicity. Rather, it is best interpreted as a consequence of minority-group
members' excess involvement in drinking, especially in heavy-drinking episodes. This
may be marginally compounded by a relatively greater conjunction of drinking and
driving behaviors in the groups discussed. The development of appropriate policy
countermeasures would thus seem to be served by a more thorough understanding of
the definitions of drinking and of driving in the black and Hispanic subcultures of the
United States.

Research Priorities

The data on black drinking patterns suggest inconsistencies between self-reported
consumption practices and medical problems induced by alcohol. Research is needed
to clarify the reasons for the apparent inconsistencies-whether, for example, self-
reports of blacks are distorted in the direction of social desirability, or whether a longer
duration of drinking among blacks (DHHS 198ti) increases the risk of medical
problems.

Since the full extent of the drunk driving problem is also not clear in either of these
minority groups, more precise and complete measures are needed of alcohol use and
abuse among blacks and Hispanics, with particular reference to drunk driving.

In addition, it is important to determine the extent to which the higher DUI arrest or
rearrest rates among these two groups reflect real differences in drunk driving or
differential law enforcement by police. The relationship of other variables to drinking
patterns and drunk driving among blacks and Hispanics should also be more extensively
explored. Such variables include age, income level, geographic and urban/rural distribu-
tion, and car ownership.

Perhaps most important, researchers should develop and test prevention strategies
tailored to specific subcultures in which alcohol contributes to social bonding, social
status, social integration, and coping with misfortune. The appropriate choice of inter-
vention strategies will be enhanced by a better understanding of the cause of drunk
driving problems among blacks and Hispanics. However, the evidence at hand is
sufficient to begin the process of prevention research.


232

REFERENCES

Ames, G. and Mora, J. "Alcohol Problem Prevention in Mexican-American Populations." Un-
   published paper. Berkeley, CA: Prevention Research Center, 1988.
Bureau of Census. I980 Census of Population, General Social and Economic Characteristics,
   United States Smnmary, PC-80-l-Cl. Washington, DC Supt. of Dots., U.S. Govt. Print.
   Off., 1984. pp. I-12, l-13.

Bureau of Census. StatisticalAbstract of the United States: 1988,108th Edition. Washington, DC:
   Supt. of Dots., U.S. Govt. Print. Off., 1987. p. 37.
Caetano, R. A note on arrest statistics for alcohol-related offenses. DrinEdng Md Dnrg 13acrices
   Surveyor 19(Apr.):12-17, 1984.

Caetano, R. Alcohol use among Hispanic groups in the United States.j4rnetica?t Jownal of Drug
   and Alcohol Abuse 14:293-308,1988.

Caetano, R. and Herd, D. "Drinking in Different Social Contexts Among White, Black and
  Hispanic Men." Presented at the Sixth Annual Meeting of &American College of
   Epidemiology, New Orleans, Oct. 1-2, 1987.

Ciqer, R. and Mozersky, K Social correlates of drinking and driing. Quarterly Journal of Studies
   on Alcohol, Supplement 4:58-l 17, 1968.

Department of Health and Human Services. A review of drinking patterns and alcohol problems
  among U.S. blacks, by Herd, D. In: Report of the Secretary's Task Force on Black ana'
  Minority Health, Vol. VII: ChemicalDependency and Diabetes. Washington, DC Supt. of
   Dots., U.S. Govt. Print. Off., 198&r. pp. 7-140.

Department of Health and Human Services. Patterns and problems of drinking among U.S.
  Hispanics, by Caetano, R. In: Report of the Secretaty's Task Force on Black and Minority
   Health, Vol. VII: Chemical Dependency and Diabetes. Washington, DC Supt. of Dots.,
   U.S. Govt. Print. Off., 19m. pp. 143-186.

Dufour, M.; Malin, H.; Bertolucci, D.; and Charles, C. "Death Certification Practices in Aicohol-
   Related Traffic Fatalities." Presented at the 112 Annual Meeting of the American Public
   Health Association, Anaheim, CA, Nov. 1984.

Dufour, M.C.; Bertolucci; D.; and Weed, J. "Multiple Cause Mortality Data: General Description,
   Methodological Issues, and Preliminary Findings." Presented at the National Institute on
   Aicohd Abuse and Alcoholism Conference on the Epidemiology of Alcohol Use and
   Abuse Among U.S. Ethnic Minority Groups, Bethesda, MD, Sept. ll-14,1985.
Herd, D. "The Epidemiology of Drinking Patterns and Alcohol-Related Problems Among U.S.
   Blacks." Presented at the National Institute on Alcohol Abuse and Alcoholism Conference
   on the Epidemiology of Alcohol Use and Abuse Among U.S. Ethnic Minority Groups,
   Bethesda, MD, Sept. 1 l-14,1985.

Hyman, M.M. Accident vulnerability and blood alcohol concentrations of drivers by demographic
   characteristics. Quarterly Journal of Studies on Alcohol, Supplement 4:34-57,196&1.
Hyrnan, M.M. The social characteristics of persons arrested for drivingwhile intoxicated. Quarter&
   Journal of Studies on Alcohol, Supplement 4:138-177,1968b.
Hyman, M.M.; Helrich, AR.; and Benson, G. Ascertaining police bias in arrests for drunken
   driving. Quarterly Journal of Shdies on Alcohol 33: 148-159,1972.
May, G.W., and Baker, W.E.Human and environmental factors in alcohol-related traffic accidents.
   In: Israelstam, S., and Lambert, S., eds. Alcohol, Drugs, and Trafic Safety: Proceedings of
   the Sirth International Conference on Alcohol, Drugs and Traffic Safety. Toronto: Addic-
   tion Research Foundation of Ontario, 1974. pp. 129-145.
Smith, J. and Shaw, J. "Interim Report Identifying Population Subgroups at High Risk for
   Impaired Driving." Unpublished report by Triton, Inc., submitted to Zelphia Gouldson,
   U.S. Department of Transportation, Washington, DC, May, 1987.
National Highway Traffic Safety Administration. FatalAccident Reporting System 1986: A Review
   of Information on Fatal Trafic Accidents in the United States in 1986. Washington, DC:
   1988. p. v.

National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health, Siah Special Report to
   the U.S. Congress. DHHS Pub. No. (ADM)87-1519. Washington, DC: Supt. of Dots., U.S.
   Govt. Print. Off., 1987.

National Institute on Alcohol Abuse and Alcoholism. Alcohol use and abuse among the Hispanic
   American population, by Alwcer, AM. In: Alcohol and Health Monograph No. 4: Special


YOUTH AND OTHER SPECIAL POPULATIONS

233

Populafion Issues. DHHS Pub. No. (ADM)82-1193. Washington, DC: Supt. of Dots., U.S.
Govt. Print. Off., 1982. pp. 361-382.

National Institute on Alcohol Abuse and Alcoholism. Alcoholism: Studies regarding black
   Americans 1977-1980, by King, L.M. In: Alcohol and Health Monograph No. 4: Special
   Popuiution Zssrtes. DHHS Publication No. (ADM)82-1193. Washington, DC: Supt. of
   Dots., U.S. Govt. Print. Off., 19826. pp. 385407.
National Safety CouncilAccidenr Facts. Chicago: the Council, 1986. p. 59.
Rabow, J. and Watts, R.K Alcohol availability, alcoholic beverage sales and alcohol-related
   problems. Journal of Shrdies on Alcohol 43:767-801,1982.
Wailer, J.A; King, E.M.; Nielson, G.; and Turkel, H.W. Alcohol and other factors in California
   highway fatalities. Journal of Forensic Sciences 14:429#, 1%9.
Wells-Parker, E.; McMillen, D.L.; Anderson, BJ.; and Ian&urn, J.W. Interactions among DUI
   offender characteristics and traditional intervention modalities: A long-term recidivism
   follow-up. Submitted for publication, 1988.

Wilson, R.W. and Williams, G.D. "Alcohol Use and Abuse Among U.S. Minority Groups: Results
   from the 1983 National Health Interview Survey." Unpublished paper.
Wolfe, AC. Changes in the incidence of drunk driving in the United States 1973-1986. In: Noordzij,
   P.C., and Reszbach, R. eds. Alcohol Drugs, and Trafic Safefy-l-86. Amsterdam: EI-
   sevier, Sept. 9-12,1986. pp. 305-308.

Zylman, R. Race and social status discrimination and police action in alcohol-affected collisions.
   Journal of Safety Resewch 4:75-W, 1972.


234

Treatment

Rehabilitation Countermeasures for
    Drinking Drivers

     Kathryn Stewart          .\
Pacijic Institute for Research and Evaluation
      Hennq Virginia

     Vernon S. Ellingstad
Department of Psychology, Universiy of South Dakota
      Vermillion, South Dakota

The primary goal of rehabilitative programs for drunk driving offenders is to reduce
the probability of subsequent drinking and driving. Punishment, such as licensing
penalties, lines, and incarceration, is also designed to prevent subsequent drinking and
driving either by making the consequences of arrest so unpleasant and costly as to
discourage the offense or by eliminating the offenders' capacity to drive (by putting them
in jail or by invalidating their drivers' licenses).

Rehabilitation is based on one of two assumptions: That offenders drink and drive
because they lack knowledge about the effects of alcohol, the potential consequences of
drinking and driving, and strategies for avoiding drinking and driving; or that drinking
and driving results from an abusive, addictive, or otherwise uncontrolled pattern of
alcohol consumption. Therefore, offenders must receive education to help them ration-
ally choose not to drink and drive or they must receive treatment so they can eliminate
abusive drinking and thus stop drinking and driving.

The goals of rehabilitation are certainly important-almost one-third of convicted
drinking drivers have a previous offense (Sweedler and Smith 1984). Preventing some
part of this recidivism is desirable. From the perspective of individual offenders, gaining
information and skills and receiving treatment to allow them to avoid drinking and
driving can save them from additional expense, humiliation, inconvenience, and potential
tragedy. Rehabilitation can also have positive effects on other areas of the offenders'
lives if abusive drinking is reduced.

It is important to emphasize that even programs that are extremely effective in
reducing recidivism cannot be expected to have major effects on traffic safety. Reed
(1981) estimated that even if all persons arrested for drunk driving were prevented from
ever combining drinking and driving again, fatal crashes would decrease by only 3
percent. Other efforts aimed at prevention or general deterrence such as well-publicized
enforcement crackdowns have the potential to save many more lives.

Characteristics of Rehabilitation Countermeasures

There is wide variation in what are referred to as rehabilitative programs. Programs
can vary in length, format, content, and structure. Programs may be quite brief (8 to 10


TREATMENT

235

hours) or more lengthy (50 or 100 hours). They maybe presented in a concentrated form
over a few days or stretched over several weeks or months or even years. The format may
be didactic with offenders sitting through a series of lectures, or the program may include
more active participation by the offender. Some programs include group or individual
counseling. Some programs involve spouses or other people close to the offender.

The content of programs also varies greatly. Some programs' focus on information
about the effects of alcohol, the law, potential consequences of drinking and driving, and
strategies for avoiding drinking and driving (including both strategies for decreasing
drinking and strategies for avoiding driving while intoxicated, such as appointing desig-
nated drivers). Other programs focus more heavily on helping offenders to identify
abusive or addictive drinking patterns and providing (or persuading participants to seek)
alcoholism treatment. Programs also exist that emphasize development of the right
hemisphere of the brain as a way of reducing problem drinking or that teach assertiveness
skills in hopes that these skills will help participants avoid drinking and driving.

Rehabilitative programs also vary considerably in the ways they are used. For ex-
ample, in some States, offenders go through an assessment process to determine the
nature and severity of their alcohol problems and are assigned to one of a number of
rehabilitative programs based on the outcome of the assessment. In other States,
offenders are assigned to programs based on other criteria such as blood alcohol
concentration at the time of arrest or the number of previous alcohol-related offenses.
The manner in which compliance with rehabilitative orders is enforced also varies, as
well as other penalties that are applied along with rehabilitation.

States vary in the way these programs are administered. Some programs are delivered
by State agencies while others are carried out under contract with a wide variety of
private agencies (everything from alcoholism treatment facilities to driving schools). The
amount of control that the State exerts in determining program content, format, and
standards also varies. States monitor program quality and adherence to standards in
varying degrees as well.

Issues in Rehabilitation Program Evaluation

Assessment of the effectiveness and value of rehabilitation programs is at best a
complicated endeavor, and a number of important issues must be considered in evaluat-
ing such programs and in considering the results of evaluation studies. The criterion
issue, or the explicit definition of program success, is a pervasive problem for any
complex applied program, but is particularly difficult for rehabilitation programs oper-
ated within a larger traffic safety context. In this context an alcohol treatment program
would be successful if rehabilitation reduced the probability of subsequent involvement
in alcohol-related crashes, or at least, if the frequency of the behavior assumed to lead
to such crash involvement (i.e., drunk driving) was diminished.

Measures such as alcohol-related crash involvement or driving while intoxicated
(DWI) or driving under the influence (DUI) arrests and convictions are frequently
chosen as criteria of success. But these measures pose at least two important meth-
odological problems. First, and perhaps most importantly, being arrested for DUI or
even being involved in an alcohol-related crash should probably be considered as only
incidental to the drinking problems toward which many treatment programs are
directed; these measures are certainly not comprehensive indicators of the intended
effects of treatment. Second, despite the fact that alcohol-related crashes and drunk
driving arrests occur frequently enough to justify countermeasures, the probability of
these recidivist events is so low that statistical comparisons between treatment and
no-treatment groups are usually not sensitive to treatment effects (the comparisons


236

BACKGROUND PAPERS

usually have low statistical power). That is, the sample size must be very large or the
group differences in recidivism very substantial for these differences to be empirically
identified.

To address these methodological problems, some evaluations of rehabilitation
programs have used other measures of success such as self-reports of drinking behavior,
indices of personal adjustment, and other indicators tied more closely to the expectations
of the treatment programs. Such measures are not without their methodological
shortcomings, including their frequent reliance on unsubstantiated self-reports.

Another methodological problem, which has constrained assessments of treatment
effectiveness at least as much as measurement shortcomings, concerns the adequacy of
the experimental or quasi-experimental designs for contrasting treatment against no-
treatment effects. In an ideal case, treatment evaluations would be conducted under
carefully controlled experimental conditions, with individuals randomly assigned to
treatment and no-treatment conditions, and the posttreatment performance of treat-
ment and control groups compared. These conditions have not been uniformly available
in rehabilitation evaluation studies, and many of the results reported in the literature
represent less than rigorous experiments.

Evaluation Results

Keeping in mind the variability in the nature of rehabilitative programs and the
difficulties in accomplishing a full and fair assessment of their effectiveness, we may
proceed to a discussion of the results of evaluations of rehabilitation programs con-
ducted during two distinctly different periods. The Alcohol Safety Action Projects
(ASAP) of the 1970s introduced rehabilitation modalities as part of an integrated set of
alcohol/traffic safety countermeasures. The 1980s brought a number of locally tailored
programs, including a program based on skills-building tested in California, the Week-
end Intervention Program originated at Wright State University in Ohio, and programs
to provide court-mandated alcoholism treatment.

The ASAP Era

In June of 1970, the National Highway Safety Bureau (later to become the National
Highway Traffic Safety Administration- NHTSA) of the new U.S. Department of
Transportation introduced nine traffic safety countermeasure demonstration projects,
which came to be known as Alcohol Safety Action Projects or ASAPs. Twenty additional
ASAPs were funded iu 1971, and a final six projects were initiated during 1972. Each
ASAP was designed to operate as a local drinking/driving control system (Joscelyn and
Jones, 1971) which coordinated the efforts of traditional traffic safety and driver control
agencies such as traffic courts, police departments, motor vehicle departments, and
community health resources. Some of the ASAPs operated in single metropolitan areas,
others covered large city/county regions, and still others operated as statewide projects.

The NHTSA intent in funding these local projects was to provide for a demonstration
(or rather, 35 replications of a demonstration) of the feasibility of an integrated systems
approach to the alcohol traffic safety problem. The goal of each project was to reduce
alcohol-related motor vehicle crashes by reducing the number of persons who drive while
intoxicated or impaired. Rehabilitation modalities shared this project goal with law
enforcement agencies, judicial systems, and public information and education com-
ponents of the ASAPs. The conceptual model that prescribed the general role of
rehabilitation in the ASAPs is shown in figure 1.

ASAP rehabilitation countermeasures were conceived of as a bridge between the


TREATMENT

COURTS

o CONVICTION

. SENTENCING

ASAP "TRANSITION"

and/or

  COUNSELING CHEMOTHERAPY

        I            1

I r&sir-

  COMMUNITY
HEALTH RESOURCES

o DETOXIFICATION

. IN-PATIENT

o INOIV. THERAPY

Fhe
Jail     PREiENTENCE     ALCOHOL      GROUP
                 __+ SAFETY                 REFERRAL
Revocation    INVESTIGATION      SCHOOL    THERAPY,                 o ??
Suspensh .
Probation   I              4           4               - o MENTAL HEALTH
                    I         I    I        CLINICS
  I                                             0 ETC..
                        PROBATION

Figure 1. ASAP rehabilitation: A court-referral system

traffic court systems that adjudicated drunk driving offenses and various community
heahh and mental health resources that provided alcohol treatment. As demonstration
projects, the ASAPs were expected to provide rigorous assessments of all counter-
measures employed by the projects, including rehabilitation. Each project included an
evaluation function to accomplish this purpose.

ASAP Rehabilitation Countermeasures

ASAP rehabilitation systems were, in each of the 35 projects, designed to supplement
the driver control functions of the police, courts, and licensing agencies. A fundamental
assumption of ASAP rehabilitation countermeasure programs was that a significant
proportion of individuals arrested and convicted of drunk driving offenses were "prob-
lem drinkers" whose control over their drinking behavior (and thus drinking/driving
behavior) was Iimited. This assumption created a systems requirement to perform at
least a minimal diagnosis to discriminate "problem" from"nonproblem" drinkers among
the ASAP? drunk driver clientele, and presentence investigations represented a primary
liaison between the traffic courts and each project's rehabilitation countermeasures
program.

A substantial number of rehabilitation programs were conducted by the projects, or
received referrals from the ASAPs. Thirty-two of the thirty-five projects used an "alcohol
safety school" as a rehabilitation modality. Most of these schools were conducted by the
ASAPs themselves. Some projects used the alcohol safety school as a re-education/
rehabilitation modality for nonproblem drinkers, some as a treatment alternative for
problem drinkers, and still others as a rehabilitation countermeasure for both problem
and nonproblem drinkers. The schools were short-term (2-6 sessions), educationally
oriented programs designed to handle a substantial number of drunk driver referrals.
The school was frequently the sole rehabilitation assignment for nonproblem drinkers
while for problem drinkers, schools were often used in conjunction with other treatment
alternatives.

237


238

BACKGROUND PAPERS

In 10 ASAPs, special group therapy programs were developed and conducted by the
projects themselves. Generally, these programs used weekly or biweekly sessions of an
hour or two in length that extended over a period of a month to 6 weeks. The primary
source of alcohol rehabilitation services across the ASAP sites was, however, the existing
rehabilitation system of the community, and most ASAP treatments were provided by
community treatment agencies. Outpatient treatment services provided by these agen-
cies included both group therapy and individual counseling. Some projects established
cooperative arrangements with local Alcoholics Anonymous chapters and utilized AA
as a referral resource. Limited use was made, across projects, of inpatient treatment
referrals. A few projects used chemotherapy (primarily disulfiiam) as a treatment
modality, usually in combination with some kind of group or individual therapy.

Analyses of treatment effectiveness were conducted at the individual project level and
also at the overall program level (Ellingstad and Springer 1976). The general approach
taken to the evaluation of rehabilitation effectiveness at both levelsinvolved comparing
the performance of individuals who had been exposed to ASAP-sponsored or -coor-
dinated treatment with the performance of individuals who were not referred to
rehabilitation. Unfortunately, with but two exceptions (Nassau County, New York and
Phoenix, Arizona), the demonstration projects were not structured to provide robust
experimental tests of rehabilitation with random assignment of clients to treatment and
no-treatment conditions. The "no-treatment controls" at most ASAP sites were of
individuals excluded from treatment because there was no room in the treatment
programs when they entered the system, they refused to participate, or for one reason
or another they were judged to be unsuitable for entry into treatment.

Project-level analyses of treatment program effectiveness were reported to NHTSA
annually in Analysis of Akohol Rehabilitation Efforts, a mandated analytic study
prepared by the local project evaluation component. A number of summaries of these
studies have been reported (see, for example, Ellingstad, 1976; Spiegel and Struckman-
Johnson 1978). Evaluations included overall assessments of rehabilitation system effec-
tiveness (all treatment modalities combined) as well as assessments of individual
rehabilitation countermeasures. Criteria on which these analyses were based included
crash recidivism, arrest recidivism, and in some cases, other measures obtained by testing
or interviewing program participants. The most common criterion of program success
was alcohol-related arrest recidivism. While isolated reports of treatment impact on
traffic safety criteria (crash or arrest recidivism) came from some of the 35 projects, an
inverse relationship was also apparent between the methodological adequacy of the
analytic study and its likelihood of reporting significant results.

Despite the generally pessimistic results of these analyses when critically evaluated,
some indications of success were present. Process-oriented studies of alcohol safety
schools almost universally demonstrated them to be capable of altering levels of
knowledge and attitude, even though the effects of these treatment programs on
recidivism was equivocal. Most analyses of the more intensive treatment programs
showed no clear evidence of treatment effectiveness. A notable exception concerned the
Disulliram Clinic operated by the Los Angeles ASAP. This program demonstrated a
statistically significant reduction in recidivism associated with disulfiram treatment in a
well-controlled and statistically sound analysis.

Program-level analyses of ASAP rehabilitation countermeasure effectiveness were
also performed by pooling data (mostly arrest recidivism data) submitted by the in-
dividual projects (Ellingstad and Springer 1976). Comparisons of survival rates (propor-
tions of clients avoiding rearrest) over a 3-year followup period for nonproblem drinkers
(as determined in presentence investigations) showed the pooled across-project trcat-
ment group to have outperformed the pooled no-treatment group. This program-level
result was at least suggestive that treatment may have had some of its intended effect on
nonproblem drinkers. A similar comparison for problem drinkers did not show sig-


TREATMENT

239

nificant differences in survival rates between individuals who had been referred to ASAP
treatments and those who had not received treatment.

It seems fair to conclude that, on balance, the results produced by the ASAPs in
identifying effective alcohol rehabilitation countermeasures were disappointing. Sig-
nificant methodological problems constrained both project- and program-level analyses
of rehabilitation system effectiveness and prevented clear tests of treatment effect. The
absence of adequate experimental controls seemed to be the principalissue.

The Short-Term Rehabilitation Study

It became apparent after the first few years of ASAP operations that the methodologi-
cal problems alluded to previously were likely to seriously handicap assessments of
rehabilitation effectiveness within this program. Because of this concern and because of
project-level interest in a relatively new alcohol treatment program called Power Motiva-
tion Training (PMT), a series of important changes in the implementation and evaluation   i
of ASAP rehabilitation countermeasures were introduced beginning in 1973 (Ellingstad
1976b). PMT, developed by McBer and Company, alcohol treatment researchers, was
based on a distinct set of theoretical principles and consisted of a well-defined and
carefully described set of therapeutic procedures. Moreover, PMT was a short-term
modality that did not depend on highly trained professional therapists and could be
readily implemented within the ASAP rehabilitation systems (Cutter, et al. 1975). The
PMT program was formally begun in eight sites in early 1975. McBer and Company,
under contract with NHTSA, trained therapists at the participating sites (Boyatzis 1976).
In addition, an evaluation function was created to develop a system to collect, monitor,
and process data from the PMT sites and to develop instruments to provide measures
of relevant indices of treatment effectiveness. The name was changed to the Short-Term
Rehabilitation (STR) Study to reflect the fact that several treatment alternatives in
addition to PMT were to be included in the experimental designs at some of the sites,
and that an additional three ASAPs that did not use PMT but did employ random
assignment procedures and no-treatment control groups were to be added to the study.

Each site in the STR study used its presentence investigation procedures to identify
a pool of mid-range problem drinkers considered to be the most appropriate clients for
PMT and related treatment programs (both social or nonproblem drinkers and alco-
holics were excluded). From this pool, clients were randomly assigned to either treat-
ment or control conditions. A comprehensive data collection procedure involving
extensive interviews, questionnaires, and record checks was conducted at the time of
assignment, as well as at 6-, 12-, and l&month followup contacts.

A total of 3,663 clients were randomly assigned to treatment and no-treatment
conditions at the 11 sites, with 2,462 clients exposed to various short-term rehabilitation
modalities and 1,201 clients assigned to no-treatment or "minimum exposure" control
groups (some sites required a minimal treatment such as the distribution of literature
about alcohol and driving instead of a true no-treatment control condition - this affected
only four sites),

The extensive data collection employed within the STR study provided for a large
battery of outcome criteria including: traffic safety outcome measures such as crash and
arrest recidivism; direct indices of drinking behavior such as duration of abstinence,
average level of alcohol consumption, and incidence of abusive drinking; lie status
measures such as current drinking problems, physical health problems, and employ-
ment/economic stability; and measures of personality characteristics (Ellingstad and
Struckman-Johnson 1978).

Detailed analyses were conducted for each set of dependent variables within the
experimental designs of each of the 11 STR sites individually (Struckman-Johnson and
Ellingstad 197&z). No compelling evidence of treatment effectiveness was found in any


240

of these analyses and, in fact, statistically significant negative effects were observed in
two or three instances.

Program-level analyses were also performed on data pooled from the 11 sites (Struck-
man-Johnson and Ellingstad 197%). A large number of statistical comparisons revealed
some evidence of treatment effectiveness for alcohol safety schools (employed as a
treatment alternative by four of the STR sites), and some evidence suggested a negative
treatment effect for PMT as a single modality treatment assignment.

The CDUI Project

Despite the fact that the STR study had involved thousands of drunk driver clients
and had been able to achieve the methodological requirements (random assignment and
control groups) of a true experiment, the fact that the study encompassed 11 very
different jurisdictions presented organizational difficulties that may have prevented as
powerful a test of rehabilitation countermeasures in the traffic safety context as might
be desired. In late 1976, a massive, single site experimental project called the Com-
prehensive Driving Under the Influence of Alcohol Offender Treatment Demonstration
(CDUI) Project was initiated in Sacramento, California.

The CDUI Project operated from September 1977 through January 1981 in
Sacramento County, receiving its referrals from the Sacramento County Municipal
Court. The project employed two separate experimental designs, one for first-offense
drunk drivers, the other for drivers convicted of multiple DUI offenses. The lirst-
offender design provided random assignment of 4,639 individuals convicted of DUI to
one of three treatment alternatives: (1) an in-class education program consisting of four
classroom sessions of 2 l/2 hours each over a 4-week period, using a standard alcohol
education program patterned after others in use around the United States; (2) a home
study program consisting of an organized set of reading materials designed as a self-study
package, which was presented to the clients in a l-hour orientation session; and (3) a
control group who received no treatment. All clients were placed on 2-year informal
probation and received a reduced line as an incentive to participate. In addition to the
treatment assignments, one-half of each treatment group was randomly assigned to
receive quarterly monitoring letters to remind them of their probation status and to
encourage them to drive soberly. Half the clients were also randomly assigned to receive
followup interviews designed primarily to collect life activities data for treatment out-
come analyses.

Both the in-class and home study education programs were shown to produce
significant reductions in DUI recidivism relative to the no-treatment control group.
Neither program, however, had significant impact on crash involvement or on the variety
of life status measures collected at followup intervals 10 and 20 months subsequent to
treatment entry (Reis 1982).

The principal CDUI multiple offender design involved a postconviction presentence
(PCPS) procedure under which a guilty plea to DUI was accepted prior to referral, but
final disposition and sentencing was postponed 13 months to permit participation in the
assigned treatment condition. Those clients who successfully completed the assigned
treatment then had the charge reduced to reckless driving, thereby avoiding the man-
datory licensing action that would have resulted from the DUI conviction. The 1,103
clients available to the PCPS multiple offender design were randomly assigned to the
following conditions: (1) Control (341): No educational or rehabilitative treatment, no
educational counseling, no chemotherapy, and no biweekly contacts; (2) Biweekly
contacts only (326): Twenty-six 15-minute individual interviews with a probation officer
every other week for 1 year; (3) Skills workshop (110): A group educational counseling
approach developed for the CDUI project consisting of 34 2-hour group counseling
sessions with the first 16 sessions meeting weekly and the final 18 sessions every other


TREATMENT

241

week for the remainder of the year of treatment; (4) Skills workshop and chemotherapy
(109): Three supervised administrations of disulliram per week for the first 6 months of
the assignment were combined with the skills workshop group therapy program;
(5) Educational eclectic therapy (109): Counselors conducting eclectic groups had
complete freedom to organize group therapy sessions according to their preferred style.
The first four 2 l/2-hour sessions were alcohol education classes identical to the
first-offender classes. They were followed by 28 weekly 2-hour group therapy sessions;
and (6) Educational eclectic therapy and chemotherapy (108): Three supervised admin-
istrations of disulliram per week for the first 6 months of the assignment were combined
with the educational eclectic therapy program.

Followup of multiple offender clients over a 20-month period showed both counseling
programs to produce significant reductions in DUI recidivism in comparison to the
no-treatment control group. Adding chemotherapy to counseling programs did not
improve the recidivism performance of these rehabilitation programs. Chemotherapy
was shown to be effective in reducing levels of alcohol consumption for up to 14 months
beyond the termination of disultiram treatment in clients who completed a counseling  :
program. None of the multiple offender treatments affected crash involvement (Reis
1982).

In contrast to the earlier ASAP and STR experiences, the CDUI results provided
considerably more encouragement with respect to the efficacy of alcohol rehabilitation
programs operated within the context of a traffic safety system.

Post-ASAP Rehabilitation Programs

Despite the mixed and disappointing results of evaluations of the various rehabilita-
tive programs carried out in the ASAP era, the concept of rehabilitation still generated
interest. Additional program models have been tested in recent years.

Skills Building

While some ASAP programs were able to show some reduction in recidivism and
subsequent crashes, the magnitude of the reductions was disappointing. However, many
of the program models evaluated seemed rather weak and not well grounded in theoreti-
cal or empirical knowledge about alcohol abuse or behavior change (Kunkel 1983).
Moreover, little attention seemed to have been paid to the quality of implementation.
Programs as they occur in actual practice often bear little resemblance to programs as
they appear on paper (French and Kaufman 1981). It seemed possible that the dii-
appointing outcomes might be due in part to weak program models or poor
implementation.

To give rehabilitation countermeasures the best chance of showing effectiveness, the
State of California sponsored an evaluation effort that included an extensive program
model development effort and careful attention to quality of implementation (Stewart
et al. 1987). The model program that was developed resembled traditional first-offender
programs implemented in the ASAPs in many respects. It included information on the
effects of alcohol, on drinking and driving laws, on symptoms of alcohol addiction, etc.
It also had several distinctive features, including a focus on the development of skills to
enable the offenders to separate drinking from driving. This aspect of the program was
based on Bandura's Self-Efficacy model (Bandura 1977) in which participants develop
strategies for dealing with a series of risky situations of increasing difficulty.

Over the course of the program, offenders were helped to develop, rehearse, and
practice realistic strategies to avoid drinking and driving. In addition, rather than


242

BACKGROUND PAPERS

attempting to deal with serious problems such as alcoholism within the constraints of the
program, a strong emphasis was placed on assessing the offenders' problems and
referring them to other helping resources in the community. The program was structured
to include a great deal of enforced participation so that the offenders were compelled
to be actively engaged in the program. Staff at the program sites received extensive
training and ongoing technical assistance and monitoring to ensure that the quality of
implementation would be high.

The program had two segments. The first segment was a6-week (15 hour) educational
program and the second was a 7-week (11 hour) counseling program. Offenders were
randomly assigned to the education-only or the education-plus-counseling segments to
determine whether programs of differing lengths and intensities would have different
effects.

The two versions of the model program were compared to two existing California
programs and to a control group (which participated in community service projects but
received no formal program content). Participants were randomly assigned to these
program conditions. The driver records of the participants in the four groups were
followed over 5 to 11 months to determine recidivism rates. In addition, a sample of
participants was interviewed before program entry and again 6 months later to include
more sensitive indicators of program success by broadening outcome measures to
include drinking behavior, symptoms of alcohol dependency and undetected drinking
and driving. Close associates of a sample of the respondents were also interviewed to
validate self-reports of drinking and drinking/driving.

Even given this carefully designed, well-implemented program, no differences could
be detected between the self-reported drinking behavior and drinking/driving behavior
of first offenders randomly assigned to the four program conditions, including the control
condition. Though some decreases in drinking and in frequency of drinking and driving
were reported, these decreases were reported equally by respondents in all program
groups. Thus, no evidence was found of the superiority of any program type over any
other, including the control group, which received no program at all. In fact, the observed
changes could be due to the natural reaction to any intervention or could be the result
of a statistical artifact (regression to the mean). The followup time for recidivism was
quite short, but no significant differences in recidivism were detected.

Thus, the modest effects demonstrated by other evaluations of rehabilitative
programs were not improved upon by altering program content and format. Within the
range of standard programs, no program type appears to have any outcome advantage
over any other, and the potential traffic safety effects of any program are very small
indeed.

The Weekend Intervention Program

The Weekend Intervention Program (WIP) (Siegal and Moore 1985) was based on
the assumption that it is unrealistic to expect a long-term pattern of problem drinking to
be altered after a short period of treatment or education. The intervention approach
does not &y to treat the problem drinker. Instead, it is designed to identify whether a
problem exists, to assess its extent and severity, and to refer offenders in need of
treatment to appropriate facilities. The offenders follow through on the referral on their
own, sometimes with the encouragement or order of the court.

As the title implies, the program takes place over the weekend. Educational and
counseling activities takes place in a medical school, and clients are housed in a nearby
motel in the evenings under police supervision. The goals of the program are to carry
out an assessment or diagnosis, to break down denial in those participants who have a
serious problem, and to prepare offenders to accept treatment if needed.


TREATMENT

243

An evaluation of WIP indicated that the program was effective in lowering the
recidivism rate as compared to nonequivalent comparison groups who received a
suspended sentence or who were sentenced to jail. The effect was strongest for repeat
offenders. During a l- to 2-year followup of repeat offenders, 21.8 percent of WIP
participants recidivated compared to 26.8 percent of jailed offenders and 30.4 percent
of offenders with suspended sentences. For first-time offenders, the recidivism rate for
WIP participants was 9.2 percent while the rate for all other first offenders was 12.7
percent (Siegall987).

The program was acceptable to the community in Ohio. It was easily understood by
the public and was acceptable to law enforcement and judicial personnel. It was less
expensive than traditional incarceration and, apparently, had a more positive effect on
subsequent drinking and driving (Siegal and Moore 1985). Clearly, however, the effects
on recidivism were modest. The program may serve a function in the community by
providing an acceptable form of punishment that may also be advantageous to the
offender, but its effects on traffic safety were negligible.

Compulsory `keatment Models

Some more intensive program models have been tried to deal with habitual offenders
or those with severe alcohol problems. One intervention is court mandated alcoholism
treatment for offenders who are addicted. Questions have been raised about the appro-
priateness or efficacy of compulsory treatment. Some research indicates that the out-
come of treatment for patients receiving treatment as part of a suspended sentence for
drunk driving compare favorably with improvements in alcoholics treated voluntarily
(Ben-Arie et al. 1983). A 7- to g-year followup was carried out with 50 offenders who
had been diagnosed alcoholic (most of whom were multiple offenders) and who received
compulsory treatment. At the time of followup, 14 of the offenders had been convicted
of further driving offenses. Thus, the treatment cannot be considered highly successful
in terms of reducing recidivism. Forty percent of the offenders were either sober or
generally sober, indicating that the treatment may have been useful in overcoming
alcoholism (Ben-Arie, et al. 1986).

A second model that has been implemented in several locales is the combination of
incarceration and treatment. Special facilities are set up to incarcerate drunk driving
offenders, usually repeat offenders. During their incarceration, inmates participate in a
highly structured education and treatment program, usually including detoxification (if
necessary), educational sessions, and group and individual counseling. A program of this
type carried out in Massachusetts reported a recidivism rate of 6 percent compared to
a statewide rate of 25 percent and a 19-percent rate for low security institutions similar
to the program's (LeClair 1987).

In the Netherlands, an educational program for incarcerated drunk drivers used
volunteers from various areas of the drunk driving system to teach sessions on the nature
and impact of alcohol abuse and provide information on community alcoholism treat-
ment services. Positive effects were reported on knowledge, attitudes, and driving
behavior when it was evaluated (Bovens 1987).

These studies provide some preliminary support for compulsory treatment programs,
either as mandated by the courts or as a component of incarceration. Here again,
however, while some individual offenders may be helped to overcome addictive drinking
or to avoid later drinking and driving, the impact on traffic safety is quite smalL

Conclusions

Because of the nature of the alcohol-related crash problem, rehabilitative approaches
can only have a very small effect on traffic safety, even if maximally effective. A wide


244

BACKGROUND PAPERS

variety of rehabilitative programs based on a variety of theoretical models, and delivered
in a variety of settings have never been able to'achieve more than modest effects on
recidivism. Although many evaluations of these programs suffered from methodological
weaknesses, the conclusion seems inescapable that to achieve improvements in traffic
safety, other strategies must be employed.

Rehabilitative programs may serve other purposes, such as providing an additional
appropriate and acceptable form of punishment to offenders, enforcing a general
societal message that drlnkiig and driving is unacceptable behavior, and providing a
mechanism for intervention into the driig problems of individuals. It is important to
keep in mind, however, that these possible benefits must be weighed against the costs of
the programs. Rehabilitative programs are not free.In many States, a substantial industry
(often a for-profit industry) supportiig hundreds or even thousands of employees has
grown up to provide these mandatory programs. Usually, the direct cost of the programs
is borne primarily by fees paid by offenders. These fees can be viewed as just another
part of the fines and other monetary penalties offenders are required to pay. From this
perspective, the effectiveness of the programs may not be an issue. However, the extent
to which these fees are purchasing services valuable to the individual or to society may
be called into question.

While possible benefits to individuals have been discussed, these beneficial effects
have not been thoroughly evaluated. A number of evaluations report attitude changes in
offenders (Foon 1988). However, evaluations that measured drinking levels or improve-
ments in other life areas, found very few effects (Stewart et al. 1987, Reis 1982). The
possibility that some programs may actually have harmful effects cannot be ignored. In
some States, rehabilitative programs are not closely monitored, and the appropriateness
of program content and the qualifications of staff may not be carefully evaluated.
Programs must deal with content that is highly charged emotionally. There is risk of
harmful effects if these areas are not handled with skill and caution.

It is important to compare the effectiveness of rehabilitative programs to other
sanctions - specifically license penalties. A 1984 study (Sadler and Perrine) compared
the impact of alcohol treatment programs to that of license suspensions on subsequent
crash rates and drunk driving recidivism. The study found that license suspensions have
a significant positive impact on traffic safety, more so than did the treatment programs
(although treatment programs had a greater impact on alcohol-related crashes and
arrests). Hagen et al. (1980) found that license suspensions and revocations produced
significant reductions in subsequent convictions and crash rates for multiple offenders.
In a review of a number of evaluations of the effectiveness of license actions, Peck et al.
(1985) drew this conclusion: "... there is no question that license suspensions have a
significant effect in reducing the accident and drunk driving frequency of convicted DUI
offenders."

Recommendations

Given the weak traffic safety benefits of rehabilitation countermeasures, it is very
important that the continuation of rehabilitative programs not be allowed to deflect
attention or resources away from drinking/driving countermeasures that have more
powerful effects.

Strategies that primarily attempt to bring about specific deterrence will necessarily
be limited in their ability to improve traffic safety. Even within that limited realm,
licensing penalties have been shown to be more effective in reducing recidivism than
rehabilitative programs, whatever their form. In many States, participation in a
rehabilitative program is offered as a substitute for license suspension or revocation.


TREATMENT

Such substitution is clearly counterproductive from the standpoint of traffic safety. If the
positive effects of rehabilitative programs are sufficient to justify their continued exist-
ence, these programs must be used in addition lo rather than instead of license penalties.

A larger question can be raised about all drinking/driving strategies that focus on
individual behavior with little consideration of the environment that shapes that behavior
(Wallack 1984). It is easier for society to blame the problem of, drinking and driving on
a defmed group of individuals rather than on money-making produc'ts, industries, and
systems that support drinking and driving and amplify its destructive potential (Vingilis
1987). In our zeal to deal with the population of identified drinking drivers, we should
not lose sight of social forces such as the political and economic climate, cultural
patterns, and values and norms that all combine to determine how alcohol is used and
what consequences that use will have for our health and Gfety.

245

REFERENCES

Bandura, A. Self-efficacy: Toward a unifying theory of behavior change. Psychological Review
   S&191-215, 1977.

Ben-Arie, 0.; George, G.C.W.; and Hirschowitz, J. Compulsory treatment of 50alcoholic drunken
   drivers. South Afican Medical Journal 63~241-243, 1983.
Ben-Arie, 0.; Swartz; and George, G.C.W. The compulsory treatment ofalcoholic drunken drivers
   referred by the courts: A 7 to 9 years outcome study. The Journal of Law and Psychiatry
    1986.

Bovens, R. Alcohol program: An educational program for drunken drivers in prison. In: Brand-
   Koolen, M.J.M., ed. Studies on the Dutch Prison System. Berkeley, CA: Kugler Publica-
   tions, 1987. p.151-157.

Boyatzis, R.E. "Implementation of Power Motivation Training as a Rehabilitation Counter-
   measure for DWIs. Technical report No. DOT-HSSOl- 834, McBer and Company,
   Boston, February 1976.

Cutter, H.S.; McClelland, D.C.; Boyatzis, R.E.; and Blancy, D.D. "The Effectiveness of Power
   Motivation Training for Rehabilitating Alcoholics." Technical report, McBer and Com-
   pany, Boston, 1975.

Ellingstad, V.S. "1975 Interim Analyses of ASAP Rehabilitation Efforts, Interim Report." Human
   Factors Laboratory, University of South Dakota, March, 1976a.
Ellingstad, V.S. "Program Level Evaluation of ASAP Diagnosis, Referral and Rehabilitation
   Efforts. Vol. IV: Development of the Short Term Rehabilitation (STR) Study." Technical
   report DOT-HS-191-3-759- F4, Human Factors Laboratory, University of South Dakota,
   June, 1976b.

Ellingstad, V.S., and Springer, T.J. "Program Level Evaluation of Diagnosis, Referral and
    Rehabilitation Efforts. Vol. III: Evaluation of Rehabilitation Effectiveness." Technical
   report DOT-HS-191-3- 759-F3, Human Factors Laboratory, University of South Dakota,
   June, 1976.

Ellingstad, V.S., and Struckman-Johnson, D.L. "The Short Term Rehabilitation Study. Vol.11:
   Development and Description of Measurement Battery." Report HFL-78-12, Human
   Factors Laboratory, University of South Dakota, November, 1978.
French, J.F., and Kaufman, N. Handbook for Prevention Evahtation. Rockville, MD: National
   Institute on Drug Abuse, 1981.

Foon, AE. The effectiveness of drinking-driving treatment programs: A critical review. Inrerna-
   rional Journal of the Addictions 23(Z): 15 l-174, 1988.
Hagen, R.E.; McConnell, EJ.; and Williams, R.L. Abstract of Suspension and Revocation Eflects
   on rhe DUI Offender. Sacramento, CA California Department of Motor Vehicles, 1980.
Joscelyn, J.D., and Jones, R.K. A Systems Analysis of rhe Trafic Law System: Summary Volume.
  NHTSA Report No. DOT-HS-800-640, Institute for Research in Public Safety, Indiana
   State University, October, 1971.

Kunkel, E. Driver improvement courses for drinking drivers reconsidered. AccidentAnalysis and
   Prevention 1.5(6):429, 1983.

LeClair, D.P. Use of Prison Conjinemenr for the Treatment ofMuhiple Dnrnk Driver wenders: An
   Evalumion of the Longwood Treatment Center, Bcutive Summq. Massachusetts


246

BACKGROUND PAPERS

Department of Corrections, Division of Research. Washington, DC: National Institute of
Justice, U.S. Department of Justice, 1987.

Peck, R.C.; Sadler, D.D.; and Perrine, M.W. The comparative effectiveness of alcohol rehabilita-
   tion and licensing control actions for drunk driving offenders: A review of the literature.
  Akoho& Drugs and Lkiving l(4): 1539,198s

Reed, D.S. Reducing the costs of drinking and driving. In: Moore, M.H., and Get-stein, D.R., eds.
  Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC: National
   Academy Press, 1981.

Reis, R. E., Jr. Ike Trafic Safety Eflectiveness of Education Programs for First mense Drunk
  Drivers. Final report, Comprehensive Driving Under the Influence of Alcohol Offender
   Treatment Demonstration Program, County of. Sacramento Health Department.
   Sacramento, CA California Department of Motor Vehicles, 1982.
Sadler, D.D., and Perrine, M.L.W., The Long-Tenn Traffic Safety Impact of a PilotAlcoholAbuse
   Treatment as an Alfemative to License Szqension. Sacramento, CA: California Depart-
   ment of Motor Vehicles, 1984.

Siegal, HA Intervention: A Successful Technique for Repeat offenders: Reyrt of an Evaluation,
  Alcohol LIrugs and Trafic Safety. Eighth International Conference on Alcohol, Drugs and
   Traffic Safety. Amsterdam: Elsevier, 1987.

Siegal, HA., and Moore, D. "Rehabilitating the Drinking or Drug Impaired Driver: Its Evolution
   From Education to Intervention." Paper presented at the 34th International Congress on
   Alcoholism and Drug Dependence, Calgary, Alberta, 1985.
Spiegel, D.K., and Struckman-Johnson, D.L. "1977 Interim Assessments of Drinker Diagnosis,
   Referral and Rehabilitation." Report HFL-78- 5, Human Factors Laboratory, University
   of South Dakota, July, 1978.

Stewart, K; Epstein, L.; Gruenewald, P.; Laurence, S.; and Roth, T. "The California First DUI
   Offender Evaluation Project." Final Report, Pacific Institute for Research and Evaluation,
   Walnut Creek, California, 1987.

Struckman-Johnson, D.L., and Ellingstad, V.S. "The Short Term Rehabilitation Study. Vol.111:
   Site Specific Analyses of Effectiveness." Report HFL-78-11, Human Factors Laboratory,
   University of South Dakota, November 197&z.

Struckman-Johnson, D.L., and Ellingstad, V.S. "The Short Term Rehabilitation Study. Vol. IV
   Program Level Analyses of Effectiveness." Report HFL-78-9, Human Factors
  Laboratory, University of South Dakota, November 19786.
Sweedler, B.M., and Smith, L. "The Repeat Offender Drunk Driver: Where Has the System
   Failed."Paper presented at the International Workshopon Punishment and/orTreatment
   for Driving Under the Influence of Alcohol and Other Drugs, Stockholm, Sweden, 1984.
Vingilis, E. The six myths of drinking-driving prevention.hlealth Education Research 2(2):145-149,
    1987.

Wallack, L. Practical issues, ethical concerns and future directions in the prevention of alcohol-
   related problems. Journal of Primary Prevention 4: 199-224, 1984.


Citizen Advocacy

247

Independent Citizen Advocacy:
The Past and The, Prospects

John D. McCarthy, Ph.D. and Debra S. Harvey, MA '

Depariment of Sociology and Life Cycle Institute
   The Catholic University ofAmerica

During the last decade, a widespread movement of citizen advocate groups has
emerged whose members, many of whom are victims of drunk drivers, work to reduce
the level and consequences of drunk driving. Their efforts are widely seen by a variety
of observers as having had some success. For instance, Senator John Danforth in recent
congressional hearings said of MADD,

This organization has made the public realize that drunk driving is not a
victimless crime. This change in public attitude has made it possible for those
of us in Congress and in State legislatures to pass stronger drunk driving laws.
(1988)

Franklin Zimring (1988), a consistently skeptical social observer, discussing these
local advocacy groups says, ",. the mobilization by the groups] of public opinion has been
partially responsible for the increased prominence of drunk driving as a public policy
issue" (p. 374), and goes on to say, "My guess is that citizen action groups are a more
important explanation [than others] of the passage of legislation in the 1980s" (p. 380).
Finally, Mark Wolfson (1988) concluded in his systematic evaluation of the effects of
local advocacy that the efforts of these groups positively affected State legislative
initiatives and "may have [had] some influence on fatalities" (p. 9).

Any organized effort to encourage the continued growth and vitality of this inde-
pendent citizens' movement must depend upon an adequate description and under-
standing of its emergence, the community support and attention it receives, its typical
structural forms, the personal lives of its activists, and the nature and extent of its
organized activities. It must depend, too, upon an understanding of the typical difficulties
that such movements encounter in maintaining continued high levels of citizen advocacy.

The Development of the Local Movement *

The citizens' movement against drunk driving consists of a number of different
national and local organizations. At the national level are two umbrella groups, Mothers

1  The original research described in this chapter was supported, in part, by a grant from the National
Science Foundation (SEs-8419767) and continuing support from the Life Cycle Institute at The Catholic
University of America. We thank Mark Wolfson for his continuing contributions to this research.

2  Most of the evidence upon which this description is based was gathered during the 1985-86 period and
refers to the experience within the United States. Any changes the movement has undergone since then are,
therefore, not reflected in this account.


248

BACKGROUND PAPERS

Against Drunk Driving (MADD), headquartered in Hurst, Texas, and Remove Intoxi-
cated Drivers-USA (RID), headquartered in Schenectady, New York. Both groups have
a large number of local chapters spread across many States. In addition to MADD and
RID, there are a number of regional and local citizens' groups that are not affiiated with
any national umbrella group, which we call "out.liers." After an exhaustive attempt to
generate a census of local groups, we estimate that 458 local groups, including MADD
chapters, RID chapters, and outliers, existed in 1985. The pattern of foundings of these
groups and their present distribution across the United States is described below.

Remove Intoxicated Drive; (RID). The citizens' movement against drunk driving
began in 1978. During that year, three local groups formed in New York State. These
groups were later to become affiiated with a national umbrella group, Remove Intoxi-
cated Drivers (RID), started by Doris Aiken in Schenectady, New York in 1979. In 1979,
four more groups started in New York that were to affiliate with RID. In 1980, two more
RID chapters formed, both in New York State.

In 1981,14 RID chapters formed, including four in New York. That was the first year
in which RID chapters formed outside of New York State-in Oklahoma, Mas-
sachusetts, Tennessee, New Jersey, Wisconsin, Colorado, Connecticut, Pennsylvania,
and Texas. The growth of RID peaked in 1982, when 18 new groups formed (see figure
1). As of 1985, RID had 70 active chapters in 23 States, although the majority were in
New York (22 chapters), Illinois (6 chapters), and Tennessee (5 chapters).

Mothers Against Drunk Driving (MADD). Candy Lightner and others formed a group
called Mothers Against Drunk Drivers (later to become Mothers Against Drunk Driv-
ing) in Sacramento, California, in 1980 after Candy's daughter was killed by a drunk
driver. A second MADD chapter formed in California in 1980. In contrast to RID,
MADD was quick to diversify geographically: the nine MADD chapters formed in 1981
were in California (2 chapters), Florida (2 chapters), Ohio (2 chapters), Pennsylvania,
Texas, and Kentucky (1 chapter each). The growth of MADD accelerated at a breath-
taking pace over the next few years (see figure 1). As of 1985, an estimated 377 MADD
chapters existed, with at least one chapter in every State except Idaho and Montana.
Chapters of MADD were most heavily concentrated in California (29 chapters), Plorida
(25 chapters), and Texas (26 chapters).

Orttliers. The pattern of founding of groups that are not affiliated with any national
organization has been somewhat harder to estimate. Since they are not affiliated nation-
ally, no comprehensive listing of these groups is maintained. Information could be
collected directly from only 11 groups, although this is almost certainly an underestimate
of their actual number. One outlier group, Concerned Citizens and Victims of Drunk
Drivers, of Reno, Nevada, was one of the earliest groups, having formed in 1979.

As of 1985, outliers included a number of regional coalitions, such as the Alliance
Against Intoxicated Motorists (AAIM), which is concentrated in Illinois, and Rid
Arizona of Intoxicated Drivers (RAID), which, as the name suggests, is limited to
Arizona. In all, outliers were found in Arizona, California, Illinois, Nevada, New
Hampshire, North Carolina, Oregon, Utah, and Virginia.

Thus, the citizens' movement against drunk driving began with the formation of a few
local groups, two of which developed first into primarily regional movements in New
York State and California. However, by 1985 the movement had become truly national
in scope, with an estimated 458 local groups and at least one in every State but
Montana. 3

3  We have not included certain kinds of groups that devote extensive efforts to the issue of drunk driving
in our analysis of advocacy groups. Such groups include locals of Students Against Driving Drunk (SADD)
and bt Alcohol Consciousness Concerning the Health of University Students (BACCHUS), which are,
respectively, high school and college student groups.


CITIZEN ADVOCACY

Figure 1: New Foundings and Cummulative Number of Groups by Year

249

                          0
                         0
                        0
                      0
                     0
                    0
                  0
                 /
               /
              /
             /
           /
          /
         /
       /
      I
     /
    /
  /
/
/                                mouPNPES

                                    MADD
                                  --
                                    RD
                                  -m-m__

                         YEAR

1978       1979       19BO       1981       1982       1983       1984       I.985     Total

wcx                            2         9        88        104        93        81       377

l-u!2          3         4         2        14        1B         l.2        10         7       70

Outlier                1                  1         4         3        1         1       11

lbtal         3         5         4        24       110        119       104        89      458

Patterns of Local Group Founding

The aggregate temporal pattern of local anti-drunk driving advocacy group founding
through 1985 can be seen in figure 1. Only a few groups formed between 1978 and 1980,
while a burst of foundings occurred in 1981. The peak year for new foundings was 1983,
with the number of new groups founded dropping off through 1984 and 1985. While the
rate of new group formation declined during these years, the total number of local groups
continued to expand.

The pattern of emergence of these local groups was uneven between 1978 and 1985.
Many communities lacked a local advocacy group dedicated primarily to the issue of
drinking and driving in 1985, while other communities saw a group form rather late in
the period. Our analyses (McCarthy et al. 1988; McCarthy and Wolfson 1988) of this
process indicated that neither a high rate of alcohol-related motor vehicle fatalities nor
the prior existence of an Alcohol Safety Action Project, each of which might be expected
to do so, predicted the formation of an advocacy group by 1985 in a local community.
Community size was important because larger communities were more likely to see
groups formed Bnd formed early than were smaller communities. We concluded that this
founding pattern is similar to the diffusion of other kinds of innovations (see Hamblin
et al. 1973). To the extent that common understandings concerning drinking and driving
as a soluble problem and specific models for citizen advocacy are available, the more
citizens in any community, the more likely a local group will emerge. Given that most
groups are formed by a single highly motivated individual, family, or small cluster of
friends, group foundings are quite unpredictable events.


250

BACKGROUND PAPERS

Some observers have interpreted the decline in the rate of founding new local groups
to mean that this movement has begun to lose its vitality and general community support.
We interpret the pattern, however, to reflect the natural limit on new group formation.
First, the majority of large American communities had a local group in 1985. Second,
MADD has limited new group formation, to a single group in each county, with a few
exceptions. Finally, many local groups see the commnnity they serve as broader than just
the city or county where they reside. Our anafysis showed that, in 1985,55 percent of the
American population lived in a county which had a local advocacy group; 67 percent
lived in a county in which such a group recruited members; and 95 percent lived in a
media market that included such a group (McCarthy et al. 1987). These figures strongly
support our assessment that local groups had come close to saturating local communities
across the United States by 1985.

Patterns of Local Group Dissolution

Many emergent local advocacy groups do not get off the ground, and others leave
almost no trace after very short corporate lives. Our analyses were based upon groups
which existed during 1985. As a result, we have no information on those groups that
emerged earlier but failed to survive, although we estimate a 5- to 25-percent failure rate.
Frank Weed (19%) found a failure rate of about 20 percent for local MADD chapters
over the 25 months ending in June 1987. This rate is consistent with our upper limit
estimate. Weed's analysis showed, similar to studies of other types of local groups
(Freeman et al. 1983), that younger groups fail at much higher rates than older groups.
He also found that groups with more independent local leadership and with wider and
deeper local community support were more likely to survive than groups without these
features.

The population of local advocacy groups addressing drunk driving in any period, then,
is the result of previous patterns of group founding and group dissolution. As a conse-
quence, any effort to maintain a large number of active groups in this movement requires
an understanding of the processes of both organizational formation and dissolution.

Community Support and Public Attention

Strong, consistent national governmental support is demonstrated in several ways,
including the efforts of the Presidential Commission on Drunk Driving, wide congres-
sional support for legislation such as encouraging States to raise the drinking age and to
employ "administrative revocation," and Federal executive agency initiatives on drunken
driving demonstrate consistent and strong nationa governmental support. Local group
leaders report wide and deep community-level support for their efforts. The national
and local media attention to the issue of drunk driving and the activities of citizen
advocates has been extensive as well.

National and Local Support

Several notable aspects of national and local support exist. One is the flowofresonrces
from Federal Agencies to local citizens' groups. Such resources can be expected to
increase the local capacity to mobilize around the issue. These resources take several
forms.

1. Literature designed to help organize a local citizens' group against drunk driving
has been produced and widely disseminated by the National Highway Traffic
Safety Administration (NHTSA) (1982, 1983). One packet of materials con-
sisted of well-organized and simply presented steps to be followed and goals to


CITIZEN ADVOCACY

251

be pursued in beginning a local citizens' group. Analysis of information col-
lected from local groups suggested that nearly 80 percent of them received some
of the literature they used in their activities in 1985 from NHTSA (McCarthy et
al. 1987).

2. Financial support has been provided to local groups attempting to organize
around the drunk driving issue. During the early days of the movement, NHTSA
provided funds to support the development of a few local citizens' organizations
(Mann 1983). Since then, NHTSA has continued to provide some level of
indirect support. This is evident, for example, in NHTSA's 1984 budget which
requested the appropriation of funds for

Citizen Support: generating community support for comprehensive
programs, thus providing a political base for increased counter-
measure activity. As shown recently in New York, Maryland, West
Virginia, California, and elsewhere, an organized and informed
body of individuals can bring about major change in State laws and
alcohol programs. (NHTSA 1984)

This description of the activities of NHTSA makes clear its practice of en-
couraging the growth of citizens' groups focusing on the drunk driving issue.

3.  Extensive efforts were made by a number of Federal Agencies, especially the
National Institute on Alcoholism and Alcohol Abuse (NIAAA) (Vejnoska
1982), to create networks of citizens concerned about drunk driving and to
encourage them to organize. In addition, NHTSA, in concert with the National
Safety Council and others, has continued to help organize the annual
"Lifesavers" conferences that bring together local activists; Federal, State, and
local officials; industry representatives; and researchers.

4.  Early organizers of the anti-drunk driving movement were employed by NHTSA
to generate local activity and additional technical support (Golden 1983).
5. The ongoing regional workshops for local advocacy groups sponsored by
NHTSA continue one important form of national support for the movement.

The national public opinion evidence also shows widespread support for the general
goals of these advocates. In 1977,84 percent of the American population agreed with
the statement. "There should be stricter laws on drinking and driving;" and in 1982,92
percent of the population agreed with that statement (Public Opinion 1983). In June of
1984, almost 80 percent of the American population favored a national law raising the
legal drinking age to 21 years, and even larger majorities of people over the age of 30
supported such legislation. In 1984,30 percent of the public favored laws fining drivers
and front seat passengers $50 for not wearing seat belts (Gallup Poll 1984). Even broader
support was shown for such laws among younger citizens.

A national telephone survey of adults carried out for MADD by a research and
consulting firm (Epilon 1985) provided additional evidence of the wide public support
for this movement. Large majorities of the respondents believed that MADD:
       - should be involved in victim assistance programs (81 percent),
       - should be involved in promotingprevattive legislation (77 percent),
       - should be involved in promotingpwtirive legislation (83 percent),
       - should be involved in reviewing court decisions (67 percent),
       - should be involved in educating youth (92 percent), and
       -  should be involved in educating the public at large (90 percent).
Finally, leaders of the local group reported widespread contact and support from
local community organizations. Groups working on drinking and driving issues came into
contact with a wide variety of individuals and groups, but primarily with the local police,


252

BACKGROUND PAPERS

the central offices of MADD and RID, high schools, judges, andstate police. Numerous
contacts were also reported with churches, legislators, civic groups, and NHTSA. More
than 85 percent of the leaders reported that, overall, their communities supported their
activities and goals. Over half the groups reported that the State and local police,
NHTSA, the national central offices, and other MADD groups were very supportive.
Churches and high schools were seen as very supportive for about half of the groups.

When asked to choose the community organization that had been the most suppotive
of their work, leaders overwhelmingly chose the local police and the State police. After
police, the most supportive groups were the central of&es of MADD or RID. Both
offices have worked closely with their local groups, providing support and advice. Local
prosecutors were also seen as the most supportive by a large number of groups.

Only a few local groups have opposed the work of the anti-drunk driving advocates,
and even these groups (e.g., bar and restaurant owners, alcoholic beverage distributors
and retailers, and the trial lawyers bar) were mentioned as being antagonistic by only a
small minority of local leaders. Moreover, opposition to the movement tends to be issue
specific. For example, representatives of the beer industry actively opposed the efforts
of these groups in some States to pass 21-year-old drinking age legislation (Wolfson
1988). Nevertheless, this opposition does not extend to the overall goal of the move-
ment - the reduction of drunk driving- nor to many of its specific objectives that do not
threaten the economic interests of the industry. In fact, segments of the beer industry
have at times provided resources, in the form of literature and financial support, to some
of the local groups, and have recently supported national legislation aimed in part at
facilitating administrative revocation of drivers' licenses (Rumbaugh 1988).

National and Local Media Attention

Access to the mass media, in particular to print and broadcast news, is an import
resource for any advocacy movement. The mass media represent a potential mechanism
for "communicating with movement followers, reaching out to potential recruits,
neutralizing would-be opponents, and confusing or otherwise immobilizing committed
opponents" (Molotoch 1979, p.71). Knowing this, advocates invest extensive effort in
attempting to gain positive coverage of their issue and their advocacy.

We have been systematically monitoring national and local print media coverage of
the drinking and driving issue. We obtained counts of the number of national newspaper
stories devoted to the issue from the National Newspaper Index, 1979-1987, which
indexes stories in Tire Christian Science Monitor, l7ze Los Angeles Times, T&e New York
lTmes, TIte WaN Street Journal, and The Washington Post. We obtained counts of
periodical stories on drunk driving from Magazine Indexes, 1979-1987. This data base
consists of an index of 370 popular periodicals. Our local newspaper counts of drunk
driving stories were obtained from Newsbank, a service that indexes more than 500 daily
newspapers, including at least one in every State of the United States.

Figure 2 shows the trends in coverage of the drunk driving issue derived from these
three sources between 1979 and 1987. The peak year of coverage for each type of print
medium was 1983. Coverage of the issue declined quite consistently after 1983. It is
unknown whether this trend was also reflected in local and national broadcast media.
Nevertheless, the decline in coverage can be seen as handicapping efforts by advocates
to generate continuing community awareness of the issue of drunk driving. Whether the
trend reflects declining vitality among advocate groups or is responsible for increasing
alcohol-related fatalities, as some (Stevens 1987, Dukakis 1988) have suggested, cannot
be easily determined.

We asked local leaders to give us their evaluations of the extent of media coverage of
the drunk driving issue in their communities. We also looked at the local newspaper
coverage in 96 communities. Both perceptions of the level of local coverage and actual


CITIZEN ADVOCACY

Figure 2: Print Media Coverage of Drunk Driving

200

lm                                            ---
        /----- c_------------____ -------
   -      -e--
02
1979     1980      1981      lQ62     1903      1964     l905     1906      1907

253

wa.L-
--
NATIoN*L-
s-----

YEAR

          1579     1980     1981     1982      1983     1984     1985     1986     1987
laxal
Nevspa;le=     63      94       223     395       423       411      331      224      163

Natimal
-papers     17       3       17      El.      169       162       76      68       58

Fericdids     3       1       13      35       50       42       36       26       29

print coverage were strongly related to how active the local group was in attempting to
get such coverage. We also found that the more general community support the leaders
saw, the more support they saw from the media. Activities related to getting media
attention were fundraisers, speeches, and an active membership (as opposed to groups
primarily dependent upon leaders). Likewise, when the news was perceived favorably,
the leaders reported high levels of recruiting from media sources.

Local Groups, Activists, and Activities

Information gathered from local advocacy groups across the country allowed us to
describe their typical dimensions and the characteristics of their leaders. While a few of
the groups were very large and resource rich, the typical group was small, with an average
of 35 members and a mailing list of 100 names. About six people beyond the leaders did
volunteer work for the typical group during an average month. Seventy percent of the
groups had annual revenues of $2,500 or less in 1985, with the median revenue being
$1,229.

Most of these local groups relied primarily on leaders, volunteers, and donations of
money and other resources (e.g., telephones, postage, and supplies) to carry on their


254

BACKGROUND PAPERS

work. Though they were widely supported by their communities (Ungerleider et al.
1986), they depended primarily upon their members for labor and financial support
(Weed 1989). G iven that we have counted more than 450 groups, this adds up to about
2,250 leaders, 2,700 regular volunteers, 15,750group members and45,OOO people on local
mailing lists in 1985.

The profile of the typical activist in this movement was quite similar to activists in
other advocacy movements (Verba and Nie 1972; Eitzen 1970). Because of the size of
the groups, the officers typically did much of the work. Not surprisingly, the typical
chapter officer was a woman. She either did not work outside of the home or worked
part-time. Often she was married with school-age children at home. Though all officers
tended to be highly involved (Weed 1987), the chapter president tended to be the most
active (McCarthy, et al. 1987). She was, typically, about 43 years old and had had some
college education. Weed (1987), in his survey of the MADD chapters, wrote "Presidents
were less apt to be in the labor force that other officers, and when they were employed
they tended to hold slightly higher status jobs" (p. 265).

Victims were heavily represented in all leadership positions in local groups, but the
presidents were the most likely to report being victims (McCarthy et al. 1987). About
one-fourth of the typical local group members were victims. The majority of presidents
were also at least partly responsible for starting the organization. This was consistent
with other studies (Weed 1987; Ungerleider et al. 1986) on the leaders of MADD
chapters. Further, many leaders were already involved in other volunteer groups. This
led Weed to conclude that "MADD tends to be run by activists who have been victimized
rather than victims who have become activists" (1988b, p. 19).

The most important program emphases at the local level were public awareness, youth
education, and attitude change on the issue of drunk driving (McCarthy et al. 1987).
Victim support and changing laws were emphasized less, as was recruiting new members.
When asked to rate the program area in which they were most successful, the leaders
overwhelmingly chose public awareness and changing public attitudes. About a quarter
of the groups indicated that they had been very active in attempting to change laws during
1985. The groups used activities such as candlelight vigils, public booths, project gradua-
tion,4safe rides, and poster contests extensively. Leaders spoke widely and gained
substantial access to the broadcast media.

The Structure of the National Movement

National advocacy movements exhibit wide variations in form. Some, for instance,
have very large and strong national advocacy operations but very little organized, local,
grassroots strength, while others have the obverse. In some movements, local groups are
under the very close control and supervision of a national organization, while in others,
these ties are very weak. Figure 3 represents the national structure of the citizens'
movement against drunk driving in 1985. Both RID and MADD national offices
provided support services of many kinds to their local groups, although MADD had
substantially more resources for doing so. Both groups had organized intermediate levels
of coordination at the State level. The formal tie between MADD national and local
groups was, at least in theory, tighter than that between RID groups because of the
Internal Revenue Service status of MADD. Each local group was a subgroup of a single
national 5Ol(c)3 organization. This status meant that the national organization bear some
level of financial responsibility for local groups. Frank Weed reported that "The opera-

4  Project graduation is a variety of activities that may include offering high school students free rides to
and from graduation parties or arranged overnight lodging to sponsoring alternative alcohol-free parties.


CITIZEN ADVOCACY

255

Gcoqraphicsl
Level of
Ornanitat ior2

National

Figure 3: The Structure of the National Citizens'
Advocacy Movement Against Drunken Driving

state

Local
Cl-OUPS

Emup Structure

tions of the local chapters are virtually autonomous and the central office of MADD has
some difficulty getting reports from all its chapters in a clear and timely manner" (1987,
p.7). Local RID chapters, on the other hand, were not linked to RID national in this way,
and each group made its own decision about its I.R.S. status. In fact, in 1985, the majority
of local RID groups, as well as the outliers we contacted, had already received or had
applied for formal nonprofit status.

Regardless of the formal nature of the tie between locals and nationals, however, local
leaders reported extensive contacts and high levels of support from their national group
as well as from State coordinators where they existed. Likewise, lateral contacts and
support were common at the grassroots level; that is, local leaders reported high levels
of contact and support from other local groups working on the drinking and driving issue
in their areas regardless of the national affiliation of the other group. The majority of
local leaders reported some contact with local SADD groups, and about a third reported
extensive contact (McCarthy et al. 1987).

The major strength of the anti-drunk driving advocacy movement lies in its extensive
local groups. Weed's analysis of the failure of local MADD chapters between 1985 and
1987 demonstrated that local groups are more likely to survive when they are more
independent of the central office on operating policies but cooperative in carrying out
common activities (198&).This suggests that the typical fierce independence of the local
groups throughout this movement is also one of its major strengths.

Lessons from Independent Citizen
Advocacy Movements

Observations across many citizen advocacy movements make obvious the difficulties
in predicting their emergence and their ebbs and flows. Many thousands of fatalities in


256

BACKGROUND PAPERS

alcohol-related automobile crashes occurred, for instance, before the first citizen a.d-
vocacy group emerged to address this problem. It took the development of a widespread
belief that the number of these incidents could be reduced by collective efforts before
local groups began to form (Gusfield 1975, 1981). The continuing formation of new
groups, the continuity of older groups, and the perseverance of the individual activist
leaders and volunteers who staff them depend-upon a variety of factors beyond the
objective extent of the drinking and driving problem itself. These factors are central to
an understanding of how advocacy movements grow and decline. A number of them are
particuldy important for assessing the future prospects for growth, stability, or decline
of the citizens' advocacy movement against drunk driving.

~crivisr lives. Few activists understand the potentially massive Ievel of commitment of
time and energy they are making when they begin their advocacy careers. We know
(McCarthy and Zald 1977; McAdam 1987) that one's ability to devote such large
amounts of time to advocacy are, for most people, constrained by other obligations such
as jobs and parenting. Movements that depend on leaders who have little availabIe time
to devote to activism are handicapped. The drunk driving movement benefits from its
heavy reliance upon women leaders who do not work outside the home. Our research
showed that local leaders who were employed full-time devoted substantially less time
to the activities of their local group than those who were not. Having children in the home
did not seem to hinder activism in this movement, however, since many of the local groups
were physically based in the home of the president and integrated family members into
the activities of the group (Harvey and Wolfson 1987).

nle temporal and spatial dimensions of victimhood. Most advocacy movements form
around a commonly timed victim experience. The citizens' movement that formed in
response to the Three Mile Island nuclear "accident," for instance, depended upon many
citizens responding in unison to a common event (Walsh and Warland 1983). Such
movements experience common cycles of increasing and then declining enthusiasm
among victim activists. The anti-drunk driving movement, on the other hand, given the
discrete and disconnected nature of the victim experience, can expect to see a constant
replenishment of the pool of new victims who might become activists. This is so because
alcohol-related fatalities continue at high rates in most communities. To the extent that
new pools of victims and other concerned citizens can be integrated into the activities of
ongoing local advocacy groups, this movement should transcend the pattern of decline
that results from the typical common timing of victimization.

Bureaucratization and goal displacement. A typical pattern of transformation charac-
terizcs the history of many citizen advocacy groups. As such organizations acquire more
and more resources, leaders, who have a financial and personal stake in their operations,
begin to lose track of their original goals (Perrow 1979). This pattern is especially likely
to result from wide success. At the local level, the citizens' movement against drunk
driving seems likely to avoid these consequences since most groups depend almost
exclusively upon volunteer labor and are resource poor. Our evidence in 1985, however,
showed that the vast majority (72 percent) of the presidents of the local groups were
original group founders (McCarthy et al. 1987). Since most of the groups were thenvery
recently founded, this may not represent a problem of too long-entrenched leadership.

Cenfralization and decentralization. A lively debate continues among observers of
citizens movements about the relative advantages and disadvantages of decentralized
and centralized organizational structure (Gamson 1975; Piven and &ward 1977).
Centralization allows more national coordination and the concentration oflocal energies
toward common goals. However, it has the disadvantages of bureaucratization described
above. But decentralization-that is, a movement composed of quite autonomous local
groups -has certain advantages, too (Gerlach and Hine 1970). Most important is the
likelihood of more creative innovation in goals and tactics. If a centralized organization
undertakes an innovative campaign that is poorly conceived, an entire movement can
suffer the consequences. This is part of the reason why large, national advocacy groups


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257

become cautious. However, if an autonomous local organization does SO, the costs of its
failure are minimal. If such innovation is successful in one locale, it can be tried in others.
This way, new successful forms and goals of advocacy spread rapidly across local groups.
Another advantage of decentralization is that an entire movement is less responsible, in
the eyes of the public and potential supportive groups, for "rogue" locals, that is, focal
groups that deviate widely from the common goals and tactics pf the larger movement.

The movement against drunk driving is highly decentralized in comparison with many
other advocacy movements. This feature of its structure seems to have been responsible,
in part, for the constant development of new programs and approaches in local com-
munities. To the extent that solutions to the problem of drinking and driving can be
achieved at the local and State levels, its decentralized form can be seen as an advantage.
To the extent that solutions to its problems lie at the nationaI Ievel, this feature of its
national structure may represent a disadvantage.

Support by tzomictims. Many advocacy groups are made up, primarily, of individuals
who are not the direct victims of the problem for which the groups seek solutions. At the
grassroots level, the drunk driving movement is, as we have seen, heavily peopled by
victims. To the extent that their commitment to continued efforts for solutions to the
problems of drinking and driving are greater than nonvictims, this movement will benefit
from such heavy levels of victim involvement.

Likewise, the range and level of support by elite groups is crucial to the success of
advocacy movements. This movement has benefited greatly from the strong support of
such outside groups as we have shown, and, probably, would have been far less vital
without that extensive support. NHTSA has continued to be supportive in many ways.
The annual "Lifesavers" conference, supported by a number of outside groups, has been
important in networking local leaders with one another as well as with researchers, police
representatives, and industry supporters, especially insurance companies, which have a
special stake in the issue of drinking and driving. To the extent that the past levels of
such support continue, this factor suggests that the movement will not decline in vitality.

Media cycles alld adwcacy morpemertt cycles. Many factors contribute to under-
standing the extent of media coverage of any issue at a particular time. These include,
importantly, major events that focus attention on the issue, concerted campaigns to focus
attention on the issue by advocates, and processes internal to the production of the media
outcomes themselves. Consequently, media attention to any social issue does not neces-
sarily reflect its objective importance or the strength and efforts of the advocates
concerned about the issue (Graber 1984). The rapid decline in print media attention to
drinking and driving during the last several years, therefore, does not necessarily reflect
a decline in public concern about the issue or a declining effort by local groups to
continue to generate public awareness around the issue.

Cycles of media attention lie the one we see here are typical and have drawn the
attention of many observers. Anthony Downs (1972) argued that social problems will
suddenly become prominent, grasp the public attention for a short time, and then
gradually lose public attention. This cycle, he explained, is embedded in the nature of
both problems and media. Problems, once understood, are difficult to solve. And, since
the public consumes news partially as entertainment, a problem must be exciting, and
continue to be exciting, to maintain the public's interest.

Our research, which linked the extent of local leaders' activities in 1985 to the extent
of local print media coverage in their communities in 1985, demonstrated that the more
effort local leaders invested in attempting to gain such coverage of the issue, the more
coverage they actually got. Yet, to the extent that the declining media attention to the
issue of drunk driving is the result of general processes of media coverage rather than
the level of effort and skill of advocates to bring the issue to public attention, it will be
more difficult to reverse the cycle we have observed.


258

Consensus and conflict. Most advocacy movements meet substantial public and
organized opposition. The anti-drunk driving movement is unusual in that it has achieved
wide and deep support for its goals. But advocacy movements can rapidly gain or lose
public support depending upon how they frame the issues and propose their solutions.
For instance, Lo (1984) explained how the previously unpopular advocates for property
tax reform in California altered their goals'and, as a result, became the successful "tax
revolt" movement.

The anti-drunk driving movement could easily frame its goaIs in ways that wouId
substantially narrow the breadth of its community support. If it is seen as a
"prohibitionist" movement, declining support could be expected. The Epsilon Survey
(1985) presented evidence showing that citizens who perceived the movement as "anti-
alcohol" were far less likely to support its instrumental goals than those who viewed it
otherwise. Most organized elements of the movement have insisted on defining the issue
of drunk driving to preclude public perceptions of "anti-alcoholism." To the extent that
this framing of the problem continues to dominate the goals and rhetoric of the
movement, it will probably continue to garner the wide and deep community support it
has seen in the past.

Encouraging Advocacy Movements

Individuals and organized groups can facilitate or, alternatively, attempt to inhibit,
the efforts of advocacy groups (Marx 1979; Wolfson 1989). Members of the general
public, governmental actors, and representatives of all types of private groups at the
national, State, and local level have many avenues for encouraging or discouraging the
efforts of advocacy movements. The effectiveness of such efforts depend, in an important
part, upon the characteristics of the movement in question, such as its organizational
form, its level and location of community support, its leaders, and its typical tactical
approaches.

The three main types of facilitating efforts aim at (1) increasing the level of general
community support, (2) indirectly improving the opportunities for organized advocacy
efforts, and (3) making direct support available to organized advocacy groups. Each type
of facilitation has been common in the movement against drunk driving. Examples of
specific forms for each type follow.

   0  Creating general community support for

           -  Advocacy and advocacy groups
           -  Concern for the general issue
           - Specific goals of advocacy (e.g., "administrative revocation")
           - Specific advocacy actions (e.g., a Surgeon General's
        Conference)

   o  Indirectly improving advocacy effectiveness

           -  Make general models for advocacy available
           -  Facilitate communication among advocates
           - Set broad legislative and regulatory agendas
           -  Provide new opportunities for advocacy (e.g., task forces)

   o  Direct support of advocacy

           -  Provide useful materials (e.g., literature)
      - Provide expertise
           -  Provide training (e.g., use of volunteers)
           -  Provide direct support (e.g., money or space)


CITIZEN ADVOCACY

259

These examples of specific forms of facilitation of advocacy do not exhaust the
possibilities. Conclusions about the most effective relative mix of the three types of
facilitation and their most effective specific forms for the citizens' movement against
drunk driving demand serious deliberation.

REFERENCES

Danforth, J.C. "Hearing on S. 2.549, The Drunk Driving Prevention Act of 1988." Statement
  presented at the Senate Committee on Commerce, Science and Transportation, Con-
   sumer Subcommittee, August 2,1988.

Downs, A. Up and down with ecology - The `Issue-Attention Cycle'. Public Interest 2838-50,
    1972.

Dukakis, M.S. No holds barred (Letter to the Editor). Boston Magaike lO:February, 1988.
Eitzen, D.S. A study of voluntary association members among middle<lass women. Rural SocioG
   ogy 35:84-91, 1970.

Epsilon. Chapter Survey Research for Mothers Against LIrunk Driving. Burlington, MA: Epsilon
   Market Research and Analysis, 1985.

Freeman, J.; Glenn, R.; Carroll, M.; and Hannan, T. The liability of newness: Age dependence in
  organizational death rates. American SociologicalReview 48:692-710, 1983.
Gallup Poll. Support 21-year drinking age law, seat belt usage on the increase. Guihlp Poll
   226(July):2-8, 1984.

Gamson, WA. 77le ScraregV qfSociolProtest. Homewood, IL: Dorsey, 1975.
Gerlach, L.P., and Hine, V.H. People, Power, Change: Movements of Social Transformation.
   Indianapolis, IN: Bobbs-Merrill, 1970.

Golden, S. Driving the Drunk Off the Road. Washington, DC: Acropolis Books, 1983.
Graber, D.A. Mus Media and American Politics. Chicago, IL: Congressional Quarterly Press,
    1984.

Gusfield, J.R. Categories of ownership and responsibility in social issues: Alcohol abuse and
   automobile use. Journal of DrugIssues .S(Fall):285-303, 1975.
Gusfield, J.R. The Culture ofPublic ProblemxDrinking-LIrivingand the Symbolic Order. Chicago:
   University of Chicago Press, 1981.

Hamblin, R.; Jacobsen, R.B.; and Miller, ,J.L.L. A Mathematical Theory of Social Change. New
   York: Wiley, 1973.

Harvey, D.S., and Wolfson, M. "Influences on the Commitment of Social Movement Activists."
  Paper presented at the Annual Meeting of the DC Sociological Society, Arlington, VA,
    1987.

Lo, C.Y.H. Mobilizing the tax revolt: The emergent alliance between homeowners and local elites.
  Research in Social Movements, Conflicts and Change 6293-328, 1984.
Magazine Indexes. Menlo Park, CA: Information Access Corporation, 1979-1987.
Mann, P. Arrive Alive. New York: Woodmere Press, 1983.
Marx, G.T. External efforts to damage or facilitate social movements: Some patterns, explanations,
  outcomes and complications. In: Zald, M.N., and McCarthy, J.D., eds. The Dynamics of
   Social Movements. Cambridge, MA: Winthrop, 1979. pp. 94-125
McAdam, D. Structural and attitudinal factors in recruitment to high risldcost activism. American
   Journal of Sociology 92( 1):64-90, 1987.

McCarthy, J.D., and Wolfson, M. "Exploring Sources of Rapid Social Movement Growth: The
   Role of Organizational Form, Consensus Support, and Elements of the American State."
   Paper presented at the Workshop on Frontiers in Social Movement Theory, University of
   Michigan, Ann Arbor, MI, June 8-l 1, 1988.

McCarthy, J.D., and Zald, M.N. Resource mobilization and social movements: A partial theory.
   American Journal of Sociology 82(6):1212-1241,1977.
McCarthy, J.D.; Wolfson, M.; Baker, D.P.; and Mosakowski, E. The founding of social movement
  organizations: Local citizens' groups opposing drunken driving. In: Carroll, G.R., ed.
  Ecological Models of Organizations. Cambridge, MA: Ballinger, 1988. pp. 71-84.
McCarthy, J.D.; Wolfson, M.; and Harvey, D.S. "Chapter Survey Report: Project on The Citizens'
  Movement Against Drunk Driving." Washington, DC: Center for the Study of Youth
   Development, Catholic University of America, 1987.


260

BACKGROUND PAPERS

Moiotoch, H. Media and movements. In: Zaid, M.N., and McCarthy, J-D., eds. The Dynamics of
   Social Movements. Cambridge, MA Winthrop, 1979. pp. 71-93.
National Highway Traffic Safety Administration. National Highway Traffic Safety Administrution
  .Budget Estimates, F&xi Year 1985, Submission to the office of the Secretary. 1984.
National Highway Traffic Safety Administration. Who's Going to Call the First Meeting?Action
  GuideforLocalDrunkDrivingPrograms. Washington, DC: Supt. of Dots. U.S. Gov. Print.
   Off., 1983.

National Highway Traffic Safety Administration. How to Save Lives and Reduce Injuries:A Citizen
  Activist Guide to Effective~FightDrunkDriving, by Sandy Golden. Washington, DC: Supt.
   of Dots. U.S. Gov. Print. Off., 1982.

National Highway Traffic Safety Administration. Results of National Alcohol Safety Action
  proiecrs. Washington, DC: the Administration, 1979.
National Newspaper Index. Menlo Park, CA: Information Access Corporation, 1979-1987.
Newsbank. New Canaan, CT: Newsbank, 1979-1987.
Perrow, C. Complae Orgunilatiom: A Critical Essay. Glenview, IL: Scott, Foresman, 1979.
Piven, F.F., and Cloward, R.A Poor People's Movements: Why They Succeed and How They Fail.
   New York: Pantheon, 1977.

Public Opinion. Opinion roundup. Public Opinion (April/May):30,1983.
Rumbaugh, R. "Hearing on S. 2549, The Drunk Driving Prevention Act of 1988." Statement
  prepared for Senate Committee on Commerce, Science and Transportation, Consumer
   Subcommittee, August 2, 1988.

Stevens, W.K. Deaths from drunken driving increase." New York Times October 29, 1987.
Ungerleider, S.; Bloch, Sk; and Conner, R.F. Reportfrom the Drunk Driving Prevention Project.
   Eugene, OR: Integrated Research Services, 1986.
Vejnoska, J. Voluntarism: Rich heritage of the alcohol field. Alcohol Health and Research World
   6:4-7,36-40,1982.

Verba, S., and Nie, N.H. Participation in America Political Democracy and Social Equality. New
   York: Harper and Row, 1972.

Walsh, EJ., and Warland, R.H. Social movement involvement in the wake of a nuclear accident:
   Activists and free riders in the TM1 area.American Sociological Review 48:764-780,1983.
Weed, FJ. Grass-roots activism and the drunk driving issue: A survey of MADD chapters. Law &
   Poticy 9:259-278,1987.

Weed, FJ. "Factors Related to Failure in Small Activist Organizations.".Paper delivered at the
   annual meetings of the Southern Sociological Society, Nashville, TN, 1988u.
Weed, FJ. "The Role Played by Victim-Activists in the Anti-Drunk Driving Movement." Un-
   published paper, Department of Sociology, University of Texas at Arlington, 19m.
Weed, FJ. The impact of support resources on local chapter operatins in the drunk driving
   movement. i%e Sociology Quarterly 30(March), 1989.
Wiener, C. The Politics of Alcoholism: Building an Arena Around a Social Problem. New
   Brunswick, NJ: Transaction Books, 1981.

Wolfson, M. "The Consequences of Asocial Movement: An Organizational Analysis of the Impact
   of the Citizens' Movement Against Drunken Driving." Unpublished Ph.D. dissertation,
   Department of Sociology, Catholic University, Washington, DC, 1988.
Wolfson, M. The citizens' movement against drunken driving and the prevention of risky driving:
   A preliminary assessment. Alcohol; Drug and Driving 5( 1):73-84, 1989.
Zimring, F.E. Law, society, and the drinking driver: Some concluding reflections. In: Laurence,
   M.D.; Snortum, J.R.; and Zimring, F.E., eds. Social Control of the Drinking Driver.
   Chicago, IL: University of Chicago Press, 1988. pp. 371-384.