The use of safety belts has long been considered an effective way to reduce deaths and injuries on the nation’s highways. The Department of Transportation (DOT) estimates that 10,000 additional lives could be saved annually if all of the occupants of motor vehicles used safety belts. Safety belt technology has existed for more than a century, but belts were not installed in new cars sold in the United States until the mid-1960s. Even after the belts were available, relatively few people used them. In 1984, New York became the first state to enact a law mandating the use of safety belts. Other states soon enacted similar laws. Currently, 48 states and the District of Columbia have some form of law on using belts. DOT’s National Highway Traffic Safety Administration (NHTSA) has estimated that safety belt use increased from 11 percent in 1982 to 67 percent in 1994. More than 40,000 people have died in traffic accidents in the United States almost every year since 1960. In 1966, 50,894 fatalities occurred on the highways; in 1994, about 40,700 people died. Although crashes of airplanes and trains receive more attention from the media, the number of highway fatalities far exceeds those that occur in all other modes of transportation combined. NHTSA estimates that annually about 20,000 occupants of motor vehicles die in crashes while not using about 600,000 occupants are injured in crashes while not using safety more people are killed or seriously injured in road crashes than are the victims of crimes, and traffic crashes cost society over $130 billion annually. NHTSA estimates that from 1982 through 1994, 65,290 lives were saved by safety belts, and about 1.5 million moderate to critical injuries were prevented. Despite these successes, enormous costs are still generated when people do not use safety belts. NHTSA reported in June 1994 that not using belts results in 10,000 deaths and 200,000 moderate to critical injuries annually. NHTSA estimates that these deaths and injuries cost society $20 billion annually in medical costs, lost productivity, and other injury-related expenses. Safety belts were developed in the 1880s to keep people from bouncing off horse-drawn buggies. However, automobile manufacturers did not offer safety belts in vehicles until the 1950s. In 1961, a few states required that belts be installed in the new cars sold in their states. In 1962, manufacturers began to install safety belt anchorages at the factory, making it easier for car dealers or owners to add safety belts later. In 1964, U.S. manufacturers began making safety belts standard equipment in the front seat of their cars. Various analyses have been conducted to show what happens to belted and unbelted occupants of vehicles involved in crashes. Figure 1.1 shows how a steering wheel, instrument panel, and windshield absorb crash forces affecting an unbelted dummy. In May 1992, we reported the results of various studies on the effectiveness of safety belts, laws on the mandatory use of belts, and the costs of not using belts. These studies showed that using safety belts generally reduced the rates of both fatalities and serious injuries by 50 to 75 percent in crashes involving motor vehicles. The studies also showed that state laws on safety belt use reduced both fatalities and serious injuries by 5 to 20 percent, even though the use of belts was relatively low during the periods in which these studies were performed. Most studies that addressed hospital costs reported that the crash victims who had used belts averaged 60 to 80 percent lower hospital costs than those who had not used belts. The studies also found that the occupants not using belts who were injured in crashes paid less than one-half of their hospital costs, since most of the costs were paid through insurance premiums or Medicare and Medicaid. The tax-supported programs paid between 8 and 28 percent of the hospital costs. The Congress and federal agencies have encouraged the installation and use of safety belts since the mid-1960s, and the states began enacting laws on safety belt use in the mid-1980s. Under the initial federal efforts, safety belts were required to meet minimum standards. Since few occupants of vehicles voluntarily used manual safety belts, DOT issued a rule in 1984 mandating that passive restraints—automatic safety belts and airbags—be phased in beginning with 1987 model year cars. Under the rule, the installation of passive restraints could be avoided if states representing two-thirds of the U.S. population enacted satisfactory laws mandating safety belt use. This provision focused attention on mandatory use laws and prompted automobile manufacturers and others to provide funding and support for such laws. The first state law mandating safety belt use was enacted in New York in 1984; by 1986, a total of 22 states and the District of Columbia had such laws in effect. Since DOT’s data showed little increase in safety belt use between 1987 and 1990, the Congress acted in 1991 to again focus attention on increasing the use of safety belts. The Intermodal Surface Transportation Efficiency Act of 1991 (ISTEA) (P.L. 102-240) included financial incentives—grants and penalties—to encourage the states to enact basic safety belt laws and increase belt use. ISTEA provided for grants for up to 3 years to those states that had laws mandating safety belt use and that achieved minimal levels of belt use. The grants totaled $12 million per year for fiscal years 1992 through 1994. ISTEA also required those states that did not have basic safety belt laws to transfer up to 3 percent of their federal-aid highway funds to their state highway safety programs. Maine and New Hampshire are the only states that do not have laws on safety belt use. This report’s objectives were to determine (1) the nation’s progress in achieving goals for the use of safety belts, (2) the strategies used most successfully by some states to increase safety belt use, and (3) federal strategies that could help increase this use. Our work was requested by the Chairman and Ranking Minority Member, Subcommittee on Transportation and Related Agencies, House Committee on Appropriations. To conduct our work, we visited NHTSA’s headquarters in Washington, D.C., the agencies responsible for highway traffic safety programs in 10 states (California, Colorado, Idaho, Maryland, Mississippi, New Hampshire, New Jersey, New York, North Carolina, and South Carolina), and the seven NHTSA regional offices with responsibility for the 10 states. We judgmentally selected the 10 states to include a cross section of state safety belt programs. In making our selections, we considered whether a state’s survey on safety belt use had been approved by NHTSA, whether the state had a law on safety belt use involving primary or secondary enforcement, the fine the state assessed for noncompliance with the law, the state’s reported rate of safety belt use (so that we selected states with relatively high and low use), and the period in which the state’s last survey on safety belt use had been conducted. At NHTSA and the state agencies, we obtained and reviewed pertinent documents and discussed activities concerning safety belts with officials. More specifically, at the various locations, we obtained and reviewed pertinent documents, including NHTSA’s Regional Action Plans and the states’ Highway Safety Plans, which described the state’s strategies for increasing the use of safety belts and provided information on past successes; reviewed materials developed for public information and education campaigns and for community-based traffic safety programs; discussed with state officials what the federal government is currently doing to increase safety belt use, what is and is not working well, and what changes are desirable; reviewed appropriate laws and regulations and other relevant documents; reviewed the methodologies NHTSA used to calculate the rate of seat belt analyzed the methodologies used in state surveys to determine whether the states were consistent in how the surveys were planned and conducted; and reviewed NHTSA’s guidelines on the state surveys of safety belt use to determine the extent to which the guidance provides for consistent surveys. Also, as requested, we met with the Canadian officials responsible for implementing safety belt programs to learn what strategies Canada had used to achieve that country’s reported 90-percent rate of safety belt use. We provided DOT with a draft of our report for review and comment. We conducted our review between June 1994 and December 1995 in accordance with generally accepted government auditing standards. NHTSA has reported that safety belt use increased from 11 percent in 1982 to 67 percent in 1994. However, DOT’s recent goals for safety belt use nationwide have not been met. For example, DOT had a goal of 70-percent belt use by the end of 1992 and reported belt use in 1992 to be 62 percent. DOT’s current goal is to reach a rate of 75-percent belt use nationwide by 1997. Using two different methodologies, NHTSA has estimated the rate of safety belt use nationwide in 1994 to be either 67 or 58 percent. NHTSA recognized that its methodology for estimating the 67-percent nationwide rate of belt use was not precise because it relied on individual state surveys that did not measure belt use consistently. For example, 22 states surveyed only passenger cars, while 20 states surveyed cars, light trucks, and vans. Also, some states counted belt use by drivers only, while others included use by other passengers as well. During October and November 1994, NHTSA conducted a nationwide survey to gather more detailed data on the use of restraints. This survey found a nationwide use rate of 58 percent—63 percent in passenger cars and 50 percent in light trucks. The rate in light trucks is important because these vehicles now constitute about 40 percent of the new vehicles sold. Given NHTSA’s estimates of a 58-percent or 67-percent nationwide rate of belt use in 1994, significant progress must be made to meet DOT’s goal of a nationwide rate of 75-percent belt use by 1997. NHTSA has used various methodologies for estimating the rates of safety belt use, and all show substantial increases since the early 1980s. NHTSA’s data indicate that the increase has been gradual from one year to the next with two exceptions. First, the largest increase occurred during 1985-86 when the first state safety belt laws went into effect. The second largest increase occurred during 1991-93 when ISTEA provided financial incentives for the states to enact safety belt laws and NHTSA initiated new programs with state enforcement agencies. The estimates indicate relatively small increases in belt use before 1985, from 1987 through 1990, and between 1993 and 1994. Figure 2.1 shows the changes in safety belt use nationwide since the early 1980s relative to the number of state laws on safety belt use. Measures of safety belt use over time have been available from a variety of sources, such as data about the occupants of vehicles involved in crashes, telephone surveys, and surveys of belt use that NHTSA performed until 1991 in 19 cities. For reasons discussed below, the various sources show very different rates of belt use. However, as figure 2.2 shows, all of the data sources show a substantial increase in belt use since the early 1980s. In addition, the indicators show larger increases during periods of increased federal and state emphasis on safety belt programs. These other sources show different but not necessarily more reliable use rates than those generally quoted by NHTSA and shown in figure 2.1. From 1982 to 1991, NHTSA used a survey that sampled belt use in 19 cities as an indicator of the nationwide rate of belt use. These surveys were useful for tracking changes in use rates in the particular cities included in the study, but the results from the sample cities could not be statistically extrapolated to metropolitan areas not in the sample or to any nonmetropolitan area. A telephone survey has been conducted almost every year since 1983, and the results show higher belt use than NHTSA has reported. This higher result is understandable because other studies have shown that respondents to telephone surveys tend to report higher use than is actually observed. Data about the occupants of vehicles involved in crashes indicate belt use rates both higher and lower than NHTSA’s two reported estimates, but these different results can be explained logically. NHTSA’s Fatal Accident Reporting System (FARS) contains data only from crashes in which someone died. Belt use by the victims in these crashes tends to be low because people who use belts tend to be injured or uninjured rather than killed, so they are more likely to be reported, not in FARS, but in NHTSA’s General Estimates System (GES) as involved in a crash resulting in injury or property damage only. In addition, the belt use reported in the GES data is higher because the data generally come from statements made by the vehicles’ occupants, who tend to tell police officers that they were complying with belt use laws. This tendency is particularly evident in crashes involving property damage only and no apparent injury. While the rates of safety belt use from the federal data on crashes are of limited value in estimating belt use nationwide, they can be useful for NHTSA and the states in evaluating the reasonableness of the use rates shown in the state surveys. The results of the state surveys can be expected to be higher than the FARS results and lower than the GES results for each state for the reasons explained above. NHTSA has developed a model that uses FARS data to predict actual belt use, and these results have been compared with the results from state surveys. While the model does not consider all of the relevant differences among the states, NHTSA officials told us that these comparisons of estimates of safety belt use from the state survey data and FARS generally support the reasonableness of the results of the state surveys. Figure 2.2 also demonstrates the importance of changes in the surveys’ methodology and the effects such changes can have on the results of an analysis. Figure 2.1 shows NHTSA’s analysis of nationwide rates of belt use between 1983 and 1994. According to NHTSA, the sources of the information were the 19-city survey from 1983 through 1990 and the state surveys from 1991 through 1994. Figure 2.2 shows that there were 2 years—1990 and 1991—in which the rates from both the 19-city survey and the state surveys were computed. The state surveys, using a different methodology, showed results 4 percentage points higher in 1990 and 8 percentage points higher in 1991 than the 19-city survey showed. As a result, a substantial portion of the 10-percentage point increase shown in figure 2.1 between 1990 and 1991 was caused by the change in the surveys’ methodology. Although NHTSA may have used the best available data for those years, the change in methodology is an important factor to consider when analyzing the trend. NHTSA’s estimate of a 67-percent nationwide rate of safety belt use for 1994 is not reliable because the rate is based on state surveys that used different methodologies that do not consistently measure belt use. For example, 22 states surveyed only passenger cars, while 20 states surveyed cars, light trucks, and vans; the other states surveyed two of the three vehicle categories. Five states measured belt use by drivers only, and the others measured use by drivers and occupants of the vehicles’ right front seat; no state surveyed belt use by the occupants of the rear seats. The methodologies used for the state surveys also varied in selecting observation locations and in weighting the results. Some states exempted sparsely populated areas from their sampling plans, while others considered all geographic areas eligible for sampling. Also, some states conducted annual surveys, while others did not. NHTSA estimated the 67-percent nationwide rate of safety belt use for 1994 by using 34 state surveys conducted in 1994, 16 surveys conducted before 1994, and information on belt use from Wyoming’s crash data. NHTSA calculated the nationwide use rate by taking each state’s most recent rate and weighting the rate by each state’s population as a proportion of the total U.S. population. In our opinion, this methodology does not provide a reliable estimate of the nationwide rate of safety belt use because it relies on state surveys that use very different methodologies. NHTSA has acknowledged that the state surveys on safety belt use differ in design. However, NHTSA pointed out that 28 states—representing over 70 percent of the U.S. population—conducted probability-based observational surveys. Nevertheless, the agency also said that the remaining states conducted surveys in which their observation sites, while usually adequate in number, were not randomly selected. As a result, no confidence intervals can be calculated from these survey results. In our May 1992 report, we found that statewide data on safety belt use was questionable. NHTSA analysts had told us that the statewide rates of safety belt use provided by the states were generally not based on probability sampling techniques that would provide statistically valid estimates. The states had used a variety of methods that differed in reliability. The states’ data on the rate of belt use were particularly important at that time because ISTEA provided for grants to the states on the basis of these rates. Funds were allocated to the states during fiscal years 1992-94 in part on the basis of the rates of safety belt use as measured by the state surveys. To improve the quality of the data in the state surveys, in June 1992 NHTSA finalized guidelines for state observational surveys of belt use. These guidelines allowed the states substantial latitude in designing and carrying out the surveys. Although the guidelines were very flexible and NHTSA helped the states conform with the guidelines, only 28 states received NHTSA’s approval of their survey methodology. NHTSA officials said that some additional states might be performing a survey that either conforms to the guidelines or nearly conforms, but these states did not need NHTSA’s approval of their survey plan. Since the grants are no longer available, there is no financial incentive for the states to have their survey plan conform with NHTSA’s guidelines. “Available state estimates of safety belt use cannot be used to produce a national estimate. Review of the designs of all states that have conducted state-level surveys of occupant restraint systems has confirmed that results across states are not comparable and cannot be used to produce a national estimate.” We agree with the contractor’s comments. However, NHTSA officials said that the lack of consistency among the state surveys does not preclude using the surveys to develop a reasonable annual estimate of belt use nationwide. They also said that it was important for states to continue to perform surveys so that each state can identify trends and specific local problems with belt use. Recognizing that the data from the state surveys were limited in scope, NHTSA in 1994 conducted a special national analysis—the National Occupant Protection Use Survey (NOPUS). Data were collected by observing traffic at about 4,000 randomly selected sites in 25 states during October, November, and December 1994. NOPUS was used to estimate the nationwide rate of belt use and to obtain detailed data on (1) belt use by vehicle type and the occupant’s age and gender and (2) the misuse of belts. The initial results from NOPUS were released by NHTSA in early 1995 and showed an overall nationwide rate of safety belt use of 58 percent for 1994. These results indicate, among other things, that the drivers tend to use safety belts more frequently than the passengers in the right front seat and that belt use is higher in the western United States than in the rest of the country. The NOPUS’ breakout by vehicle type showed an overall rate of 63-percent belt use for the occupants of passenger cars and a 50-percent rate of use for the occupants of light trucks. This breakout for light trucks is particularly important because these vehicles make up about 40 percent of the new vehicles sold. NHTSA recently estimated that annually 3,600 occupants of light trucks die and 54,000 are injured because they do not use safety belts. This disparity in belt use rates between the occupants of passenger cars and light trucks indicates that special emphasis and targeted programs may be needed to increase belt use in light trucks. Part of the disparity could relate to the fact, discussed in chapter 4, that several states’ laws on belt use do not cover the occupants of light trucks. NHTSA officials believe that NOPUS’ findings generally support the estimates of the nationwide rate of belt use calculated from the state surveys but agree that comparing the rates in the NOPUS and the state surveys is difficult. NHTSA plans to conduct another NOPUS survey if funds become available, but the agency plans to continue using the state surveys to annually estimate the nationwide rate of belt use. The 67-percent weighted average from the state surveys and the 58-percent rate from NOPUS both fall within the range of estimates of belt use based on other data. Both estimates reveal that substantial progress must be made if DOT’s goal of 75-percent belt use by 1997 is to be achieved. Safety belt use increased from 11 percent in 1982 to a reported 67 percent in 1994. Much of the increase resulted from the adoption of laws mandating safety belt use by 48 states and the District of Columbia. Increases in belt use can also be noted during the years in which federal funds were provided to the states for improving their safety belt programs. Belt use in light trucks and vans has remained relatively low. These vehicles are not covered by federal law or by the laws of several states. NHTSA has recognized that individual state surveys do not measure belt use consistently. NHTSA could improve the guidelines for the state surveys, but the effect of such improvements could be minimal since the state laws vary significantly and NHTSA does not offer financial incentives to encourage the states to improve their surveys. Given NHTSA’s two reported nationwide rates of belt use—67 or 58 percent—significant progress must be made if the nation is to achieve DOT’s goal of a rate of 75-percent use of safety belts by 1997. The states that are most successful in increasing safety belt use have comprehensive programs that include primary enforcement laws, visible and aggressive enforcement, and vigorous public information and education programs. Primary enforcement laws allow law enforcement officials to stop and ticket a vehicle’s occupants solely for not using their safety belts. Ten states currently have safety belt use laws allowing primary enforcement, while 39 states including the District of Columbia have laws allowing for only secondary enforcement. NHTSA estimated that the rates of belt use in the states with primary enforcement laws were 15 percentage points higher in 1994 than the rates in the states with secondary enforcement laws. The states’ laws on safety belt use differ widely in enforcement, coverage, and fines, but the most successful programs share several common key components. Appendix I shows the 1994 rates of safety belt use that the states reported to NHTSA, as well as some information about the belt laws in each state. As reported by the states, the rates of belt use in 1994 ranged from a low of 32 percent to a high of 84 percent; four states reported rates of over 80-percent belt use, while five reported rates of less than 50-percent use. To understand the key components of a successful safety belt program and how they work together to increase belt use, we visited 10 states and their respective NHTSA regional office. As shown in table 3.1, the 10 states we visited included 3 states with primary enforcement laws, 6 states with secondary enforcement laws, and 1 state with no law. Officials in each NHTSA regional office and state we visited stressed that primary enforcement laws were the best way to increase safety belt use but that the other components were needed to maintain that rate of increase. They also stated that in the absence of a primary enforcement law, the most effective way to increase safety belt use was a secondary enforcement law combined with active community involvement in law enforcement and public education and information activities aimed at increasing the use of safety belts. Figure 3.1 shows that the 3 states with primary enforcement laws we visited significantly increased belt use after adopting such a law. Of the 10 states we visited, the average belt use of the 3 states with primary enforcement was about 20 percentage points higher than the average belt use of the 6 states with secondary enforcement. Figure 3.2 shows that the six states with secondary enforcement laws we visited experienced increases in safety belt use after adopting such a law. However, the two figures together show that the overall rates of belt use for the states with secondary enforcement are much lower than the rates of the states with primary enforcement. States with primary enforcement laws have been the most successful in increasing safety belt use. This success is the result of law enforcement officers stopping and assessing fines to a vehicle’s occupants solely for not using their safety belts. Officials of state safety belt programs work with law enforcement agencies to encourage enforcement and also to help educate and inform the public about the law and the consequences of noncompliance. According to state officials, one of the most successful ways to reach the public is by involving community groups in programs aimed at increasing safety belt use. The ability of primary enforcement laws to increase safety belt use is best illustrated by California’s upgrade of its law mandating safety belt use from a secondary enforcement law to a primary enforcement law. In November 1992, California reported a rate of safety belt use of 70 percent. At that time, California’s secondary enforcement law had been in place for about 7 years. On January 1, 1993, California implemented a primary enforcement law, resulting in an increase in safety belt use of 13 percentage points for a statewide rate of 83 percent in late 1993, according to the results of a state survey. California officials actively publicized this change in the law. A survey of some California drivers conducted during March through September 1993 found that 90 percent of those surveyed knew that they could be stopped for violating a belt law alone and 75 percent felt that the law was being strictly enforced. California increased only slightly the number of citations issued during this period. Therefore, NHTSA officials believe that the change to a primary enforcement law is the primary reason for the significant increase in belt use. Primary enforcement laws increase safety belt use, but sustained and increased safety belt use can be better achieved when these laws are supported with enforcement and public education and information activities. North Carolina provides an example of how these activities, when associated with a primary enforcement law, can dramatically increase safety belt use. Before implementing its primary enforcement law in October 1985, North Carolina had a rate of safety belt use of 24 percent. During a 15-month period when only warnings were issued to violators, the reported rates of safety belt use ranged from 41 to 49 percent. On January 1, 1987, citations began to be issued for not using a belt, and the reported rate of belt use quickly increased to 78 percent. However, after a few years, state surveys showed that the rate of belt use had dropped back to 60 percent. In September 1993, North Carolina embarked on a multiyear campaign—“Click It or Ticket”—to further increase safety belt use and reduce related injuries and fatalities. This intensive enforcement and publicity campaign is credited with increasing North Carolina’s reported rate of safety belt use by 15 percentage points in 3 months—65 to 80 percent—and with achieving North Carolina’s current rate of 81 percent. The campaign featured increased and highly visible enforcement through the use of safety belt checkpoints. These activities were publicized locally, and the message provided to the public was that activities to enforce the safety belt law were the major focus of local law enforcement agencies during the first 4 weeks of the program. This highly visible program was also directly endorsed by North Carolina’s governor, who cited the high costs society pays for individuals who do not use their safety belts. State officials report that in its first 6 months, the “Click It or Ticket” campaign saved 45 lives, prevented 320 disabling injuries, and saved more than $51 million in health care and other costs. New York has also used enforcement and public education and information activities to sustain and increase the rate of safety belt use that the state achieved after it passed the nation’s first law mandating safety belt use on December 1, 1984. Before the passage of this law, New York’s rate of safety belt use was estimated to be 16 percent. Within 6 months, the state’s reported rate of belt use increased to 57 percent. New York now reports a belt use rate of 72 percent. This gain was primarily due to the emphasis placed on enforcing the law through police training and an increase in the number of citations issued. New York has also used public information campaigns and special workshops on restraints for children. NHTSA officials told us that the state’s ability to continue to positively affect the rate of safety belt use results from their emphasis on establishing and incorporating community-based networks into programs to improve traffic safety. States with secondary enforcement laws are also successful in increasing safety belt use, but their success is limited by the difficulty in effectively enforcing the law. Today, 38 states and the District of Columbia have secondary enforcement laws, which allow a vehicle’s occupants to be ticketed for not using safety belts after they have been stopped for another violation. The success of secondary enforcement laws depends on how well the states work with law enforcement agencies to encourage enforcement and reach out to community members to educate and inform them about the laws and the importance of using safety belts. The states’ efforts to strengthen laws on restraints for children also contribute to increasing adults’ use of safety belts. For the six states with secondary enforcement laws that we visited, the laws contributed greatly to increasing the rates of safety belt use. Also important were aggressive enforcement and public education and information activities. For example, Idaho was able to increase its reported rate of belt use by 24 percentage points—from 35 percent in June 1990 to 59 percent in September 1993—through an increased emphasis on education and enforcement at the local level. Idaho used some of its highway safety funds to provide grants to the local law enforcement agencies that administered these programs. These agencies provided the community with information and education on safety belts and child restraints, and trained law enforcement officers on the use of restraints and the need for increased enforcement. To receive these grants, the enforcement agencies were required to have a policy of writing one safety belt citation for every five citations for hazardous violations. This approach greatly increased the number of citations issued for safety belt violations and resulted in a statewide rate of belt use of 61 percent in 1994. New Jersey was also able to increase its rate of safety belt use substantially through increased enforcement activities. From 1990 to 1991, New Jersey doubled the number of safety belt citations issued, resulting in a reported increase of 18 percentage points—from 50 percent to 68 percent—in its rate of safety belt use. New Jersey also was very active in public information and education, including a “101 Days of Summer” publicity campaign that emphasized why it was important to use safety belts and activities connected with “Buckle Up America Week.” New Jersey’s safety officials are attempting to upgrade the state’s safety belt law to a primary enforcement law because they believe this change could immediately increase the state’s rate of safety belt use by up to 12 percentage points. New Jersey reported a current rate of safety belt use of 64 percent. Other states with secondary enforcement laws we visited have not experienced the level of increase in use rates that Idaho and New Jersey have. Colorado, for example, reported an increase in its use rate to 51 percent from 18 percent when it implemented its law on July 1, 1987, but has not been able to make substantial progress since that time. As of January 1995, Colorado reported a use rate of 54 percent. However, the state believes its rate will likely increase as its many activities are implemented. For example, the state is training law enforcement officers to enforce the safety belt law and is conducting a “Drive Smart Colorado” campaign that assists community leaders in developing strategies and programs to ensure the safety of the traveling public. Also, Colorado recently amended its law on restraints for children to increase the age of the children covered by the law from 4 to 16. New Hampshire, which has no law on mandatory belt use, shows how having a law on restraints for children and aggressive public information and education about that law can contribute to increased adult use of safety belts. In 1984, New Hampshire found that only 16 percent of drivers were using safety belts. Since then, the largest reported annual increase in New Hampshire’s rate of safety belt use by adults—from 37 percent in 1988 to 50 percent in 1989—coincided with an increase in the age of the children covered by the law on restraints for children from up to age 4 to up to age 12. This change in the law provided New Hampshire with the opportunity to educate and inform the public about the child restraint law and the consequences of not using safety belts and then being involved in a traffic accident. In September 1994, New Hampshire reported a rate of safety belt use by adults of 54 percent. State officials said that this latest increase can be attributed to another change in the child restraint law (effective Jan. 1, 1994), which requires children up to age 4 to be restrained in a proper restraint system—a car seat. The states that are most successful in increasing their rates of safety belt use have comprehensive programs that include mandatory primary enforcement laws that are visibly and aggressively enforced. These states also actively educate and inform the public about the laws, their benefits, and the consequences of noncompliance. Those states that do not have mandatory safety belt laws involving primary enforcement can also achieve increased safety belt use through increased enforcement of their secondary enforcement laws and through effective efforts to educate and inform the public. However, given the benefits in increased use rates that primary enforcement laws provide, the effectiveness of the state programs that are currently based on secondary enforcement laws could be dramatically increased through the implementation of primary enforcement laws, assuming the other program elements are continued. Stronger state laws on safety belt use could increase the rates of belt use, annually preventing thousands of deaths and serious injuries and saving up to $20 billion. Various studies have shown that the public pays for most of the costs resulting from not using safety belts through higher taxes and insurance premiums. While various federal actions could be taken to increase safety belt use, an effective strategy would encourage the states to have comprehensive programs, including primary enforcement laws with aggressive enforcement, coverage of all occupants in vehicles with belts installed, fines that discourage noncompliance, and public education. The current federal policy, contained in ISTEA, encourages the states to have a law mandating safety belt use that covers occupants of passenger cars’ front seats. ISTEA does not specify a primary or secondary enforcement law and does not require occupants of passenger cars’ rear seats or any occupants of light trucks and vans to use safety belts. In June 1994, NHTSA reported that the nonuse of safety belts by occupants of passenger cars results in about 6,200 deaths and 150,000 moderate to critical injuries each year. Additionally, 3,600 occupants of light trucks and multipurpose vehicles die and 54,000 are injured unnecessarily because they do not use safety belts. NHTSA estimated that these deaths and injuries cost society $20 billion annually in medical costs, lost productivity, and other injury-related expenses. Most of these costs are borne by society in the form of tax-supported programs and insurance premiums. In response to a mandate in ISTEA, NHTSA analyzed data from seven states to determine the benefits of medical care for crash victims and who pays for that care. This Crash Outcome Data Evaluation System (CODES) project linked statewide data from police reports on motor vehicle crashes with computerized data from emergency medical services, hospital emergency departments, hospital discharges, and other activities so that the costs of the medical treatment of people injured in traffic crashes could be tracked. CODES obtained data on about 880,000 vehicle drivers for various periods between 1990 and 1992 in the seven states. The final report is expected to be provided to the Congress in February 1996. The preliminary data from CODES indicates there is a direct relationship between safety belt use and the medical costs resulting from traffic crashes. The average charges for all drivers (including those not hospitalized) in the CODES study who were involved in crashes was $562 for those not using safety belts and $110 for those using belts. Thus, those drivers using safety belts averaged 80 percent lower charges. For crash victims who were actually admitted to hospitals, the average charges were $13,937 for those not using safety belts and $9,004 for those using belts, which indicates a 35-percent reduction in hospital charges when safety belts were used. The data from CODES are consistent with the data from other studies. Our May 1992 report on the effectiveness of safety belts presented the results from eight studies containing data on the effectiveness of safety belts in reducing hospital charges. All the studies showed that hospital costs were lower for the vehicle occupants using safety belts than for the occupants not using belts. The victims who used belts had average hospital costs that were from 27 to 87 percent lower than those of the victims who did not use belts; most of the studies showed costs between 60 and 80 percent lower. Stated another way, most of the studies showed the hospital costs for the crash victims who did not use belts to be 2-1/2 to 5 times the cost for the victims who used belts. The studies also provided data showing that safety belts reduce other costs related to injuries in traffic crashes, such as ambulance costs or insurance claims costs for personal injury. While the studies discussed in that report indicated a higher rate of temporary and permanent disability for the victims who did not use belts, the data on such long-term effects were generally not available. Unfortunately, none of the studies captured information on the level of income replacement resulting from providing disability or welfare benefits to victims who did or did not use belts. CODES and other studies have shown that society pays a large part of the costs of medical treatment for those injured in traffic crashes. Preliminary data from CODES show that the public paid 16 percent of these costs through such programs as Medicare and Medicaid. About 69 percent was paid by private insurance, which spread the cost to all who pay insurance premiums. At the time the victims were discharged from the hospital, only 15 percent of the charges were classified as paid by others, generally “self payers.” NHTSA pointed out in its draft report that these self payers often are unable to pay their bills, and the cost of providing this care is ultimately passed on through higher charges for those who do pay. CODES data show that the general public may pay a larger portion of the costs than some of the earlier data showed. NHTSA published a report in January 1992 that used data from five states to estimate the costs of hospital care for people injured in motor vehicle crashes in 1990 and the sources of payment of those costs. Those data show that 29 percent was paid by government sources, 52 percent by insurance, and 19 percent by others. Five studies of hospital costs that we reviewed for our May 1992 report also collected data on medical payments for crash victims. Among the victims who did not use belts, from 8 to 28 percent were covered by Medicare or Medicaid, from 41 to 55 percent were covered by insurance, and the remaining 22 to 49 percent were considered self payers. Some costs not covered by public programs or insurance ultimately will not be paid by the injured person or the person’s family, so a portion of the costs to self payers will be paid by other sources of funding for the hospitals. The federal government has recognized the benefits of safety belts and has been requiring their installation and encouraging their use since the mid-1960s. Federal efforts have been effective in encouraging the states to enact basic laws on mandatory safety belt use. NHTSA has not been successful, however, in encouraging the majority of states to enact a primary enforcement law that covers occupants in all types of motor vehicles that have belts installed. NHTSA has encouraged the states to enact a law mandating safety belt use and has distributed material for the states and others to use in urging the public to use safety belts. NHTSA has also initiated national campaigns for public information and awareness and has assisted in state and local campaigns to increase safety belt use. In addition, the states receive federal funding to help them implement highway safety programs. About $170 million was requested for fiscal year 1996 for assistance to the states under the federal highway safety program. DOT encourages the states to use the funds in support of program areas that are national priorities. The Secretary of Transportation has established a goal of a nationwide rate of 75-percent belt use by 1997, in place of an earlier goal of 70-percent use by 1992. NHTSA has worked with the states and local agencies to achieve these goals. NHTSA’s primary focus in increasing safety belt use has been through encouraging states to enact stronger laws and through related efforts in enforcement and public education. Officials in the states we visited told us that NHTSA’s assistance has helped them develop safety belt programs at the state and local levels. They also said that the federal funds have been an important element in state and local activities for education and enforcement. To varying degrees, the states have used NHTSA’s public information materials and have joined in the federal promotional campaigns. NHTSA has encouraged the states to strengthen their safety belt laws. However, most state laws provide for secondary enforcement and minimal fines for violations, cover only occupants of the vehicles’ front seat, and often exempt the occupants of light trucks. Our May 1992 report concluded that stronger and more comprehensive laws were needed and that society could save billions of dollars annually through increased safety belt use. As discussed in chapter 3 of this report, the most effective state laws have strong enforcement provisions and cover all occupants of passenger cars, light trucks, and vans. Since our 1992 report, nine states have enacted new laws on belt use, but these laws are similar to the earlier laws—generally providing for secondary enforcement and relatively low fines. Overall, little progress has been made recently in getting the states to adopt stronger and more comprehensive safety belt laws. As table 4.1 shows, most state laws cover the occupants of the front seat only, and some exempt the occupants of light trucks and/or vans. Ten states provide for primary enforcement, and 39 states (including the District of Columbia) provide for secondary enforcement. Only 11 state laws cover the occupants of rear seats, and 7 state laws exempt the occupants of light trucks and vans. Only 4 states assess fines for violations of belt use laws that exceed $25, and 13 states assess fines of $10 or less, including 2 states that do not assess any fine. Although 49 states (including the District of Columbia) now have laws on safety belt use, compared with 42 in 1991, the laws could be stronger and more comprehensive. Ten states have primary enforcement laws—the same number as in 1991. While California and Louisiana have enacted a primary enforcement law since 1991, Mississippi and Wisconsin have changed from primary to secondary enforcement. The states’ fines for violating belt use laws have changed little since 1991, and most are so low that they have little influence on motivating nonusers of belts to buckle up. “the Committee believes that more aggressive action needs to be taken to achieve a 75 percent seat belt usage rate by 1997. Specifically, the Committee directs NHTSA to develop and distribute it to all states a model seat belt use law as part of its 1996 program.” “Enact legislation that provides for primary enforcement of mandatory safety belt use laws. Consider provisions such as adequate fine levels and the imposition of driver license penalty points.” NTSB sent its recommendations to all the states with a secondary enforcement law and those without safety belt laws, asking the states to report any actions taken on its recommendations. Our May 1992 report discussed the relevant provisions of ISTEA and stated that “the act’s provisions may do little to encourage states to strengthen their existing laws.” The grants established by ISTEA to encourage belt use were available for a 3-year period—1992-94—and did not require strong state laws as a condition of receiving the grants. The penalty provision transfers the fiscal year 1995 funds of the states that have no safety belt law as of October 1, 1993. This provision transfers up to 3 percent of a state’s federal-aid highway funds to the state’s highway safety programs. Under current law, in 1996 only Maine and New Hampshire will be subject to the safety belt penalty, which is estimated at about $1.6 million for each state. ISTEA requires the states to have laws on mandatory safety belt use to avoid the penalty, but it does not require primary enforcement or state fines for nonuse of belts. Also, the act applies only to the occupants of passenger vehicles’ front seats and defines passenger vehicles to exclude vehicles constructed on a truck chassis. As a result, state laws do not have to include the occupants of passenger cars’ rear seats or any occupants of pickup trucks or many vans, even though over 10,000 occupants of such vehicles die each year in crashes. While the number of deaths resulting from crashes of light trucks and vans might be sufficient reason for focusing greater attention on increasing belt use in these vehicles, other data also point to this need. Recent data on crashes show that occupants killed in light trucks were ejected at twice the rate of occupants of passenger cars. NHTSA officials told us that safety belts are very successful in preventing such ejections. NHTSA estimated that annually 3,600 occupants of light trucks die and 54,000 are injured because they do not use safety belts. Also, a 1994 national survey of belt use showed an overall rate of 63-percent use for occupants of passenger cars and 50 percent for occupants of light trucks. The disparities between the use rates in cars and light trucks indicate that special emphasis and targeted programs are needed to increase belt use by the occupants of light trucks. NHTSA currently does not have such emphasis or programs. NHTSA officials told us that they have limited authority to encourage the states to enact stronger safety belt laws—primary enforcement, higher fines for nonuse, and coverage for all occupants of vehicles. Additionally, NHTSA officials told us that the current political environment that favors local and state initiatives over federal efforts has further reduced the agency’s ability to influence state and local activities. The state officials we interviewed reflected the attitude that the states welcome federal funds but not federal requirements or advice. They told us that the states still want federal funds for their programs but do not want any federal influence on how the funds are spent. They generally agreed that federal financial and technical assistance have helped them increase belt use, thereby reducing deaths, injuries, and the related costs to society. Several said that the positive changes might not have occurred without NHTSA’s influence and the conditions under which the states could accept federal funds under ISTEA. While NHTSA’s focus has been on encouraging the states to enact and enforce laws on safety belt use, other federal agencies have required, through federal regulations and an executive order, that certain occupants of vehicles use safety belts. The Federal Aviation Administration requires each occupant over 2 years old in an airplane to use safety belts during takeoff and landing. Likewise, the Federal Highway Administration requires commercial drivers of interstate trucks and buses to use safety belts. Furthermore, Executive Order 12566, issued in September 1986, requires federal employees to use safety belts when driving on official duty. Federal efforts have been effective in encouraging federal employees to use safety belts in motor vehicles. For example, 48 federal organizations reported a rate of at least 90-percent belt use during 1993 based on observational surveys. Although federal and state officials often disagree on the roles that federal and state agencies should play in traffic safety, several recent polls indicate general public acceptance of laws on mandatory safety belt use. A recent nationwide public opinion poll of 1,000 people by McKeon and Associates found strong support for safety belt laws. A large majority opposed any weakening or repeal of the laws. These results support findings in individual states. For example, California reported widespread public knowledge about and compliance with the state’s recent primary enforcement law. Also, a poll conducted in 1994 for South Carolina found that 88 percent of the state’s residents supported the state’s law on mandatory safety belt use. Safety belt use laws and programs in Canada have been very effective in achieving a high rate of belt use. As of mid-1994, Canada reported that its nationwide rate of belt use was about 90 percent in passenger cars and 88 percent in all vehicles, including vans and light trucks. Five of the 12 Canadian jurisdictions reported rates of belt use over 90 percent. Only one jurisdiction reported a use rate lower than 75 percent. In comparison, NHTSA estimates that the rate of safety belt use in the United States in 1994 averaged either 58 percent or 67 percent, depending on the methodology used. Laws mandating safety belt use were enacted in all 12 Canadian jurisdictions between 1976 and 1992; most were enacted during the 1980s. All the jurisdictions’ laws require primary enforcement (compared with 20 percent of the states in the United States), and all the laws cover occupants of light trucks and vans. Fines for noncompliance are generally higher in Canada than those in the states, and five Canadian jurisdictions provide for demerit points against driver’s licenses for violating belt use laws. In contrast, no U.S. state requires demerit points for such violations. Four states, however, provide demerit points for violating laws on restraints for children. Canada’s success with safety belts appears to result in large part from designating increased belt use as a top national priority. Safety belt use in Canada had leveled off at about 75 percent between 1987 and 1989. In 1989, Canadian officials endorsed the recommendation “to have each jurisdiction set itself the goal of reaching a seat belt use rate of 95% for all occupants by 1995.” The Canadian Council of Motor Transport Administrators developed a strategy, known as the National Occupant Restraint Program (NORP), to assist the jurisdictions in reaching the goal of 95-percent. NORP involved a 6-year strategy in two phases. Phase I was a short-term strategy during late 1989 and all of 1990 that included centralizing the development of training and briefing materials and the delivery of those materials through coordinating committees in each jurisdiction. Phase II, covering 1991-95, involved coordinating, in each jurisdiction, intensive campaigns for enforcement and awareness as well as efforts to reduce the number of exemptions from the laws on safety belt use. The province of Newfoundland’s experience illustrates how the Canadian strategy has worked. The province enacted its law on mandatory safety belt use in 1982. In 1989, the rate of belt use was observed to be 64 percent. In 1990, Newfoundland adopted demerit points for violations of the law, and belt use increased to 84 percent. The demerit system assesses 2 points for most driving infractions, including nonuse of belts, and the accumulation of 12 points in a 2-year period results in suspension of the license. As public awareness campaigns and enforcement programs continued in 1991, belt use increased to 91 percent. One of the strategies recommended by NORP was the issuance of at least 4,000 citations for safety belt violations per year per million population; the rate for 1991 in Newfoundland was 12,525. In 1992, Newfoundland removed many of the exemptions in its belt use law, and the rate of use reached almost 95 percent. The rate remained above 95 percent during 1993 and 1994. This high level of belt use was maintained despite a decrease in the number of citations issued per million population from 12,525 in 1991 to 507 in 1993. A Canadian official said the public has been motivated more by the demerit points provided by the law than by the $45 fine. The Congress faces difficult decisions in balancing the federal and state roles concerning safety belts while reducing deaths, injuries, and the costs to society. Increases in the rate of belt use can still be made in many states through better enforcement of existing laws, but the larger increases are likely to be achieved through stronger and more comprehensive state laws on belt use. Stronger state laws could help reduce the thousands of deaths and serious injuries and save up to $20 billion in costs annually because safety belts are not used. The general public, through higher taxes and insurance premiums, pays most of the medical costs for those who fail to use safety belts. The large number of deaths and injuries and the costs to society for nonuse of safety belts will likely continue unless the states adopt stronger and more comprehensive safety belt laws. Federal strategies can be improved in a variety of ways. The House Committee on Appropriations recently directed NHTSA to develop and distribute to the states in 1996 a model safety belt law in order to more aggressively encourage nationwide use of safety belts. States could be encouraged to implement comprehensive safety belt programs that provide for primary rather than secondary enforcement; coverage of all of the occupants in all of the vehicles in which belts are installed, including the occupants of passenger cars’ rear seats and the occupants of light trucks and vans; and aggressive enforcement and higher fines/penalties to encourage belt use. Strong federal involvement has the advantage of facilitating the nationwide implementation of comprehensive strategies that have proven to be successful in the states in increasing belt use and reducing deaths, injuries, and the costs to society. A disadvantage is that the states would have less authority to structure their own programs. NHTSA has reported that the rate of belt use by the occupants of light trucks is only 50 percent. Considering that light trucks now constitute about 40 percent of the new vehicles sold and are increasingly being used to transport passengers, deaths, injuries, and costs could be avoided by giving special attention to increasing belt use by the occupants of these vehicles. Increased seat belt use has the potential to avoid thousands of deaths and serious injuries and save billions of dollars in medical costs, lost productivity, and other expenses resulting annually from the nonuse of safety belts. The federal government’s role in encouraging safety belt use is ultimately a policy decision for the U.S. Congress. Current federal legislation provides for both grants and penalties to encourage the states to enact safety belt laws or improve enforcement of existing laws. Comprehensive programs that include primary enforcement laws, aggressive enforcement, and vigorous public education offer the best opportunity for increasing belt use. If the Congress wants to promote this type of program nationwide, it could encourage the states to adopt a primary enforcement law that covers all occupants in all vehicles in which belts are installed. Those states that do not enact such a comprehensive law could continue to be subject to the provision in the Intermodal Surface Transportation Efficiency Act requiring a transfer of up to 3 percent of their federal-aid highway funds to their state highway safety programs. In view of the large differences in the rates of safety belt use between the occupants of passenger cars and the occupants of light trucks, we recommend that the Department of Transportation provide special emphasis and targeted programs to increase belt use by the occupants of light trucks. We provided copies of a draft of our report to DOT for its comments. We met with agency officials, including the Director, Office of Occupant Protection, NHTSA, and these officials agreed with the report’s findings, conclusions, matter for congressional consideration, and recommendation. The officials agreed that an effective way to increase the nationwide rate of safety belt use is for the states to have a primary enforcement law that contains fines to discourage noncompliance and is aggressively enforced. They agreed that such a law should also cover all of the occupants of all motor vehicles in which belts are installed. The officials provided a number of editorial and technical comments, which we have incorporated in the report where appropriate. Usage rate (%) Motor vehicles after model year 1964 designed to carry no more than 10 persons Motor vehicles equipped with safety belts Motor vehicles after model year 1971 designed to carry 10 or fewer passengers Motor vehicles except for buses and other public conveyances Passenger motor vehicles designed to carry no more than 10 persons and trucks of less than 6,000 lbs unladen weight Passenger cars, small trucks, vans, taxis, ambulances, and recreational vehicles Passenger motor vehicles (passenger car, station wagon, camper, trucks with load capacity of 1,500 lbs or less, vanpool) Motor vehicles except for farm tractors, medical vehicles, and letter carriers Motor vehicles with seating capacity of eight passengers or fewer Motor vehicles, trucks of unladen weight more than 5,000 lbs except buses and farm tractors Passenger cars after model year 1964 designed to carry 10 passengers or less Motor vehicles except medical, emergency, rental, and commercial vehicles and buses Motor vehicles with weight under 8,000 lbs except for medical and emergency vehicles (continued) Usage rate (%) Motor vehicles manufactured after 12/31/64 except special-use vehicles Passenger motor vehicles manufactured after 12/31/64 (including buses but excluding trucks, tractors, and recreational vehicles) Motor vehicles designed to carry 10 passengers or fewer except for all-terrain vehicles, trailers, and special-use vehicles (continued) Usage rate (%) Passenger automobiles manufactured after 6/30/66 Motor vehicles designed to carry 10 passengers or fewer except trailers, school buses, and trucks Motor vehicles except medical vehicles, taxis, buses, and other special-use vehicles Motor vehicles designed for carrying 10 passengers or fewer except trailers and special-use vehicles Motor vehicles manufactured with safety belts and designed to carry no more than 11 passengers except special-use vehicles Passenger cars, commercial cars, commercial tractors, and trucks with factory-equipped safety belts Passenger cars (excluding trucks, tractors, pickups, vans, recreational vehicles, farm-use vehicles, passengers with medical excuses, and postal carriers) (continued) Usage rate (%) Motor vehicles manufactured after 6/30/66 except special-use vehicles Motor vehicles except special-use vehicles Motor vehicles except special-use vehicles Motor vehicles including passenger cars, multipurpose passenger vehicles except trailers, buses, trucks, and special-use vehicles (continued) Usage rate (%) No usage rate provided. Ronnie E. Wood, Assistant Director R. Kenneth Schmidt, Evaluator-in-Charge (retired) MeShae Brooks-Rollings Karlton P. Davis Susan K. Hoffman David K. Hooper Lynne Goldfarb Paul D. Lacey Sara Ann Moessbauer Phyllis F. Scheinberg Mike Volpe The first copy of each GAO report and testimony is free. Additional copies are $2 each. Orders should be sent to the following address, accompanied by a check or money order made out to the Superintendent of Documents, when necessary. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. U.S. General Accounting Office P.O. Box 6015 Gaithersburg, MD 20884-6015 Room 1100 700 4th St. NW (corner of 4th and G Sts. NW) U.S. General Accounting Office Washington, DC Orders may also be placed by calling (202) 512-6000 or by using fax number (301) 258-4066, or TDD (301) 413-0006. Each day, GAO issues a list of newly available reports and testimony. 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Summary: Pursuant to a congressional request, GAO reviewed whether federal and state efforts have been successful in increasing the use of safety belts in motor vehicles, focusing on: (1) the progress that has been made in achieving seat belt use goals; (2) state strategies that have been successful in increasing seat belt use; and (3) federal strategies that could increase seat belt use. GAO found that: (1) since 1982, the use of safety belts nationwide has increased significantly; (2) the National Highway Traffic Safety Administration (NHTSA) is unable to report on safety belt use with any accuracy because state surveys use varying methodologies to measure seat belt usage; (3) NHTSA could increase the reliability of usage rates if it developed narrower survey guidelines, but changes are unlikely, since state seat belt laws vary and NHTSA no longer provides financial incentives to encourage states to improve their surveys; (4) states with the highest usage rates generally have primary enforcement laws, which allow law enforcement officers to ticket violators solely for not using seat belts, visible and aggressive enforcement, and active public information programs; (5) states with primary enforcement laws averaged 15 percent higher use rates than states with secondary enforcement laws; (6) financial disincentives in federal transportation law have encouraged many states to adopt primary and secondary enforcement laws; (7) as of 1992, 17 states did not require occupants of light trucks or vans to use safety belts; (8) the lack of laws governing restraint use in light trucks has become an increasing problem, since these vehicles have unfavorable rollover rates and their sales are increasing; (9) the fines assessed for not using seat belts remain low; and (10) the federal government and states could increase the use of safety belts by developing and distributing a model safety law and enacting laws that provide for primary enforcement, coverage of all occupants in all types of vehicles, aggressive enforcement, and higher fines.