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Study Protocol

Daily level predictors of impaired driving behaviors in young adults: Protocol design for utilizing daily assessments

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington, United States of America

Roles Conceptualization, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing

Roles Formal analysis, Project administration, Writing – original draft, Writing – review & editing

Roles Formal analysis, Writing – original draft

Affiliations Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington, United States of America, Department of Psychology, University of Washington, Seattle, Washington, United States of America

• Brittney A. Hultgren, 
• Katarina Guttmannova, 
• Christine M. Lee, 
• Daniela Acuna, 
• Rachel L. Cooper, 
• Jason R. Kilmer, 
• Jennifer M. Cadigan, 
• Brian H. Calhoun, 
• Mary E. Larimer

• Published: September 27, 2022
• https://doi.org/10.1371/journal.pone.0275190
• Reader Comments

Motor vehicle crashes remain a leading cause of death among young adults (ages 18–25) in the United States. Many drivers implicated in these crashes are under the influence of alcohol, cannabis, or the simultaneous use of alcohol and cannabis. Extremely limited research has assessed impaired driving behaviors and their predictors at the daily level. Perceived norms and motives to use substances have empirical support suggesting they may impact impaired driving-related behavior. Novel approaches to assess these associations at the daily level are needed and may inform future intervention and prevention programs.

The goal of the current study is to utilize electronic daily assessments to assess driving under the influence of alcohol, cannabis, or simultaneous use and riding with a driver impaired by these substances to assess variability and predictors of these impaired driving-related behaviors at the daily level. This present manuscript details a protocol, measures, and a plan of analyses to assess how within-person differences in perceived norms and motives to use are associated with the likelihood of engaging in impaired driving-related behaviors.

Participants include young adults in Washington State who report simultaneous use in the past month and either driving under the influence of alcohol, cannabis, or simultaneous use, or riding with a driver under the influence of both substances in the past 6 months. Individuals who verify their identity and meet eligibility requirements will complete a baseline assessment after which they will be scheduled for training on the daily assessment procedure via Zoom. Next, they will be invited to complete daily surveys on Thursday, Friday, Saturday, and Sunday every other week for 6 months and a 6-month follow up assessment. Analyses will utilize multilevel models with days nested within individuals.

The study is currently recruiting participants. A total of 192 participants have been recruited and 100 have completed the study protocol. Data collection is expected to be completed in Fall 2022.

Conclusions

This study utilizes a novel design to assess impaired driving and predictors at the daily level among young adults at high risk of impaired driving-related behaviors. Findings will provide unique data that will shape the knowledge base in the field of social science and public health substance use research and that may be helpful for future prevention and intervention efforts on impaired driving.

Citation: Hultgren BA, Guttmannova K, Lee CM, Acuna D, Cooper RL, Kilmer JR, et al. (2022) Daily level predictors of impaired driving behaviors in young adults: Protocol design for utilizing daily assessments. PLoS ONE 17(9): e0275190. https://doi.org/10.1371/journal.pone.0275190

Editor: Emily Chenette, PLOS (Public Library of Science), UNITED KINGDOM

Received: July 1, 2022; Accepted: September 12, 2022; Published: September 27, 2022

Copyright: © 2022 Hultgren et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion. Deidentified research data will be made publicly available when the study is completed and published.

Funding: This research was funded by a grant (R01CE003129; PI: BH) from the National Center for Injury Prevention and Control (NCIPC) within the Centers for Disease Control and Prevention (CDC). This grant is a collaborative agreement and therefore employees from the funder have provided input for research design, data collection, and have read the manuscript. However, The views expressed in this paper do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The current paper details the protocol for an ongoing study assessing daily variability and predictors of impaired driving and riding with an impaired driver within young adults (aged 18–25), specifically with impairment by alcohol, cannabis, or simultaneous use of alcohol and cannabis. Motor vehicle crashes are the leading cause of death in young adults in the United States [ 1 ] and approximately 32% of young adult drivers involved in fatal crashes are impaired by alcohol [ 2 ]. Partly due to tremendous public health efforts, alcohol-impaired driving and its related injuries and fatalities have declined since the 1980s; however, these declines have stagnated since 2009 [ 3 ]. Additionally, with the legalization of medical and non-medical (or “recreational”) use of cannabis in many states [ 4 ], an increase in driving under the influence of cannabis, as well as simultaneous use, has been reported [ 5 , 6 ]. Some research suggests that vehicle crash risk is almost 10% higher with simultaneous use compared to alcohol use alone [ 7 ]. Together, this suggests that novel approaches are needed to inform prevention and intervention efforts targeting impaired driving while under the influence of alcohol, cannabis, and simultaneous use.

The current study will assess impaired driving-related behaviors at the daily level, providing a novel examination of how day-to-day changes may impact the decision to drive impaired or ride with an impaired driver. Examination at the daily level is important because some individuals who engage in these risky driving behaviors will not do so every day, or every time they use alcohol and/or cannabis. Extremely limited work has focused on daily-level predictors of impaired driving-related variables that may illuminate why these high-risk behaviors occur on some days and not others. One study reported individuals are more likely to drive after drinking alcohol when they consumed more than what is typical for them, with a stronger association observed when subjective intoxication was lower (i.e., when participants perceived themselves to be less intoxicated than what is typical for them [ 8 ]. Another recent study assessing young adult who simultaneously use alcohol and cannabis reported participants were more likely to drive impaired and ride with an impaired driver on days when they engaged in simultaneous use compared to alcohol-only days [ 9 ]. These findings underscore that impaired driving-related behaviors are most likely impacted by within-person differences that fluctuate over time. However, no research has assessed daily-level factors that influence these impaired driving-related behaviors beyond that of actual substance use and perceived impairment. This paper provides details of a novel protocol used to assess driving under the influence of alcohol, cannabis and simultaneous use, riding with a driver impaired by these substances, and two factors that may affect these impaired driving-related behaviors at the daily level: motives to use and normative beliefs. These variables have been shown to be malleable by prevention efforts and intervention in the past (e.g., [ 10 – 12 ]), and this research could provide valuable implications for new interventions efforts aimed at preventing impaired driving.

Motives to use

Motivations to use alcohol and cannabis are typically separated into several domains that are differentiated by whether they are internally or externally generated and positively or negatively reinforcing including: 1) Social– using to increase being social with others (external, positively reinforcing); 2) Coping– using to reduce negative feelings or emotions (internal, negatively reinforcing); 3) Enhancement– using to increase positive feelings or emotions (internal, positively reinforcing); 4) Conformity– using to “fit in” and reduce feelings of social isolation or rejection (external, negatively reinforcing) [ 13 , 14 ]. A fifth motive, Expansion , relates to using a substance to increase perceptual or cognitive enhancement [ 15 , 16 ]. While drinking and, to a lesser extent, cannabis use has shown associations with higher levels of social motives to use in young adults [ 17 , 18 ], more evidence suggests coping motives are associated with experiencing consequences of alcohol and cannabis [ 19 – 22 ]. Specifically, one study showed a direct association between drinking to cope and a subscale of alcohol-related consequences defined as risky behaviors, which included a self-report of alcohol impaired driving [ 23 ]. However, higher reports across all five domains of motives were correlated with driving under the influence of cannabis [ 24 ].

This past research suggests between-person differences in alcohol and cannabis motives and their associations with driving under the influence exist. However, recent research suggests that motives for use may also vary within individuals over time [ 21 , 25 – 28 ], and these more temporal motives may be more strongly associated with substance use and consequences than globally assessed motives. For example, a study that assessed general college semester motives to drink and event-level drinking motives for Spring Break found only event-specific motives, and not the general motives, were associated with alcohol use and consequences during Spring Break [ 29 ]. Taken together, this research indicates a need to understand how motives to use alcohol and cannabis at the daily level may be associated with both impaired driving and riding with an impaired driver. By understanding the effects of motivations to use on these risky outcomes, we may be able to better tailor prevention messaging and focus interventions on gaining skills to identify and address motivations with the strongest associations to impaired driving-related behaviors.

Perceived descriptive norms

Perceived descriptive norms assess how much or how often individuals perceive their peers engage in a specific behavior [ 30 , 31 ]. Similar to alcohol and cannabis use motives, perceived descriptive norms of use have long shown to have a significant associations with alcohol use [ 32 , 33 ] and cannabis use [ 34 – 36 ], as well as consequences related to their use [ 37 , 38 ]. Regarding impaired driving-related behaviors, several studies have indicated the more individuals believe their peers engage in alcohol-impaired driving, the more likely they are to drive under the influence of alcohol themselves [ 39 – 42 ]. Less research has assessed the association between perceived norms of driving impaired by cannabis use and engaging in these behaviors. A study by Whitehill et al. [ 43 ] indicated young adults who perceived their peers used cannabis and rode with cannabis impaired drivers were more likely to both drive under the influence of cannabis and ride with a cannabis-impaired driver. Another study reported perceived peer norms of cannabis use were associated with an increased likelihood of driving while intoxicated by alcohol, cannabis, and simultaneous use one year later [ 44 ]. This suggests a continued need to assess associations between normative perceptions and actual engagement in impaired driving-related behaviors. Additionally, other research suggests that norms can vary significantly within individuals across days [ 45 ], indicating assessing the association between norms and behaviors for impaired driving-related behaviors should be considered and examined at the daily level.

Barriers in assessing impaired driving behaviors

Despite research indicating that assessing risky driving-related behaviors and potential risk factors at the daily level may be necessary to understand important relationships that could aid in prevention efforts [ 46 ], extremely limited research has done so. One reason that daily assessments have not been utilized more readily to assess impaired driving-related behaviors is the difficulty in assessing these behaviors.

A review of the alcohol-impaired driving literature shows a wide range of wording for questions assessing driving under the influence of alcohol. Overall, there are typically two ways researchers ask these questions. One way is to ask about subjective impairment. For example, how often or whether you have “drove while drunk on alcohol” [ 47 ], “…driven when you perhaps had too much to drink,” [ 48 ], or “under the influence of alcohol” [ 49 ] are all questions that used. Other instruments ask about driving after drinking in general or a specific number of drinks consumed, such as “how many times did you drive a car or other vehicle when you had been drinking alcohol,” [ 50 ] or “…after having 5 drinks in a row,” [ 51 ]. Both these options have merits but also limitations. A large limitation is that of social desirability. Alcohol impaired driving is an illegal activity that carries potential financial, legal, and physical injury repercussions and is widely viewed negatively in society [ 52 ]; as such, individuals may underreport these behaviors in self-assessments. Additionally, if driving under the influence is asked when impairment is subjective, the participant needs to think their impairment was enough to be dangerous to drive. This is problematic due to the research showing that, compared to individuals who do not drive impaired, those who do drive impaired are more likely to underestimate their blood alcohol concentration (BAC) and level of impairment [ 53 ], which can lead to underreporting of the behavior. If alcohol-impaired driving is assessed using number of drinks, researchers do not always ask the period over which participants consume alcohol, or how long it was after they drank that they drove. If these details are asked, it may be difficult for participants to answer in retrospective surveys with longer recall time periods (e.g., 6 months, 1 year).

Assessment of driving under the influence of cannabis provides bias issues similar to alcohol-impaired driving in respect to social desirability and relying on participants’ evaluation of their own impairment. Frequent cannabis users may experience tolerance and, as one recent meta-analysis found, experience less impairment in relation to individuals who use cannabis less often [ 54 ]. However, research also suggests certain neurocognitive tasks associated with impaired driving, slowed reaction time, are impeded for regular and occasional cannabis users after using cannabis [ 55 ] and that there may be considerable between-person differences in the effects of tolerance on impaired driving [ 56 ]. The diversity of cannabis products, their varying routes of administration, and unprecedented concentration of tetrahydrocannabinol (THC; i.e., the main active ingredient in cannabis [ 57 ]) make it extremely difficult to estimate impairment levels in a comparable way to alcohol. Based off laboratory assessments of the effects of THC, impaired driving can occur if driving took place within 2–6 hours after cannabis use (see [ 58 ] for review). A more recent meta-analysis of these studies suggests most periods of impairment will last 5 hours and dissipate within 7 hours of use [ 54 ]. The most recent guidelines from Fischer et al. [ 59 ] suggest driving can be impaired 6–8 hours after inhaling cannabis and that impairment can last 8–12 hours after use of edibles (i.e., oral ingestion). Again, asking participants to report on driving within a specific number of hours after using cannabis over longer assessment periods (i.e., 6 months; 1 year) has the potential to lead to underreporting due to recall bias and further justifies a daily assessment approach.

Another difficulty when examining substance use (especially polysubstance use) and potential consequences, such as impaired driving, at the daily level is assessing the order and overlap of impairment and events. In regard to use of alcohol and cannabis in the same day, there are times when such use is simultaneous, in that the effects of the two substances overlap, and there are times when it is concurrent, in that the substances are used in the same day, but not at the same time and their effects do not overlap [ 60 , 61 ]. To be able to get more objective assessments of impairment by simultaneous use and subsequent impaired driving behaviors, the timing of use of each substance and driving behavior is needed. This need may suggest that momentary assessments are necessary; however, surveys to be completed in the moment while under the influence of alcohol and/or cannabis may have issues with missing or incomplete data, and participants should not complete assessments while in the act of driving. While advances in biomedical technology are bringing us closer to momentary assessments of impairment such as a wearable continuous alcohol monitors (e.g., BACtrack Skyn), these devices are still new, and they have known difficulties in data loss and translating transdermal alcohol content (TAC) to BAC [ 62 – 64 ]. Additionally, such devices are presently only available for alcohol use and will not determine use of or impairment by cannabis. It is anticipated that non-invasive biosensors will eventually be available to assess both alcohol and cannabis impairment. Meanwhile, with impaired driving contributing significantly to fatal motor vehicle crashes [ 3 ], there is an urgent need to assess and understand correlates of these risky driving-related behaviors to inform and improve intervention and prevention efforts. Therefore, the current study is utilizing a novel self-report daily assessment design that focuses on reported times of actual use to establish an estimated window of risk for impaired driving, as well riding with an impaired driver. This study is assessing young adults who are at high risk of engaging in these behaviors, and we provide details of the protocol for recruitment, retention, and assessment, as well as challenges and modifications to address them.

The purpose of this paper is to detail the protocol for a daily assessment study designed to examine impaired driving behaviors and associations between these behaviors and perceived descriptive norms and motives to use alcohol and cannabis among young adults at high-risk of impaired driving-related behaviors.

Project overview

The current project aims to assess how factors of perceived norms and motivations to use alcohol and cannabis are associated with impaired driving and riding with an impaired driver at the daily level. Young adults (aged 18–25) who engage in simultaneous use and have a recent history of driving under the influence or riding with a driver under influence of simultaneous use of alcohol and cannabis are asked to complete daily assessments in a measurement burst design (that is, completing assessments Thursday through Sunday, every other week) for 6 months. These days were chosen for assessments due to young adult substance use mostly occurring on or around the weekends [ 65 , 66 ] and higher rates of alcohol impaired driving on the weekends [ 67 ]. In these daily assessments, participants report on the previous day’s alcohol and cannabis use, motivations for using, perceptions of others’ use and engagement in risky driving behaviors. Each day, they also answer questions about their past-day transportation use. For all alcohol-, cannabis-, and transportation-use questions, participants are specifically asked about the time periods of use to establish overlap and windows of risk. This study was approved by the university’s institutional review board.

Target population and eligibility

Original eligibility criteria included being between the ages of 18 and 25, currently residing in Washington State (WA), reporting simultaneous use at least once in the past 30 days, and reporting driving under the influence of simultaneous use of alcohol and cannabis or riding with a driver under the influence of simultaneous use at least once in the past 6 months. Recruitment started for the current study on March 15, 2021. At this time, many restaurants and other establishments still enforced restrictions due to the COVID-19 pandemic. Additionally, many young adults experienced several major environmental changes including virtual classes, job change or loss, and living back with parents or other family [ 68 ]. Several recent studies suggest a reduction in alcohol and substance use for young adults at the onset of the pandemic [ 69 , 70 ]. These factors may have negatively impacted eligibility rates for the current study. Due to a lower than anticipated percentage of participants meeting eligibility criteria, as of September 8, 2021, participants are eligible if they report driving under the influence of simultaneous use or alcohol only or cannabis only (i.e., relaxing the eligibility criteria to include impaired driving by either substance instead of only simultaneous impairment) and meet all other previous eligibility criteria. Participants must be proficient in reading English to enroll. Participants are excluded if they do not meet the eligibility criteria, report they plan to be living outside WA for more than 1 month in the next 6 months, their mailing address is not within WA state, they do not correctly answer attention-check questions, or they fail the online CAPTCHA test (see below).

Sample size and recruitment

This study anticipates recruiting a total of 400 participants and is currently actively recruiting. There are a total of 52 daily assessments for participants to complete. The sample size was based off simulation-based power analyses that were informed by parameter estimates obtained from similar intensive longitudinal data on young adult simultaneous use in Washington state [ 9 , 71 ]. Power analyses estimated our ability to detect a daily-level association between enhancement motives and riding with an impaired driver on simultaneous use days in a logistic mixed effects model that accounted for the clustered nature of the data (20,800 person-days clustered within 400 participants) and the intra-cluster correlation (ICC) [ 72 , 73 ]. Simulations were performed across varying effect sizes (odds ratios ranging from 1.10 to 1.28) and sample sizes (300–400 participants). Based off previous daily data collection, riding with a simultaneous use impaired driver was selected for the sample size calculation as it was the outcome with the lowest base rate. Thus, our estimates are conservative. In the data used to provide parameter estimates for the power analyses, riding with a simultaneous use impaired driver occurred on 12.6% of simultaneous use days and the effect size for the daily-level association between enhancement motives and riding with a simultaneous use impaired driver was indicated by an odds ratio of 1.28 ( OR = 1.28, 95% CI : 0.95, 1.73). Thus, we assumed that riding with a simultaneous use impaired driver would occur on approximately 12.6% of sampled days (i.e., 6.5 of 52 days, on average), and we used an odds ratio of 1.28 as a starting point for the effect size. Using 500 simulations per condition, we estimated we would be sufficiently powered to detect associations with odds ratios greater than or equal to 1.15 with 300 or more participants.

Recruitment utilizes several techniques. The primary form of recruitment is through social media, including posting content and paid advertisements on Facebook, Instagram, TikTok, and Twitter. Unpaid social media posts are also uploaded to Facebook, Instagram, Twitter, and Reddit, and information on the study is provided on a research website for the university. Drawings for giveaways of e-gift cards for amounts ranging between $10–$25 for individuals to follow, like, and tag friends within comments of posts on Instagram and Twitter are also being used. The study also has a website to provide information on what participation involvement entails and the contact form (see below). Study team members are in contact with state and local stakeholders, community and wellness centers, and unions to ask them to share our social media posts, to share electronic information about our study, or to be sent physical recruitment flyers. COVID-19 has delayed posting of flyers in many public locations, but since WA has re-opened more flyers will be posted in libraries, community billboards in cafes and other locations. Flyers include phone and e-mail contact information for the research team as well as the URL and a QR code to complete the initial contact form. Lastly, individuals who have completed previous research studies within the center with which the current research team is affiliated with and have provided consent to be contacted for other research opportunities are being contacted via e-mail and/or phone to invite them to complete the screening survey. All recruitment materials and communication with potential and current participants explain the study as assessing young adult transportation and health behaviors.

Contact form

Participants who are interested in enrolling in the study are directed to complete the initial contact form. This form asks participants to provide their contact information: name, mailing address, e-mail address, and date of birth. There are also checks to help ensure individuals who are completing the contact form are live participants (i.e., not robots) residing within WA who have not already participated. First, participants must pass a CAPTCHA image test to ensure they are a live person and not a robot attempting to complete the form automatically. If participants cannot complete the CAPTCHA, they cannot submit their contact form. Within the form, participants need to complete four attention-check items that ask question such as “Please select the Toyota model Camry from the list below.” If their mailing address is not located in WA state, they are not in the age-eligibility window [i.e., 18 – 25 ], or they answer an attention-check question incorrectly, participants receive a thank you message that lets them know they are not eligible at this time. Participants who have completed all requirements and initial eligibility checks will receive a message thanking them for their interest in participation and letting them know a research team member will be contacting them with information on the next steps.

Phone verification

After successful completion of the contact form, participants are called by a study team member or an undergraduate/post-baccalaureate research assistant to confirm the participant’s name, date of birth, mailing address and email address. Participants who initially opt out of text messages in the contact form are asked if they would like to receive text messages or continue with only email notifications. Once verified, participants are emailed a link to the screening survey. This verification process was initially implemented because previous studies we have conducted with similar recruitment techniques encountered issues with numerous fake participants (i.e. robots) entering a study, and we have found this verification procedure to be mostly effective correcting this issue. Therefore, to allow for easier flow of participants from the contact form to screening survey, we have currently adjusted the protocol to allow potential participants to be emailed a link to the screening survey if they are not reached via phone, but their voicemail includes their name. We still have experienced some participants to pass through the phone verification who were determined to provide false information (e.g., older than 25, live outside WA state) and therefore have added an additional identity check during the virtual training (see below).

Screening survey

After verification, individuals are emailed a personalized link that directs them to the research statement and the screening survey. The research statement includes information about the study, the screening survey, and the rest of the study procedures if they are eligible. After providing consent, participants are automatically directed to the screening survey. This survey takes approximately 10 minutes to complete and is used to confirm the rest of the eligibility requirements. This survey includes additional demographics, questions on participants’ alcohol, cannabis, simultaneous use, and other drug use, transportation availability and habits in the past 6 months, impaired driving-related behaviors in the past 6 months (e.g., alcohol-impaired driving, riding with a cannabis impaired driver), information on past driving tickets/citations, and other health risk and mental health behaviors and symptoms (i.e., sleep behavior, positive and negative affect, and anxiety symptoms). Due to potential changes in transportation related to the COVID-19 pandemic, we also ask participants to indicate if their use of different forms of transportation (e.g., public transportation, ride services) has changed due to the COVID-19 pandemic. Participants who meet eligibility requirements are immediately redirected to the Baseline survey.

Baseline survey

Eligible participants directed to the Baseline survey will first receive a consent form detailing the next steps of the study procedure. Participants must provide consent prior to answering the Baseline survey questions. This survey takes approximately 25–35 minutes to complete, and it assesses more detailed questions about alcohol and cannabis use and consequences, perceived norms of peer use and impaired driving-related behaviors, motives of use, personality traits (i.e., impulsivity and conscientiousness), aggressive and distracted driving, transportation use and availability, impaired driving-related behaviors, and adverse childhood experiences. At the end of the Baseline survey, participants are directed to an online scheduler to schedule a virtual training session on the daily assessment protocol.

Virtual training for daily assessments

Training sessions are one-on-one, facilitated by the study team, and typically take 15–20 minutes. These sessions occur over the HIPAA compliant Zoom platform. The purpose of the training is to orient participants further on when to complete the daily surveys, what questions will look like, and the payment schedule they should expect. First, participants are asked to verify their identity and residency by either showing their WA State identification or another form of identification and a piece of mail showing their address. Participants are trained on 1) how to measure a standard drink based on the definition by National Institute on Alcohol Abuse and Alcoholism [ 74 ], 2) our definition of cannabis/cannabis is, “any products with THC (including products with both THC and CBD),” and 3) our definition of vehicle is “car, light truck, or motorcycle” are explained. Due to COVID-19 pandemic-related restrictions, it is possible participants are having many interactions with other people virtually, instead of in person. Therefore, in the training sessions, we describe that we are defining a virtual interaction as “direct interaction with people virtually/online in real time” and describe some examples that qualify such as Zoom or Facetime calls and playing video games with an audio chat feature (such as Xbox Live); as well as examples that do not qualify such as scrolling through Instagram or Facebook, watching and sharing videos on TikTok, and text messaging with a friend. Participants are also shown screenshots of some of the assessment questions. A specific example is shown on how to answer questions about the timing of behaviors (see Fig 1 and further explanation in the Daily Assessment Procedure section). Lastly, participants are quizzed on their knowledge of the procedures by providing the participant with hypothetical scenarios and discussing with the study staff how they would provide answers in the survey. These scenarios are designed to assess their knowledge of our study definitions and how to determine the standard number of drinks. Participants are also provided with an opportunity to ask any additional questions about the study and are provided all the contact information and social media links again.

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Note: Participants first receive the screen shown in panel “A.” When a 4-hour period is chosen, below it 1-hour increment options appear as shown in panel “B.”.

https://doi.org/10.1371/journal.pone.0275190.g001

To increase participant study flow, we have created an optional recorded training for participants with whom we have difficulty scheduling the virtual one-on-one training. If scheduling attempts are unsuccessful (e.g., participant does not schedule a training within two weeks; participant has two or more missed scheduled training times), participants are sent a link to the training video and a quiz with 10 questions. Participants must answer 80% correct to move on to the daily assessment survey portion of the study. Participants are allowed to take the quiz multiple times until they achieve the score needed to move them forward, as its purpose was to train participants in daily assessment protocol and language.

Daily assessment procedure and monitoring

Participants start their daily assessments depending on when they complete their virtual training. If they have a training session on Monday or Tuesday, participants start their surveys on the Thursday of that same week. If participants complete their training on Wednesday through Friday, they start completing daily assessments on Thursday of the following week. Participants complete surveys on Thursday, Friday, Saturday, and Sunday every other week for 6 months. On Wednesdays of an active assessment week, participants are sent a reminder text message or email (if they have not provided consent to text them) that they will be sent a survey invitation tomorrow. Wednesday reminders are sent at 4:00pm. Participants are sent a text message or email that includes the URL to the daily assessment survey on Thursday–Sunday at 10:00am with reminders at 12:00pm, 2:00pm, and 4:00pm if they do not complete the daily assessment. The survey is open from 10:00am to 5:30pm, but—to allow for completion time—participants are told the survey closes at 5:00pm. If a participant misses all four surveys in an assessment week, the study staff call them to verify they are receiving the invitations and that they are not having any technical difficulties with the surveys.

Six-month follow-up assessment

After completing 6 months of the daily assessment procedures participants are invited to the 6-month follow-up survey. This survey is similar to the Baseline survey and assesses alcohol, cannabis, simultaneous use, and other drug use, alcohol and cannabis consequences, transportation availability and habits, impaired driving-related behaviors, and driving tickets/citations in the past 6 months. Participants also report on other health risk and mental health behaviors and symptoms (e.g. depressive symptoms), and impaired driving-related cognitions (e.g., norms, motives).

Compensation

Participants can receive up to $281 for completing the study procedures. A $5 e-gift card is provided for completing the Screening survey, $25 for completing the Baseline survey, and $30 for completing the 6-month assessment. For the daily assessment procedures, participants receive $3 for each survey and a $5 bonus for completing all four surveys within one week. Therefore, participants can receive up to $17/week for each assessment week of the daily assessments.

Daily assessment measures

Mood and affect..

Participants are asked to rate how the current day and yesterday were on 5-point scale from Very bad (-2) to Very Good (2). They also complete the Positive and Negative Affect scale short form adapted for daily assessments [ 75 ].

Transportation.

Participants are asked if they went anywhere yesterday. If they indicate they did, they are asked what forms of transportation they used out of the following list: 1) Public transportation (e.g., bus, light rail), 2) Taxi or cab, 3) Ride Service (Uber, Lyft), 4) Got a ride from someone such as a friend or family member (not a taxi or ride service), 5) Drove yourself 6) Rode a bicycle 7) Walked. For each type of transportation option that is chosen, participants are asked a follow-up question on the times they used the transportation. Participants see response options that are initially presented in 4-hour intervals. Once a 4-hour time interval is selected it, the assessment narrows and moves on to response options that are 1-hour intervals (see Fig 1 ). Participants who report getting a ride from someone are asked to indicate who they received a ride from with a “check all that apply” list that includes: 1) Parent or guardian, 2) Family member other than a parent or guardian, 3) Friend, 4) Significant other, partner, or spouse, 5) Other: _______. One question assesses the daily impact the COVID-19 pandemic has had on their transportation choices with response options ranging from 0 “Not at all” to 4 “Extremely.”

Substance use.

Participants indicate “Yes/No” to whether they 1) drank alcohol and 2) used cannabis. If they report yes to both alcohol and cannabis/cannabis, participants are asked to respond Yes/No to “Did you use alcohol and cannabis at the same time, that is so their effects overlapped yesterday” to assess self-reported simultaneous use. Participants who indicate simultaneous use on the previous day report how much the feeling or effect of alcohol overlapped with the feeling or effect of cannabis using a 4-point scale that ranges from 0 “Not at all” to 3 “A great deal.” Participants are also asked to indicate which hours they drank alcohol and which hours they used cannabis yesterday by first responding to the same 4-hour intervals that are used to assess transportation use that, once selected, move to 1-hour interval windows. For alcohol use, participants are asked to report the number of drinks consumed for each hour they indicated they drank. Participants who reported cannabis used on the previous day are asked to indicate the ways they used cannabis yesterday from a “check all that apply” list that includes: 1) Smoked it, 2) Ate it, 3) Drank it, 4) Vaporized it (with a vape pen or e-cig), 5) Used it by dabbing and 6) Used it some other way.

Time-ordering of transportation and substance use.

Since the focus of this study is to assess impaired driving behaviors, we need to be able to assess the time-ordering of participants’ substance use and transportation if they said they used both in the same 1-hour interval. For example, if a participant reports driving from 1pm–2pm and reports drinking from 1pm–2pm, it is not known if the participant started drinking before or after they were driving. To disentangle this, participants who have overlapping time periods of substance use (i.e., alcohol and/or cannabis use) and transportation use (e.g., driving, ride share, using a bicycle) are asked a follow-up question through which participants indicate whether the transportation occurred during or after they started using alcohol/cannabis or whether it occurred before they started using alcohol/cannabis (See Fig 2 for an example).

Note: For every 1-hour period a participant chooses for both a transportation and alcohol and/or cannabis use question, they are provided with this follow-up question to determine when transportation occurred in relation to the substance use.

https://doi.org/10.1371/journal.pone.0275190.g002

Riding with an impaired driver . Participants who report getting a ride from someone are asked to answer Yes/No to whether the driver: 1) Drank any alcohol before driving, 2) Drank 4 or more drinks within 2 hours of driving, 3) Used cannabis within 3 hours of driving, and 4) Used alcohol and cannabis within 3 hours of driving. This is asked specifically for each person a participant indicates that gave them a ride.

Motivations for alcohol and/or cannabis use.

Participants who report using alcohol and/or cannabis on the previous day are asked the question “Yesterday, to what extent did you use alcohol and/or cannabis for the following reasons?” using response options that range from 0 “Not at all” to 4 “Extremely.” Participants report on 14 possible motives that were adapted from past research [ 13 , 76 – 78 ]. Two items assess conformity motives (e.g., “So I wouldn’t feel left out”); seven items assess coping motives of which two assess social anxiety specifically (e.g., “To manage social anxiety”); two items assess motives for social reasons (e.g., “To make a social gathering more enjoyable”); two items assess enhancement motives (e.g., “To feel good”); and one item assesses use for an altered perspective, (e.g., “To alter my perspective or to think differently”), sometimes referred to as an expansion motive [ 15 , 16 ].

Motivations to not use alcohol and/or cannabis.

Participants who do not report any alcohol or cannabis use are asked “Yesterday, to what extent did you choose NOT to use alcohol and/or cannabis for the following reasons?” using response options that range from 0 “Not at all” to 4 “Extremely.” Participants report on 12 possible motives. Six of the items are from previous research [ 79 , 80 ] and ask about motives related to work or school obligations that day, not having any one to drink or use cannabis with, not being able to get either substance, not having a desire to use either substance, and not usually using either substance on that day of the week. Five items have been used in other daily assessments and assessed needing money for other things, not wanting it to interfere with work/school today, having children around, having parents around, and other:_______ [ 76 ]. One additional item was added for the current study which assessed the motive “I needed to drive somewhere.”

Participants are asked three questions to assess perceived descriptive norms of substance use and eight questions to assess perceived descriptive norms of impaired driving and riding with an impaired driver. All norm questions prompt participants to “Think of the people you were around (either in-person or virtually/online) yesterday.” For substance use, participants are asked how many of these people they think were using or had used: 1) alcohol, 2) cannabis, and 3) alcohol and cannabis at the same time. Participants report on their perceptions of others around them driving impaired by reporting how many of these people they think drove 1) After drinking any alcohol, 2) After drinking 4 or more drinks in 2 hours, 3) Within 3 hours after using cannabis, and 4) Within 3 hours after using both alcohol and cannabis at the same time. To assess perceptions of others around them riding with an impaired driver, participants answered these four questions again but regarding how many of these people they though were a passenger of a driver under each of the four circumstances (e.g., After drinking any alcohol). Response options for all norm questions were on a 7-point scale: 0 people, 1–2 people, 3–5 people, 6–10 people, 11–25 people, 26–50 people, and 50+ people. A scale was chosen instead of an open response to reduce cognitive burden on participants [ 81 ], and these response choices were chosen to reflect a range of possible different size groups from only 1–2 other people all the way up to a larger party, or crowded bar/restaurant.

Context questions.

Participants indicate how many people they were around (either in-person or virtually/online) yesterday using the same scale used to assess the norm questions that ranges from “0 people” to “50+ people.” They then have a checklist to indicate their relationship to the participants (e.g., parent(s) or guardian(s), friend(s), coworker(s)). Additionally, participants are asked to indicate if they worked a “graveyard” or 3 rd shift, such as working midnight to 8am. Participants who report not going anywhere the previous day (and therefore not using any transportation) are asked to indicate what they did yesterday from a “check all that apply” list that includes: 1) Attended school virtually or completed school work, 2) Worked from home, 3) Took care of a child or other family member, 4) Video chatted with friends or family members, 5) Used social media, 6) Played video games, 7) Completed chores or housework, 8) Watched TV or streamed movie(s) or TV show(s), 9) Napped, 10) Exercised, 11) Other:_______.

Sleep, exercise, and diet.

Participants are asked additional questions related to sleep, exercise and diet when they indicate either 1) they did not travel or 2) they did not use alcohol or cannabis, they are asked questions on health behaviors. These additional questions are asked to make the survey length is approximately equal across days. Participants are asked six questions taken from the Consensus Sleep Diary [ 82 ] on their sleep last night including the time they went to bed, the time they got up that day, how long it took them to fall asleep, how much they were awake in the middle of the night, how long they were awake before they got out of bed, and the quality of their sleep the night before. Exercise the previous day is assessed using four questions from the daily adaptation of the Godin Leisure Time Exercise Questionnaire [ 83 , 84 ]. Daily diet was assessed by asking the number of servings they had the previous day of 1) fruits, 2) vegetables, and 3) 8oz of sugary drinks such as soda.

Additional transportation risk behaviors.

Participants who do not report using alcohol or cannabis are asked additional transportation-related risk behaviors. Again, this choice was made to make the survey approximately equal in length if participants did not use substances. Seat belt use was assessed for participants who did not use either substance but reported driving or riding in a car (either from a friend/family member, cab/taxi, or ride service). Participants report on how often they wore a seat belt while they were in car yesterday using the response options 0 “Never,” 1 “Sometimes,” and 2 “Every time.” Participants who report not using either substance but report driving are also asked to indicate Yes/No to the question “Did you read or send any text messages while driving yesterday?” and rate their drowsiness while driving using the response options 0 “Not at all tired or drowsy,” 1 “A little bit,” 2 “A moderate amount,” and 3 “Very tired or drowsy.”

Reasons for not traveling.

To contextualize participants’ responses, if participants report not traveling anywhere the previous day, they are asked to respond to six questions on their reasons for not using transportation using a 5-point scale that ranges from 0 “Not at all” to 4 “Extremely.” The reasons assessed are 1) COVID-19, 2) Not having a transportation option available, 3) Not having money for transportation, 4) Responsibilities at home, 5) Low mood or feeling down, 6) Not feeling like going anywhere.

Arguments, disagreements, and stressful events.

Participants who report 1) not traveling and/or 2) not using alcohol and/or cannabis are asked questions about arguments or disagreements they had the previous day, using a revised version of the Daily Inventory of Stressful Events (DISE; [ 85 , 86 ]) Again, this choice was made to provide surveys of approximately the same length. Participants are asked to respond Yes/No if they experienced the following yesterday: 1) Did you have an argument or disagreement with anyone, 2) Did anything happen that you could have argued about but decided to let pass to avoid disagreement, 3) Did anything happen at school or work that most people would consider stressful, 4) Did anything happen where you live that most people would consider stressful, 5) Did anything happen to a close friend that most people would consider stressful, and 6) Did anything else happen to you that most people would consider stressful. For each of these six experiences that are endorsed, participants are asked to rate how stressful the experience was for them using a 4-point scale that ranges from 0 “Not at all” to 3 “Very.”

Data analysis plan

Generalized linear mixed models (GLMMs) will be used to assess the main aims and address the nature of the nested data. Daily assessments (Level 1) will be nested within individuals (Level 2) to account for clustering of occasions within individuals and accommodate unequal observations per person [ 72 , 73 , 87 ]. Outcomes are assessed at the event level; therefore, binary distribution will be used, and findings will be expressed in terms of odds ratios (OR). Norms and motives will be assessed as both time-invariant and time-varying predictors of all impaired driving-related outcomes. Level 1 variables will be person-mean centered and Level 2 variables will be grand-mean centered. Models will be adjusted for sex, age, race/ethnicity, availability of safe alternative transportation, and estimated event-level alcohol use. Since the minimum legal age to purchase and use cannabis is 21 in WA, we will assess age both as a continuous covariate and with results stratified by those under 21 compared to participants 21 and older. These analyses will allow us to assess the within- and between-person variability across 6 months. Additionally, we will be able to assess whether both overall- and event-level perceived norms and motives to use are associated with increased odds of impaired driving-related outcomes.

As of June 22, 2022, we have had a total of 5,867 participants complete the initial contact form. Of those, 2,238 (38.1%) had their identity verified and completed the screening survey. A total of 264 (11.8%) participants were eligible. Of the eligible participants, 232 (87.9%) completed baseline and 200 (86.2%) were scheduled for a virtual training or completed the video training and quiz. Nine participants have dropped from the study—six prior to completing any daily assessments, two shortly after starting daily assessments, and one after completing 36 of 52 daily surveys. Seven participants were removed from the study because it was determined they provided false information and did not live in Washington. Five of these individuals were removed prior to completing any daily assessments, the other two shortly after starting daily assessments. All data from participants who provided false information and daily assessment data for the two participants who dropped shortly after starting daily assessments were removed. As of June 22, 2022, 192 participants started daily assessments. Of the 8,152 potential daily assessments that could have been completed on or prior to June 22, 2022, 81.2% were completed and an additional 2.3% have partial data. The racial and ethnic composition of the 192 daily assessment participants is: 64.1% White, 21.4% Asian/Asian American, 3.6% Black/African American, 1.0% Native Hawaiian/Pacific Islander, 0.5% American Indian/ Alaskan Native, 6.3% Multiracial, 3.1% Other Race, and 10.4% Hispanic or Latino/a. Enrolled participants are an average 21.97 (SD = 1.99) years old, 70.8% reported female as their birth sex and 29.2% reported male as birth sex. Gender identification was 63.5% women, 28.1% men, 1.0% trans men, 5.7% genderqueer/ gender non-conforming, and 1.5% other gender not listed or no answer. Sexual orientation was 57.3% straight/heterosexual, 22.9% bisexual, 2.1% gay, 2.1% lesbian, 4.2% questioning, 7.8% queer, and 3.6% other. A total of 59.4% participants are college students and 43.2% have received a 4-year degree. As of June 22, 2022, 115 participants were invited to the 6-month follow-up assessment and 100 have completed. Recruitment and enrollment are anticipated to continue until the target sample size of 400 or on December 1, 2022, whichever comes first.

Significance of future findings

The current study will assess how both perceived norms of impaired driving behaviors and motives to use alcohol and cannabis are associated with impaired driving-related outcomes, including driving under the influence of alcohol, cannabis, and simultaneous use and riding with a driver under the influence of these substances. The protocol detailed in this paper provides information on our innovative approach in assessing within-person and between-person associations potentially related to impaired driving outcomes. Impaired driving-related behaviors and their predictors have extremely limited research focused on daily-level associations [ 8 , 88 ]. Therefore, the current study will provide unique informative data that will shape the knowledge base in the field of social science and public health substance use research and that may be helpful for future prevention and intervention efforts aimed at reducing harms related to substance use and advancing traffic safety and preventions of impaired driving-related behaviors.

The current study utilizes daily assessments with detailed timing questions as opposed to momentary ecological assessments because of the limitations related to completing assessments in the moment while under the influence [ 89 , 90 ]. This detailed time assessment will allow us to determine impairment with less subjectivity than self-report of impaired driving and will provide insight on how often young adults may be driving impaired without judging themselves as impaired.

Past and current challenges

This study has had several challenges to overcome. The largest challenge has been from the COVID-19 pandemic. Recruitment was originally planned to start in summer of 2020; however, due to lockdown restrictions and numerous closures in Washington State, recruitment was delayed. It was anticipated that many young adults would not be driving or traveling at all during this time due to these restrictions including closures of businesses and a full ban of indoor dining. The Governor’s decrees and changes of state and local restrictions were closely monitored, and it was decided to start recruitment when the indoor dining ban was lifted across most of the state. Since research on young adult drinking at the onset of the COVID-19 pandemic suggested a reduction in drinking [ 69 , 70 ], there were still concerns that our eligibility percentages would be lower than initially anticipated. The rate of individuals screening in were tracked, and in early September (approximately 6 months after the study’s launch) it was decided to open the eligibility criteria to allow young adults with reports of any impaired driving by alcohol, cannabis, or simultaneous use (instead of only under the influence of simultaneous use) to screen into the study. Another current challenge the study is experiencing is the percentage of participants who identify as female compared to those who identify as male. This is a common issue among health behavior research—that more females participate than males [ 91 ]—and is also indicative of the gender distribution of individuals who engage in social media, particularly Instagram, from where a large percentage of our participants are recruited. Survey research suggests 44% of women, but only 36% of men, in the United States use Instagram [ 92 ]. To address this, we are utilizing social media outlets that have a larger percentage of male users, specifically Reddit, and we have planned in-person recruitment strategies in the future.

Limitations

While the current study provides an innovative way to assess impaired driving-related outcomes and its projected findings may provide information that significantly improves intervention and prevention efforts, it is not without limitations. First, the sample consists of young adults who self-report either driving under the influence of alcohol, cannabis, or simultaneous use, or riding with a driver under the influence of simultaneous use of both substances. Thus, the findings may not be generalizable to individuals who engage in these behaviors but do not self-report them, nor to individuals who have never engaged in these behaviors. Future research is needed on what factors influence the first engagement in these behaviors, as previous research has repeatedly shown high associations between driving impaired in the past and future impaired driving [ 93 , 94 ]. Second, the sample is specific to young adults in WA state, and additional research will be needed to determine if there are differences among other age groups—both older and younger than 18–25—and within other states with differing cannabis legalization statuses. Lastly, this data is being collected during the COVID-19 pandemic with variability occurring in businesses (including bars, music venues, and night clubs) being open, their hours of operation, and their capacity. As outlined above, while care was taken to ameliorate the obvious effects of the COVID-19 pandemic, it is unclear how these business restrictions and regulations, along with other changes occurring during the COVID-19 pandemic, will impact the overall findings, as is the case with many data collected during this time.

This study will provide much needed information for prevention and intervention efforts on impaired driving behaviors. The intensive daily data collected will allow for innovative examination of potentially malleable predictors. This study is a cooperative agreement with CDC’s National Center for Injury Prevention and Control (NCIPC), and the scientific collaborators and scientific program officers have provided regular support and oversight that has been invaluable to the progress and success of the project. Additionally, the project has both current and future plans for involving additional partners at the state, region, and community level. We have received feedback on initial measures and are having continual open conversations about recruitment and current and future programs and initiatives to reduce impaired driving behaviors. In an effort to quickly translate research findings to “real world” settings, our team will be meeting with several stakeholders in Washington who are involved in impaired driving prevention to understand their successes and challenges, lessons learned that are useful for the present study, and how results from this research could be most helpful for their programs and prevention efforts. Once concluded, this project will provide reports on the findings of these results and the implications they may provide for these existing initiatives to stakeholders. Thus, the current project has potential for real-world impact on impaired driving behavior through this rapid dissemination of findings to partners, coalitions, and other key stakeholders.

Acknowledgments

The authors would like to acknowledge our collaborators at CDC, Amy C. Schumacher and Merissa A. Yellman, for their continued support and valuable feedback on this project.

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Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem (2018)

Chapter: 3 interventions to reduce drinking to impairment, 3 interventions to reduce drinking to impairment, introduction.

Most interventions to reduce alcohol-impaired driving have focused on decreasing the likelihood that someone will drive after already being impaired by alcohol. Conversely, less attention has been focused on reducing drinking to impairment before driving. This has been demonstrated in policy activity; during the past two decades the implementation of driving-oriented policies has increased among states, while the implementation of effective drinking-oriented policies has remained virtually unchanged ( Nelson et al., 2015 ). However, there are a number of effective interventions to reduce drinking to the point of impairment (i.e., binge drinking 1 ), and some of these interventions have an independent effect on reducing impaired driving and alcohol-impaired driving crashes ( Elder et al., 2010 ; Fell et al., 2009 ; Hingson et al., 2008 ; McCartt et al., 2010 ; Rammohan et al., 2011 ; Xuan et al., 2015a ). Therefore, increasing adoption of interventions that have been proven to reduce excessive drinking is an important and underused strategy to reduce morbidity and mortality from alcohol-impaired driving.

___________________

1 Binge drinking is defined as drinking at or above levels during a drinking occasion/episode that typically results in impairment-level BACs (i.e., ≥0.08%) for most men and women drinking at typical drinking rates. This corresponds to drinking five or more drinks for men and four or more drinks for women in about 2 hours. Most public health and epidemiologic studies use five/four thresholds, and members of the general public interpret the binge drinking term to mean drinking to the point of impairment or intoxication.

As illustrated in the committee’s conceptual framework (see Figure 1-5 ), the first two behaviors that the committee identified as points of intervention for reducing alcohol-impaired driving fatalities are alcohol consumption and drinking to impairment. Chapter 2 underscores the proximal relationship between binge drinking and alcohol-impaired driving. This chapter will highlight the drinking-oriented interventions (i.e., policies, programs, systems, and strategies) that have a strong evidence base supporting their population-level effectiveness, while other interventions discussed may be promising but underevaluated, or relatively ineffective but commonly used or familiar. These interventions will be examined within the context of the concepts and considerations for comparing interventions that were discussed in Chapter 1 , as well as barriers to implementation and strategies to overcome them, lessons learned from other countries, and key research needs. This chapter is organized by the most salient intervention opportunities identified in the conceptual framework that target alcohol consumption (particularly consumption stemming from illegal sales to underaged or intoxicated persons) and interventions designed to reduce binge drinking, including policies and laws, enforcement, educational interventions, and technological interventions.

The chapter presents discussions of policies and laws that target the alcohol environment (e.g., policies to maintain or increase price of alcohol, limit physical availability, reduce illegal alcohol sales, and restrict alcohol marketing) and shape drinking behaviors that reduce alcohol-related harms (e.g., alcohol-impaired driving crashes). The committee applied an upstream, preventive approach to reducing alcohol-impaired driving fatalities and used the best available evidence to inform the selection of these specific policies and laws from an array of options for states and localities. However, it is important to recognize that some upstream interventions and policies have a broader reach than others. Some (e.g., social host liability) are targeted directly at preventing impaired driving, while others (e.g., enforcing underage drinking laws) target unlawful consumption. However, some of these polices (e.g., raising the price and reducing the number of alcohol outlets) operate further upstream and affect all consumers. The policy-relevant effect is that these actions reduce choice overall while aiming to reduce excessive or harmful alcohol consumption. The committee acknowledges that population-level policies may be more controversial than polices that are more precisely targeted at high-risk consumers, excessive consumption, or risky behavior. While these interventions have been shown to reduce most types of alcohol-related harm at the population level and achieve the desired public health benefits, they also have the potential to reduce liberties of responsible adult consumers. However, there are health benefits to these population-level policies beyond only reducing alcohol-impaired driving, for example,

reducing violence and child abuse and neglect ( Foran and O’Leary, 2008 ; Kuhns et al., 2014 ; Widom and Hiller-Sturmhofel, 2001 ). Ultimately, these considerations have to be balanced by policy makers in light of the values of their particular community. For purposes of this report, however, the committee believes the evidence shows that the trade-offs outweigh the potential reduction in individual choice.

Historically, the support for and enactment of effective policies and laws have been the impetus for reducing alcohol-impaired driving fatalities ( Fell and Voas, 2006 ). Furthermore, these policies do not operate in siloes. As discussed in Chapter 1 , progress in this area requires a comprehensive approach, which includes a set of complementary policies to reduce hazardous drinking, enhanced with enforcement. Throughout this chapter, the committee offers recommendations to all levels of government on which sets of policies and laws to adopt or improve to reduce alcohol-impaired driving. These are the policies and laws that the committee has determined will have the greatest effect on population health by reducing excessive drinking and ultimately, alcohol-impaired driving.

POLICIES TO MAINTAIN OR INCREASE PRICE

Raising alcohol taxes to reduce impaired driving and related consequences.

Alcohol taxes have perhaps the strongest and most consistent evidence base of any U.S. policy for reducing excessive drinking and related harms, and there is also strong evidence that higher alcohol taxes reduce alcohol-impaired driving and motor vehicle crash fatalities ( Elder et al., 2010 ; Wagenaar et al., 2009 , 2010 ). The 2016 Surgeon General’s Report on Alcohol, Drugs, and Health identifies price and tax policies as an evidence-based policy to reduce alcohol misuse and related problems ( HHS, 2016 ). Despite this, alcohol taxes do not cover alcohol-related costs and have declined in inflation-adjusted terms at both federal and state levels ( Naimi et al., 2017 ; Sacks et al., 2015 ).

In the United States, alcohol taxes may be applied as specific excise taxes , which are based on a fixed dollar amount per volume and are sometimes referred to as volume-based taxes . This is the most common type of tax, and it is the only form of federal taxation on alcohol. Some states also have ad valorem excise taxes , which are based on a percentage of price. Most but not all states apply the general sales tax to alcohol ( APIS, 2016c ).

Higher alcohol taxes, which are imposed on the producers of alcohol, are typically passed through to consumers as higher prices. While the

industry could soften the effect of taxes by reducing their prices, alcohol taxes are typically passed on to consumers at an equal or even higher rate ( Ally et al., 2014 ; Kenkel, 2005 ; Young and Bielinska-Kwapisz, 2002 ). Consequently, consumers face higher alcohol prices. The bulk of the evidence suggests that higher prices reduce both overall consumption and high-risk alcohol-related activities and adverse outcomes. The evidence base is strong, with consistent findings across a variety of study designs including quasi-experimental time series analyses and panel studies (see, for example, Elder et al., 2010 ; Wagenaar et al., 2009 , 2010 ; Xuan et al., 2013 ). In addition, higher taxes are protective for a range of outcomes that are related to binge drinking, including interpersonal violence, sexually transmitted infections, and unintentional injuries including motor vehicle crashes ( Wagenaar et al., 2010 ). See Figure 3-1 for a conceptual model that delineates the causal pathway by which an increase in alcohol taxes could reduce excessive alcohol consumption and harmful consequences.

Drinking, Binge Drinking, and Impaired Driving

Efforts to reduce the health, social, and economic costs of alcohol-impaired driving and alcohol-related crashes and crash fatalities depend on reducing the frequency and intensity of alcohol impairment in the

population and on reducing the likelihood that those who are impaired will drive a motor vehicle. Overall, approximately 5 percent of drinkers report having driven after “having had perhaps too much to drink” during the past 30 days ( Flowers et al., 2008 ). Binge drinking, which typically results in a level of blood alcohol concentration (BAC) that produces impairment, is therefore a precursor to alcohol-impaired driving among those who subsequently drive a motor vehicle. In addition, 12 percent of binge drinkers report having driven a motor vehicle during or within 2 hours of their most recent binge drinking episode. Those who reported binge drinking and subsequent driving consumed an average of 8 drinks, and 26 percent of them consumed 10 or more drinks ( Naimi et al., 2009 ). In cross-sectional surveys, 84 percent of those who report having driven “after having perhaps too much to drink” also report binge drinking; self-reported binge drinkers account for 88 percent all of impaired driving episodes ( Flowers et al., 2008 ). Because survey respondents may drink and binge drink less than the population as a whole, and because survey respondents may underreport their own consumption or related activities such as driving after binge drinking, it is likely these estimates are conservative.

Higher Taxes Reduce Alcohol Consumption and Binge Drinking

Higher prices for alcohol are related to lower consumption and reduced binge drinking among adults and youths ( Elder et al., 2010 ; Wagenaar et al., 2009 ; Xuan et al., 2013 ). One summary measure of the effect of taxes on consumption is the price elasticity of demand; this is a proxy for the tax elasticity of demand. Across multiple studies, the average price elasticity of demand for alcohol is –0.65, which means that every 10 percent increase in price is associated with a 6.5 percent reduction in consumption ( Wagenaar et al., 2009 ). Even among heavy drinkers the price elasticity for alcohol is –0.28 ( Wagenaar et al., 2009 ). Furthermore, there is a strong inverse relationship between taxes and binge drinking ( Xuan et al., 2015b ) and taxes and outcomes related to binge drinking, which demonstrates that taxes still have a strong effect on those who drink excessively ( Elder et al., 2010 ; Wagenaar et al., 2010 ).

Higher Taxes Reduce Impaired Driving and Motor Vehicle Crash Fatalities

There is also strong and direct evidence that higher taxes reduce impaired driving and fatal motor vehicle crashes. A meta-analysis by Wagenaar et al. (2010) examined effect sizes in studies that assessed a diverse set of alcohol-related outcome measures, including traffic crashes and alcohol-related driving measures. The study combined independent estimates in random-effects models to calculate aggregate effect estimates

across 50 studies. Among the 21 studies that specifically examined effects of alcohol prices or taxes on traffic safety outcomes, all 34 independent estimates showed an inverse association, with 68 percent of those estimates reaching statistical significance. The average effect size for the 34 independent estimates was –0.112 (p<0.001). The authors concluded that doubling the alcohol tax would lead to an 11 percent reduction in traffic crash deaths ( Wagenaar et al., 2010 ).

A systematic review by the Guide to Community Preventive Services convened by the Centers for Disease Control and Prevention (CDC) also found that alcohol-impaired driving was inversely related to the price of alcoholic beverages ( Elder et al., 2010 ). The review included 11 studies that evaluated the effects of alcohol prices or taxes on motor vehicle crashes. Across the studies, the association between alcohol prices or taxes and motor vehicle injuries and fatalities was generally significant. Furthermore, the authors report that the magnitude was comparable to the relationship between alcohol prices or taxes and alcohol consumption. The elasticities reported in these studies were generally higher in the studies that examined outcomes more proximally related to alcohol consumption (e.g., alcohol-related crashes) when compared to those that are less directly related (e.g., overall crash fatalities). The authors also reviewed three studies that assessed the relationship between alcohol prices or taxes and price elasticities for self-reported alcohol-impaired driving. Price elasticities in samples from the United States and Canada (range of –0.50 to –0.81; all p<0.05) showed that there was consistent evidence of an inverse relationship between price and impaired driving.

A recent (2017) interrupted time series study investigated the effect of an increase in alcohol sales tax in Maryland on the rate of drivers involved in an injury crash who were “alcohol-positive” (i.e., drivers for which the investigating officer perceived any alcohol involvement or their BAC was above 0.00%). The authors found that the 2011 tax increase (from 6 percent to 9 percent) lead to a significant 12 percent reduction in alcohol-positive drivers aged 15–20 years (p<0.007) and 21–34 years (p<0.001). For drivers ages 55 and above, the rate of alcohol-positive drivers increased during the post-intervention period, which the authors posit could be related to this age group’s average socioeconomic status in the state of Maryland and thus, decreased price sensitivity. Overall, the study also showed a 6 percent reduction (p<0.03) in the population-based rate of alcohol-positive drivers after the increase was enacted. The effect was modeled using three denominators—per population of Maryland, licensed drivers in Maryland, and vehicle miles traveled in Maryland—which all found similar results. The authors controlled for a number of factors (e.g., monthly unemployment prevalence in Maryland and annual state per-capita personal income) and included a proxy, alcohol-negative crashes, to control

for external factors such as the economy, advancements in car safety, and highway design ( Lavoie et al., 2017 ).

Cost-Effectiveness of Raising Alcohol Taxes

Raising taxes has been shown to reduce impaired driving and related consequences; these are important and valued benefits. Moreover, the additional, direct program costs of collecting the taxes are relatively small as the tax collecting infrastructure is already in place. Furthermore, the higher tax revenue raised by the government (i.e., federal or state) can more than offset these relatively small costs, depending on the size of the tax increase. Thus raising taxes is likely to generate government revenue. However, there may be a level of taxes beyond which taxes would no longer increase revenue; that is, if individuals reduced their consumption or price of alcohol consumed, or turned to untaxed black markets. Another potential cost would be the lost enjoyment (utility) to those drinkers who reduced their drinking levels. The committee considers that loss of utility to be small. Conversely, on a population level, this cost would be more than offset by reduced societal costs such as lost productivity and diminished utility (e.g., physical or emotional pain for victims or their friends and family) that result from excessive alcohol consumption and alcohol-impaired driving injuries and fatalities. In sum, considering all these costs leads the committee to the conclusion that raising taxes would be cost-beneficial.

Other Considerations in Raising Taxes, in Addition to Their Effectiveness

Despite evidence of effectiveness for reducing alcohol-impaired driving and alcohol-related crash fatalities, taxes are low and therefore represent an important “old” but neglected strategy that could be much more aggressively implemented. Thus, raising taxes represents an important public health opportunity. Currently, alcohol-specific excise taxes in states and at the federal level are low in absolute terms. Specifically, the federal tax on a standard drink (0.6 oz., or 14 grams of ethanol) of beer is $0.05, a standard drink of wine is $0.04, and a standard drink of distilled spirits is almost $0.13 ( TTB, 2016 ). In 2015, the average state alcohol-specific excise tax per standard drink was $0.03 for beer, $0.03 for wine, and $0.05 for spirits. These taxes therefore account for a small percentage of the price of alcohol. Furthermore, federal and state taxes have eroded in inflation-adjusted terms relative to historical levels. Federal alcohol taxes have not been changed or adjusted for inflation since 1991. While alcohol taxes historically (late 1800s through early 1900s) accounted for more than one-third of federal government revenue, they now account for less than half

of 1 percent of federal government revenue ( Cook, 2007 ). Among states from 1991 to 2015, the average inflation-adjusted (in 2015 dollars) specific excise tax rate declined 30 percent for beer, 27 percent for wine, and 32 percent for spirits (see Figure 3-2 ). Alcohol tax erosion is not a new phenomenon. Average declines in specific excise taxes since their inception (which varied by state following the repeal of Prohibition) are more than twice as large as those from 1991 to 2015 ( Naimi et al., 2018 ).

Taxes can be levied to reduce alcohol consumption, and/or to cover costs related to the use of alcohol, particularly those costs that are borne by those other than the drinker or alcohol-related businesses. These costs are sometimes referred to as external (or secondhand or spillover costs). Currently, alcohol taxes are considerably lower than the external costs or harms related to a standard drink of alcohol. For example, the external cost per one standard drink of alcohol is approximately $2.00, of which approximately 40 percent is paid by federal and state government ( Sacks et al., 2015 ). This cost estimate includes health care costs (e.g., hospitalization, ambulatory care, specialty care for alcohol use disorder), lost productivity (e.g., impaired productivity at work, absenteeism), and other costs such as criminal justice corrections and alcohol-related crimes. By comparison, after factoring in federal and state alcohol taxes, the average tax per standard drink is less than $0.20 ( Naimi, 2011 , 2018 ).

Preventing medical and social harms to others is generally an important justification for public health interventions, and taxation in particular. Many of the adverse health effects and social harms from alcohol also include secondhand effects. In the case of alcohol-impaired driving, this would include all the effects on those other than the drinking driver, as evidenced by fatality data from comprehensive national and state level data sources (e.g., data from the Fatality Analysis Reporting System [FARS] and state highway safety offices) ( NCSA, 2016 ; Quinlan et al., 2014 ; Retting, 2017 ). Other types of alcohol-related secondhand health effects include alcohol-related violence victimization, as demonstrated by high-quality meta-analytic reviews ( Foran and O’Leary, 2008 ; Kuhns et al., 2014 ), and child abuse and neglect, for which the evidence is not yet conclusive ( Widom and Hiller-Sturmhofel, 2001 ). In the case of tobacco policy, for example, adverse health outcomes from secondhand (e.g., external) smoke harms were an important consideration for adopting indoor smoking bans and other tobacco control policies ( WHO and Task Force Initiative, 2007 ). Because of the effect of higher taxes on a number of other alcohol-related health outcomes, social problems, and economic costs, spillover effects from raising alcohol taxes would result in additional benefits beyond their impact on alcohol-related motor vehicle crash fatalities (e.g., reduced underage drinking, reduced alcohol-related violence).

There are some concerns, however, about how increasing alcohol taxes will affect some drinkers and some special populations. The same tax per drink is paid by all drinkers, and thus drinkers who impose no harm on others will pay taxes. Yet, this is an inevitable side effect, and those who drink the most will pay the majority of increased alcohol-related costs. Specifically, those drinking in excess of recommended federal drinking guidelines would pay approximately five times as much in additional costs from tax increases compared to nonexcessive drinkers,

and as a group heavy drinkers would pay at least 72 percent of aggregate additional costs. Furthermore, the total increase in alcohol-related costs (i.e., product plus tax) for most nonexcessive drinkers would be modest in absolute terms ( Naimi et al., 2016 ).

There may be concern that increasing alcohol taxes could disproportionately burden disadvantaged or vulnerable populations. However, as a group, low-income persons tend to consume less alcohol than those with higher incomes—in part because low-income and minority groups are more likely to abstain from consuming alcohol ( Esser et al., 2014 ). Therefore, additional costs from tax increases are actually higher for whites, for those with higher incomes, and for those who are employed ( Naimi et al., 2016 ). A review that included nine studies assessing the relationship between price or taxes and drinking among young people found that alcohol taxes are also protective for underage drinking ( Elder et al., 2010 ); this is important as underage drinkers constitute another important vulnerable population who are disproportionately likely to cause and incur harms from alcohol consumption.

Alcohol-related trade groups contend that alcohol taxes could adversely affect businesses that produce or sell alcohol ( DISCUS, n.d. ). However, research suggests that money diverted from alcohol production and consumption to other sectors of the economy could produce gains for those sectors. Additionally, the resulting reduction in excessive drinking could increase productivity. Economic modeling studies of the employment effects of alcohol taxes found that alcohol tax increases would actually lead to net increases in jobs at the state level, because of the transfer of jobs and spending from alcohol-related sectors to other, more labor-intensive sectors of the economy, such as government services or health care ( Wada et al., 2017 ).

Increasing alcohol taxes raises revenue for whichever level of government imposes the taxes, such as state and federal governments. Raising alcohol taxes is thus a highly cost-effective policy intervention. Despite this, and the clear interest by government in additional revenue sources, taxes have been allowed to decline in inflation-adjusted terms over time. Increasing alcohol taxes is generally met with stiff opposition from alcohol-related trade groups and industries ( Babor et al., 2018 ).

Public opinion polling has been used as a tool to measure support for alcohol taxes ( Global Strategy Group, 2005 ; Gonzales Research & Marketing Strategies, 2009 ; Raabe, 2006 ; Richter et al., 2004 ). Jernigan et al. (2009 , p. 13) assert that such “polling has consistently found substantial levels of support for increasing alcohol taxes, particularly if the proceeds or some portion thereof are dedicated to preventing and treating alcohol problems [e.g., increasing access to treatment] or expanding access to health care.” Prior evidence suggests that public awareness of the efficacy

of tax increases to reduce alcohol-related problems is low. Findings from a 1996 national survey showed that almost 80 percent of respondents did not believe alcohol tax increases would decrease injuries. Despite this, the respondents accurately assessed the role of alcohol in fatal falls, drowning, and poisoning, and overestimated its role in motor vehicle fatalities ( Girasek et al., 2002 ). Interviews with policy makers in three states—Illinois, Maryland, and Massachusetts—that recently increased state alcohol taxes confirmed this finding: policy makers were both unaware and skeptical of the ability of alcohol tax increases to influence alcohol consumption or problems ( Ramirez and Jernigan, 2017 ).

Increasing alcohol taxes is a highly effective strategy for reducing binge drinking and alcohol-related motor vehicle crash fatalities. In this section, the committee reviews a body of evidence including high-quality systematic reviews (e.g., Community Preventive Services Task Force 2 review by Elder et al., 2010 ) and meta-analyses (e.g., Wagenaar et al., 2009 , 2010 ) that shows a consistent inverse relationship between alcohol taxes and alcohol consumption and binge drinking (see Chapter 2 for a discussion of the proximal relationship between binge drinking and alcohol-impaired driving), as well as motor vehicle crash fatalities. In addition to the empirical evidence that indicates the efficacy of increased prices and taxes for reducing binge drinking and alcohol-related motor vehicle crash fatalities, there are practical considerations that support the need for increased taxes. As discussed in this chapter, the erosion of alcohol taxes over the years, the cost-effectiveness of taxes as a population-based intervention, and the potential for wide reach provide additional rationale for increasing alcohol taxes. In addition, current alcohol excise taxes are very low, represent a small fraction of the price of alcohol, and do not cover alcohol-related costs. Drawing from the empirical evidence and the aforementioned considerations, the committee recommends:

Recommendation 3-1: Federal and state governments should increase alcohol taxes significantly.

By significantly , the committee means that alcohol taxes should be increased enough so that they have a meaningful impact on price, thence reducing alcohol-related crash fatalities. Increases should comprise a meaningful percent of the net-of-tax price (e.g., 30 percent or more) of

2 The Community Preventive Services Task Force was formerly known as the Task Force on Community Preventive Services. Task Force publications prior to 2012 are cited as the latter, and those published after 2012 are cited as the former.

alcohol products, and cover the marginal external (i.e., secondhand) costs incurred by the sale of alcohol. 3

These taxes can be levied as specific excise taxes (which in the United States are based on a fixed amount per unit volume of alcohol) or as ad valorem excise taxes (based on a percentage of price). Specific excise taxes may be preferred because it is the volume of ethanol that is associated with impaired driving. As a percentage of sale price-based taxes, ad valorem taxes are lower for less expensive alcohol products, which tend to be consumed by target groups, such as heavy drinkers and those who are more price sensitive (e.g., underage persons and young adults). However, volume-based excise taxes erode with inflation and therefore need to be indexed to inflation. Ideally, taxes would be based on ethanol content rather than beverage type. Taxes can be earmarked to support alcohol-related activities (e.g., funding sobriety checkpoints), which may enhance public support.

The Three-Tier System of Alcohol Distribution and Wholesale Pricing Policies

Since the end of Prohibition in 1933 most states have used a three-tier system to regulate the distribution of alcohol ( Durkin, 2006 ). The first tier consists of producers and alcohol importers ( NABCA, 2015 ; South Carolina Legislature, 2007 ). They sell directly to licensed wholesalers (tier two) who then sell to retailers who are licensed to sell alcohol to the public (tier three) ( Durkin, 2006 ; South Carolina Legislature, 2007 ). Table 3-1 shows the distribution of the three tiers. The system was set up primarily to prevent organized crime from controlling alcohol sales as they did during Prohibition ( Martin, 2001 ). In addition, the system was established to prevent alcohol producers from dominating community life, as they did during the period when saloons were the primary community institution and producers controlled the saloons ( Aaron and Musto, 1981 ). To that end, each tier is regulated individually by the state, and no individual or company can invest in more than one tier ( Martin, 2001 ). The system also helps to ensure orderly markets, prohibit the sales of alcohol to minors, and facilitate the collection of taxes ( Martin, 2001 ).

3 At the time this report was being finalized in December 2017, Congress passed a tax bill (Tax Cuts and Jobs Act of 2017, H.R.1, 115th Cong., 1st sess.) that would decrease federal alcohol excise taxes by about 16 percent. A recent analysis by the Urban-Brookings Tax Policy Center estimated the number of motor vehicle fatalities attributable to the reduction in alcohol taxes proposed by this legislation based on four empirical studies ( Looney, 2017 ). The author concluded that the legislation would cause between 280 to 660 additional motor vehicle deaths and 1,550 total alcohol-related deaths from all causes per year.

TABLE 3-1 The Three-Tier System of Alcohol Distribution

SOURCE: Information from NABCA, 2015 .

A report from the National Alcohol Beverage Control Association discusses the economic, regulatory, commercial, and public health benefits of the three-tier system and cautions against the deregulation of the system ( NABCA, 2015 ). Of note, one benefit is that the three-tier system maintains higher prices of alcohol products. In addition, the report cites industry actors, from manufacturers to wholesalers and distributors, who have expressed support for the three-tier system. Findings from a 2015 survey conducted by the Center for Alcohol Policy show that the majority of the public (89 percent) agrees that it is very important to keep the alcohol industry regulated. The key findings from the survey also indicate that the public supports the current system of alcohol regulation at the state level ( CAP, 2015 ). However, recent changes in the alcohol market, such as the rise of Web-based commerce and other outlets, pose challenges to maintaining the current three-tier system ( Schmidt, 2017 ).

The wholesalers within tier two are subject to pricing restrictions that are intended to maintain higher prices, reduce competition, corruption, and crime ( APIS, 2016b ). These laws can regulate wholesalers’ ability to provide discounts based on the quantity of alcohol purchased, require them to establish a minimum markup or maximum discount for all products, require them to post their prices publicly and hold these prices for a set amount of time (i.e., post-and-hold laws), or restrict their ability to extend credit to retailers in the form of loans or deferred invoices ( APIS, 2016b ). These restrictions are implemented differently by state and by type of alcoholic beverage; for example, in Michigan the sale of beer and wine is regulated by the three-tier system and the sale of spirits is regulated by the state, while in Missouri all three types of alcohol are regulated by the tier system but volume discounts and post-and-hold laws only apply to wine and spirits ( APIS, 2016b ). Those states that did not set up a three-tier system for alcohol distribution after Prohibition chose to operate as monopolies, regulating the distribution and sales of alcohol themselves

(for more information see the section “Policies to Address Physical Availability”) ( Foust, 1999 ; McGowan, 1997 ).

Retail Price Restrictions

Happy hours, two-for-one specials, unlimited drinks, and free drinks are examples of alcoholic drink specials that are available over a specified period of time, during which alcohol is sold at a discounted price and/or higher volume at an on-premises location such as a bar or restaurant. The laws restricting these kinds of drink specials vary by state. For example, in Alaska happy hours are prohibited but free beverage specials and unlimited beverages for a fixed price or period are allowed, while in South Carolina happy hours are permitted between 4:00 pm and 8:00 pm and specials that provide multiple servings for a single serving price are allowed ( APIS, 2016a ). Currently there are 18 states that have no laws placing restrictions on drink specials ( APIS, 2016a ).

Studies have found that these kinds of drink specials are associated with increased excessive alcohol consumption ( Babor et al., 1978 , 1980 ; Thombs et al., 2008 , 2009 ), especially among young drinkers ( Baldwin et al., 2014 ; Kuo et al., 2003 ; Van Hoof et al., 2008 ). Research also shows that about half of drinkers who drive impaired are coming from a licensed establishment (e.g., bars, restaurants, or clubs) ( Naimi et al., 2009 ). One study assessed the relationship between banning drink specials and alcohol consumption in Ontario, Canada, but owing to study design limitations the results were inconclusive ( Babor, 2010 ; NHTSA, 2005a ; Smart, 1996 ; Smart and Adlaf, 1986 ). More research is needed to determine the effects of introducing these policies on alcohol consumption and alcohol-impaired driving specifically. Enforcement and adjudication of these laws are time-consuming, as they require observation, surveillance, and undercover operations, and tend to be a low priority for enforcement officials ( NHTSA, 2005a ). Collecting place of last drink (POLD) data from alcohol-impaired driving offenders could help target enforcement at problematic establishments, thereby increasing the effectiveness of policies restricting drink specials ( NHTSA, 2005a ).

Minimum Alcohol Pricing

Minimum alcohol pricing typically sets a minimum price per standard drink based on ethanol. In the event of a price increase (e.g., alcohol tax increase), drinkers can consume less, purchase cheaper products, or a combination thereof. Substituting lower price for quality can mitigate the effects of policies that increase alcohol prices ( Gruenewald et al., 2006 ). Thus, the premise of minimum pricing is to limit substituting lower

priced alcohol for quality and excessive consumption by placing a limit on how low alcohol beverage prices can be. Minimum alcohol pricing has been shown to reduce hazardous alcohol consumption ( Gruenewald et al., 2006 ; Holmes et al., 2014 ; Purshouse et al., 2010 ) and related harms ( Stockwell et al., 2013 ; Zhao et al., 2013 ) in countries such as Canada and the United Kingdom. The available evidence indicates that less expensive products demonstrate higher price sensitivities than higher-priced products and that less expensive products are preferred by hazardous drinkers ( Stockwell et al., 2015 ). Therefore, these policies have an effect on hazardous drinkers, including low-income drinkers ( Holmes et al., 2014 ), and potentially underage persons, as they do not have a great deal of discretionary income and are relatively price sensitive.

POLICIES TO ADDRESS PHYSICAL AVAILABILITY

Regulating outlet density.

Policies to address the physical availability of alcohol to reduce excessive alcohol consumption and related harms often target outlet density, the number of establishments within a given area where alcohol may be legally sold to be consumed on-premise (e.g., bars, clubs, restaurants) or off-premise (e.g., package stores) ( Campbell et al., 2009 ). There is evidence that increased alcohol outlet density is associated with increased alcohol-related crashes ( Scribner et al., 1994 ; Treno et al., 2007 ) and self-reported impaired driving ( Gruenewald et al., 2002 ), including among underage persons ( Reboussin et al., 2011 ; Treno et al., 2003 ). An ecological study conducted in New Mexico found that areas within the highest tertile of distilled spirits outlet density were associated with a 50 percent increase in alcohol-related crash rates and a two-fold increase in alcohol-related crash fatalities when compared with the lowest tertile of outlet density ( Escobedo and Ortiz, 2002 ). 4 While there is a body of literature that documents the positive relationship between outlet density and subsequent drinking and alcohol-impaired driving, there is less research examining reductions in alcohol outlet density.

The Community Preventive Services Task Force found that there is sufficient evidence to recommend the regulation of alcohol outlet density based on the positive association between outlet density and excessive alcohol consumption, as well as related harms ( Task Force on Community Preventive Services, 2009 ). However, it is important to note that the authors concluded that the available studies specifically evaluating the

4 Distilled spirits outlet density rates were calculated for each county, and counties were divided into three groups: low, middle, and high.

relationship between alcohol outlet density and motor vehicle crashes have produced mixed results ( Campbell et al., 2009 ).

More recently, Ponicki et al. (2013) conducted a spatial panel analysis of all California zip codes from 1999 to 2008, and the results showed that local bar density was positively associated with the likelihood that motor vehicle crashes were alcohol related. Other research points to traffic flow as a moderator of the relationship between outlet density and single-vehicle nighttime crashes; that is, crashes were more likely to occur in areas with higher on-premise outlet density and highway traffic flow (i.e., motor vehicles per day). These findings have implications for local transportation and planning decisions, and the authors suggest that the effects of alcohol outlets on crashes are context dependent ( Gruenewald and Johnson, 2010 ).

There are a number of challenges to regulating alcohol outlet density. Similar to other alcohol policies, commercial and financial consequences can prompt the alcohol industry (manufacturers, distributers, and retailers) to actively oppose policies to limit or reduce outlet density ( Campbell et al., 2009 ; Giesbrecht, 2000 ). In addition, state preemption laws can limit local governments’ ability to regulate outlet density ( Mosher, 2001 ). Despite these barriers, there is evidence that employing tools such as health impact assessments can help drive policy changes to reduce outlet density ( Thornton et al., 2013 ). Another potential challenge with addressing outlet density is the measurement of outlet density in a given state or community. CDC provides guidance on how to measure alcohol outlet density and identifies three main approaches: container-based, distance-based, and spatial access-based ( CDC, 2017 ). Such public health surveillance approaches can identify high-risk areas and provide data to make the case for regulating outlet density in a given area.

Regulating Hours and Days of Sale

Policies that regulate when alcohol can be sold vary by state and retail setting (i.e., on- or off-premise) and can also vary within states that allow local jurisdictions to set their own restrictions ( Hahn et al., 2010 ). On-premise alcohol outlets are allowed to operate for a median of 19 hours per day on weekdays and Saturdays and 17 hours per day on Sundays; nine states have no restrictions on limits of hours of sale ( Hahn et al., 2010 ). All U.S. policies that limit days of off-premise sales target Sundays, 5 but these policies vary from state to state. As of 2016, 12 states

5 Sunday bans on alcohol sales originate from “blue” laws, some of which date back to pre-Revolution-era policies that prohibited working, shopping, or consuming alcohol on Sundays ( APIS 2016d ).

had full bans or minor exceptions (e.g., selling at wineries or on special events); other states have reduced hours, bans on spirits, or no bans at all ( APIS, 2016d ).

In 2010 the Community Preventive Services Task Force (Task Force) reviewed the evidence on regulating hours and days of sale. Hahn et al. (2010) examined studies assessing the effects of increased hours of sale in on-premise settings on excessive alcohol consumption and related harms. The authors concluded that limiting hours of alcohol sales in on-premises settings was effective in reducing alcohol-related harms (no studies were found on the effects of sales in off-premises settings) ( Hahn et al., 2010 ). The Task Force reviewed studies conducted in high-income countries, but no research was available on how limiting hours of sales would affect alcohol-impaired driving fatalities in the United States specifically. The Task Force also found that an increase in 2 or more hours of sale led to an increase in harm, while there was insufficient evidence to determine the effect of increasing hours of sale by less than 2 hours ( Hahn et al., 2010 ).

The Task Force also synthesized the evidence on maintaining or reducing days of sale. The authors reported that maintaining existing limits on days of sale is effective at preventing alcohol-related harms, and increasing days of sale leads to increased alcohol-related harms and decreasing days of sale leads to decreased alcohol-related harms ( Middleton et al., 2010 ). Another study on days of sale and alcohol-related crash fatalities used a quasi-experimental approach to assess the effect of repealing or scaling back bans on Sunday sales in 14 states ( Stehr, 2010 ). The results demonstrated an effect in New Mexico only, where Sunday sales were associated with a 3.7 percent increase in alcohol-related traffic fatalities. Stehr (2010) posits that this finding is related to a corresponding increase in alcohol consumption in New Mexico (14.1 percent and 8 percent increases in the sale of beer and spirits, respectively—much higher than what was reported in the other states).

A 2017 systematic review of policies regulating hours and days of alcohol sales included studies that assessed the effect on motor vehicle crashes and fatalities from a number of countries including Australia, Canada, the United Kingdom, and the United States ( Sanchez-Ramirez and Voaklander, 2017 ). The authors reported mixed results on the effect of extended hours of sale on motor vehicle crashes and fatalities. This included a study that found that the extension of bar hours in the United Kingdom was associated with a decrease in motor vehicle crashes ( Green et al., 2014 ). The authors of the review conclude that the relationship between these policies and motor vehicle outcomes is complex, and more research is needed in this area.

There are a number of barriers to maintaining or imposing limits on hours and days of sale. This type of regulation could affect alcohol sales,

which would beget opposition from the alcohol manufacturing, distribution, and retail industry ( DISCUS, 2017 ; Hahn et al., 2010 ; Middleton et al., 2010 ). According to the Community Preventive Services Task Force, state preemption laws could also undermine local efforts to regulate the sale of alcohol ( Hahn et al., 2010 ), which has been a common barrier for local public health prevention efforts ( IOM, 2011 ).

State Monopolization of Alcohol Sales

There are currently 17 states 6 as well as several jurisdictions in Alaska, Maryland, Minnesota, and South Dakota in which government agencies control the sale of beer, wine, and/or spirits ( NABCA, 2017 ). The government monopoly standardizes the price of alcohol throughout a state and the profits are kept by the state ( Simon, 1966 ). Overall, privatization of alcohol sales is associated with an increase in the price of alcohol ( Simon, 1966 ). However, Hahn et al. (2012) theorize that privatized systems may offer a wider array of low-priced products that could appeal to high-volume or high-risk drinkers. A study conducted in Iowa found that after privatization only 37.4 percent of those surveyed who purchased spirits in the past month noticed that sales prices had increased since privatization ( Fitzgerald and Mulford, 1993 ). In its evidence review, the Community Preventive Services Task Force concluded that the privatization of alcohol sales increases per capita alcohol consumption, and by proxy, alcohol-related harm ( Hahn et al., 2012 ). The review also found that remonopolization of alcohol sales is associated with decreased alcohol consumption ( Hahn et al., 2012 ). The median increase in per capita sales of alcohol of the studies reviewed was 44.4 percent ( Hahn et al., 2012 ). Trolldal (2005) evaluated the effects of the privatization of alcohol sales in Alberta, Canada, on fatal motor vehicle crashes and found a nonsignificant decrease. The author speculated that there may not have been a great effect because alcohol wholesales were still monopolized and that private alcohol sales were confined to distilled spirits stores. Another study conducted in Iowa after the privatization of wine and spirit sales also found no significant decrease in motor vehicle crashes ( Fitzgerald and Mulford, 1992 ). The privatization of alcohol sales, however, does result in higher alcohol outlet density, which may account for some of the harmful effects ( Hahn et al., 2012 ).

6 These states are Alabama, Idaho, Iowa, Maine, Michigan, Mississippi, Montana, New Hampshire, North Carolina, Ohio, Oregon, Pennsylvania, Utah, Vermont, Virginia, West Virginia, and Wyoming.

Alcohol Sales Concurrent with Driving

One important yet understudied feature of the alcohol environment is the sale of alcohol that is concurrent with or very proximal to driving. This includes the concurrent sale of alcohol and gasoline, the sale of consumption-ready single-serving drinks, drive-through package stores, and the sale of alcohol in fast-food establishments. In many cases this also includes the marketing of alcohol, such as beer, with the sale of gasoline. While there is not a substantial evidence base to draw from in this area, it is important to address because the nature of these sales often involve driving shortly after purchase.

There is some limited evidence on the relationship between drive-through package stores and alcohol-related motor vehicle crashes. One study explored alcohol purchase locations among convicted impaired drivers in New Mexico. For offenders who bought the alcohol they drank prior to their arrest, drive-through stores were the preferred outlet of purchase. The authors found a statistically significant relationship between purchase at drive-through package stores and screening as high-risk problem drinkers (p<0.01) and drinking in the vehicle prior to arrest (p<0.01) ( Lewis et al., 1998 ). Another study conducted in New Mexico examined the spatial relationship between drive-through package store locations and alcohol-related crashes before and after the state banned drive-through alcohol sales using cross-sectional and longitudinal regression analyses. The authors found an increasing trend of alcohol-related crashes relative to total crashes prior to the ban and a decreasing trend after the ban. However, there was no statistically significant relationship between the number of drive-through outlets and the rate of alcohol-related crashes ( Lapham et al., 2004 ).

Some states have implemented restrictions on the sale of alcohol concurrent with or proximal to driving, such as bans on drive-through package stores. These are often presented as common sense measures to reduce alcohol-related harm. More research is needed to determine the effects of the sale of alcohol concurrent with driving on alcohol-impaired driving.

Open Container Laws

Related to alcohol sales concurrent with driving are open container laws, which were designed to reduce alcohol-impaired driving by prohibiting the possession or consumption of open alcoholic beverage containers in a motor vehicle. 7 As part of the 1998 Transportation Equity Act for the

7 An open container is defined as “any bottle, can, or other receptacle that contains any amount of alcoholic beverage, and that is open or has a broken seal, or the contents of which are partially removed” ( APIS, 2016e ).

21st Century, Congress stipulated that states enact open container laws that meet six specific criteria or have a portion of their federal highway funds allocated to alcohol-impaired driving countermeasure programs, law enforcement, and/or hazard elimination ( APIS, 2016f ). 8 These criteria require that state law prohibit possession of alcoholic beverage containers and consumption of alcohol in motor vehicles; cover the entire passenger area; apply to all types of alcoholic beverages; apply to all vehicle occupants; apply to all vehicles on public highways; and provide for primary enforcement of the law. While the parameters of the law vary by state, 40 states and the District of Columbia are in compliance with federal requirements ( Advocates for Highway and Auto Safety, 2017 ). As of 2016, six states had no form of open container law. In addition to the open container laws that have been passed by most states, as of 2013, 39 states currently have laws that allow on-premise establishments to re-seal an opened, but unfinished bottle of wine so that it can be transported in a vehicle without violating the open container law ( NCSL, 2013 ).

There is a limited body of evidence that examines the relationship between open container laws and drinking while driving or alcohol-impaired driving ( Goodwin et al., 2015 ). Stuster et al. (2002) conducted pre- and post-analyses of four states (Iowa, Maine, Rhode Island, and South Dakota) that passed open container laws in 1999. The authors found a decline in alcohol-related crashes among the states that passed the law over the 6-month period following enforcement when compared to the same 6-month period of the prior year. The decline was not statistically significant. However, the findings also showed that states with no open container laws had significantly greater proportions of alcohol-related fatal crashes than states with partially or fully compliant laws. Furthermore, the states that had enacted fully compliant laws had the lowest proportions of alcohol-related crashes among the four states examined. Two other studies have also found a relationship between open container laws and reduced alcohol-related fatalities ( Benson et al., 2000 ; Eisenberg, 2003 ), while one multivariate regression analysis found no significant effect ( Chang et al., 2012 ). More recent research suggests that while having an open container law is not related to alcohol-impaired driving, enforcement of open container prohibitions is associated with reduced self-reported alcohol-impaired driving ( Lenk et al., 2016 ). Given the limited available evidence and the high number of states that have open container laws, there is an opportunity to further investigate the effects of these laws and their levels of enforcement.

This chapter discusses how the alcohol environment can shape alcohol-related outcomes such as excessive drinking (a precursor to impaired

8 23 U.S.C. § 154.

driving) and alcohol-impaired driving. One important feature of this environment is the physical availability of alcohol (e.g., outlet density and hours and days of sale), which can vary by community or state. In this section, the committee presents an overview of the recent literature on outlet density and hours and days of sale from high-quality systematic reviews by the Community Preventive Services Task Force (e.g., Campbell et al., 2009 ; Hahn et al., 2010 ; Middleton et al., 2010 ) and individual studies with a variety of methodologies and outcome data sources (e.g., telephone surveys, hospital discharge data, state forensic data, and state highway and transportation department data) ( Escobedo and Ortiz, 2002 ; Gruenewald et al., 2002 ; Treno et al., 2003 , 2007 ). Collectively, this body of evidence suggests a strong, positive association between physical availability of excessive alcohol consumption and alcohol-related harms. Although this relationship is more clearly demonstrated by the evidence for other alcohol-related harms, alcohol-impaired driving and crashes are also affected by physical availability and have a strong link to excessive consumption ( Flowers et al., 2008 ). This evidence indicates a need to limit physical availability in areas that have not already done so. It is important to note that more research is needed to determine optimal physical availability policies to reduce alcohol-impaired driving specifically. Furthermore, each state and locality will have different concentrations of physical availability and existing policies, thus requiring a tailored approach based on that area’s needs and available policy levers. Therefore, the committee recommends:

Recommendation 3-2: State and local governments should take appropriate steps to limit or reduce alcohol availability, including restrictions on the number of on- and off-premises alcohol outlets, and the days and hours of alcohol sales.

In addition, states should consider restricting or eliminating alcohol sales in locations in which the customer is driving or may drive shortly after purchasing alcohol (i.e., potentially high-risk outlets with respect to drinking and driving), such as at drive-through windows at package stores, gasoline stations, and fast-food restaurants.

POLICIES TO REDUCE ILLEGAL ALCOHOL SALES

Minimum legal drinking age laws and enforcement.

Federal legislation encouraging a minimum legal drinking age (MLDA) of 21 was passed in 1984, and by 1988 all states and the District of Columbia had enacted a minimum legal age of 21 for the purchase and

possession of alcohol ( Fell et al., 2008 ). Most states enforce laws against the sale of alcohol to minors through local law enforcement agencies and alcohol beverage control agencies ( Elder et al., 2007 ). Both types of agencies often lack resources to effectively carry out their enforcement duties. The federal Enforcement of Underage Drinking Laws Program aimed to help alleviate such resource constraints, allocating $25 million in federal block grants to all states and the District of Columbia. Since 2010, funding for this program decreased and eventually dissipated (see Table 7-1 for funding of this and other federal substance abuse prevention programs).

There is a robust evidence base that supports the passage and maintenance of MLDA laws based on the effects they have had on decreasing alcohol-related harm in persons under age 21. Based on strong evidence for the effectiveness of MLDA laws of 21 in decreasing alcohol-related vehicle crashes and injuries among 18- to 20-year-olds, the Community Preventive Services Task Force recommended maintaining current MLDA laws ( Shults et al., 2001 ). A systematic review of 49 studies examining the effects of raising and lowering the MLDA indicated 10 to 16 percent decreases in alcohol-related crashes when the MLDA was raised and increases of similar magnitude when it was lowered ( Shults et al., 2001 ). Wagenaar and Toomey (2002) published a review of the effects of MLDA laws based on 79 studies published from 1960 to 2000. Among the studies, 58 percent found an inverse relationship between the age 21 MLDA and traffic crashes; none found an opposite association ( Wagenaar and Toomey, 2002 ). DeJong and Blanchette (2014) conducted a review of the evidence on the age 21 MLDA from 2006 to 2013 and concluded that this research has reinforced the finding that the federal MLDA law has led to a reduction in alcohol-related crashes and consumption among youth, with other positive effects for this population in the long term.

Enforcement of MLDA Laws

While MLDA laws have been found to be effective ( HHS, 2016 ), strict and consistent enforcement is needed to optimize the effect of these laws. Elder et al. (2007) reviewed eight studies analyzing the effects of programs implemented by local law enforcement or alcohol beverage control agencies that aimed to increase compliance checks in community retailers. When enhanced enforcement programs were in place, including high intensity and publicity, successful purchases of alcohol by decoys who lacked identification proving their age decreased by an average of 42 percent (range of 17 to 57 percent decrease). Results of two studies indicated

that the effects of enhanced enforcement decreased when enforcement programs were discontinued ( Scribner and Cohen, 2001 ; Wagenaar et al., 2005 ). One study indicated that enhanced enforcement was correlated with a 20 percent reduction in self-reported alcohol consumption and binge drinking among high school students ( Barry, 2004 ). Publicized enforcement of MLDA and driving while impaired (DWI) laws has also been shown to reduce drinking and driving in a college community as measured by roadside surveys ( McCartt et al., 2009 ).

Enforcement programs, which include age-related compliance checks, are underutilized and require improvements. The National Research Council (NRC) and the Institute of Medicine (IOM) report Reducing Underage Drinking: A Collective Responsibility (2004) discusses the need for enhanced enforcement against retailers who sell to minors. The report explores this issue in the context of the success of tobacco control and youth smoking, citing the Synar Amendment 9 as a model to inform underage alcohol sales enforcement. This amendment mandates tobacco sales compliance checks and ties the enactment and enforcement of laws prohibiting the sale of tobacco to minors to state block grant funding for substance abuse prevention. Ultimately, the committee recommended that states bolster compliance check programs using media campaigns and license revocation ( NRC and IOM, 2004 ).

Enforcement programs may be ineffective if perception of a lack of support from the community is high, as law enforcement agencies may not have sufficient incentive to carry out enforcement efforts ( Elder et al., 2007 ). A study of 17,830 students surveyed in the 2007 Oregon Health Teens Survey found that perceived community disapproval of adolescents’ alcohol use and adolescents’ personal beliefs were positively associated with perceived local law enforcement of MLDA laws ( Lipperman-Kreda et al., 2010 ). Enforcement programs that solely target retailers for reducing sales to minors may result in minors substituting retailers with social providers such as friends, family, and strangers ( Elder et al., 2007 ). Therefore, preventing alcohol sales to minors depends on a series of complementary policies and practices that target prevention of purchase, possession, consumption, and internal possession, 10 such as compliance checks, social host laws, dram shop liability laws, and others. These poli-

9 The Synar Amendment was enacted with the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (Public Law 102-321) in 1992 with the goal of reducing youth access to tobacco. The amendment mandates that all states enact and enforce laws that prohibit the sale and distribution of tobacco to individuals under the age of 18. In order for states to receive their Substance Abuse Prevention and Treatment Block Grant, they must comply with the Synar Amendment ( SAMHSA, 2017 ).

10 A minor-in-possession charge requires “evidence of alcohol in the minor’s body, as determined by a blood, breath, or urine test, but does not otherwise require any specific evidence of possession or consumption (e.g., through witness observation or an admission on the part of the minor)” ( APIS, 2016g ).

cies and practices will be discussed as strategies to reduce illegal sales to minors in the following sections.

Dram Shop Liability Laws

Dram shop liability laws permit legal action against commercial establishments serving alcohol to underage persons or already intoxicated persons regardless of age ( Scherer et al., 2015 ). (For the history of dram shop liability and insurance, see Sloan et al.’s [2000] Drinkers, Drivers, and Bartenders. ) Owners and servers may be held liable when illegal beverage service (i.e., to intoxicated or underage patrons) results in injury, death, or damages from alcohol-related vehicle crashes ( Rammohan et al., 2011 ). Survey data of commercial servers suggest an association between a state’s status of dram shop laws (i.e., strictness) and perceived risk of liability ( Sloan et al., 2000 ). Dram shop liability laws, in combination with enhanced enforcement documenting alcohol service violation history, provide important data for connecting injury caused by intoxicated drivers and the drinking establishment at which they were served ( Graham et al., 2014 ).

The Community Preventive Services Task Force recommends the use of dram shop liability laws to prevent and reduce alcohol-related harms ( Rammohan et al., 2011 ; Task Force on Community Preventive Services, 2011 ). Using methodology from the Guide to Community Preventive Services , Rammohan et al. (2011) examined 11 studies and found that dram shop liability laws were correlated with a 6.4 percent average decrease in alcohol-related driving fatalities (values ranged from 3.7 to 11.3 percent). Reductions were also found across all studies for other measured outcomes, including all-cause motor vehicle fatalities, alcohol consumption, alcohol-related violence, and alcohol-related diseases.

Using FARS data, Scherer et al. (2015) found that dram shop liability laws were correlated with a 2.4 percent decrease in the ratio of drinking to nondrinking drivers under age 21 involved in fatal crashes ( Scherer et al., 2015 ). The authors estimated that 64 lives had been saved in the jurisdictions that have the law and that 9 more lives could be saved each year if the six states without the law were to adopt it. The authors also found that strong dram shop liability laws were significantly correlated with lower per capita beer consumption.

In 1983 and 1984, two widely publicized server liability cases took place in Texas. Analysis of single-vehicle nighttime crashes in the state from 1978 through 1988 indicated significant decreases of 6.5 and 5.3

percent following the 1983 and 1984 case filings, respectively. As the decreases were found to have taken place at the time the lawsuits were filed and not when the courts issued their decisions 3 to 4 years later, increased awareness of server liability laws and concern from retail alcohol establishment owners generated through newspaper publicity are likely to have contributed to the reductions ( Holder et al., 1990 ).

The Community Preventive Services Task Force did not find any studies examining the cost-benefit of dram shop liability laws. However, Rammohan et al. (2011) note that litigation may not be cost-effective or achievable in certain cases, as establishing proof that illegal beverage service took place (and resulted in injury) may be difficult ( Martineau et al., 2013 ). Obtaining legal services may also be especially burdensome for those of low socioeconomic status. Most of the studies examined in the systematic review were conducted prior to widespread enactment of dram shop liability laws in the late 1990s ( Rammohan et al., 2011 ; Task Force on Community Preventive Services, 2011 ). More research is needed to analyze the effectiveness of these laws, especially as states have enacted shorter statutes of limitation and more stringent requirements for legal evidence.

Social Host Liability

Another complementary policy that is designed to reduce underage and hazardous drinking is social host liability. Social host laws assign criminal or civil liability for providing alcohol to someone under the legal drinking age and/or to an obviously intoxicated adult if damages or injury are caused by that individual (e.g., in a motor vehicle crash) ( NHTSA, 2016 ; Voas and Lacey, 2011 ). The primary purpose is to hold individuals or noncommercial providers of alcohol liable, whereas dram shop liability applies to licensed establishments. As of 2016, 21 states had general hosting laws, 10 states had social host laws specific to underage parties, and 19 states and the District of Columbia had no social host laws ( APIS, 2016h ). The purpose of such laws is to deter adults from hosting parties where underage drinking occurs, purchasing alcohol for underage drinkers, providing alcohol for underage persons, and overserving alcohol ( Voas and Lacey, 2011 ). The majority of adolescents obtain alcohol from social sources ( Pemberton et al., 2008 ); thus, they are an important point of intervention to reduce underage drinking and subsequent impaired driving. Additionally, there has been public support for assigning liability to social hosts for alcohol-related injuries ( Wagenaar et al., 2001 ).

Social host liability laws differ from state to state, and implementation is an important factor that requires investigation. Findings from California suggest that social host laws with strict liability and swift, administrative

civil penalties could reduce underage drinking in private settings, especially among youth who have already initiated alcohol use ( Paschall et al., 2014 ). While social host laws may send a powerful message, effective dissemination of that message is required for effectiveness ( Grube and Stewart, 2004 ; Holder and Treno, 1997 ; Voas and Lacey, 2011 ). In the 2004 NRC and IOM report on underage drinking, the authors posit that the mixed findings on social host laws could be attributable to the lack of a comprehensive program that ensures that the public is aware of potential liability exposure. To that end, the report discusses media campaigns as an integral component of implementing social host liability laws.

Over the past few decades, there has not been a substantial amount of evidence on social host laws and alcohol-impaired driving, and the existing evidence is conflicting ( Goodwin et al., 2015 ; NRC and IOM, 2004 ; Voas and Lacey, 2011 ). Early study findings using data from the Behavioral Risk Factor Surveillance System showed that social host laws had a deterrent effect with respect to binge drinking and drinking and driving ( Sloan et al., 2000 ; Stout et al., 2000 ). More recently, Fell et al. (2014) examined the effects of social host laws on the ratio of drinking drivers under age 21 to nondrinking drivers under age 21 involved in fatal crashes from 1982 to 2010. Social host civil liability laws (allow suing social hosts for injuries caused by underage drinking guests) had a negative but nonsignificant (p = 0.054) effect, and social host prohibitions (prohibit hosting underage drinking parties) had no effect on the ratio of drinking to nondrinking drivers under age 21 in a fatal crash. Dills (2010) investigated the effect of the presence of a social host liability law on self-reported driving after drinking and alcohol-impaired driving fatalities at the state level from 1975 to 2005 among 18- to 20-year-olds. The author found significant reductions of 5 to 9 percent and 3 percent in alcohol-related traffic fatalities and driving after drinking, respectively ( Dills, 2010 ). Given the insufficient body of research around social host laws and alcohol-impaired driving, more research is needed in this area ( Hingson and White, 2014 ; Wagoner et al., 2013 ).

Responsible Beverage Service and Server Training

Responsible beverage service (RBS) has been studied as a potential point of intervention to reduce excessive drinking and subsequent alcohol-impaired driving ( Fell et al., 2017 ; Graham, 2000 ; Linde et al., 2016 ; Rammohan et al., 2011 ; Saltz, 1987 ; Scherer et al., 2015 ; Shults et al., 2001 ). Research indicates that approximately half of drivers arrested for alcohol-impaired driving had their last drink at a licensed establishment ( Fell et al., 2010 ; Gallup, 2000 ; O’Donnell, 1985 ), and this is consistent with self-reported data on driving after binge drinking ( Naimi et al., 2009 ).

The training for servers typically focuses on serving procedures, signs of intoxication, methods for verifying age, and intervention strategies. There are also aspects of manager training that incorporate the abovementioned, in addition to policy and procedure development and staff supervision ( APIS, 2016e ). Public acceptance has been relatively high for RBS policies, with a national survey indicating that 89 percent of the population was in favor of policies mandating server training ( Wagenaar et al., 2000 ).

Programs for server training can be mandatory, voluntary, or a combination of both. States with voluntary beverage service training programs typically provide incentives for retailers (e.g., defense in dram shop liability lawsuits, discounts for dram shop liability insurance, or mitigation of fines or other penalties for service violations). It is important to note that incentives such as protection from dram shop liability can have unintended consequences. These protections can hinder the effectiveness of dram shop laws, which have been shown to be effective in reducing alcohol-related harm ( Rammohan et al., 2011 ), as discussed previously. As of 2016, 12 states and the District of Columbia had mandatory service training laws, 20 had voluntary laws, 6 had a combination of mandatory and voluntary policies, and 12 had neither ( APIS, 2016e ). In the past, there have been federal incentive grants for states that engage in specific server training activities, 11 such as training point-of-sale personnel to recognize signs of intoxication, but those have since been rescinded.

In Countermeasures That Work , Goodwin et al. (2015) review the evidence on RBS and conclude that the findings on the effectiveness of server training have been mixed. They note that few studies have examined the effect of RBS on alcohol-impaired driving crashes specifically. The Community Preventive Services Task Force conducted a review of interventions to reduce alcohol-impaired driving, including training programs for servers of alcoholic beverages. Shults et al. (2001) concluded that, based on the rules of evidence presented in The Community Guide , there was sufficient evidence that intensive, high-quality, face-to-face server training (when supplemented with active management support) is effective in reducing the level of intoxication among patrons (and is therefore likely to have an effect on impaired driving if the affected patrons cease drinking or continue elsewhere in a safe environment after leaving). Shults et al. (2001) also noted that optimally, server training would be established in all licensed establishments in a community to have a community-wide effect. However, research on such community-wide alcohol server interventions is limited ( Shults et al., 2001 ). A recent study of demonstration projects that incorporated RBS and enhanced alcohol enforcement for

11 23 U.S.C. § 410, https://www.gpo.gov/fdsys/pkg/USCODE-2006-title23/pdf/USCODE-2006-title23-chap4-sec410.pdf (accessed October 2, 2017).

problem bars in two communities also produced mixed findings ( Fell et al., 2017 ). Jones et al. (2011) completed a systematic review of multiple countries (including the United States) and found that server intervention programs designed to reduce alcohol use in drinking environments had mixed effects on patrons’ alcohol consumption. The observed effects on patron drinking were minimal, except where training was mandated ( Jones et al., 2011 ). In summary, more research is needed to determine the critical elements that contribute to the effectiveness of RBS policies and training.

Sales to Intoxicated Persons

Sales to intoxicated persons (SIP) laws make it illegal to sell alcohol to an obviously intoxicated person. These laws, which can be criminal or administrative, exist in every state except Florida and Nevada. In Wyoming, it is only illegal to sell alcohol to an intoxicated person at a drive-through window at a package store. There is substantial variation in state SIP laws with respect to the state’s definition of intoxication, who is held liable (e.g., licensees, servers, or social hosts), the evidence required to establish a SIP violation, and subsequent penalties ( Mosher et al., 2009 ). SIP laws are an example of another alcohol-related policy for which the overall effectiveness likely depends on the quality and consistency of enforcement practices.

Alcohol Law Enforcement

As discussed previously, enforcement is a crucial determinant of adherence to the policies to reduce illegal alcohol sales. Alcohol law enforcement aims to increase compliance with laws by increasing perceived likelihood of arrest among those who are subject to legal restrictions ( NHTSA, 2005b ). Enforcement approaches can include compliance checks for underage sales, bar inspections, undercover operations, and educational programs ( Ramirez, 2017 ). There is research that suggests the enforcement of policies to limit alcohol service to underage persons and intoxicated patrons reduces alcohol-related harm and improves public safety ( McKnight and Streff, 1994 ; Ramirez, 2017 ; Ramirez et al., 2008 ).

Lenk et al. (2014) conducted a survey of randomly selected local and state alcohol enforcement agencies to gather information on enforcement of sales to obviously intoxicated patrons. The findings, which reflected responses from 1,082 local and 49 state agencies, showed that only about 20 percent of local and 60 percent of state agencies conducted enforcement activities to reduce SIP in their jurisdictions. Furthermore, less than half of the agencies employed specific enforcement strategies at least

monthly, and for local agencies, enforcement activities were more common when there was a full-time officer who was specifically assigned to such activities.

For alcohol law enforcement agencies, the number of licensed establishments that require monitoring and enforcement varies from state to state. In most states (e.g., Alabama, Utah, Virginia), there are 250 licensees or less per one alcohol law enforcement agent, but in some states (e.g., Missouri, Wisconsin) there are more than 1,000 premises per agent ( Ramirez, 2017 ). Levy and Miller (1995) conducted a cost-benefit analysis of increased enforcement of laws forbidding service to intoxicated patrons, based on a case study in Michigan, and found that the benefits greatly outweighed the costs. Their study findings also demonstrated a 22 percent increase in the number of intoxicated patrons who were refused service after implementing a program that used undercover police officers to monitor service in licensed establishments.

The 2017 County Health Rankings included a review of the evidence on SIP law enforcement. The key finding was that the available evidence indicates that efforts to enforce SIP laws can reduce overservice and alcohol-impaired driving, especially when implemented in areas at risk for excessive alcohol consumption ( County Health Rankings, 2017 ). Another key element of enforcement is the administration of sanctions or legal charges for evidenced violations. States have a number of penalties for violations including fines, license suspensions, and revocations ( Mosher et al., 2009 ), yet these penalties are often reduced or appealed.

Challenges for Enforcement

While promising, enforcement of policies to reduce illegal alcohol sales is largely lacking ( Goodwin et al., 2015 ; Mosher et al., 2009 ) because of a number of the following factors: cultural norms, lack of political will, lack of a systematic approach to enforcement ( Graham et al., 2014 ; Mosher et al., 2009 ; NHTSA, 2005a , b ; Ramirez, 2017 ), and lack of resources to detect and track violations ( Mosher et al., 2002 , 2009 ; NHTSA, 2005b ). For example, in some states, the number of licensed establishments outnumbers the amount of available law enforcement personnel ( Ramirez, 2017 ). Alcohol law enforcement agents have many responsibilities in addition to enforcing alcohol laws (e.g., gaming, tobacco, drugs, and human trafficking) ( Ramirez, 2017 ).

Promising Strategies

Despite the barriers that exist for effective enforcement of alcohol policies, there are promising strategies that have emerged from common

practices and the literature that can be applied to enhance enforcement efforts. For example, some states collect data on POLD when an individual is arrested for DWI and then target those establishments ( NHTSA, 2005a ). In 2012 the National Transportation Safety Board made a safety recommendation to the 50 states, the District of Columbia, and Puerto Rico to require law enforcement agencies to collect POLD data as part of any arrest or crash investigation involving an alcohol-impaired driver ( NTSB, 2012 ) (see Chapter 6 for more discussion of POLD data). In addition to data collection, it is important to publicize enforcement efforts to ensure that there is a high perceived risk of being apprehended and receiving a sanction. Furthermore, developing political will to support ongoing enforcement through research and media fosters sustainability of efforts. Mosher et al. (2009) emphasize the importance of interagency collaboration and adopting a structure of enforceable consequences for violations and adequate penalties that cannot be negotiated or made eligible for exemption for specific licensees (e.g., licensees who have completed RBS training).

As discussed in this chapter, the illegal sale of alcohol subsumes sales to already-intoxicated adults and to underage persons. The available research indicates that both types of illegal sales are related to binge drinking and to increased risk of alcohol-impaired driving. The committee discusses a number of interventions that can reduce illegal sales, binge drinking, and alcohol-impaired driving with varying degrees of evidence. Among some of these policies, the evidence of effectiveness is strong (i.e., informed by high-quality systematic reviews and studies across multiple contexts). This includes MLDA laws (see, for example, DeJong and Blanchette, 2014 ; Shults et al., 2001 ; Wagenaar and Toomey, 2002 ), enforcement of MLDA laws (see, for example, Barry, 2004 ; Elder et al., 2007 ; Scribner and Cohen, 2001 ; Wagenaar et al., 2005 ), and dram shop liability laws (see, for example, Holder et al., 1990 ; Rammohan et al., 2011 ; Scherer et al., 2015 ). For other illegal sales-related policies, there is a good theoretical justification but mixed evidence of effectiveness depending on the type of policy and degree of enforcement. These include social host liability laws (see, for example, Fell et al., 2014 ; Paschall et al., 2014 ; Wagoner et al., 2013 ) and responsible beverage service practices and policies (see, for example, Fell et al., 2017 ; Jones et al., 2011 ; Shults et al., 2001 ). For laws preventing SIP, there is a strong theoretical basis for their implementation, yet a relative lack of empirical evidence on these policies, in part because most states have them, which limits opportunities for well-designed evaluations.

Research also indicates that enforcement programs are underutilized and require more resources to be effective. To reach the below conclusion the committee relied on evidence ranging from empirical studies

evaluating enforcement programs and systematic reviews of studies to legal, administrative, and qualitative data. These include, but are not limited to, the NRC and IOM (2004) report Reducing Underage Drinking: A Collective Responsibility , a Community Preventive Services Task Force review of enhanced enforcement laws prohibiting sales to minors ( Elder et al., 2007 ), a NHTSA (2005b) research report that uses legal and interview data to inform its findings on the role of alcohol beverage control agencies in enforcing alcohol laws, and data from the National Liquor Law Enforcement Association ( Ramirez, 2017 ; Ramirez et al., 2008 ). The decline in federal funding for the enforcement of underage drinking programs further demonstrates the diminishing resources allocated to such programs (see Table 7-1 ). It is also noteworthy that the evidence from empirical studies and qualitative data show that quality of implementation and complementary activities (e.g., media publicity and collection of POLD data) to enhance enforcement are important ( Elder et al., 2007 ; McCartt et al., 2009 ; NRC and IOM, 2004 ; NTSB, 2012 ). Furthermore, to reduce excessive alcohol consumption prior to driving at the population level, there is a need for a comprehensive set of policies that minimize the illegal sale of alcohol to underage persons and already-intoxicated persons. Given the evidence presented in this chapter on the effectiveness of policies to reduce illegal alcohol sales and the need for enhanced enforcement of these policies, the committee offers the following recommendation and conclusion:

Recommendation 3-3: Federal, state, and local governments should adopt and/or strengthen laws and dedicate enforcement resources to stop illegal alcohol sales (i.e., sales to already-intoxicated adults and sales to underage persons).

Conclusion 3-1: Some policies to reduce illegal alcohol sales are not effective due to a lack of enforcement activities. In addition, a systematic approach to enforcement (i.e., increased resources, data collection and sharing, multisector collaboration, and publicity) is needed to optimize the effects of such alcohol policies.

Recommendation 3-3 includes the following laws and actions:

• Strong penalties for licensees who engage in illegal alcohol sales to already-intoxicated adults;
• Dram shop liability laws without caps;
• High-quality mandatory responsible beverage service training for managers and sellers;
• Strong social host laws and other laws to limit adults from providing alcohol to underage persons;
• Improvement of enforcement of MLDA laws, including passing laws to permit compliance checks using underage decoys and conducting such compliance checks;
• Collection of POLD data; and
• Adequate enforcement personnel to enforce existing laws in this area.

POLICIES TO REDUCE THE HARMFUL EFFECTS OF ALCOHOL MARKETING

At least 25 longitudinal studies have found associations between young people’s exposure to alcohol marketing in a variety of forms—from traditional marketing to online marketing to sponsorships and alcohol-branded merchandise—and their subsequent drinking behavior ( Anderson et al., 2009b ; Jernigan et al., 2016 ; Smith and Foxcroft, 2009 ). Another study, completed before the dramatic increase in alcohol advertising on cable television, looked at the effect of alcohol advertising on motor vehicle traffic fatalities and concluded that a complete ban on broadcast alcohol advertising could save between 2,000 and 3,000 lives per year, and ending the tax deductibility of alcohol advertising could prevent approximately 1,300 deaths per year ( Saffer, 1997 ).

One of the distinguishing features of alcohol advertising since 2000 has been the dramatic expansion of advertising, especially for distilled spirits, on cable television. Distillers maintained a voluntary ban on television advertising in general until 1996, and in 2001 struck an agreement with NBC to begin advertising on that broadcast network ( Elliott, 2001 ). However, outcry from Congress and from public health advocates led NBC to back away from the agreement, and distillers in response moved rapidly onto cable networks ( Jernigan and O’Hara, 2004 ). In 2000, distillers spent $4.3 million, or 1.2 percent of their measured advertising budgets, on television; by 2016, this amount had grown to $227.6 million, or 56.8 percent of their budgets ( Impact Databank, 2017 ).

Marketing does not only consist of advertising, but rather rests on the “four Ps” of product, place, price, and promotion ( Hastings et al., 2005 ). (See Chapter 2 for discussions of industry activities within the four Ps.) Other sections of this report have discussed policy options to address the first three Ps. Since commercial speech enjoys strong protection from the First Amendment in the United Sates, alcohol marketing has been primarily governed by industry self-regulation. Findings from a systematic review show that numerous peer-reviewed studies have found this self-regulation to be ineffective ( Noel et al., 2016 ), and there have been

significant debates in the United States about how it could be improved. In 2004, the NRC and IOM recommended that the industry move from its then-current voluntary standard of only advertising where at least 70 percent of the viewing, reading, or listening audience was of legal purchase age (that is, over age 21) to a 25 percent maximum for underage audiences immediately, and eventually to a 15 percent maximum for underage audiences. This was based roughly on the proportion of the underage population at greatest risk of initiating drinking—the 12- to 20-year-old group ( NRC and IOM, 2004 ). In 2011, 24 state and territorial attorneys general added their endorsements to the 15 percent standard ( Shurtleff et al., 2011 ). In that same year, alcohol industry trade associations announced a lowering of their standard to 28.4 percent, based on the 2010 census numbers. In 2007, one company—Beam Global Spirits—adopted the 25 percent maximum; an independent evaluation of that standard concluded that, even with imperfect implementation, it led to a reduction in youth exposure to alcohol advertising for that company’s brands compared to its competitors, and at the same time it did not result in an increase in the company’s advertising costs for reaching adult audiences ( Ross et al., 2016 ). The authors concluded that other alcohol companies should consider adopting a similar standard to the 25 percent maximum.

However, the lack of voluntary movement toward a stricter standard by most alcohol companies has resulted in continued disproportionate youth exposure to alcohol advertising. One study examined magazine advertising of alcohol brands most likely to be consumed by young people (determined through a national survey of youth alcohol consumption by brand [ Siegel et al., 2013 ]), and found that such brands were more likely than other brands to advertise in magazines with higher youth readerships, demonstrating the inadequacy of the industry’s voluntary guidelines in protecting youth from disproportionate exposure compared to adults ( King et al., 2017 ).

The industry’s voluntary guidelines also include numerous provisions regarding the content of alcohol advertising. However, independent evaluation of the implementation of these guidelines has found them to be ineffective ( Babor et al., 2013 ). Enforcement of content regulations is also more likely to raise First Amendment issues, which helps to explain why much of the policy debate regarding alcohol industry self-regulation has focused on placement guidelines.

While much of the regulatory authority over alcohol advertising lies at the federal level, and specifically in the U.S. Department of the Treasury, an agency without an explicit public health or safety mission, state and local governments have also demonstrated that they can play a role in reducing both youth and population-level exposure to alcohol advertising. The Center on Alcohol Marketing and Youth’s (2012) report State

Laws to Reduce the Impact of Alcohol Marketing on Youth: Current Status and Model Policies identifies the following specific actions that states can take:

• Prohibit false and misleading alcohol advertising;
• Prohibit advertising that targets minors;
• Claim state jurisdiction over electronic media, at least theoretically permitting them to require, for instance, higher audience standards for advertising placed in media such as radio that originate locally;
• Restrict outdoor alcohol advertising in locations where children are likely to be present;
• Prohibit outdoor alcohol advertising near schools, public playgrounds, and churches;
• Restrict alcohol advertising on alcohol retail outlet windows and outside areas;
• Prohibit alcohol advertising on college campuses; and
• Restrict alcohol industry sponsorship of civic events (e.g., fairs, music concerts, and sporting events).

While no state has employed all of these powers, the fact that they all exist in state law in at least one and often numerous states suggests that there is more potential at the state and local levels for reducing exposure to alcohol advertising than has yet been used.

Another promising strategy regarding alcohol marketing is the use of countermarketing. Countermarketing campaigns are a form of media campaigns that seek to offset pro-alcohol influences and promote health promotion messages ( CDC, 2003 ). They often emphasize the harmful and/or deceptive strategies companies use to market a product that can be harmful for particular audiences (e.g., youth) in an effort to neutralize these influences and promote healthier behavior. While there is very little experience and no studies of effectiveness regarding this for alcohol use, it has been an effective strategy for reducing tobacco use ( Apollonio and Malone, 2009 ). Several well-funded, high-profile tobacco countermarketing media campaigns in California, Florida, and nationally (e.g., the truth campaign) have contributed to reduced rates of youth smoking and adult cigarette consumption in these areas ( Farrelly et al., 2002 ; Hu et al., 1995 ; Sly et al., 2002 ). (For more on media campaigns, see the following section, “Education and Awareness.”)

One important consideration in assessing the impact of alcohol marketing and developing interventions to reduce the harmful effects of such marketing is the changing media landscape, particularly for youth. Traditional means of watching television (e.g., cable or satellite television) are being replaced with online streaming services. Of note, Pew Research

Center’s survey data from 2017 show that 61 percent of adults ages 18–29 use streaming services as their primary means of watching television ( Raine, 2017 ). Such changes in television consumption could potentially have implications for the frequency, duration, and intensity for which youth are exposed to alcohol marketing. Therefore, updated research is needed on the effects of such changes in media consumption on exposure to alcohol marketing among youth.

In this section, the committee has presented an overview of the empirical and historical evidence around alcohol marketing exposure and regulation. To examine the link between alcohol marketing and consumption among underage persons, the committee drew from peer-reviewed systematic reviews of longitudinal studies on youth exposure to alcohol marketing and drinking outcomes ( Anderson et al., 2009b ; Jernigan et al., 2016 ; Smith and Foxcroft, 2009 ). While there is only one study cited that examines and demonstrates a positive relationship between alcohol advertising and motor vehicle crash fatalities ( Saffer, 1997 ), there is a strong theoretical basis for this association, particularly for youth. Given that young people (ages 21–24) are at high risk of alcohol-impaired driving ( Lipari et al., 2016 ; NCSA, 2016 ) and the available research strongly indicates that they are influenced by alcohol marketing, as evidenced by the systematic reviews cited above, the committee has identified alcohol marketing as an important point of intervention to reduce alcohol consumption, and by extension, alcohol-impaired driving among underage persons. Furthermore, numerous studies have found the alcohol industry’s self-regulation of its marketing to be ineffective and insufficient because the voluntary standards are permissive and vague, not consistently followed, and without penalties for violations ( Babor et al., 2013 ; King et al., 2017 ; Noel and Babor, 2016 ; Noel et al., 2016 ; Siegel et al., 2013 ). Therefore, the committee recommends:

Recommendation 3-4: Federal, state, and local governments should use their existing regulatory powers to strengthen and implement standards for permissible alcohol marketing content and placement across all media, establish consequences for violations, and promote and fund countermarketing campaigns.

EDUCATION AND AWARENESS

School-based education programs.

School-based alcohol education programs aim to prevent or delay youth drinking as well as prevent related risky activities such as drinking and driving and/or riding with drinking drivers. Although educational

programs are popular with policy makers, the public, and alcohol-related economic operators, in general school-based educational programs have limited evidence of producing change, particularly at the population level. The available evidence is inconsistent or shows no effect on behavior change related to alcohol alone or in combination with driving ( Elder et al., 2005 ; Foxcroft and Tsertsvadze, 2012 ; NRC and IOM, 2004 ; Mann et al., 1986 ; Shope et al., 2001 ). However, more research is needed as many education programs have not been evaluated ( Anderson et al., 2009a ; Goodwin et al., 2015 ; Lee et al., 2016 ; Mann et al., 1986 ; NRC and IOM, 2004 ; Stigler et al., 2011 ; Washington Traffic Safety Commission, 2014 ). In addition, education programs can be costly since they are delivered to relatively small groups of individuals, and their effects degrade quickly unless actively maintained. Anderson et al. (2009a) concluded in The Lancet that while school-based programs are not effective in modifying behavior, they can play an important role in increasing visibility of alcohol on public agendas. Other intermediate outcomes of programs include the promotion of social and emotional competencies and resilience among youth participants ( Stigler et al., 2011 ).

There are a number of limitations with school-based programs and the current literature that examines them. Programs have been criticized for having weak evaluation designs and short follow-up times while only measuring intermediate outcomes such as alcohol knowledge, attitudes, and intent ( Mann et al., 1986 ; Washington Traffic Safety Commission, 2014 ). There is a documented need for additional robust studies with alcohol-impaired driving outcome measures such as DWIs and alcohol-related crashes; for example, examining driving behaviors of students after an education program and measuring more specific traffic safety outcomes ( Elder et al., 2005 ; Mann et al., 1986 ; Shope et al., 2001 ; Washington Traffic Safety Commission, 2014 ). Some of the alcohol education programs studied have been successful in increasing youth knowledge about alcohol and alcohol misuse, as well as influencing attitudes and intent toward alcohol, but these positive effects usually dissipate after 6 months to 1 year. Therefore, intensity, duration, and quality of the program are key elements that require further investigation.

Despite the limitations and inconsistent evidence on school-based programs, there are some positive spillover effects. For example, school-based programs can engage groups such as Students Against Destructive Decisions (SADD) and parent–teacher associations to raise awareness about alcohol-impaired driving. Elder et al. (2005) cite a number of positive effects of participation in peer organizations such as SADD, including personal growth, social support, and a sense of citizenship in the school community. At the school level, such effects include stronger attitudes against alcohol-impaired driving and riding with an impaired driver,

increased knowledge of alternatives, and increased access to alcohol-free events ( Elder et al., 2005 ).

Alcohol Warning Labels

Legislation requiring alcohol warning labels was enacted in 1989, which stated that all alcoholic beverage containers sold in the United States must display the following warning label.

GOVERNMENT WARNING: (1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. (2) Consumption of alcohol impairs your ability to drive a car or operate machinery, and may cause health problems. 12

As of 2012, the United States is 1 of 31 countries that require warning labels on alcoholic beverages ( WHO, 2014 ). The scientific evidence on whether warning labels are effective in decreasing excessive drinking is inconclusive. A cross-sectional survey occurring 6 months after implementation of the alcohol warning labels in the United States found that 16 percent of respondents remembered the message about the risks of driving impaired, and about 25 percent of the respondents who reported being heavy drinkers and who had driven under the influence of alcohol in the past had seen the label ( Greenfield and Kaskutas, 1993 ). However, it is important to note that such cross-sectional data do not lend themselves to causal inferences. Another study also found that those who reported driving under the influence of alcohol in the past were more likely to remember the warning label than those who had not ( Parker et al., 1994 ). Other studies found alcohol warning labels to be ineffective in changing behavior and encouraged different approaches ( Creyer et al., 2002 ; Stockley, 2001 ). For example, the use of color, icons, increasing clarity, contrast, shape and/or size of the message, simplicity, and specificity of the message are all factors that can contribute to consumer awareness.

Research also suggests that providing standard drink labels on alcoholic beverage containers increases the drinker’s accuracy in assessing alcohol content ( Stockwell, 1993 ; Stockwell et al., 1991 ). Some argue that this would help responsible drinkers moderate their consumption ( Kerr and Stockwell, 2012 ). Others argue against standard drink labels, citing an Australian study that found that young drinkers use standard drink labels in order to select stronger drinks ( Jones and Gregory, 2009 ). Other cues beyond labels, however, can be used to assess alcohol content such as IPA, imperial, or double. Standard drink labels therefore might not provide new information to consumers.

12 27 CFR § 16.21 subpart C sec 16.21(1).

In the United States, beer and distilled spirits advertisements are self-regulated by the alcohol industries and do not require that a warning be included in ads ( Beer Institute, 2015 ; DISCUS, 2011 ). Often, however, consumers are told to “drink responsibly” or “drink in moderation” in these ads. An analysis of advertisements appearing in magazines found that 87 percent of them included a responsibility message but that these messages did not define responsibility and were often used to promote the product rather than convey information ( Smith et al., 2014 ). Not only is the information provided in the responsibility messages vague, but an eye-tracking study found that the responsibility messages in print advertising did not capture the attention of teenage viewers ( Thomsen and Fulton, 2007 ). These findings suggest that ambiguous responsibility messages are ineffective in capturing the attention of consumers, providing helpful public health information, or encouraging drinkers to be responsible and/or moderate in their alcohol consumption. Guidelines for the size, content, and placement of alcohol warning labels are needed in order to increase effectiveness.

Media Campaigns

There is strong evidence, based on findings from a variety of high-quality systematic reviews across numerous health behavior domains, that mass media campaigns can promote meaningful changes in health behavior at the population level when implemented alongside broader, community-level interventions ( Hornik, 2002 ; Wakefield et al., 2010 ). This work further identifies a variety of factors that increase or decrease the likelihood of success in changing behavior at the population level. Effective campaigns are typically characterized by the following:

• High levels of exposure among the target audience over an extended period of time;
• Implementation alongside other complementary interventions (e.g., tax increases or enforcement of legal sanctions against an unhealthy and illegal behavior);
• Widespread availability and access to relevant products and services (e.g., smoking cessation aids, condoms for safer sex); and
• Use of formative research and behavior change theory to guide their design ( Hornik, 2002 ; Noar, 2006 ; Randolph and Viswanath, 2004 ; Snyder et al., 2004 ; Wakefield et al., 2010 ).

The strongest evidence in support of mass media campaign effectiveness in changing behavior stems from evaluations of well-funded mass media campaigns to reduce tobacco use ( Wakefield et al., 2010 ). Work in

this area further suggests that behavior change campaigns can have complementary effects on creating a public opinion and a policy climate that supports the passage of stronger tobacco control policies ( Niederdeppe et al., 2007 , 2017b ).

Evidence of Media Campaign Effectiveness in Reducing Alcohol-Related Fatal Crashes

Several systematic and meta-analytic reviews have attempted to assess the causal effect of media campaigns to reduce alcohol-impaired driving and its consequences, both with and without accompanying interventions. Efforts to reduce alcohol-related traffic fatalities in the United States face a variety of challenges to campaign effectiveness ( Wakefield et al., 2010 ). Social norms around alcohol use in general are much more permissive than social norms around drinking and driving ( Greenfield and Room, 1997 ). The alcohol industry spends an enormous amount of resources to promote the sale and use of alcohol. Alcohol use disorder is a widespread problem, as alcohol is an addictive substance. In light of this context, it is perhaps no surprise that several systematic reviews find only limited evidence that alcohol control campaigns are associated with reduced alcohol-related harm ( Anderson et al., 2009a ; Chisholm et al., 2004 ; Doran et al., 2008 ; Spoth et al., 2008 ), often noting limitations in the breadth and quality of the studies assessing their effects. Several of these reviews, however, note that media campaigns are likely an integral component of multipolicy interventions to reduce alcohol-related harm in general because they support awareness and compliance with policies and may enhance public and policy maker commitment to laws and regulations (e.g., Anderson et al., 2009a ; Doran et al., 2008 ).

Campaigns specific to preventing traffic crashes and fatalities paint a more optimistic picture. Elder et al.’s (2004) systematic review concluded that carefully planned and well-funded media campaigns, when implemented alongside other prevention activities (including increased legal enforcement of drunk driving laws), are associated with a 13 percent decline in alcohol-related traffic crashes. Another study found that strategic efforts to increase news media coverage of efforts to reduce alcohol-impaired driving, combined with other community mobilization and enforcement activities, reduced alcohol-related injury crashes relative to a control community ( Holder et al., 2000 ). Furthermore, Bergen et al. (2014) concluded that sobriety checkpoint programs are effective when well publicized with mass media campaigns to promote awareness of these enforcement initiatives. While Yadav and Kobayashi (2015) did not find sufficient evidence that media campaigns alone or concurrent with increased enforcement reduced alcohol-related fatal crashes, these

authors featured different inclusion criteria than several previous reviews, were unable to account for the volume of media campaign exposure achieved by the interventions, and concluded that the heterogeneity of study design and quality precluded definitive conclusions about media campaign effect. Finally, while there is a lack of rigorous evaluation data on the campaign, the Ad Council and the U.S. Department of Transportation’s “Friends don’t let friends drive drunk” campaign that aired in the 1980s is often credited with contributing to a cultural shift that countered the norm of drinking and driving ( Ad Council, 2016 ; Glascoff et al., 2013 ).

Systematic reviews of the evidence supporting (non-alcohol-related) traffic safety campaigns further underscore the value of media campaigns in conjunction with increased enforcement or other policy interventions. Two reviews found strong evidence that public education campaigns, when combined with enhanced legal enforcement, increase use of child safety seats and reduce related fatal injuries ( Zaza et al., 2001 ) and increase use of safety belts and reduce traffic-related fatalities ( Dinh-Zarr et al., 2001 ; Williams et al., 1996 ). The public’s perception of the risk of legal consequences is important in determining the effectiveness of media campaigns. This is reflected in the likelihood that a person will drive while impaired ( WHO, 2016 ) and intervene as a bystander ( Guerette et al., 2013 ).

These studies make a strong case that campaigns against alcohol-impaired driving, combined with increased enforcement, have strong potential as a strategy to reduce alcohol-related fatal crashes. Some important caveats are in order, however. The only available study included in a systematic review of designated driver interventions ( Ditter et al., 2005 ) failed to find evidence of behavioral changes in response to a modestly funded designated driver campaign in Australia ( Boots and Midford, 1999 ). This suggests that the content and target of mass media campaigns is likely an important consideration, a conclusion that echoes findings from other behavioral contexts highlighting the importance of using formative research and behavior change theory to guide campaign design (e.g., Noar, 2006 ; Randolph and Viswanath, 2004 ). Recent evidence also underscores the need for significant funding to generate widespread levels of campaign exposure in this context ( Niederdeppe et al., 2017a ).

These findings emphasize the need for well-funded media campaigns that are able to achieve widespread exposure among target audiences (see Hornik, 2002 ; Wakefield et al., 2010 ). The definition of a “well-funded” campaign has not been standardized for alcohol-impaired driving, but has been operationalized for anti-tobacco campaigns. For example, CDC cites gross ratings points (GRPs) as an indicator for the recommended budget level and makes the case that between 1,600 and 2,800 GRPs,

which equates to about five to seven exposures per month, are sufficient ( CDC, 2014 ). More importantly, this is a rate of exposure that donated time is not likely to achieve. Unfortunately, most recent campaigns against alcohol-impaired driving appear to have relied on donated airtime from broadcasters ( Ad Council, 2013 , 2016 ). Sustained, well-funded media campaigns in other behavioral contexts have been funded from one of three sources: tax revenue (e.g., NCI, 2008 ), industry litigation (e.g., Farrelly et al., 2009 ), or acts of Congress ( Hornik et al., 2008 ). It therefore seems unlikely that the typical model of relying on donated air time to generate exposure to alcohol-impaired driving related media campaigns is likely to achieve levels of exposure needed to have a large-scale effect on alcohol-related fatal crashes.

Furthermore, the changing nature of the media landscape warrants consideration in the development of media campaigns to reduce alcohol-impaired driving. As highlighted in the section “Policies to Reduce the Harmful Effects of Alcohol Marketing,” traditional means of watching television are changing to online streaming services ( Raine, 2017 ). Given the shifting landscape of media consumption, research into the most effective media by which to disseminate campaigns could optimize efforts to increase exposure to messages that run counter to alcohol-impaired driving.

Cost-Effectiveness Estimates

There are some cost-effectiveness studies on the effect of mass media campaigns on alcohol-related crash fatalities, although these assessments have the same causal evaluation challenges as noted above. Several cost-effectiveness reports that assess mass media campaigns conclude that media campaigns do not affect health outcomes and thus are not considered to be cost-effective ( Anderson et al., 2009a ; Chisholm et al., 2004 ; Cobiac et al., 2009 ). This may be attributable to the variability of mass media campaign studies, as heterogeneity among studies makes it difficult to make any conclusions on the effectiveness of these campaigns and, therefore, the cost-effectiveness of them ( Yadav and Kobayashi, 2015 ).

Some studies demonstrate that these campaigns may be cost-effective under some circumstances, although these conclusions are based on a small subset of the population. Elder et al. (2004) evaluated several alcohol-impaired driving media campaigns in the United States and Australia for cost savings and found three of them to be cost-effective. Effectiveness was measured in terms of the following outcomes: drinking and driving behavior, alcohol-related crashes, and crash-related injuries or fatalities.

Several studies (see Bergen et al., 2014 , for a review) also examined mass media campaigns to make drivers aware of upcoming sobriety checkpoints. These studies found that a combination of sobriety checkpoints and mass media campaigns have the potential to reduce the burden of alcohol-related traffic injuries, and that high coverage of mass media campaigns and a very low frequency of sobriety checkpoints is cost-effective and more efficient than sobriety checkpoints alone.

In summary, there appears to be little research and few clear findings on the cost-effectiveness of media campaigns with respect to alcohol-related fatalities. In many of the studies mentioned above, media campaigns (largely considered in isolation) have not been found to be effective overall, and as a result are not found to be cost-effective. Nevertheless, systematic reviews by both Elder et al. (2004) and Bergen et al. (2014) conclude that media campaigns plus increased enforcement (for Bergen et al. in the context of increased sobriety checkpoints) are both effective and can serve as cost-effective interventions to reduce alcohol-impaired driving and related crash fatalities. Wakefield et al.’s (2010) comprehensive review of systematic reviews makes clear that well-designed and well-funded media campaigns can influence behavior when combined with broader community-level interventions.

In this section, the committee reviews a body of evidence including systematic reviews specific to alcohol-impaired driving (e.g., Community Preventive Services Task Force review by Elder et al., 2004 ; more recent reviews by Bergen et al., 2014 , and Yadav and Kobayashi, 2015 ), systematic reviews on media effects on other driving-related interventions (e.g., Zaza et al., 2011 , on child safety seat use; Dinh-Zarr et al., 2001 , on more general use of safety belts), and a comprehensive synthesis of systematic review evidence across a wide variety of behavioral domains ( Wakefield et al., 2010 ). The committee assesses this evidence, along with other recent and relevant studies that were not included in these reviews, with the recognition that media campaigns are rarely conducted in isolation, vary considerably in size and quality, and typically lack randomized designs that permit unambiguous causal inference. Nevertheless, the committee argues that the accumulated body of evidence permits the following conclusion:

Conclusion 3-2: There is sufficient evidence to conclude that well-funded media campaigns are an important component of alcohol-impaired driving enforcement policy interventions to ensure their successful adoption and impact. Campaigns are more likely to be effective when rigorous formative research and behavioral change theories inform their design and dissemination.

TECHNOLOGICAL INTERVENTIONS

Personal devices and technology for estimating bac.

Interventions that allow drinkers to estimate their BAC levels accurately, and thus better assess their risk, have the potential to reduce alcohol-impaired driving fatalities. There is good evidence that drinkers, and specifically those with high BAC levels, are poor at estimating their BAC ( Beirness, 1987 ; Beirness et al., 1993 ; Martin et al., 2016 ; Thombs et al., 2003 ). Individuals who underestimate their BAC are more likely to judge they are fit to drive when they are over the BAC limit set by state law ( Beirness, 1987 ; Beirness et al., 1993 ) 13 and they are more likely to take more risks while driving ( Laude and Fillmore, 2016 ). Recent work has shown that one’s perception of intoxication has a bigger effect on risk taking than actual physiological levels of intoxication ( Corazzini et al., 2015 ; Proestakis et al., 2013 ). Making individuals aware of their level of intoxication might reduce risk taking.

There has been research and policy interest since the 1970s in determining whether BAC feedback through breath-testing devices could be used as an intervention to prevent alcohol-impaired driving ( Oates, 1978 ; Russ et al., 1988 ). Breath-testing devices have been validated against blood alcohol levels ( Kriikku et al., 2014 ; Schechtman and Shinar, 2011 ; Van Tassel et al., 2004 ). Theorized positive benefits of BAC feedback include decreasing alcohol consumption to not exceed the BAC limit set by state law and increasing the likelihood of opting not to drive ( Russ et al., 1988 ).

Despite the theoretical benefits, providing BAC feedback through breath-testing devices was not shown to reduce alcohol-impaired driving in a review of studies conducted in the 1970s and 1980s ( Russ et al., 1988 ). The majority of these studies were conducted on the premises of drinking establishments in Canada, New Zealand, and the United States. A more recent study from 2008 found that self-administered BAC feedback enabled individuals leaving drinking establishments to more accurately determine whether they could legally drive, but it did not change individuals’ perceived fitness to drive ( Johnson et al., 2008 ). The lack of behavioral change when presented with information on risk (communicated as BAC) underscores the predictable irrationality of those who repeatedly drive after drinking to above the limit set by state law ( Ariely, 2008 ). For example, individuals who drive after drinking, compared to those who do not, understand DWI laws better but are poorer planners, more

13 In these two studies, estimation of BAC was measured during a simulated naturalistic social drinking situation ( Beirness, 1987 ) and a voluntary roadside survey of nighttime drivers ( Beirness et al., 1993 ).

impulsive, and myopic decision makers ( Sloan et al., 2014 ). Some studies have even suggested that BAC feedback has the potential to increase driving after drinking among those with BAC levels less than 0.05% ( Bullers and Ennis, 2006 ; Johnson and Voas, 2004 ; Johnson et al., 2008 ). At or below this level, drinkers tend to overestimate their BAC in this range. Therefore, there is concern that BAC feedback in this range could lead to these individuals to decide it is safe to drive since they are under the limit set by state law, despite feeling some effects of impairment. More research is greatly needed to determine the net benefit and unintended consequences of BAC feedback on decisions to drive after moderate drinking.

Although personal breath-testing devices have existed since the 1980s, data are very sparse on who uses them, their accuracy, and their effect on public health. 14 Despite variability in accuracy of personal breath-testing devices ( Ashdown et al., 2014 ), these devices do not currently require FDA approval to be marketed to consumers.

Personal breath-testing devices appear to be more common in European countries. One survey estimated 11 percent of Finnish households with licensed drivers owned a personal breath-testing device in 2007 ( Radun et al., 2009 ). In this survey, more men than women reported owning a breath-testing device; 24 percent of those who owned one did not use it. The respondents reported 77 percent used it the day/morning following drinking, rather than while drinking (18 percent) or just before driving home after drinking (6 percent). In 2012, France passed a law requiring a breath-testing device to be carried in every vehicle ( BBC, 2012 ). The law was suspended a year later because of shortages and reported test inaccuracy of the device. The effort was later criticized because of commercial financial conflicts of interest with the breath-testing kit manufacturer. Independent analyses of outcomes are not currently available ( Radun et al., 2014 ).

In the last 5 years, there have been two major innovations that have led to a new generation of personal breath-testing devices marketed to consumers. The first is new fuel cell sensors that can maintain consistent measurements for up to 1 year of use without needing to be professionally calibrated. The second innovation is smartphone connectivity via Blue-tooth or a headphone jack connection ( Andrews, 2013 ). Smartphone applications associated with personal breath-testing devices can now provide an automated interpretation of BAC levels and cautionary messages, as well as the estimated time to return to BAC levels less than 0.02%. These apps track levels over time, and can be used to prompt safety measures such as hailing a rideshare or sending alerts to social contacts. For those

14 For a list of approved evidential breath-testing devices, see https://www.transportation.gov/odapc/approved-evidential-breath-testing-devices (accessed October 13, 2017).

with alcohol use disorders, these smartphone-connected breath-testing devices can be used for remote alcohol monitoring via notifications to submit breath samples within a certain time frame. The smartphone camera can be used to verify the identity of the individual submitting the sample, and the submitted samples can be time-stamped and geocoded. A recent, small randomized controlled trial demonstrated that contingency management with financial incentives using this smartphone-enabled remote monitoring approach reduces alcohol consumption among those with alcohol use disorders ( Alessi and Petry, 2013 ). Furthermore, aggregated data collected from smartphone-paired breath-testing devices are able to provide a novel source of data on alcohol consumption, as well as BAC levels among the population who uses them. 15 The costs of smartphone-paired breath-testing devices range from $30 to $100 and they are now available in major household, electronic, and online retail outlets.

There is very little scientific literature on the use of newer generation personal and smartphone-paired breath-testing devices for purposes of moderating drinking and reducing alcohol-impaired driving. Industry data indicate there are two main factors cited by users for using smartphone-paired breath-testing devices: (1) making sure their BAC is under the limit set by state law before they drive, and (2) avoiding a DWI. A 2016 survey study by the Colorado Department of Transportation in which 225 bar patrons were given a smartphone-paired breath-testing device reported that using a breath-testing device lowered their risk of a DWI and that the patrons were much less likely to drive impaired compared to prior to using a breath-testing device ( Colorado DOT, 2016 ). 16

A major limitation of breath-testing devices is that they require active use and engagement and only provide point-in-time estimates of BAC levels. This could potentially be dangerous if an individual’s BAC is ascending, and they receive a reading that is below the limit set by state law, indicating that it would be safe to drive. Therefore, there is great potential and interest in having passively collected, continuous estimates of BAC as could be collected through transdermal alcohol sensors that measure alcohol content in skin sweat. Starting in the early 2000s, transdermal alcohol sensors have been used for remote monitoring in the criminal justice system (see Chapter 5 for a discussion of monitoring alcohol use among DWI offenders). These devices have included a tamper-resistant ankle bracelet and a wrist-wearable device ( Swift et al., 1992 ).

15 See, for example, the BACtrack consumption report, https://www.bactrack.com/pages/bactrack-consumption-report (accessed October 13, 2017).

16 The Colorado DOT has since partnered with BACtrack, a personal breath-testing device company, to offer their products to Colorado residents for a discounted price ( Colorado DOT, 2017 ). This partnership and its outcomes have not yet been evaluated.

These devices capture the presence of alcohol consumption in a continuous, passive fashion ( Marques and McKnight, 2007 ; Sakai et al., 2006 ) and have been used for contingency management in treatment of those with alcohol use disorder ( Dougherty et al., 2014 ).

However, compared with breath-testing devices, there are more challenges to providing real-time BAC estimates owing to lag time in skin accumulation of alcohol. The mathematical translation of transdermal alcohol content to estimated BAC in real time is an area of active research ( Leffingwell et al., 2013 ). In addition, smartphone-paired transdermal alcohol sensors that could be integrated with smart watches are in development ( Gutierrez et al., 2015 ). Finally, there is emerging research on passively monitoring alcohol intoxication based on how individuals use their smartphone with the ability to accurately detect light drinking and heavy drinking episodes with 96 percent accuracy ( Bae et al., 2017 ).

Like other smartphone-enabled personal monitoring applications and devices, breath and alcohol sensors have the potential to facilitate changes in health behavior, but they are not likely to change behavior in isolation ( Patel et al., 2015 ). These devices will need to be coupled with theoretically guided and evidence-based behavioral engagement strategies to reduce alcohol-impaired driving. These engagement strategies can be made more effective by incorporating feedback loops and concepts from behavioral economics that shape decision making, such as lottery-based designs that offer rewards combined with anticipated regret associated with not securing the reward ( Patel et al., 2015 ). Future research and development is needed to determine whether coupling alcohol monitoring with behavioral strategies that take advantage of smartphone connectivity can lead to reductions in alcohol-impaired driving ( Sahabiswas et al., 2016 ). Promising strategies include ongoing feedback support, real-time notifications of peers and loved ones, leveraging social norms, contingency management, prompting the use of ridesharing services, and pairing with in-vehicle devices and smartphone applications that monitor driving.

In this section, the committee reviews the literature on drinkers’ self-estimates of BAC and whether BAC feedback from personal breath testing reduces decisions to drive at levels consistent with impairment. There is good evidence from multiple studies that drinkers with high BAC levels underestimate their BAC and that those who underestimate their BAC perceive they are fit to drive when their BAC is over the limit set by state law (e.g., Beirness, 1987 ; Beirness et al., 1993 ; Martin et al., 2016 ; Thombs et al., 2003 ). However, there is a lack of evidence from studies conducted in the 1970s to early 2000s to support that personal BAC feedback reduces alcohol-impaired driving. Starting in 2013, a new generation of consumer-marketed smartphone-paired breath-testing devices has emerged, presenting several opportunities to facilitate novel interventions

based on the interpretation and sharing of the data generated by these devices. From a policy perspective, given that breath and transdermal alcohol sensors are increasingly being marketed to consumers and are being used to make decisions about driving after drinking, there is a need for peer-reviewed, objective evidence to verify their accuracy, including research into unintended consequences related to binge drinking and alcohol-impaired driving, before recommending widespread adoption. If it is found that some consistently underestimate BAC, there is a need for more regulatory oversight of this market such as by requiring FDA 510(k) premarket clearance before marketing to consumers. 17

Conclusion 3-3: Consumer marketed personal breath-testing devices are an emerging technology with the potential to reduce alcohol-impaired driving by promoting more accurate BAC self-estimation. However, these technologies require further investigation of their accuracy and effects on behavior before promoting widespread use.

Other BAC Estimation Tools

Traditionally, BAC estimation tools have existed in the form of wallet-size cards, often titled “know your limit” and distributed to patrons of a licensed establishment. While “know your limit” cards do not have sufficient evidence to determine their effectiveness, they have been widely used for decades ( Johnson and Clapp, 2011 ). As discussed with the personal breath-testing devices, the limitations and potential pitfalls of estimation tools have been explored in the literature ( Johnson and Voas, 2004 ; Johnson et al., 2008 ). Another related tool that has emerged with the advent of smartphones and other handheld devices is mobile applications that allow individuals to gauge their BAC levels. Similarly to the “know your limit” cards, these applications allow users to input information on their sex, weight, and the number of drinks consumed during a fixed period of time to calculate their BAC. Some of these applications include an estimated time frame for reaching a BAC of 0.00%. It is important to note that these mobile application estimation tools have not been well evaluated. Nonetheless, they have potential for widespread use given the common platform on which they are offered, which warrants systematic investigation of their effectiveness and potential negative consequences.

17 A 510(k) is a premarket submission made to FDA to demonstrate that the device to be marketed is at least as safe and effective, that is, substantially equivalent, to a legally marketed device (21 CFR § 807.92(a)(3)) that is not subject to premarket approval ( FDA, 2017 ).

CONCLUDING OBSERVATIONS

Throughout this chapter, the committee has identified a number of areas that require further investigation to inform the implementation and design of drinking-oriented interventions. Addressing these evidence gaps would allow for more targeted and evidence-based interventions to reduce alcohol-impaired driving fatalities. The following subjects indicate research areas for which investigation would benefit the field of alcohol-impaired driving:

• Effects of introducing retail price restrictions on excessive alcohol consumption and alcohol-impaired driving;
• Specific effects of social host laws on underage alcohol consumption and alcohol-impaired driving;
• Key elements of effectiveness for responsible beverage service training and policies;
• Effect of permitting alcohol sales concurrent with or proximal to driving (e.g., drive-through package stores, sale of alcohol at gasoline marts, sale of alcohol at fast-food restaurants) on alcohol-impaired driving and related crashes and fatalities, including spatial analyses;
• Effectiveness of various strategies to reduce the effect of alcohol advertising on underage drinking and alcohol-impaired driving;
• Design, messaging, and placement of effective alcohol warning labels; and
• Effectiveness of BAC estimation tools, such as personal breath-testing devices and mobile applications, in addition to potential consequences or misuse.

While the country has made great strides in adopting alcohol-related policies, programs, and strategies, a revised and comprehensive approach is needed to once again achieve progress in reducing alcohol-impaired driving. It is important to note that progress will require a multicomponent approach, encompassing multilevel interventions that work synergistically. This could include maintaining and enhancing the enforcement of alcohol policies to influence price, availability, illegal sales, and responsible marketing; increasing the use of underused strategies such as age-related compliance checks; and more. This chapter examines the evidence-based and promising interventions that shape the likelihood of drinking to impairment and makes recommendations for how to inform, implement, and optimize these interventions. This is a crucial phase in the sequence of behaviors that lead to alcohol-impaired driving. The next chapter will explore interventions that reduce the act of alcohol-impaired driving itself.

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Alcohol-impaired driving is an important health and social issue as it remains a major risk to Americans' health today, surpassing deaths per year of certain cancers, HIV/AIDS, and drownings, among others, and contributing to long-term disabilities from head and spinal injuries. Progress has been made over the past decades towards reducing these trends, but that progress has been incremental and has stagnated more recently.

Getting to Zero Alcohol-Impaired Driving Fatalities examines which interventions (programs, systems, and policies) are most promising to prevent injuries and death from alcohol-impaired driving, the barriers to action and approaches to overcome them, and which interventions need to be changed or adopted. This report makes broad-reaching recommendations that will serve as a blueprint for the nation to accelerate the progress in reducing alcohol-impaired driving fatalities.

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Drug-Impaired Driving: The Contribution of Emerging and Undertested Drugs

Impaired driving is often with alcohol use and frequently leads to accidents, injuries, and fatalities. According to the National Highway Traffic Safety Administration, one person was killed every 39 minutes in an alcohol-related crash in 2021. [1] But alcohol is not the only concern; the use of illicit drugs, legalized drugs such as cannabis, and the abuse of prescription medications may also impair a driver’s abilities. In 2022, an estimated 13.6 million people drove under the influence of illicit drugs during the prior year. [2]

In 2007, the National Safety Council (NSC) introduced testing scope and cutoff standardization for impaired driving cases and traffic fatalities to improve testing consistency. Since 2013, it has recommended that forensic toxicology labs regularly test blood for 35 of the most often encountered drugs and metabolites. Referred to as Tier I drugs ( Figure 1 ), they are now included as a testing standard in many forensic toxicology labs. [3] Furthermore, these compounds can be detected and confirmed with commonly used analytical instrumentation.

Figure 1. List of Tier I and Tier II drugs. Tier II drugs can be both individually named drugs and classes of drugs (e.g., atypical antipsychotics).

NSC also created a second drug category with significant impairment potential, termed Tier II drugs. These drugs include emerging novel psychoactive substances, prescription drugs, and traditional drugs of abuse with limited or regional prevalence, many of which require advanced instrumentation for detection. Most laboratories test for Tier I drugs, but only test for select Tier II drugs when they are regionally relevant. Therefore, the frequency and the types of Tier II substances contributing to drug-impaired driving cases and fatal crashes is not well understood.

NIJ-funded researchers from the Center for Forensic Science Research and Education examined blood samples from over 2,500 driving under the influence of drugs (DUID) cases. The goal was to create a detailed picture of both Tier I and Tier II drugs that contribute to impaired driving cases and compare results to the NSC’s recommended testing scopes. Researchers also analyzed drug presence at various blood alcohol concentrations to assess the operational impact of different testing thresholds and stop limit testing.

What is Stop Limit Testing?

If a sample meets or exceeds a pre-determined blood alcohol concentration threshold, some labs will not perform any additional drug tests. This cutoff is most commonly either 0.08% or 0.10%. [4] The legal blood alcohol limit in the U.S. across every state is 0.08%. Labs that adhere to this practice will not detect other drugs that may cause or contribute to driving impairment.

This stop limit testing can interfere with a comprehensive understanding of drug involvement in impaired driving. Why do so many labs use it?

• Toxicology labs have limited budgets and resources.
• Driving impairment can be explained by the blood alcohol concentration alone.
• A lack of enhanced penalties for drug use means there is no need to measure beyond the blood alcohol level.
• Agencies that use the laboratories’ services have requested this limit.

National Safety Council Recommendations Are Supported

Researchers estimated the frequency with which drugs contribute to the national DUID problem by testing 2,514 cases using a scope of 850 therapeutic, abused, and emerging drugs. They examined deidentified blood samples randomly selected from a pool of suspected impaired driving cases. The samples were collected from NMS Labs in Horsham, Pennsylvania, between 2017 –2020.

Of the 2,514 suspected DUID cases examined:

• The overall drug positivity (Tier I or Tier II drugs) was 79%, nearly double the 40% positive for alcohol ( Figure 2 ).
• A smaller portion of cases (23%) tested positive for both drugs and alcohol.
• Only 17% of the cases were positive for alcohol alone.
• Naturally occurring cannabinoids experienced a statistically significant increase in positivity over the four years.

Figure 2. The frequency of cases with (a) no drugs or ethanol detected (4%), (b) ethanol detected (40%), (c) drugs and ethanol detected (23%), and (d) drugs detected (79%).

Alcohol use in combination with drugs spanning multiple categories was common, as was multiple drugs used in combination. THC (the primary psychoactive component of marijuana) was most often found with ethanol (n=359), and it was frequently found with amphetamine/methamphetamine (n=146).

Samples with a blood alcohol content of 0.08% or higher that were also positive for either Tier I or Tier II drugs occurred 19% of the time (n=478). Cases with blood alcohol content of 0.10% (the cutoff used most frequently by toxicology labs) were also positive for Tier I or Tier II drugs 17.3% of the time (n=434). This suggests that laboratories employing stop limit testing may miss many drug-positive cases.

“Limiting testing based on alcohol results precludes information of drug involvement in several cases and leads to underreporting of drug contributions to impaired driving,” said Mandi Moore, one of the researchers involved in the study.

The research supported NSC’s recommendations for Tier I and Tier II testing. Tier I drugs were found in 73% of suspected impaired driving cases while only 3% contained just Tier II drugs. This suggests that Tier I testing captures the vast majority of drug-involved DUID cases. However, some Tier II drugs (diphenhydramine, gabapentin, hydroxyzine, and two novel psychoactive substances) were found as often or more often than some Tier I drugs, potentially indicating their increased prevalence and a need to re-examine guidelines.

Study Limitations

The cases used in this analysis were exclusively from Pennsylvania. Therefore, they provide a geographically limited snapshot rather than a comprehensive characterization for the entire U.S. population. However, the sample size of over 2,500 cases was “suitable to meet the research goals outlined” by the researchers.

Because Tier II and novel psychoactive substances were found in relatively low frequencies, the researchers did not develop or validate additional confirmatory methods as they had previously planned.

Filling in the Big Picture Details

This work increases awareness of drugs that labs are less likely to test for and labs’ role in addressing the DUID problem. It also demonstrates how frequently DUID cases involve drugs other than alcohol. Although stop limit testing can be justified, data on both alcohol and drug use creates the clearest picture of DUID contributing factors. Current estimates of drug frequency in DUID cases are likely to be inaccurate and actual usage is likely to be higher than previously believed due to stop limit testing. Equipping labs with sufficient resources could encourage labs to eliminate stop limit testing.

About This Article

The work described in this article was supported by NIJ award number 2020-DQ-BX-0009 , awarded to the Frederic Rieders Family Renaissance Foundation.

This article is based on the grantee report “ Assessment of the Contribution to Drug Impaired Driving from Emerging and Undertested Drugs ” (pdf, 26 pages), by Amanda L.A. Mohr and Barry Logan, The Center for Forensic Science Research and Education (CFSRE) at the Frederic Rieders Family Renaissance Foundation.

[1] NHTSA.gov, accessed January 29,2024, https://www.nhtsa.gov/risky-driving .

[2] Select Illicit Drugs include the use of marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, or methamphetamine. For more information, see "Table 8.35A" in  2022 NSDUH Detailed Tables, Substance Abuse and Mental Health Services Administration,  https://www.samhsa.gov/data/sites/default/files/reports/rpt42728/NSDUHDetailedTabs2022/NSDUHDetailedTabs2022/NSDUHDetTabsSect8pe2022.htm#tab8.35a .

[3] ANSO/ASB Standard 120.

[4] Amanda D’Orazio, Amada Mohr, and Barry Logan, “Updates for Recommendations for Drug Testing in DUID & Traffic Fatality Investigations, Toxicology Laboratory Survey,” Willow Grove, PA: The Center for Forensic Science Research & Education at the Frederic Rieders Family Foundation, June 28, 2020, https://www.cfsre.org/images/content/research/toxicology/Survey_Report_Final.pdf .

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Driving Under the Influence of Marijuana and Illicit Drugs Among Persons Aged ≥16 Years — United States, 2018

Weekly / December 20, 2019 / 68(50);1153–1157

Alejandro Azofeifa, DDS 1 ; Bárbara D. Rexach-Guzmán, MPH 2 ; Abby N. Hagemeyer, PhD 3 ; Rose A. Rudd, MSPH 4 ; Erin K. Sauber-Schatz, PhD 4 ( View author affiliations )

What is already known about this topic?

The use and co-use of alcohol and drugs has been associated with impairment of psychomotor and cognitive functions while driving.

What is added by this report?

During 2018, approximately 12 million (4.7%) U.S. residents aged ≥16 years reported driving under the influence of marijuana, and 2.3 million (0.9%) reported driving under the influence of illicit drugs other than marijuana during the past 12 months.

What are the implications for public health practice?

Development, evaluation, and further implementation of strategies to prevent alcohol-, drug-, and polysubstance-impaired driving coupled with standardized testing of impaired drivers and drivers involved in fatal crashes could advance understanding of drug- and polysubstance-impaired driving and assist states and communities with prevention efforts.

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In the United States, driving while impaired is illegal. Nonetheless, an estimated 10,511 alcohol-impaired driving deaths occurred in 2018.* The contribution of marijuana and other illicit drugs to these and other impaired driving deaths remains unknown. Data from the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health (NSDUH) indicated that in the United States during 2014, 12.4% of all persons aged 16–25 years reported driving under the influence of alcohol, and 3.2% reported driving under the influence of marijuana ( 1 ). The impairing effects of alcohol are well established, but less is known about the effects of illicit substances or other psychoactive drugs (e.g., marijuana, cocaine, methamphetamines, and opioids, including heroin). This report provides the most recent national estimates of self-reported driving under the influence of marijuana and illicit drugs among persons aged ≥16 years, using 2018 public-use data from NSDUH. Prevalences of driving under the influence of marijuana and illicit drugs other than marijuana were assessed for persons aged ≥16 years by age group, sex, and race/ethnicity. During 2018, 12 million (4.7%) U.S. residents reported driving under the influence of marijuana in the past 12 months; 2.3 million (0.9%) reported driving under the influence of illicit drugs other than marijuana. Driving under the influence was more prevalent among males and among persons aged 16–34 years. Effective measures that deter driving under the influence of drugs are limited ( 2 ). Development, evaluation, and further implementation of strategies to prevent alcohol-impaired, † drug-impaired, and polysubstance-impaired driving, coupled with standardized testing of impaired drivers and drivers involved in fatal crashes, could advance understanding of drug- and polysubstance-impaired driving and support prevention efforts.

NSDUH annually collects information about the use of illicit drugs, alcohol, and tobacco among the noninstitutionalized U.S. civilian population aged ≥12 years via household face-to-face interviews using a computer-assisted personal interviewing system. § Respondents aged <16 years were excluded from this analysis because they are typically too young to drive. Unweighted sample sizes for the 2018 survey cycle included 47,570 respondents aged ≥16 years. Driving under the influence of marijuana was defined as an affirmative response to the question “During the past 12 months, have you driven a vehicle while you were under the influence of marijuana?” Driving under the influence of illicit drugs other than marijuana was defined as an affirmative response to one or more of the questions (each asked separately) that asked about each illicit drug: “During the past 12 months, have you driven a vehicle while you were under the influence of (cocaine, hallucinogens, heroin, inhalants, methamphetamine)”? Public-use NSDUH data on driving under the influence of marijuana and illicit drugs other than marijuana were examined by sex, age group, and race/ethnicity. Data were weighted to provide nationally representative estimates. Statistical analyses were performed using SAS (version 9.4; SAS Institute). Prevalence measures and 95% confidence intervals (CIs) were determined for each response category.

During 2018, the overall prevalence of driving under the influence of marijuana (4.7%) exceeded that of driving under the influence of illicit drugs other than marijuana (0.9%) among persons aged ≥16 years ( Table ). This pattern persisted when the data were stratified by sex, race/ethnicity, and age group. The prevalences of driving under the influence of marijuana and driving under the influence of illicit drugs other than marijuana were higher among males (6.2%, 1.3%, respectively) than among females (3.2%, 0.5%, respectively). The prevalence of driving under the influence of marijuana was highest among non-Hispanic multiracial persons (9.2%). The prevalence of driving under the influence of marijuana ranged from 0.6% among persons aged ≥65 years to 12.4% among persons aged 21–25 years; the second highest prevalence (9.2%) was reported among persons aged 16–20 years ( Figure ). The highest reported prevalences of driving under the influence of illegal drugs other than marijuana were among persons aged 21–25 years (1.9%) and 26–34 years (1.9%).

Although 4.7% of the U.S. population aged ≥16 years reported driving under the influence of marijuana and 0.9% reported driving under the influence of illicit drugs other than marijuana, these estimates are lower than the 8.0% (20.5 million) who reported driving under the influence of alcohol in 2018 (NSDUH, unpublished data, 2019). The highest prevalence of driving under the influence of marijuana was among persons aged 21–25 years. The second highest was among the youngest drivers (those aged 16–20 years), who already have a heightened crash risk because of inexperience ¶ ; thus, their substance use is of special concern. In a study of injured drivers aged 16–20 years evaluated at level 1 trauma centers in Arizona during 2008–2014 ( 3 ), 10% of tested drivers were simultaneously positive for both alcohol and tetrahydrocannabinol, the main psychoactive component of marijuana. Data from the 2018 NSDUH indicate a high prevalence (34.8%) of past-year marijuana use among young adults aged 18–25 years ( 4 ). Studies have reported that marijuana use among teenagers and young adults might alter perception, judgement, short-term memory, and cognitive abilities ( 5 ). Given these findings, states could consider developing, implementing, and evaluating targeted strategies to reduce marijuana use and potential subsequent impaired driving, especially among teenagers and young adults.

Research has determined that co-use of marijuana or illicit drugs with alcohol increases the risk for driving impairment ( 5 , 6 ). The use of these substances has been associated with impairment of psychomotor and cognitive functions while driving ( 6 , 7 ). In addition, previous research has demonstrated evidence of a statistical association between marijuana use and increased risk for motor vehicle crashes; however, methodologic limitations of studies limit inference of causation ( 8 ). Scientific studies have been unable to link blood tetrahydrocannabinol levels to driving impairment ( 8 ), and the effects of marijuana in drivers likely varies by dose, potency of the product consumed, means of consumption (e.g., smoking, eating, or vaping), length of use, and co-use of other substances, including alcohol. Additional data are needed to clarify the contribution of drug and polysubstance use to impaired driving prevalence and the resulting crashes, injuries, and deaths.

A national roadside survey using biochemical specimens among drivers aged ≥16 years found that during 2013–2014, the percentages of weekend nighttime drivers who tested positive for alcohol, marijuana (i.e., tetrahydrocannabinol) and illicit drugs were 8.3%, 12.6%, and 15.1%, respectively ( 9 ), although a positive test does not necessarily imply impairment. Collecting and testing biologic specimens (e.g., blood or oral fluids) currently required to test for drugs has challenges, including, in some circumstances, the need for a judge to order collection and testing (which can delay roadside testing, thus allowing drug levels to drop with time); variation in substances tested and methodology used by different toxicology laboratories; and the current state of development of oral fluid testing. The increased use of marijuana and some illicit drugs in the United States ( 4 ) along with the results of this report, point to the need for rapid and sensitive assessment tools to ascertain the presence of and impairment by marijuana and other illicit drugs. In addition, adoption and application of standards for toxicology testing and support for laboratories to implement recommendations are needed to improve understanding of the prevalence of drug- and polysubstance-impaired driving ( 10 ).

The findings in this report are subject to at least five limitations. First, because NSDUH data are self-reported, they are subject to recall and social desirability biases. Second, variations in laws and regulations among states and counties regarding marijuana could have resulted in negative responses to the NSDUH substance use survey questions for fear of legal consequences, leading to an underestimation of the prevalence of the use and driving under the influence in some jurisdictions. Third, the NSDUH questions are not limited to driving under the influence of marijuana only or each illegal substance only; therefore, persons might be driving under the influence of more than one substance at a given time. Fourth, self-reported data are subject to the respondents’ interpretations of being under the influence of a drug. Finally, NSDUH does not assess whether all respondents drive; therefore, reported percentages of impaired drivers might be underestimated.

Impaired driving is a serious public health concern that needs to be addressed to safeguard the health and safety of all who use the road, including drivers, passengers, pedestrians, bicyclists, and motorcyclists. Collaboration among public health, transportation safety, law enforcement, and federal and state officials is needed for the development, evaluation, and further implementation of strategies to prevent alcohol-, drug-, and polysubstance-impaired driving ( 2 ). In addition, standardized testing for alcohol and drugs among impaired drivers and drivers involved in fatal crashes could advance understanding of drug- and polysubstance-impaired driving and assist states and communities with targeted prevention efforts.

Acknowledgments

Margaret E. Mattson, PhD, Division of Evaluation, Analysis and Quality, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland; Applied Epidemiology Fellowship Program, Council of State and Territorial Epidemiologists, Atlanta, Georgia.

Corresponding author: Erin K. Sauber-Schatz, [email protected] , 770-488-0566.

1 Consultant, Washington, DC; 2 Consultant, San Juan, Puerto Rico; 3 Applied Epidemiology Fellowship, Council of State and Territorial Epidemiologists, Atlanta, Georgia; 4 Division of Injury Prevention, National Center for Injury Prevention and Control, CDC.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

* https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812826 .

† https://www.cdc.gov/motorvehiclesafety/impaired_driving/strategies.html .

§ https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health . Starting in 2016, NSDUH replaced questions regarding driving under the influence of illicit drugs overall with questions about driving under the influence of individual substances, including cocaine, hallucinogens, heroin, inhalants, marijuana, and methamphetamines.

¶ https://www.cdc.gov/motorvehiclesafety/teen_drivers/teendrivers_factsheet.html .

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• Shults RA, Jones JM, Komatsu KK, Sauber-Schatz EK. Alcohol and marijuana use among young injured drivers in Arizona, 2008–2014. Traffic Inj Prev 2019;20:9–14. CrossRef PubMed
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Abbreviation: CI = confidence interval. * Numbers and percentages are weighted to represent the 2018 U.S. civilian, noninstitutionalized population and are not mutually exclusive. † Illicit drugs other than marijuana in this analysis are cocaine, hallucinogens, heroin, inhalants, and methamphetamines. § Whites, blacks, American Indian/Alaska Natives, Hawaiian/Other Pacific Islanders, Asians, and multiracial persons were non-Hispanic; Hispanic persons could be of any race.

FIGURE . Percentage of all persons aged ≥16 years* who reported driving a vehicle under the influence of marijuana or illicit drugs other than marijuana † , § , ¶ in the past year, by age group** — National Survey on Drug Use and Health, United States, 2018

* Percentages are weighted to represent the 2018 U.S. civilian, noninstitutionalized population.

† Illicit drugs other than marijuana in this analysis include cocaine, hallucinogens, heroin, inhalants, and methamphetamines.

§ Not mutually exclusive.

¶ Estimated percentage of adults aged ≥65 years who reported driving under the influence of illicit drugs other than marijuana was <0.02% and thus not shown.

** With 95% confidence intervals indicated by error bars.

Suggested citation for this article: Azofeifa A, Rexach-Guzmán BD, Hagemeyer AN, Rudd RA, Sauber-Schatz EK. Driving Under the Influence of Marijuana and Illicit Drugs Among Persons Aged ≥16 Years — United States, 2018. MMWR Morb Mortal Wkly Rep 2019;68:1153–1157. DOI: http://dx.doi.org/10.15585/mmwr.mm6850a1 .

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Impaired Driving Laws, Enforcement and Prevention

Driving while impaired refers to operating a motor vehicle while under the influence of alcohol. It is defined in the United States as a blood alcohol content (BAC) greater than or equal to 0.08% (mass of alcohol per volume of blood in the body). More than 10,000 people were killed in alcohol-impaired driving crashes in 2012, accounting for 31% of all U.S. traffic-related fatalities. In 2010, alcohol-impaired driving crashes were associated with nearly one in five of the traffic-related fatalities of children through age 14 years. Among those fatalities, more than half were passengers of vehicles with drivers who had BACs greater than or equal to 0.08%. Although the focus historically has been on alcohol impairment, drug-impaired driving is receiving increased attention from agencies and policy makers.

A host of effective strategies can be used to help address alcohol-impaired driving. These include strengthening impaired driving laws and enforcement efforts, education and awareness campaigns, and the use of technology (e.g., ignition interlocks) to prevent impaired drivers from operating vehicles. All states have laws against driving while impaired. Some states are using strategies, such as sobriety checkpoints , to further discourage impaired driving. Some are using campaigns such as “Drive Sober or Get Pulled Over” and “Buzzed Driving is Drunk Driving,” which combine increased enforcement efforts with advertising. The advertising is used to discourage impaired driving by making motorists aware that it is socially unacceptable and they can be pulled over and arrested for driving while impaired. Other strategies that can help address the problem include

• High visibility enforcement
• Prompt license revocation or suspension
• Ignition interlocks for persons convicted of driving while intoxicated
• License plate or registration confiscation
• Vehicle impoundment or immobilization
• Designated driver programs
• Alcohol server training programs
• Courts that address driving while intoxicated/driving under the influence repeat offenders through sanctions combined with drug and alcohol testing, treatment, and follow-up care and monitoring

Related Transportation and Heath Tool Indicators

• Alcohol-Impaired Fatalities

How can this strategy result in health benefits?

• Reduce motor vehicle-related injuries and fatalities

How has this worked in practice?

New Mexico’s Comprehensive Impaired-driving Program

The New Mexico Department of Transportation obtained funds from NHTSA in 2004 for a comprehensive state level impaired driving program. The program ran from 2005 to 2009, initially in five target counties, with a sixth county added in 2007. It included statewide media campaigns, an interagency leadership team, and increased, high visibility enforcement efforts and prosecutorial training. Program effectiveness was measured using driving while intoxicated crash, injury, and fatality rates, arrest rates, and conviction rates; blood alcohol concentration patterns; and public awareness. The results demonstrated effectiveness of the statewide and targeted efforts. Alcohol-involved fatal crashes decreased by 36.5% in those counties participating in the program, compared with a 31.6% decrease for the state as a whole. Alcohol-impaired fatal crashes decreased by 35.8% in the focus counties, compared with a 29% decrease for the state, which contrasted sharply with a 6.9% decrease in neighboring states for the same time period. New Mexico dropped from having the seventh highest alcohol-related fatality rate in the United States in 2004, before program implementation, to having the 19th highest rate in 2009.

Where can I learn more?

NHTSA provides statistics about impaired driving, materials for campaigns against impaired driving, and case studies of effective practices to stop impaired driving.

The CDC’s Injury Prevention & Control, Motor Vehicle Safety website includes resources on topics ranging from safety for older adult drivers to safety for pedestrians and motorcycle safety. It also has state data, cost and policy information. Within that website are the CDC’s Motor Vehicle Safety Costs pages, which include information on cost data and prevention policies. CDC Injury Prevention & Control: Motor Vehicle Safety - Impaired Driving includes data and statistics for crashes involving impaired drivers, research, and policy recommendations, including a CDC/NHTSA evaluation of key features of interlock programs and the use of interlocks in 28 states from 2006–2011. Within that website are the CDC’s Motor Vehicle Safety Ignition Interlock pages.

The Governors Highway Safety Association (GHSA) addresses the issue of driving while impaired, maintains up-to-date charts of alcohol- and drug-impaired driving laws and all state highway safety laws , discusses strategies for prevention of impaired driving and enforcement of laws, and sets a policy on impaired driving.

Mothers against Drunk Driving (MADD) is the nation’s largest nonprofit working to protect families from impaired driving and underage drinking. MADD also supports impaired driving victims and survivors.

NHTSA provides statistics about impaired driving, materials for campaigns against impaired driving, and case studies of effective practices to prevent impaired driving. NHTSA’s Countermeasures That Work report assists state highway safety offices in selecting science-based traffic safety countermeasures for major highway safety problem areas, including impaired driving.

The Guide to Community Preventative Services website includes resources about interventions to reduce alcohol-impaired driving.

Evidence base

Bergen G , Pitan A , Qu S , Shults RA, Chattopadhyay SK, Elder RW, Sleet DA, Coleman HL, Compton RP, Nichols JL, Clymer JM, Calvert WB, Community Preventive Services Task Force. Community Preventive Services Task Force. Publicized sobriety checkpoint programs: a community guide systematic review American Journal of Preventative Medicine 2014;46(5):529-39.

Bernat DH, Dunsmuir WTM, Wagenaar AC. Effects of lowering the legal BAC to 0.08 on single-vehicle-nighttime fatal crashes in 19 jurisdictions . Accident Analysis & Prevention 2004;36(6):1089-97.

Campostrini S, Holtzman D, McQueen DV, Boaretto E. Evaluating the effectiveness of health promotion policy: Changes in the law on drinking and driving in California . Health Promotion International 2006;21(2):130-5.

Erke A, Goldenbeld C, Vaa T. The effects of drink-driving checkpoints on crashes - A meta-analysis . Accident Analysis & Prevention 2009;41(5):914-23.

Hanson DJ. Alcohol Problems and Solutions. State University of New York; 2013.

National Highway Traffic Safety Administration (NHTSA). 2012 Motor Vehicle Crashes: Overview . Washington, DC: NHTSA, U.S. DOT. DOT HS 811 856; 2013.

National Highway Traffic Safety Administration (NHTSA). Alcohol-Impaired Driving . Washington, DC: NHTSA, U.S. DOT. DOT HS 811 870; 2013.

National Highway Traffic Safety Administration (NHTSA). The Nation’s Top Strategies to Stop Impaired Driving . Washington, DC: NHTSA, U.S. DOT. DOT HS 910 712; 2007.

Ramirez A, Lacey JH, Tippetts AS. New Mexico’s comprehensive impaired-driving program: A case study . Washington, DC: NHTSA, U.S. DOT. DOT HS 811 986; 2014.

Wagenaar AC, Maldonado-Molina MM. Effects of drivers’ license suspension policies on alcohol-related crash involvement: long-term follow-up in forty-six states . Alcoholism: Clinical and Experimental Research 2007;31(8):1399-406.

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Associations of Mental Health with Driving While Impaired and Risky Driving in Emerging Adults

1 Department of Health & Exercise Science, Colorado State University, Moby B Complex, Fort Collins, CO 80523

2 Colorado School of Public Health, Sage Hall, 700 South Mason St., Fort Collins, CO 80523

3 Yale Developmental Neurocognitive Driving Simulation Research Center (DrivSim Lab), Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Avenue, Suite 260, New Haven, Connecticut, 06519

Federico E. Vaca

Jimikaye courtney, denise l. haynie.

4 Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health & Human Development, 6710B Rockledge MSC 7000 Bethesda, MD 20892-7000

Bruce Simons-Morton

Associated data.

Examined cross-sectional associations of driving while impaired (DWI) and risky driving with mental and psychosomatic health among U.S. emerging adults.

Data were from years 1–4 after high school (waves 4–7) of the NEXT Generation Health Study, a nationally representative study starting with 10th grade (2009–2010). Outcome variables were DWI (dichotomous variable: ≥ 1 day vs. 0 days in the last 30 days) and risky driving Checkpoints Self-Reported Risky Driving Scale (C-RDS). Independent variables included depressive symptoms and psychosomatic symptoms. Multivariate logistic and linear regressions were conducted with complex survey features considered.

Higher depressive and psychosomatic symptoms were associated with modestly higher likelihood of DWI (Adjusted odds ratio [AOR] ranged from 1.02 to 1.03 and from 1.04 to 1.05, respectively) and higher C-RDS scores ( b ranged from 0.06 to 0.12 and from 0.08 to 0.23, respectively) in years 1–4 after high school.

Conclusions:

Depressive and psychosomatic symptoms were associated with greater DWI and risky driving in all 4 years after high school. Negative mental and psychosomatic health should be targeted components of DWI and risky driving prevention to lower fatal motor vehicle crashes among emerging adults.

INTRODUCTION

Motor vehicle crashes remain the predominate cause of adolescent deaths in the U.S. In 2017, 2,364 U.S. teens aged 16–19 years were killed (six every day) in motor vehicle crashes. Risky driving behaviors (e.g., speeding, tailgating, and rolling through stops) are well known contributors to crash risk and are prevalent among adolescent drivers ( Simons-Morton et al. 2013 ). Adolescent drivers are more likely to underestimate dangerous driving conditions and to participate in risky driving behaviors compared to their older counterparts ( Simons-Morton et al. 2005 ).

Driving while alcohol- or drug-impaired (DWI) represents a particularly problematic type of risky driving behavior in relation to crash risk. Among high school students, the estimated national prevalence of drinking and driving in the past 30 days ranges from 9% in 2011 to 13% in 2010–2011 ( Li et al. 2013 ). Moreover, alcohol related crashes are five-fold higher among adolescents than older drivers.

We need to identify factors that lead to risky driving and adolescent DWI to develop and implement strategies to effectively improve driving safety of adolescents. Previous studies demonstrated associations of other risky and unhealthy behaviors (e.g., tobacco use, physical fights, non-use of birth control, bullying behavior) with mental health (e.g., depression and stress) and psychosomatic health (e.g., headache, sleeping problems) ( Fekkes et al. 2004 ) among adolescents, providing clear links between the other risk behaviors and mental health. Although the relations may be similar, few studies have examined associations of mental and psychosomatic health with risky driving (e.g., excessive speed may be related to stress relief and/or reduced self-control).

What evidence there is suggests experiencing psychosomatic symptoms is associated with poorer driving performance ( Tepper et al. 2020 ). Psychosomatic symptoms are physical symptoms (e.g., headache, abdominal pain, musculoskeletal pain) related to psychosocial stressors. Psychosomatic symptoms such as chronic pain are common and the prevalence has increased among U.S. adolescents, with more high school students in the 2010s reporting symptoms compared to their counterparts in the 1980s ( Twenge 2015 ). In the National Longitudinal Study of Adolescent Health, headache was the most frequently reported psychosomatic symptom (29%), followed by other symptoms such as musculoskeletal pain (27%), fatigue (21%) and stomach aches (18%) ( Rhee et al. 2005 ). Demonstrated relations with driving performance include findings that anxious individuals were more likely to make errors (e.g., failing to check their mirrors before changing lanes) and perform aggressive violations (e.g., disregarding the speed limit) while driving ( Shahar 2009 ). However, more studies are needed to examine the associations of psychosomatic symptoms with risky driving and DWI.

More is known about the association of driving-related behaviors and depression ( Cunningham and Regan 2017 ). Depression is a substantial public health problem among U.S. adolescents with the prevalence of major depressive episodes having increased from 8.7% to 11.3% in less than 10 years (2005 to 2014) ( Mojtabai et al. 2016 ). Major depressive disorder can negatively affect driving performance and safety as a result of, “slower reaction times to critical road events among participant between the ages of 18 and 65 ( Bulmash et al. 2006 ).” A cross-sectional observational study found risky driving was associated with depressive symptoms in late adolescents and adults ( McDonald et al. 2014 ). Furthermore, major depression disorder is a well-known significant predictor of alcohol-impaired driving among male adults (aged 21–64 years) ( Pogue et al. 2017 ). However, more research is needed to characterize these relationships longitudinally and among larger and representative adolescent samples.

There are dynamic changes in trajectories of depressive symptoms and psychosomatic symptoms at different ages in adolescence ( Ellis et al. 2017 ; Nummi et al. 2017 ) which may in turn contribute to risky driving behaviors, including DWI. Therefore, there is a need to examine the associations of risky driving and DWI with mental and psychosomatic health during the transition from adolescence to emerging adulthood.

We aimed to explore cross-sectional associations of risky driving and DWI with depressive and psychosomatic symptoms among U.S. emerging adults throughout the four years after high school. Findings will inform health specialists and practitioners in pediatric mental health care for the needs of early diagnosis and treatment of mental and psychosomatic health problems to avoid or alleviate immediate and lifelong behavioral consequences among emerging adults ( Hawkins-Walsh and Van Cleve 2019 ). A broad understanding of the experience of late adolescents and emerging adults will be useful to practitioners engaged in transitioning youth with mental health conditions into adult care.

We used the data from four waves (W4-W7) of the NEXT Generation Health Study, a nationally representative cohort study, which started in the 2009–2010 school year. The sampling strategy for NEXT has been previously reported ( Li et al. 2013 ). African American participants were oversampled to provide a large enough sample (N=687) to examine racial/ethnic differences. Surveys were administered in the spring semester of each wave. A total of 2785 unique participants participated in the NEXT study. Out of the total 2785 participants, 78% (N=2177), 79% (N=2202), 84% (N=2306), and 83% (N=2323) completed the survey in W4 through W7, respectively. Parental consent or participant assent were obtained. After turning 18, participant consent was individually obtained. The study protocol was approved by the Institutional Review Board of the National Institute of Child Health and Human Development.

Dependent Variables

Driving while alcohol- or drug-impaired:.

DWI was assessed with three items asking participants how many days they drove in the past 30 days after: (1) drinking alcohol, (2) using marijuana, or (3) using illicit drugs. Due to non-normal distribution and a severe floor effect of the data, we collapsed and recoded responses across substances to derive a dichotomous variable, DWI≥1 day vs. 0 days in the past 30 days.

Checkpoints self-reported risky driving scale:

Risky driving was measured with the 21-item Checkpoints Risky Driving Scale (C-RDS) derived from previous studies ( Simons-Morton et al. 2013 ) measuring risky driving behaviors (e.g., On how many days in the last 30 days have you: “…exceeded the speed limit in residential or school zones?”; “…purposely tailgated or followed another vehicle very closely?”, etc.). The DWI related measures were excluded from the C-RDS scale in this study to avoid redundancy and collinearity. In the current assessment the internal consistency of the C-RDS was acceptable (Cronbach alpha=0.90). We dichotomized responses on each of the 21 questions (1=≥1 day vs. 0=no days) and summed the 21 dichotomous variables, with possible counts ranging from 0 to 21 and used the C-RDS as a continuous variable.

Independent Variables

Depressive symptoms:.

We measured depressive symptoms using the Pediatric Patient Reported Outcome Measurement Information System (PROMIS) depressive symptoms scale ( Pilkonis et al. 2011 ). Participants were asked how often they felt each of 8 items was true including: (1) “I felt like I couldn’t do anything right”, (2) “I felt everything in my life went wrong”, (3) “I felt unhappy”, (4) “I felt lonely”, (5) “I felt sad”, (6) “I felt alone”, (7) “I thought that my life was bad”, and (8) “ I could not stop feeling sad” over the last 7 days, using a 5-point Likert scale, with responses ranging from (1) “Never” to (5) “Almost always”. The Cronbach’s alpha of the 8 items is 0.96 for all four waves (W4–7) indicating great internal consistency. Scores on the PROMIS were converted into T-scores based on distributions of scores in the general U.S. pediatric population (mean=50, SD=10). The T-scores were used in the linear and logistic regression analyses. Those scoring 60 or above, or one standard deviation higher than the reference population mean, were categorized as having higher depressive symptoms versus the rest of the sample. The dichotomous variable was used for the sample description of depressive symptoms.

Psychosomatic symptoms:

To measure psychosomatic symptoms participants were asked how often they have had any of the following symptoms: headache, stomach-ache, back ache, feeling low, irritability or bad temper, feeling nervous, difficulties in getting to sleep, and feeling dizzy in the last half year with 5 responses ranging from (1) “Rarely or never” to (5) “About every day” ( Currie et al. 2008 ). Items were summed (range 8–40) to indicate psychosomatic symptoms as a continuous variable. The Cronbach’s alpha of the 8 items was 0.84 for all four waves (W4–7) indicating acceptable internal consistency. Those scoring in the 75 th percentile or above were categorized as having higher psychosomatic symptoms versus the rest of the sample. No clinical cut off is available for this measure. However, given that this is a nationally representative sample, it may be a reasonable that this cut off indicates a potentially problematic level of symptoms. The continuous variable was used in the linear and logistic regression analyses and the dichotomous variable was used for the sample description of psychosomatic symptoms.

Driving licensure:

Driving licensure was identified based on participants reporting if they had a license allowing independent and unsupervised driving. The analysis sample was limited to the subsample of participants who reported having an independent driver’s license.

Demographic and control variables:

Participants reported age at each wave, and sex, race/ethnicity, urbanicity, and family socioeconomic status at W1. One parent provided the highest education of both parents during the completion of the informed consent forms at W1. We estimated family socioeconomic status using the Family Affluence Scale ( Harris et al. 2009 ), with measures including number of cars owned, number of computers owned, whether the student had his or her own bedroom, and the number of family vacations in the last 12 months. We categorized students as low, moderate, or high affluence. The highest education level of both parents was categorized as: 1) Less than a high school diploma, high school diploma or GED; 2) Some college, technical school or associate’s degree, or 3) Bachelor’s or graduate degree. We coded students’ living areas as urban, suburban, or rural.

Statistical Analysis

Although the NEXT project was a longitudinal study, we conducted a series of cross-sectional analyses rather than prospective analyses because many participants were still in the process of getting their driver’s license and sample sizes were not even across waves. All statistical analyses were conducted with SAS version 9.4 (SAS Institute, Cary, NC) and accounted for the complex survey design (i.e., stratification, clustering, and sampling weights). The standard errors were calculated based on the multistage stratified design of the survey. Linear regression was used for C-RDS and binary logistic regression was used for DWI. Unadjusted and adjusted models were conducted, the latter were conducted adjusting for sex, race/ethnicity, family affluence, highest parental education level, and urbanicity. All variables have four waves of data. Missing data were deleted listwise. The analysis was limited to the subsample of subjects with a driver’s license, therefore domain analysis was applied which provides accurate computation of statistics for subpopulations in addition to the computation of statistics for the entire study population. Interactions were conducted between demographic variables and depressive and psychosomatic symptoms for both outcome variables.

The weighted mean ages of participants at W4, W5, W6 and W7 were 19.15 years (SE=0.03), 20.25 years (SE=0.02), 21.24 years (SE=0.02), and 22.61 years (SE=0.03), respectively. Table 1 includes demographics, outcome variables and independent variables for all 4 waves (W4-W7). Along with the increasing proportion of participants with a driver’s license over four waves (76% [weighted and hereafter] at W4 to 87% at W7), DWI prevalence showed an increasing trend across the four waves, with prevalence increasing from W4 to W7 (14.63% at 4 to 23.40% at W7) based on trend analysis (W4 to W7, F value=63.32, p <.001) and paired t-test between W4 and W7 (t-value=9.85, p <.001). More specifically, prevalence of alcohol-related DWI, marijuana-related DWI, and other illicit drug-related DWI was 9.42%, 10.40%, and 3.24% at W4, 11.22%, 10.16%, and 3.02% at W5, 16.32%, 10.29%, and 2.84% at W6 and 18.99%, 11.32%, and 3.59% at W7. The levels of risky driving (C-RDS) and independent variables did not show a clear trend from W4-W7. The proportions of participants whose depressive symptom T-scores for the PROMIS were greater than 60 were 24% at W4, 24% at W5, 25% at W6, and 23% at W7. The proportions of participants whose psychosomatic symptoms scores were greater than the value at 75th percentile were 30% at W4, 33% at W5, 30% at W6, and 29% at W7.

Demographics, outcome variables and independent variables for waves 4 to 7

Notes. Please see full Table 1 including additional demographic variables and Confidence Intervals in the Appendix .

DWI: Driving while impaired; C-RDS: Checkpoints Self-Reported Risky Driving Scale; Dep. Symptoms: Depressive symptoms; Psy. Symptoms: Psychosomatic symptoms.

Table 2 shows the cross-sectional associations of risky driving (indicated by C-RDS) with depressive symptoms and psychosomatic symptoms. Higher depressive symptoms and higher psychosomatic symptoms were associated with higher C-RDS scores in all four waves (beta (β); Depressive symptoms: β and p value ranged from 0.06 to 0.11 and p <.001 to p <.05; Psychosomatic symptoms: β and p value ranged from 0.08 to 0.23 and p <.001 to p <.05). Table 3 shows the results of cross-sectional associations of DWI with depressive symptoms and psychosomatic symptoms. Higher depressive symptoms were associated with greater DWI likelihood among emerging adults in all four waves (adjusted odds ratio (AOR) ranged from 1.02–1.03 and p value ranged from p <.001 to p <.05). Higher psychosomatic symptoms were related with greater likelihood of DWI among emerging adults in three of the four waves (W5, W6, and W7) (AOR ranged from 1.04 to 1.05 and p value ranged from p <.001 to p <.01).

Linear regression of C-RDS on depressive symptoms and psychosomatic symptoms

Notes. Please see full Table 2 including Confidence Intervals in the Appendix .

β = Beta.

Logistic regression of DWI on depressive symptoms and psychosomatic symptoms

Notes. Please see full Table 3 including Confidence Intervals in the Appendix .

AOR-Adjusted Odds Ratio.

Significant interactions between three demographic variables (i.e., sex, urbanicity, and parental education) and depressive and psychosomatic symptoms are presented for C-RDS ( Supplementary Table 1 ) and DWI ( Supplementary Table 2 ), respectively. Not all interaction terms are statistically significant, and the patterns of those significant interactions are different across waves for each outcome variable.

The study findings show that higher levels of depressive symptoms and psychosomatic symptoms were significantly associated with greater likelihood of risky driving and DWI among emerging adults at each of the four years after high school, with the exception of psychosomatic symptoms and DWI at W4. Although we cannot draw a causal conclusion from the results of this cross-sectional study, it is plausible that depressive and psychosomatic symptoms could play a role in DWI and risky driving behaviors during the transitional period from adolescence to early adulthood. Risky driving and DWI may be distal outcomes of depressive and psychosomatic symptoms via higher use of alcohol and substances and more social and pyschological problems among those with depressive or psychosomatic symptoms.

Although there are few studies on the association between mental and psychosomatic health and risky driving among adolescents, the findings of this study are consistent with one study indicating that major depression was significantly predictive of alcohol-impaired driving among male adults (aged 21–64 years) ( Pogue et al. 2017 ). It has been well documented that mental health disorders, especially depressive symptoms, have been shown to be highly related to clusters of unhealthy and risky behaviors (e.g., smoking, unhealthy diet, heavy drinking, and physical inactivity) ( McDonald et al. 2014 ). Also, research demonstrates that psychosomatic health can be directly or indirectly associated with risky behaviors (e.g., repeated drunkenness, high tobacco consumption, and illicit drug use) ( Choquet and Menke 1987 ) and psychiatric disorders (e.g., depression and anxiety disorders) in early adulthood ( Bohman et al. 2012 ). Although future studies on the mechanism about how mental and psychosomatic symptoms are associated with DWI and risky driving are still underway, we propose that poor mental health may undermine one’s behavioral and cognitive functions such that mental health challenges may increase susceptibility to drinking and substance use to “self-medicate or suppress” ( LaBrie et al. 2010 ) negative affect and/or lead to impaired decision-making ( Rubinsztein et al. 2006 ). The increased susceptibility among individuals with poor mental health to drinking and substance use and impaired decision-making may in turn heighten the risk of DWI and risky driving.

We examined the moderation effects of demographic variables on the associations of depressive and psychosomatic symptoms with DWI and C-RDS. However, not all paired interaction terms are significant across all waves and we failed to see consistent patterns of those significant interactions in different waves. This indicates that demographic variables (e.g., sex, urbanicity, and parental education) may influence the associations of mental and psychosomatic health on DWI and risky driving. However, the effects may be dynamic over different ages. Further studies are needed to clarify the influence of individual characteristics on the associations of mental and psychosomatic health with teen DWI and risky driving.

There are four key limitations in our study. First, we examined DWI as a dichotomous outcome due to sparse and skewed responses. In addition, we used the overall DWI with combining alcohol, marijuana and illicit drugs specific DWI due to the overlapping responses to the three types of DWI. As a result, the transition probabilities and their correlates are only for moving from no DWI to any DWI, with no indication of changes in number/times or number/types of drugs used while driving. Second, the measurement of DWI and C-RDS were based on self-reported questions, which may be influenced by participants’ temporal mood and recent experiences. Third, we conducted a series of cross-sectional analyses over time rather than a longitudinal analysis due to the inconsistent sample sizes, along with more people obtaining independent driving licenses across waves. Fourth, although we observed statistically significant associations of depressive and psychosomatic symptoms with DWI and C-RDS among this population, it is unclear whether the associations will have any clinical significance and if so, to what extent. Given that this is a nationally representative sample, its plausible to consider that the associations identified here confirm the links between depressive and psychosomatic symptoms and DWI and risky driving to some measurable extent. However, more evidence is needed to justify the clinical significance of these links.

The high prevalence of mental ( Mojtabai et al. 2016 ) and psychosomatic ( Twenge 2015 ) health problems combined with high prevalence of teen DWI ( Li et al. 2013 ) and risky driving ( Simons-Morton et al. 2005 ) in U.S. young adults indicates the importance of understanding how mental health conditions and driving inter-relate. Most mental health disorder begin during the period of early adolescence to early adulthood 12 – 24 years old. However, mental health care needs in U.S. youth are not met due to the lack of resources available to adolescents with mental health issues ( Cummings et al. 2013 ). Nurses and nurse practitioners can be the advocates and health educators for families, adolescents, schools and communities to promote and facilitate mental health assessment and early identification and diagnosis of mental health conditions as well as facilitating the successful transition from pediatric to adult care ( Hawkins-Walsh and Van Cleve 2019 ). For example, available nurses and nurse practitioners at school- and college- based health centers can provide services for identification of mental conditions as well as timely treatment for the needs of adolescents in school and communities ( Bains and Diallo 2016 ). Assuming possible causal associations, identifying as well as treating depressive symptoms and/or psychosomatic symptoms early may be effective methods for curbing DWI and risky driving among young adult drivers in the U.S. Reducing DWI and risky driving may lower the high rate of injury and fatal motor vehicle crashes among this vulnerable population.

Depressive and psychosomatic symptoms were associated with greater DWI and risky driving in all four post-high school years. Identifying and addressing poor mental and psychosomatic health should be taken into account when considering the development and implementation of DWI and risky driving prevention programs among youth.

Supplementary Material

Acknowledgments.

This research was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (contract #HHSN275201200001I), and the National Heart, Lung and Blood Institute (NHLBI), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA), with supplemental support from the National Institute on Drug Abuse (NIDA).

(Additional references are listed in the Appendix )

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Impaired driving among rural female drug-involved offenders

Affiliation.

• 1 Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky.
• PMID: 32941075
• PMCID: PMC7722978
• DOI: 10.1080/15389588.2020.1810244

Objective: Very little is known about rural female impaired drivers despite disproportionate rates of impaired driving arrests and associated traffic fatalities in rural areas. The present study examined past-year impaired driving histories and impaired driving correlates in a sample of rural female drug-involved offenders.

Methods: Female drug-involved offenders ( N = 400) from 3 rural jails completed a confidential interview focused on substance use and related risk behaviors. After removing cases with missing data ( n = 23), participants self-reporting past-year impaired driving ( n = 254) were compared to those who did not ( n = 123) on demographic characteristics, substance use, mental health, and criminal histories. Impaired drivers also reported the substances involved in their past-year impaired driving episodes.

Results: A significantly higher percentage of impaired drivers reported past-year use of 8 of the 11 substances (including alcohol) examined when compared to other drug-involved offenders. Though symptoms of major depressive and posttraumatic stress disorders were similar, significantly more impaired drivers (49.6%) reported symptoms of generalized anxiety disorder than did other drug-involved offenders (35.0%). No differences in criminal histories were found. Nearly all (94.9%) impaired drivers reported driving under the influence of drugs in the past year; less than one-fourth reported driving under the influence of alcohol. Prescription opioids were the most prevalent substance type involved in impaired driving episodes (84.6%), followed by anti-anxiety medications (40.9%). Approximately one-third of impaired drivers reported driving under the influence of methamphetamine (33.9%), marijuana (31.5%), and alcohol (30.7%) in the past year.

Conclusions: Findings indicate that rural female impaired drivers may have more extensive substance use and mental health problems than other rural female drug-involved offenders. In addition, study results suggest that a recent history of impaired driving may serve as a marker for a more extensive substance use history. Other implications include that early identification of impaired drivers in at-risk groups may be an important opportunity to prevent future traffic injuries and fatalities.

Keywords: Impaired driving; rural; substance use; women.

Publication types

• Research Support, N.I.H., Extramural
• Research Support, Non-U.S. Gov't
• Criminals / statistics & numerical data*
• Driving Under the Influence / statistics & numerical data*
• Rural Population / statistics & numerical data*
• Self Report
• Substance-Related Disorders / epidemiology*
• United States / epidemiology

Grants and funding

• R01 DA033866/DA/NIDA NIH HHS/United States

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Nij examines drug-impaired driving and the impact of emerging and undertested drugs.

The Office of Justice Programs’ National Institute of Justice published an article today detailing NIJ-funded research that studied the impact of emerging and undertested drugs on impaired driving, and compared the results to testing recommendations by the National Safety Council.

Impaired driving is often associated with alcohol, but the use of illicit drugs and abuse of prescription medications may also impair a driver’s abilities. In 2007, NSC introduced a testing standardization for impaired driving cases and traffic fatalities to improve testing consistency.

NIJ-funded researchers examined blood samples of driving under the influence of drugs cases. The goal was to create a picture of impaired driving cases and compare the results to NSC’s testing recommendations. Researchers also analyzed drug presence in blood alcohol concentrations and “stop limit testing” — when a lab doesn’t perform additional drug testing if a sample meets or exceeds a pre-determined blood alcohol threshold.

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Assessing Impaired Driving Trends Using Comprehensive Testing & a Multistate Approach

Archived live webinar, when:  this webinar originally occurred on wednesday, december 6th, 2023 from 1pm - 2pm et.  all presentations and materials have been archived for you to access as on-demand content.  , detailed learning objectives :.

• Attendees will hear the latest updates from the CFSRE regarding drug positivity in suspected impaired driving cases using a large data set from multiple states tested using a comprehensive scope.
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Can American Healthcare Be Saved From The Biden Socialists?

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This segment of What’s Ahead warns that President Joe Biden and the extreme leftists who run his administration are determined to take over healthcare through regulation. Washington won’t actually own the hospitals, clinics, pharmaceutical companies or insurance companies. It will, in effect, run them through extensive, onerous rules on pricing, labor practices, permissible procedures and allowable research. The process has been underway for years, but the Bidenites are giving it an urgent emphasis.

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