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National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Accelerating Progress to Reduce Alcohol-Impaired Driving Fatalities; Negussie Y, Geller A, Teutsch SM, editors. Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem. Washington (DC): National Academies Press (US); 2018 Jan 17.

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Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem.

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1Summary

Despite widespread public attention to distracted and drug-impaired driving in recent years, alcohol-impaired driving remains the deadliest and costliest danger on U.S. roads today. One person dies in an alcohol-impaired driving crash every 49 minutes. The causes of alcohol-impaired driving are complex and multifaceted, but these deaths are entirely preventable. This report offers a blueprint for solving the problem by identifying numerous evidence-based and promising policies, programs, and systems changes to accelerate national progress in reducing alcohol-impaired driving fatalities. The committee embraces a vision in which no alcohol-impaired driving deaths are acceptable—Vision Zero. Each alcohol-impaired driving crash represents a failure of the system—whether that is excessive alcohol service, poor road design, or lack of effective policies or enforcement—and is preventable with a coordinated, systematic approach across multiple sectors. This report offers interventions and actions to accelerate progress to reduce alcohol-impaired driving fatalities and offers concrete recommendations to galvanize stakeholder action.

The committee's recommendations include increasing alcohol excise taxes, lowering state per se laws for alcohol-impaired driving to 0.05% blood alcohol concentration (BAC), preventing illegal alcohol sales to underage persons and to already-intoxicated adults, strengthening regulation of alcohol marketing, and implementing policies to reduce the physical availability of alcohol. The report also emphasizes the need for enhanced enforcement, including sobriety checkpoints and the use of DWI courts. It describes the need for engineering solutions, such as ignition interlocks and the Driver Alcohol Detection System for Safety (DADSS). This report underscores the value of comprehensive clinical interventions such as screening, brief intervention, and referral to treatment (SBIRT), as well as effective treatment for alcohol use disorders (AUDs) with medications and other evidence-based treatments.

The report also offers conclusions about what should be done to improve important existing interventions such as administrative license suspension/revocation laws; professional education for the judiciary, law enforcement, and health professionals; limits on diversion programs and plea agreements; and universal primary seatbelt laws. The committee suggests ways to ensure that these policies will have maximum impact—for instance, that the National Conference of State Legislatures update and develop model legislation for the effective policies identified in this report to give states benchmarks for progress.

The report also provides an overview of available data and surveillance systems and gaps and offers recommendations to provide a more comprehensive understanding of the problem of alcohol-impaired driving, identify the critical intervention points, and monitor the progress of interventions.

Taken together, the committee's recommendations have the potential to reinvigorate commitment and accelerate progress to eliminate deaths from alcohol-impaired driving. Many of these strategies are not new. However, systematically implementing these policies, programs, and systems changes would renew progress and save lives. The critical need is to revive public and policy-maker attention and resolve, and the report concludes by offering a variety of strategies to turn public concern into decisive action to address this tragic and preventable problem.

Alcohol-impaired driving remains the most deadly yet entirely preventable danger on U.S. roads today.1 Alcohol-impaired driving fatalities have remained a fairly constant proportion of all traffic deaths since 2000. Each day 29 people in the United States die in an alcohol-impaired driving crash; that is one person every 49 minutes. Despite years of success, traffic deaths from all causes are on the rise in the United States for the third straight year, and crashes remain a leading killer and cause of disabling injuries. In 2016, 37,461 people died from traffic crashes, an increase of 5.6 percent from 2015. In 2016, alcohol-impaired driving fatalities accounted for 28 percent of traffic deaths—the largest percentage of all traffic fatalities—with a total of 10,497 lives lost, a 1.7 percent increase from 2015. In comparison, distracted driving accounted for 9 percent of traffic deaths, with a total of 3,450 deaths in 2016. These data create a growing sense of urgency to reverse the current trend and improve the safety of communities, decrease associated health care costs, and save lives. (See Box S-1 for key alcohol-impaired driving facts and Figure S-1 for trends in alcohol-impaired driving fatalities over time.)

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BOX S-1

Key Facts About Alcohol-Impaired Driving.

FIGURE S-1. Number of alcohol-impaired driving fatalities and percentage of all traffic fatalities in the United States, 1982–2016.

FIGURE S-1

Number of alcohol-impaired driving fatalities and percentage of all traffic fatalities in the United States, 1982–2016.

Alcohol-impaired driving is a growing public health problem that transcends the transportation, law enforcement, and clinical care systems. Despite its persistent nature, the problem is not intractable. There are many existing evidence-based and promising strategies to address alcohol-impaired driving; however, a coordinated, multilevel approach across multiple sectors will be required to accelerate change. This report presents these interventions and opportunities.

To accelerate progress to reduce alcohol-impaired driving fatalities, the National Highway Traffic Safety Administration (NHTSA) asked the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to help identify promising interventions to reduce the fatalities caused by alcohol-impaired driving in the United States to be implemented over the next 30 to 40 years (the full charge to the committee is provided in Box S-2).

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BOX S-2

Statement of Task for the Committee on Accelerating Progress to Reduce Alcohol-Impaired Driving Fatalities.

Successful past efforts to reduce alcohol-impaired driving are well recognized. In the early 1980s alcohol-impaired driving rose to the forefront of the public's attention. Attitudes toward drinking and driving shifted as groups such as Mothers Against Drunk Driving (MADD) began opening chapters across the country and sharing victims' experiences with policy makers. From the 1980s through the early 2000s alcohol-related fatalities steadily decreased as numerous new laws were passed that helped decrease alcohol-impaired driving, including laws making it illegal to purchase alcohol under the age of 21, or to drive with a BAC of 0.10% or greater. Other alcohol-impaired driving laws increased the authority of law enforcement, allowing them to conduct sobriety checkpoints and to revoke a driver's license. Fell and Voas estimated that from 1982 to 2001 these actions saved more than 300,000 lives.

Although much progress has been made as states passed and implemented policies, these heterogeneous policies lacked benchmarks and have been enforced with varying intensity. Progress has stagnated and even reversed. The plateauing fatality rates indicate that what has been done to decrease deaths from alcohol-impaired driving has been working but is no longer sufficient. Changes that call on contributions from the transportation, law enforcement, clinical care systems, and others are needed to accelerate progress and save more lives.

Conclusion 1-1: Alcohol-impaired driving is a complex preventable public health problem that requires a comprehensive and collaborative multisector approach.

ABOUT THIS REPORT

The Committee's Approach

While recognizing that alcohol-impaired driving is a crime, and enforcement and criminal justice approaches are critically important, the committee took a holistic public health approach. The committee's approach is focused on population-level strategies aimed at providing the maximum benefit at the population level. This includes understanding the problem based on available data and surveillance, identifying risk and protective factors, reviewing the evidence for interventions, implementing interventions that will likely have the largest public health impact, and monitoring progress. A public health approach allows for exploration of the complex intersections of social, cultural, political, economic, legal, and systems-level influences on health and safety. There are often inherent tensions that exist between control measures to protect the public's health and civil/personal liberties. Reducing alcohol-impaired driving injuries and fatalities is difficult to separate from the broader public health rationale for reducing excessive alcohol consumption since drinking is the precursor for alcohol-impaired driving. In particular, while recognizing that many people enjoy alcohol responsibly, the committee believes that the evidence shows that placing some limits on the alcohol environment is warranted by the public health and safety benefits of decreasing alcohol-related driving deaths.

Conceptual Framework for Preventing Alcohol-Impaired Driving Fatalities

Traditional approaches to preventive countermeasures for motor vehicle crashes are categorized as being implemented before the event, during the event, or after the event—each point represents opportunities to intervene.2 There are many upstream or causal factors that may affect alcohol use and subsequent driving, but for the purpose of this report the committee primarily covers interventions directly related to the prevention of alcohol-impaired driving fatalities. This includes precrash interventions, such as alcohol policies that affect price, the physical availability of alcohol, and alcohol consumption, as well as alternative transportation and ridesharing options that may affect whether an impaired person chooses to drive. Figure S-2 illustrates the sequence of behaviors leading to an alcohol-impaired driving fatality, the potential intervention opportunities, and the important factors that shape the outcomes.

FIGURE S-2. Preventing alcohol-impaired driving fatalities conceptual framework.

FIGURE S-2

Preventing alcohol-impaired driving fatalities conceptual framework. NOTES: Each of the phases in this figure represents an opportunity to intervene and prevent alcohol-impaired driving fatalities. A square denotes a behavior, a diamond denotes an outcome, (more...)

In each phase of the framework, the additional layer around the perimeter of the shapes (e.g., one layer around “drink to impairment,” two around “drive impaired”) signifies increased likelihood or risk of a negative outcome among the behaviors (squares) and increased severity in the outcomes (diamond shape). An individual can exit this sequence at any point; for example, a person may consume alcohol, but not to the level of impairment. Furthermore, there are individual risk factors that affect the likelihood of drinking to impairment (e.g., being a binge drinker or meeting the criteria for AUD) and driving while impaired (e.g., prior DWI, availability of a vehicle, or possession of a driver's license). In addition, driving while impaired does not always lead to a collision and an alcohol-impaired collision does not always result in an injury or fatality. These are potential outcomes of impaired driving, as indicated by the dashed lines leading up to them. The intervention opportunities interact with one another and target multiple levels (e.g., individual, interpersonal, institutional, community, and societal). The strategies, programs, policies, and systems within these intervention opportunities need to take into account the varied environmental contexts within which they will be implemented. There are several effective and important interventions that can prevent fatalities that are not reflected in the conceptual framework or this report (for example, the automobile manufacturing process and highway and road design).

Methodology

The literature on the effectiveness and applicability of interventions provides important information for assessing which interventions are most effective, cost-effective, and suitable for either a general or more specific population. Selection of interventions ought to be based on the extant literature; however, many interventions have not been adequately evaluated for general or specific effectiveness, or evaluated for effectiveness when brought to scale. In addition, comparisons of interventions are often incomplete and difficult to conduct because studies vary in dimensions such as the appropriateness of the study design and setting, outcomes measured, failure to consider other consequences, quality of execution, interactions with other interventions, and inclusion of economic consequences. With this in mind, the committee examined the available literature on alcohol-impaired driving interventions that target alcohol consumption, drinking to impairment, driving while impaired, and the postcrash and/or postarrest phase. The committee was not charged with undertaking a systematic review of the evidence, but rather to identify which interventions are most promising to prevent alcohol-impaired driving injuries and fatalities given the current state of knowledge and environment.

A Comprehensive Approach to Address Alcohol-Impaired Driving

There is no one-size-fits-all approach that will solve the problem of alcohol-impaired driving. For a problem this large and widespread a systematic population approach is needed. Therefore, the committee does not prioritize among its recommendations; while each state needs to take a comprehensive approach to addressing alcohol-impaired driving, the exact combination of interventions for particular states will vary. When identifying conclusions and recommendations, the committee focused on interventions that are evidence based, promising, and relevant in the current environment, or where improvements are needed to increase effectiveness. While many of the strategies outlined in this report are not new, systematically implementing these policies, programs, and systems changes would renew progress and save lives.

THE ROAD AHEAD

Vision Zero

NHTSA (the sponsor of this report), the Federal Motor Carrier Safety Administration, the Federal Highway Administration, and the National Safety Council launched the Road to Zero coalition in 2016 with the bold goal to end all traffic fatalities within 30 years. The Road to Zero is consistent with the goals of Vision Zero—a philosophical approach to road safety that was crafted in the 1990s and adopted in Sweden in 1997. Vision Zero, as a unifying philosophy, has expanded to other countries and can be expanded to address alcohol-impaired driving. Its principal aim is to eliminate all serious road traffic injuries and fatalities. This innovative approach transformed the traditional approach of transportation design in which the roadbuilders simply expected road users to use the road as designed. Vision Zero was a drastic change in approach and places the responsibility for traffic safety problems on the infrastructure system designers instead of only on the drivers. The framework centers on the idea that the design and structure of roads and cars should account and accommodate for individual mistakes and choices. Each alcohol-impaired fatality represents a system failure. This approach brings in new stakeholders and creates innovative partnerships where everyone has a role and an opportunity to contribute to the shared goals.

Achieving Vision Zero in the United States

Although still in its infancy in the United States, the Vision Zero concept continues to expand as it has been adopted by over two dozen American cities. However, there are many other variations of Vision Zero that exist in the United States (for example, the Vision Zero Network, Toward Zero Deaths, and Vision Zero Task Force). The Vision Zero philosophy is spreading across the country but in a disjointed and fragmented fashion, rather than as a coordinated approach.

Implementing Vision Zero as a U.S. policy to reduce alcohol-impaired driving injuries and fatalities would be a bold step, but it is important that partners beyond the transportation and transportation system design sector recognize that traffic safety deaths are preventable and acknowledge the need for a spectrum of partners to join efforts to implement systems change to address this public health crisis. These partners include government agencies, car manufacturers, auto insurers, advocacy organizations, state and local public health agencies, technology companies, health care systems, clinicians, employers, alcohol retailers, wholesale distributors, alcohol producers, the hospitality industry, and law enforcement. Importantly, the public itself can also directly participate in preventing alcohol-impaired driving through participation in Vision Zero.

Bold goals are important and can be used to galvanize action, change social norms, and bring stakeholders together around a common vision and goal. The committee recognizes that in an economic sense, eliminating all roadway fatalities would require investments that have diminishing returns and that there are important alternate uses of those resources; however, Vision Zero is not primarily an economic goal. It is about establishing an aspirational goal that can rally stakeholders, provide focus, and make substantial progress toward achieving that goal.

Key Terms

Box S-3 highlights key terms related to impairment used throughout the report. For the purpose of this report the term alcohol-impaired driving will be used, as will DWI (instead of DUI or similar). See the report glossary for definitions of other terms in this report. Discussion of what it means to be alcohol impaired follows.

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BOX S-3

Key Impairment Terms from the Glossary.

What Is Alcohol Impairment?

The current legal definition of alcohol impairment in all 50 states is a BAC of 0.08% or higher.3 Although this is the limit set by state law, impairment begins at lower levels; even small amounts of alcohol affect the brain. Biologically, alcohol impairment occurs before reaching a BAC of 0.08%, and impairment affects driving-related skills and behaviors. The effects of alcohol include psychomotor impairment, decreased inhibition, diminished alertness and sleepiness, confusion and problems with concentration, reduced visual focus, and slurred speech. Driving requires several complex skills, and alcohol affects the capacity to drive safely by impairing information processing and reaction time and compromising judgment and coordination.

Understanding Impairment

It can be difficult for individuals to understand what it means to be impaired. Individuals differ in their degree of impairment at a given BAC. Several individual-level factors affect alcohol's physiological influence, including weight, age, sex, race, and ability to metabolize alcohol. In addition, alcohol content varies across beverage types and serving sizes differ among environments. Therefore a “drink” commonly contains more (or less) than 14 grams of pure alcohol. Alcoholic beverages themselves have changed significantly in the past 25 years. They are more affordable, of far greater variety, and more widely advertised and promoted than in earlier periods. In addition, inconsistent serving sizes and the combination of alcohol with caffeine and energy drinks, among other factors, undermine individuals' ability to estimate their level of impairment.

THE CURRENT ENVIRONMENT

It is important to understand the context in which alcohol-related fatalities occur, as noted in the committee's conceptual framework. There are two contexts that are especially salient and worth examining: the alcohol environment (e.g., social and cultural drinking norms, availability, pricing, and regulation) and the driving environment (e.g., road safety infrastructure, public transportation, and driving patterns). Especially noteworthy is the proximal relationship between binge drinking and alcohol-impaired driving.4 There is a substantial body of evidence that indicates that binge drinking is strongly associated with alcohol-impaired driving.

Conclusion 2-2: Policies to reduce binge drinking are also protective against alcohol-impaired driving, and the adoption of a comprehensive set of effective interventions and population-based strategies that take advantage of synergies across interventions would further help to reduce binge drinking and related harms.

The lack of a comprehensive population-based strategy may partly explain why the proportion of crash fatalities that are alcohol related has not declined in the last decade and has begun to increase.

ALCOHOL-IMPAIRED DRIVING INTERVENTIONS

The committee provides a suite of recommendations that when implemented together have the potential to save lives. Below and in the report, the recommendations are organized by the first four phases in the conceptual framework (alcohol consumption, drinking to impairment, driving while impaired, and postarrest and/or postcrash); they are then followed by recommendations on data and surveillance systems and for generating action. Because rural areas are disproportionately affected by alcohol-impaired driving crashes and fatalities, the report notes opportunities for this population throughout.

Interventions to Reduce Drinking to Impairment

Most interventions to reduce alcohol-impaired driving have focused on decreasing the likelihood that someone will drive after they are already impaired by alcohol. Conversely, less policy attention has been focused on reducing drinking to impairment before driving. However, there are a number of effective interventions to reduce drinking to the point of impairment (i.e., binge drinking), and some of these interventions have an independent effect on reducing impaired driving and alcohol-impaired crashes. 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.

Raising Alcohol Taxes

Alcohol taxes have perhaps the strongest and most consistent evidence base of any U.S. policy for reducing binge drinking, and strong direct evidence shows that higher alcohol taxes reduce alcohol-impaired driving and motor vehicle crash fatalities. For example, there is research suggesting that a doubling of alcohol taxes would lead to an 11 percent reduction in traffic crash deaths. Another study indicates that a 10 percent increase in alcohol price is associated with a 6 percent reduction in consumption. Despite this evidence, alcohol taxes have declined in inflation-adjusted terms at both federal and state levels. At present, alcohol taxes are considerably less than alcohol-related costs (such as health care, lost productivity, or criminal justice costs). Current federal plus state taxes do not cover alcohol-related costs, which are approximately $2.00 per U.S. standard drink. Among states, the average excise tax is only $0.03 per standard drink of beer, $0.03 per standard drink of wine, and $0.05 per standard drink of distilled spirits. Federal taxes are currently $0.05 for a standard drink of beer, $0.04 for a standard drink of wine, and $0.13 for a standard drink of distilled spirits. Given the efficacy of increased prices and taxes for reducing binge drinking and alcohol-related motor vehicle crash fatalities in particular, 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 to have a meaningful impact on price and therefore on reducing alcohol-related crash fatalities. The increases should comprise a meaningful percent of the net-of-tax price (e.g., 30 percent or more) of alcohol products, and cover the marginal, external (i.e., secondhand) costs incurred by the sale of alcohol. Specific excise taxes may be preferred because it is the volume of ethanol that leads to impaired driving. However, volume-based excise taxes erode with inflation and therefore should be indexed to inflation. Ideally, taxes should be based on ethanol content rather than beverage type. Taxes can be earmarked to support alcohol-related activities (e.g., funding sobriety checkpoints or alcohol prevention and treatment programs), which may enhance public support.

Policies to Address Physical Availability of Alcohol

Addressing the physical availability of alcohol has strong evidence for reducing excessive drinking and related harms. Among these alcohol-related harms are alcohol-impaired driving and crashes, which have a strong link to excessive consumption.

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 could consider reducing or eliminating alcohol sales concurrent with driving, such as sales at drive-through retailers or gas stations, as a common sense measure.

Policies to Reduce Illegal Sales of Alcohol and Strengthen Enforcement

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 beyond the laws currently in place.5

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).

This includes having strong penalties for licensed retailers or purveyors who engage in illegal alcohol sales to already-intoxicated adults; having dram shop liability laws without caps;6 high-quality, mandatory training in responsible beverage service for managers and sellers; having strong social host laws and other laws to limit adults from providing alcohol to underage persons; improving enforcement of minimum legal drinking age laws including passing laws to permit compliance checks using underage decoys and conducting those compliance checks; collection of data regarding place of last drink; and adequate enforcement personnel to enforce existing laws in this area.

Alcohol Advertising and Marketing

Given that young people are at higher risk of alcohol-impaired driving, that the evidence is substantial that they are influenced by alcohol marketing, and that numerous studies have found the alcohol industry's self-regulation of its marketing ineffective and insufficient because the voluntary standards are permissive and vague, not consistently followed, and without penalties for violations, 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.

Mass Media Campaigns

There is strong evidence based on findings from a variety of high-quality systematic reviews, across numerous health behavior domains, that large-scale media campaigns can promote meaningful changes in health behavior at the population level when implemented alongside broader, community-level interventions. The evidence is strongest for campaigns implemented alongside other community initiatives such as increased enforcement or community mobilization.

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.

Interventions to Reduce Driving While Impaired

There are several intervention opportunities for reducing alcohol-impaired driving, including changes in policies, laws, and enforcement; technological advances and vehicle features that could offer protections to drivers, occupants, and others; and programs or policies that could impact the sociocultural environment.

BAC Laws

BAC laws have been, and continue to be, a key intervention for reducing alcohol-impaired driving and reducing injuries and fatalities. Currently, in each state in the United States, drivers 21 years of age and older are prohibited from driving with a BAC greater than or equal to 0.08% (younger drivers have lower BAC requirements), which is the limit proscribed in state per se laws for alcohol-impaired drivers.7 In December 2018, however, Utah will be the first state to lower the BAC per se law to 0.05%. Based on the available evidence from laboratory and epidemiological studies, the committee concludes that an individual's ability to operate a motor vehicle (including a motorcycle) begins to deteriorate at BAC levels well below 0.05%, increasing a driver's risk of being in a crash. Data from countries that have decreased their legal BAC to 0.05% suggest that this is an effective policy for reducing alcohol-impaired driving injuries and fatalities. The benefits of lowering BAC are on a continuum, but they are enhanced when introduced alongside high-visibility enforcement, sobriety checkpoints, and publicity. The committee concludes that reducing the BAC law to 0.05% is an effective strategy and has the greatest potential impact on those at the highest risk of alcohol-impaired traffic fatalities.

Recommendation 4-1: State governments should enact per se laws for alcohol-impaired driving at 0.05% blood alcohol concentration (BAC). The federal government should incentivize this change, and other stakeholders should assist in this process. The enactment of 0.05% per se laws should be accompanied by media campaigns and robust and visible enforcement efforts.

The effectiveness of this policy will be enabled by legislation that currently applies to 0.08% per se laws, including, but not limited to, use of sobriety checkpoints, administrative license revocation, and penalties for refusing preliminary breath tests or blood tests that are equal to or greater than penalties for alcohol-impaired driving offenses. This means that the same laws and sanctions that currently apply to 0.08% per se laws could remain in place but enforceable at the 0.05% BAC limit. Effectiveness will also be enhanced by efforts to publicize 0.05% per se laws through mass media campaigns, by strong and sustained enforcement efforts, and through the implementation and enforcement of laws and policies to prevent illegal alcohol sales to underage or intoxicated persons (e.g., underage compliance checks with alcohol licensees and dram shop liability laws).

Sobriety Checkpoints

Sobriety checkpoints are a high-visibility enforcement strategy that aims to identify and arrest alcohol-impaired drivers as well as increase the perceived risk of arrest to deter alcohol-impaired driving. There is strong evidence supporting the effectiveness of publicized sobriety checkpoint programs to reduce alcohol-impaired driving fatalities in both urban and rural areas. The ideal frequency of sobriety checkpoints needs further research. Low-staff checkpoints have been shown to be effective and are useful in rural areas, when resources for full-scale checkpoints are not available, and other circumstances.

Recommendation 4-2: States and localities should conduct frequent sobriety checkpoints in conjunction with widespread publicity to promote awareness of these enforcement initiatives.

Driver Alcohol Detection System for Safety

The DADSS program is a cooperative research partnership between NHTSA and the Automotive Coalition for Traffic Safety to develop noninvasive, in-vehicle technology that prevents drivers from operating vehicles when their BAC exceeds the limit set by state law. Given strong public support and endorsement from various sectors, as well as having significant potential impact for reducing alcohol-impaired driving fatalities, and to leverage advancements in technology for primary prevention of alcohol-impaired driving fatalities, the committee recommends:

Recommendation 4-3: When the Driver Alcohol Detection System for Safety (DADSS) is accurate and available for public use, auto insurers should provide policy discounts to stimulate the adoption of DADSS. Once the cost is on par with other existing automobile safety features and the technology is demonstrated to be accurate and effective, the National Highway Traffic Safety Administration should make DADSS mandatory in all new vehicles.

Alternative Transportation

Alternative transportation includes smartphone-enabled ridesharing, safe ride programs, and public transportation. These services provide intoxicated people with additional ways to avoid driving while impaired. Although the evidence is mixed or emerging for the various alternative transportation options, it is an area with great promise to reduce alcohol-impaired driving fatalities.

Recommendation 4-4: Municipalities should support policies and programs that increase the availability, convenience, affordability, and safety of transportation alternatives for drinkers who might otherwise drive. This includes permitting transportation network company ridesharing, enhancing public transportation options (especially during nighttime and weekend hours), and boosting or incentivizing transportation alternatives in rural areas.

Postarrest and Postcrash Interventions

While the two previous sets of recommendations are aimed at influencing behaviors such as drinking to impairment and driving while impaired, the following recommendations focus on reducing the potential negative outcomes of these behaviors: motor vehicle crashes and serious injuries and fatalities. There were more than 1 million arrests for driving under the influence in 2015. About 20 to 28 percent of first-time DWI offenders will repeat the offense, and recidivists are 62 percent more likely to be involved in a fatal crash.

Treatment Related to the Alcohol-Impaired Driving Adjudication Process

DWI courts are specialized courts aimed at changing DWI offenders' behavior through comprehensive monitoring and substance abuse treatment. As a part of the DWI control system, these postconviction courts are a systematic mechanism for holding offenders accountable for their actions while treating the underlying causes of their impaired driving. To ensure effective oversight for high-rate recidivists and/or high BAC offenders, the committee recommends:

Recommendation 5-1: Every state should implement DWI courts, guided by the evidence-based standards set by the National Center for DWI Courts, and all DWI courts should include available consultation or referral for evaluation by an addiction-trained clinician.

An arrest for DWI or admission to the hospital for an alcohol-impaired driving injury represents an opportunity to screen and treat individuals who engage in hazardous drinking. The offender should be evaluated by a clinician with addiction training and, if medically indicated, placed in a program that includes relapse prevention medication and requires an extended period of attendance in cognitive behavioral therapy.

Recommendation 5-2: All health care systems and health insurers should cover and facilitate effective evaluation, prevention, and treatment strategies for binge drinking and alcohol use disorders including screening, brief intervention, and referral to treatment (SBIRT), cognitive behavioral therapy, and medication-assisted therapy.

Ignition Interlock Devices

Strong evidence from the United States and other countries shows that individuals convicted of alcohol-impaired driving who have an ignition interlock installed on their vehicles are less likely than others to be rearrested for alcohol-impaired driving or to crash while the device is installed. This technology is affordable for many individuals, and it is made affordable for others through funds for low-income offenders. States that have introduced all-offender ignition interlock laws appear to have experienced reductions in alcohol-related motor vehicle crash deaths.

Recommendation 5-3: All states should enact all-offender ignition interlock laws to reduce alcohol-impaired driving fatalities. An ignition interlock should be required for all offenders with a blood alcohol concentration (BAC) above the limit set by state law. To increase effectiveness, states should consider increased monitoring periods based on the offender's BAC or past recidivism.

Evidence shows that a minimum monitoring period for interlock devices of 2 years is effective for a first offense, and 4 years is effective for a second offense.

Other promising interventions in the postcrash or postarrest phase include limits on diversion programs and plea agreements; education of professionals in law enforcement to improve identification of alcohol-impaired individuals; training for prosecutors and for judges on what constitutes impairment and the proper protocols for screening for AUD; more widely and systematically used administrative license suspension or revocation laws; systems alcohol monitoring programs; and a coordinated and continuous learning trauma care system.

Data and Surveillance Needs and Opportunities

There are a variety of datasets and surveillance systems that provide information on alcohol-impaired driving in the United States. These data systems each have their respective strengths and limitations, but examining them together allows a picture of the state of alcohol-impaired driving in the United States to emerge. Having a comprehensive understanding of alcohol-impaired driving, both in regard to the rates of occurrence, traffic crashes, injuries, fatalities, arrests, and convictions as well as qualitative data on when and why people drive impaired, is vital to create specific and targeted interventions. There are data gaps (such as lack of data on place of last drink), methodological issues (such as inconsistent data collection), and a lack of integration of datasets (e.g., how many people are arrested, outcomes of arrest, and long-term outcomes in terms of recidivism).

Conclusion 6-1: Data collection and reporting of high-risk intersections, outlets, drinking behaviors before driving, risk factors, and demographic trends are needed to measure, evaluate, and accelerate progress in reducing risk of fatalities. This evaluation would be facilitated by regular, systematic data collection on geocoded crash locations linked to data systems that monitor injury and fatality information, as well as criminal justice outcomes.

Recommendation 6-1: The National Highway Traffic Safety Administration should ensure that timely standardized data on alcohol-impaired driving, crashes, serious injuries, and fatalities are collected and accessible for evaluation, research, and strategic public dissemination; ensure that data from other government agencies and private organizations are included as needed; and explore the usefulness of big data for inclusion in alcohol-impaired driving information strategies.

Reducing alcohol-impaired driving requires diligent and accurate collection of surveillance data. Examples of improvements necessary for advancing the science include standardized data definitions, harmonization of reported data, and increased capacity for data linkages.

Recommendation 6-2: To facilitate surveillance of alcohol-impaired driving that is timely, ongoing, concise, and actionable, the National Highway Traffic Safety Administration should convene a diverse group of stakeholders that includes academic researchers, law enforcement, city and state public health, transportation sector, and other federal agency representation to create and maintain a metrics dashboard, and publish brief, visually appealing quarterly and annual national and state-by-state reports that analyze and interpret progress in reducing alcohol-impaired driving.

This recommendation entails identifying the data elements and data sources that are needed to monitor changes in rates of alcohol-impaired driving risk factors (including place of last drink), arrests, crashes, injuries, and fatalities, as well as data elements needed to inform quarterly metrics and reports designed to effectively communicate such findings to the public, various public and private stakeholders, and local, state, and national policy makers. In addition, this recommendation involves ensuring that data for research on the effectiveness of interventions to reduce alcohol-impaired driving are accessible and available using techniques that reflect contemporary standards for data acquisition and downloading. The dashboard, a user-friendly interface, should contain analyzed data, including longitudinal data linking crash data with licensing data, hospital data that include costs for care, arrest data, and the results of arrest. To be most effective, and to raise awareness of alcohol-impaired driving, the data should be strategically released to inculcate action.

GENERATING ACTION

To initiate and sustain action that will bolster progress to reduce alcohol-impaired driving fatalities, a strategic and comprehensive effort needs to be put forth nationwide. Such an effort requires the engagement of stakeholders across multiple sectors such as transportation, law enforcement, public health, the private sector, and philanthropy. Table S-1 summarizes the stakeholders who are needed to ensure implementation of the evidence-based and promising tools discussed throughout this report. Furthermore, initiating sustainable action will require garnering public will to address alcohol-impaired driving and allocating the resources needed to do so by creating and sustaining public discourse to underscore the magnitude of the problem and strategies to move these efforts forward. Chapter 7 highlights the key elements, approaches, innovations, and partnerships that could generate such action and overcome barriers.

TABLE S-1. Tools and Stakeholders to Accelerate Progress to Reduce Alcohol-Impaired Driving Fatalities.

TABLE S-1

Tools and Stakeholders to Accelerate Progress to Reduce Alcohol-Impaired Driving Fatalities.

The Role of Social Movements

The report examines the history of the alcohol-impaired driving social movement that took place in the 1980s, including the groundbreaking work of MADD. For an organization or movement to lift up the cause of alcohol-impaired driving as a social issue, it will likely need to be able to capture media attention. The role of funding from NHTSA in getting MADD off the ground, and the lessons it has for the ability of well-aimed seed funding to “sprout” results, provides a successful example of funding community-level demonstration projects to identify innovative solutions and tactics. Based on extensive evidence and experience in the use of community coalitions both in the alcohol field and in other areas of public health, the committee recommends:

Recommendation 7-3: The National Highway Traffic Safety Administration, other federal partners, and private funding sources free of conflicts of interest should support training, technical assistance, and demonstration projects in the implementation of effective strategies, including policy changes, for reducing alcohol-impaired driving.

Interagency Coordination

To ensure a comprehensive approach, input and collaboration from multiple sectors are needed. Specifically, coordination and cooperation across federal agencies will be an important element in making the best use of limited resources.

Recommendation 7-2: The National Highway Traffic Safety Administration should create a federal interagency coordinating committee to develop and oversee an integrated strategy for reducing alcohol-impaired driving, ensure collaboration, maintain accountability, and share information among organizations committed to reducing alcohol-impaired driving.

The coordinating body could include the U.S. Department of Health and Human Services (Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration, Indian Health Service, the National Institutes of Health), the Alcohol and Tobacco Tax and Trade Bureau, the U.S. Department of Transportation (National Highway Traffic Safety Administration, Federal Highway Administration), U.S. Homeland Security (emergency services sector), U.S. Department of Justice, U.S. Department of Defense, and U.S. Department of Veterans Affairs. The interagency group could convene other stakeholders such as private philanthropy, schools, hospitals, public health, health care, hospitality and the restaurant industry, payers, medical insurers, and trial lawyers to further maintain accountability and share information. At a minimum, such an approach would combine one or more coordinating centers providing training, technical assistance, and ongoing coaching with demonstration project sites in a diverse array of states and settings.

The Role of Alcohol Industry

Alcohol companies have taken on an active role in traffic safety and alcohol-impaired driving. However, they generally promote ineffective or non-evidence-based policies, and generally oppose effective population-based strategies to reduce binge drinking and impaired driving.

Conclusion 7-2: Alcohol companies and alcohol-related businesses could assist efforts to reduce alcohol-impaired driving fatalities by reducing the alcohol content of existing products, refraining from marketing including sponsorships that are likely to influence excessive alcohol use, and supporting or at least not opposing effective alcohol-impaired driving countermeasures.

Actions by the alcohol industry to support efforts to reduce alcohol-impaired driving could also include, at a minimum, adhering to and strengthening self-regulatory standards, sharing needed data on alcohol sales and consumption, and subjecting industry activities to reduce harmful use of alcohol to rigorous independent evaluations, free of conflicts of interest (i.e., employing evaluation design methods as robust as those of public health interventions).

Model Legislation

States implement different alcohol-impaired driving laws and policies, and when the same policies are in place in multiple states, there is considerable variation in how they are implemented. Given the lack of progress over the last decade in reducing alcohol-impaired fatalities, a more uniform approach is needed to move toward best practices. While each state could design and implement the policies and laws that are tailored to its respective population, benchmarks for the states could provide guidance on which evidence-based strategies to adopt.

Recommendation 7-1: The National Conference of State Legislatures should draft model legislation to provide benchmarks for states that seek to reduce alcohol-impaired driving fatalities.

This recommendation is intended to improve uniformity across states and move toward best practices—it is not meant to be a coercive measure. The model legislation would also inform community coalitions and policy makers who do not have technical expertise in this area on the composition of various legal actions. A good starting point would be for the National Conference of State Legislatures to develop model legislation on lowering the BAC limit to 0.05% (see Recommendation 4-1).

ACHIEVING ZERO DEATHS

To achieve zero alcohol-impaired driving fatalities—where every alcohol-impaired driving death could be thought of as a failure of the system—a systematic, multipronged approach with clear roles and accountabilities across sectors (including public health, transportation, law enforcement, and clinical care) is needed. Victims are dying each day, and fatality rates are rising—substantial progress has been made in the past, and that progress needs to be jump-started again. Applying a Vision Zero approach where every stakeholder has an opportunity and responsibility to take action and hold others accountable will help sustain solutions for alcohol-impaired driving. This report lays out a comprehensive set of evidence-based and promising interventions and system improvements (see Table S-1) to eliminate these preventable deaths.

Footnotes

1

All references and sources can be found in the report chapters.

2

One such approach is the use of the Haddon Matrix, which is commonly used in the injury field and looks at human, environmental, and vehicle factors before, during, and after a crash. The Haddon Matrix paradigm provides an important organization to the many inputs to address alcohol-impaired driving crashes, and the committee's conceptual framework grows from that approach.

3

Utah recently passed legislation to lower the BAC law to 0.05% beginning in December 2018.

4

Binge drinking refers to drinking at or above levels during a drinking occasion/episode that typically results in impairment-level BAC (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 epidemiological studies use five/four thresholds, and members of the general public often interpret the term binge drinking to mean drinking to the point of impairment or intoxication.

5

Underage persons are defined as individuals who are under 21 years old, the minimum legal age to purchase and possess alcohol in the United States.

6

Dram shops are commercial establishments where alcoholic beverages are sold.

7

A per se law means that the act in question is illegal in and of itself.

Copyright 2018 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK500047

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