Reducing alcoholrelated traffic injury

1
Reducing alcohol-related traffic injury

• A brief review of the options
• Dr Jennie Connor
• Epidemiologist and Public Health Physician
• Department of Preventive and Social Medicine
• Otago Medical School

2
Evidence-based best practice
drinking choosing to drive

• Minimum legal purchase age ?
• Govt. monopoly on retail sales
• Hours and days of sale ?
• Outlet density ?
• Alcohol taxation ?
• Enforcement ?
• Brief interventions for hazardous drinkers

• Graduated licensing (GDLS)
• Random testing (RBT)
• Legal BAC limit ?
• Lower BAC limit for young drivers
• Automatic licence suspension
• Automatic impounding
• Alcohol interlocks

Babor et al. Alcohol no ordinary commodity, OUP
2003
3
Evidence-based best practice
drinking choosing to drive

• Minimum legal purchase age ?
• Govt. monopoly on retail sales
• Hours and days of sale ?
• Outlet density ?
• Alcohol taxation ?
• Enforcement ?
• Brief interventions for hazardous drinkers

• Graduated licensing (GDLS)
• Random testing (RBT)
• Legal BAC limit ?
• Lower BAC limit for young drivers
• Automatic licence suspension
• Automatic impounding
• Alcohol interlocks

Babor et al. Alcohol no ordinary commodity, OUP
2003
4
Effect of purchase age on traffic injury
Studies of alcohol-related crashes in the
affected age group (18-21 years)
Shults et al. Am J Prev Med 2001 21(4S)
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New Zealand

• Purchase age lowered from 20 to 18 in 1999
• IPRU evaluation of impact on alcohol-related
  traffic crashes amongst
• target group (18-19)
• trickle-down group (15-17)
• Change in each group compared to the change in
  20-24 year olds (unaffected by new law)
• Men 12 increase for 18-19 year olds
• 14 increase for 15-17 year olds
• Women 51 increase for 18-19 year olds
• 24 increase for 15-17 year olds

Kypri et al. Am J Public Health, 200696126-31
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Reducing the legal BAC limit

• Drivers over 20, now 80mg/100ml (0.08)
• Drivers under 20, now 30 mg/100ml (0.03)
• Countries with 0.08 UK, USA, Canada, New Zealand
• Countries with 0.05 Australia, Austria, Belgium,
  Bulgaria, Croatia, Denmark, Finland, France,
  Germany, Greece, Israel, Italy, the
  Netherlands, Portugal, South Africa, Spain,
  Turkey.
• Countries with 0.03 Poland
• Countries with 0.02 Norway, Russia, Sweden
• Countries with zero Czech Republic, Hungary,
  Japan, Malaysia, Romania, Saudi Arabia, Turkey
• BAC limit in many of these countries was 0.10
  (100mg/100ml)

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Adverse effects of low levels of alcohol on
driving skills (lt0.05)

• Vision eye movement and focus (tracking),
  fixation (lack of scanning), acuity, impaired
  binocular vision (judging distance), slow
  recovery from glare, poorer vision in low light,
  reduced peripheral vision
• Vigilance reduced vigilance and sedative effect,
  interaction with sleepiness (time of day and
  sleep deprivation)
• Psychomotor skills steering and braking impaired
• Information processing slowed response time,
  slowed decision-making
• Divided attention tasks performance impaired
  even at lt0.01
• Driving simulator lane deviation, speed
  variation, exceeding speed limit
• ? strong evidence that impairment of some
  driving-related skills begins with any departure
  from zero BAC

Moskowitz and Fiorentino, NHTSA 2000
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Studies of car crash risk at different levels of
BAC

• Many studies since early 60s, all have
  limitations, but patterns are the same.
• Risk increases exponentially with increasing BAC
• Risk is higher and increases faster in young and
  inexperienced drivers
• Improvements in alcohol measurement and research
  design has demonstrated substantial risk at lower
  levels of BAC than were previously thought
  important

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Auckland Car Crash Injury Study
Risk of a serious injury crash by blood alcohol
concentration, all ages
Adjusted for age, sex, time of day, seatbelt use,
sleepiness, educational level
Proportion of all injury crashes attributable to
alcohol, by BAC
Connor et al. Epidemiology, 200415337-44
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Chamberlain and Solomon, Injury
Prevention.200281-17
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Increase in fatal car crash injury risk
associated with alcohol NZ data
Keall et al, 2003
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Risk of death in night-time crash
with one passenger
Keall et al, 2003
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Risk of death in night-time crash
with one passenger
Keall et al, 2003
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The impact of lowering BAC limit
Evidence that big benefits resulted from 0.10 ?
0.08

• 1. Impact on traffic safety
• Belgium (1994)
• traffic fatalities ? 10 in 1995, another 11 in
  1996
• Haute-Savoie, France (1996)
• Alcohol-related fatal crashes ? 35
• Austria (1998)
• alcohol-related crashes ?9, but effect of low
  limit, enforcement and publicity combined
• Queensland, Australia (1982)
• fatal crashes ? 18, serious collisions ? 14,
  without RBT
• ACT, Australia (1990)
• RBT drivers 0.15 0.2 ? 34, above 0.2 ? 58
• Sweden (0.05?0.02 in 1990)
• fatal crashes ? 10, injury crashes ? 12
• proportion of drink-drivers with BAC gt0.15 ?

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The impact of lowering BAC limit

• Diverse contexts (legislation, enforcement,
  drinking culture) but traffic safety impacts are
  similar
• Predicted reduction of 6-18 in total crash
  fatalities for Canada (Mann,1998)
• 2. Impact on public attitudes and behaviour
• Affects the BAC distribution of drinking drivers
  (Germany)
• Encourages drivers to keep a better count of
  drinks
• Increases proportion of abstaining drivers and
  drivers having only 1 drink (Denmark)
• More aware of the need to control drinking. Large
  majority feel it is wrong to break the limit
  (Australia)

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Youth BAC limits in the US

• The US drinking age is 21 (since 1988)
• Zero tolerance for alcohol in drivers under 21
  (since 1995)
• In practice 0.0 0.02
• Large drop in single vehicle night time crashes
  in some states with higher enforcement and
  publicity but smaller in others (none in Texas)
  (Lacey 2000)
• Average decline in single vehicle night-time
  crashes in youth of 16 in 12 states who lowered
  youth limits compared with 1 increase in 12
  states that didnt. Adult crashes declined 5
  compared with 6 (Hingson 1994)
• Systematic review reduction in injuries and
  fatalities, particularly SVN (Zwerling 1999)
• 15 years of US data ? alcohol positive drivers
  under 21 in fatal crashes ?24 since zero
  tolerance laws (Voas 2003)

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Opposition to lowering the limit

• There is a lack of consensus amongst experts
• Out of date
• Little benefit or Little evidence of benefit
• Out of date
• Benefit is due to other concurrent policies
• Partly true, multiple interventions are superior
• Queensland study suggests important independent
  effect benefit found in diversity of contexts
• 0.05 BAC limit interferes with moderate social
  drinking
• Industry argument
• No major effect on hospitality industry elsewhere
• 0.05 is not a trivial amount of alcohol
  consumption
• Some parallels with smoking ban in pubs

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Opposition to lowering the limit

• 0.05 BAC limit will decrease public support for
  the law
• 53 of New Zealanders supported the lower limit
  (2003)
• 61 supported a youth limit of zero (LTSA)
• It targets the wrong group
• It is not being suggested that this is the only
  strategy used
• Substantial proportion (approx 38) of
  alcohol-attributable crashes are due to drivers
  with BAC lt150mg (not such high risk but more of
  them)
• High BAC drink-drivers are a mix of hard-core
  recidivist heavy drinkers and binge drinkers
• Evidence suggests lower BAC limits do deter high
  BAC drivers to some extent

Connor et al. Epidemiology, 200415337-44
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Lowering BAC limit summary

• Good evidence of effectiveness in reducing injury
• Exact size of impact hard to predict
• Enhanced by publicity and enforcement
• Good public support
• Will contribute to changing drinking culture
• Consistent with youth limit of zero

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Young drivers

• High risk of crashes without alcohol
• Multiplied by the effects of alcohol
• Options -
• GDLS plus zero limit
• and
• Reduce exposure to alcohol
• - raising legal purchase age
• Reduce exposure to risk
• - raising driving age
• - compulsory third party property insurance

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High BAC drink-drivers

• Population-based measures do reduce BACs of
  hard-core drink drivers
• Mandatory treatment for repeat drink-drivers
  (high cost)
• Brief interventions for first time high BAC
  drivers, and those injured
• Alcohol interlocks for repeat drink-drivers and
  drink-drivers with very high BACs

22
Alcohol Ignition Interlocks

• Breath-testing device connected to ignition
  system of vehicle fuel cell technology
• Fitting ordered by the courts, or offered as
  alternative
• Used in US, Canada, Australia (SA,QLD,VIC,NSW),
  Europe (France, Netherlands, Sweden)
• Programmable, can record attempts to start car,
  can require running retests, can invoke lockout
  period

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Impact of interlocks

• Reductions in recidivism of 45-90
• both first offenders and repeaters
• Recidivism returns when device removed
• interlocks do not change behaviour alone
• Less expensive than prison, more effective than
  licence suspension
• Keeps offender in community, employment,
  treatment

Traffic Injury Research Foundation, Ottawa, 2007
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Summary of strategies

• Raise minimum purchase age to 20
• Increase alcohol price through taxation
• Slow/reverse the increase in outlets and hours of
  sale
• Lower BAC limits to 50 and zero
• Increase enforcement
• Traffic-specific
• Supply of alcohol
• Increase driving age
• Make insurance compulsory
• Develop alternative transport options
• Increase interventions for high BAC drivers