Getting to Zero Alcohol-Impaired Driving Fatalities A Comprehensive Approach to a Persistent Problem (2018) / Chapter Skim
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3 Interventions to Reduce Drinking to Impairment
3 Interventions to Reduce Drinking to Impairment
Pages 109-172
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From page 109... ...
. However, there are a number of effective interventions to reduce drinking to the point of impairment (i.e., binge drinking1)
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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)
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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)
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Intervention Intermediate outcome Health outcome FIGURE 3-1 A conceptual model for the causal relationship between increased alcohol taxes and decreased excessive alcohol consumption and related harms. SOURCE: Adapted from Elder et al., 2010.
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. 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.
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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.
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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.
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. 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)
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Reprinted with permission from Alcohol Research Documentation, Inc., publisher of the Journal of Studies on Alcohol and Drugs. There are some concerns, however, about how increasing alcohol taxes will affect some drinkers and some special populations.
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; 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.)
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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.
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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)
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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)
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. 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)
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.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)
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Other research points to traffic flow as a moderator of the relationship between outlet density and singlevehicle 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)
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. 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)
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. 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)
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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)
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. There is a limited body of evidence that examines the relationship between open container laws and drinking while driving or alcoholimpaired driving (Goodwin et al., 2015)
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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)
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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)
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. 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.
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. 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)
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. The Community Preventive Services Task Force did not find any studies examining the cost-benefit of dram shop liability laws.
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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)
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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.
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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)
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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)
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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.
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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)
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. 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)
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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]
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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)
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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.
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From page 144... ...
. There is a documented need for additional robust studies with alcohol-impaired driving outcome measures such as DWIs and alcoholrelated 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)
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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)
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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 highquality 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)
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. 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.
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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)
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From page 149... ...
Furthermore, the changing nature of the media landscape warrants consideration in the development of media campaigns to reduce alcoholimpaired 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)
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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)
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. 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)
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From page 152... ...
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.
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From page 153... ...
. 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 smartphonepaired breath-testing devices range from $30 to $100 and they are now available in major household, electronic, and online retail outlets.
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. 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.
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From page 155... ...
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.
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The following subjects indicate research areas for which investigation would benefit the field of alcoholimpaired driving: • Effects of introducing retail price restrictions on excessive alcohol consumption and alcohol-impaired driving; • Specific effects of social host laws on underage alcohol consump tion 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.
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2009b. Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies.
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2009. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol related harms.
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M Sosin, and Community Preventive Services Task Force.
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2010. The ef fectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms.
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2008. Patterns of alcohol consumption and alcohol-impaired driving in the United States.
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2010. Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms.
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2016. Alcohol marketing and youth alcohol consumption: A systematic review of longitudinal studies published since 2008.
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2016. Associations between responsible beverage service laws and binge drinking and alcohol-impaired driving.
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2010. Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms.
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2014. Relationships be tween social host laws and underage drinking: Findings from a study of 50 California cities.
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2011. Ef fects of dram shop liability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms: Two community guide systematic reviews.
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1994. Alcohol outlet density and motor vehicle crashes in Los Angeles County cities.
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2009. The effect of alcohol advertising, marketing and por trayal on drinking behaviour in young people: Systematic review of prospective cohort studies.
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2009. Recommendations for reducing exces sive alcohol consumption and alcohol-related harms by limiting alcohol outlet density.
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2015. A systematic review: Effectiveness of mass media campaigns for reducing alcohol-impaired driving and alcohol-related crashes.
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Bolen, and Community Preventive Services Task Force.
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