James L. Nichols

Reviews of evidence regarding interventions to reduce alcohol-impaired driving☆

BACKGROUND Alcohol-related motor vehicle crashes are a major public health problem, resulting in 15,786 deaths and more than 300,000 injuries in 1999. This report presents the results of systematic reviews of the effectiveness and economic efficiency of selected population-based interventions to reduce alcohol-impaired driving. METHODS The Guide to Community Preventive Servicess methods for systematic reviews were used to evaluate the effectiveness of five interventions to decrease alcohol-impaired driving, using changes in alcohol-related crashes as the primary outcome measure. RESULTS Strong evidence was found for the effectiveness of .08 blood alcohol concentration laws, minimum legal drinking age laws, and sobriety checkpoints. Sufficient evidence was found for the effectiveness of lower blood alcohol concentration laws for young and inexperienced drivers and of intervention training programs for servers of alcoholic beverages. Additional information is provided about the applicability, other effects, and barriers to implementation of these interventions. CONCLUSION These reviews form the basis of the recommendations by the Task Force on Community Preventive Services presented elsewhere in this supplement. They can help decision makers identify and implement effective interventions that fit within an overall strategy to prevent impaired driving.

Reviews of evidence regarding interventions to increase the use of safety belts

BACKGROUND The use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor vehicle crashes. If all motor vehicle occupants consistently wore safety belts, an estimated 9553 deaths would have been prevented in 1999 alone. METHODS The Guide to Community Preventive Servicess methods for systematic reviews were used to evaluate the effectiveness of three interventions to increase safety belt use. Effectiveness was assessed on the basis of changes in safety belt use and number of crash-related injuries. RESULTS Strong evidence was found for the effectiveness of safety belt laws in general and for the incremental effectiveness of primary safety belt laws relative to secondary laws. Strong evidence for the effectiveness of enhanced enforcement programs for safety belt laws was also found. Additional information is provided about the applicability, other effects, and barriers to implementation of these interventions. CONCLUSIONS These reviews form the basis of the recommendations by the Task Force on Community Preventive Services presented elsewhere in this supplement. They can help decision makers identify and implement effective interventions that fit within an overall strategy to increase safety belt use.

Effectiveness of Sobriety Checkpoints for Reducing Alcohol-Involved Crashes

The goal of sobriety checkpoints is to deter drinking and driving by systematically stopping drivers for assessment of alcohol impairment, thus increasing the perceived risk of arrest for alcohol-impaired driving. This review examines the effectiveness of random breath testing (RBT) checkpoints, at which all drivers stopped are given breath tests for blood alcohol levels, and selective breath testing (SBT) checkpoints, at which police must have reason to suspect the driver has been drinking before demanding a breath test. A systematic review of the effectiveness of sobriety checkpoints in reducing alcohol-involved crashes and associated injuries and fatalities was conducted using the methodology developed for the Guide to Community Preventive Services (Community Guide) . Substantial reductions in crashes were observed for both checkpoint types across various outcome measures and time periods. Results suggest that both RBT and SBT checkpoints can play an important role in preventing alcohol-related crashes and associated injuries.

The effectiveness of legal sanctions in dealing with drinking drivers

Legal sanctions, whether administered by the courts or by State licensing agencies, NC central to deterrence-based policies for reducing alcohol-impaired driving. They are the punishments threatened in support of the law’s mandate. Examples are fines, license actions such as suspension and revocation, jail sentences, and alternatives such as community service. Deterrence theory posits that sanctions will be effective in modifying Ixhavior to the extent that they are perceived as being certain, swiftly applied, andsevere. Thcsc three primary characteristics of penalties, if appropriately perceived, have the potential to reduce drunk driving. .

Primary enforcement seat belt laws are effective even in the face of rising belt use rates.

A recent systematic literature review found that primary enforcement laws are more effective at increasing seat belt use than secondary laws in the United States. This report re-examines the studies included in the systematic review to explore whether the benefits of a primary law differ based on: (1) the baseline seat belt use rate; or (2) whether or not the primary law replaces a secondary law. States that directly enacted primary laws showed larger increases in observed seat belt use (median increase of 33 percentage points). These laws were enacted in the mid-1980s, when baseline belt use rates were below 35%. Smaller, but substantial increases in belt use were observed in states that replaced secondary with primary laws (median increase of 14 percentage points). Baseline belt use rates in these states ranged from 47 to 73%. Primary safety belt laws can further increase seat belt use even in states with relatively high baseline levels of belt use.

Effectiveness of Multicomponent Programs with Community Mobilization for Reducing Alcohol-Impaired Driving

A systematic review was conducted to determine the effectiveness and economic efficiency of multicomponent programs with community mobilization for reducing alcohol-impaired driving. The review was conducted for the Guide to Community Preventive Services (Community Guide). Six studies of programs qualified for the review. Programs addressed a wide range of alcohol-related concerns in addition to alcohol-impaired driving. The programs used various crash-related outcomes to measure their effectiveness. Two studies examined fatal crashes and reported declines of 9% and 42%; one study examined injury crashes and reported a decline of 10%; another study examined crashes among young drivers aged 16-20 years and reported a decline of 45%; and one study examined single-vehicle late-night and weekend crashes among young male drivers and reported no change. The sixth study examined injury crashes among underage drivers and reported small net reductions. Because the actual numbers of crashes were not reported, percentage change could not be calculated. According to Community Guide rules of evidence, the studies reviewed here provided strong evidence that carefully planned, well-executed multicomponent programs, when implemented in conjunction with community mobilization efforts, are effective in reducing alcohol-related crashes. Three studies reported economic evidence that suggests that such programs produce cost savings. The multicomponent programs generally included a combination of efforts to limit access to alcohol (particularly among youth), responsible beverage service training, sobriety checkpoints or other well-defined enforcement efforts, public education, and media advocacy designed to gain the support of both policymakers and the general public for reducing alcohol-impaired driving.

METHODS FOR CONDUCTING SYSTEMATIC REVIEWS OF THE EVIDENCE OF EFFECTIVENESS AND ECONOMIC EFFICIENCY OF INTERVENTIONS TO REDUCE INJURIES TO MOTOR VEHICLE OCCUPANTS

BACKGROUND Motor vehicle occupant injury prevention is included in the Guide to Community Preventive Services because of the enormous health impact of these largely preventable injuries. This article describes the methods for conducting systematic literature reviews of interventions for three key injury prevention strategies: increasing child safety seat use, increasing safety belt use, and decreasing alcohol-impaired driving. METHODS Systematic review methods follow those established for the Guide to Community Preventive Services and include: (1) recruiting a systematic review development team, (2) developing a conceptual approach for selecting interventions and for selecting outcomes that define the success of the interventions, (3) defining and conducting a search for evidence of effectiveness, (4) evaluating and summarizing the body of evidence of effectiveness, (5) evaluating other potential beneficial and harmful effects of the interventions, (6) evaluating economic efficiency, (7) identifying implementation barriers, (8) translating the strength of the evidence into recommendations, and (9) identifying and summarizing research gaps. RESULTS The systematic review development team evaluated 13 interventions for the three strategic areas. More than 10,000 titles and abstracts were identified and screened; of these, 277 met the a priori systematic review inclusion criteria. Systematic review findings for each of the 13 interventions are provided in the accompanying articles in this supplement. CONCLUSION The general methods established for conducting systematic reviews for the Guide to Community Preventive Services were successfully applied to interventions to reduce injuries to motor vehicle occupants.

Translating Evidence into Policy: Lessons Learned from the Case of Lowering the Legal Blood Alcohol Limit for Drivers

This case study examines the translation of evidence on the effectiveness of laws to reduce the blood alcohol concentration (BAC) of drivers into policy. It was reconstructed through discussions among individuals involved in the processes as well as a review of documentation and feedback on oral presentations. The Centers for Disease Control and Prevention collaborated extensively with federal and non-federal partners and stakeholders in conducting a rigorous systematic review, using the processes of the Guide to Community Preventive Services to evaluate the body of empirical evidence on 0.08% BAC laws. The timely dissemination of the findings and related policy recommendations-made by the independent Task Force on Community Preventive Services-to Congress very likely contributed to the inclusion of strong incentives to States to adopt 0.08 BAC laws by October 2003. Subsequent dissemination to partners and stakeholders informed decision-making about support for state legislative and policy action. This case study suggests the value of: clearly outlining the relationships between health problems, interventions and outcomes; systematically assessing and synthesizing the evidence; using a credible group and rigorous process to assess the evidence; having an impartial body make specific policy recommendations on the basis of the evidence; being ready to capitalize in briefly opening policy windows; engaging key partners and stakeholders throughout the production and dissemination of the evidence and recommendations; undertaking personalized, targeted and compelling dissemination of the evidence and recommendations; involving multiple stakeholders in encouraging uptake and adherence of policy recommendations; and addressing sustainability. These lessons learned may help others working to translate evidence into policy.

Scientific evidence and policy change: lowering the legal blood alcohol limit for drivers to 0.08% in the USA

The United States (US) Centers for Disease Control and Prevention (CDC), and key partners conducted a systematic review of the effectiveness of 0.08% blood alcohol concentration (BAC) laws on alcohol-related traffic mortality. Review findings of strong evidence of effectiveness were presented by partners during US Congressional hearings contributing to the passage of a bill requiring states to lower the legal BAC limit to 0.08% (80 mg of alcohol/100 ml of blood) or lose a portion of their federal highway funds. The bill was signed into law, making 0.08 the new national standard. Extensive and targeted dissemination of the evidence and recommendations to key stakeholders and partners built support for policy change at the state level.

Publicized Sobriety Checkpoint Programs

CONTEXT Publicized sobriety checkpoint programs deter alcohol-impaired driving by stopping drivers systematically to assess their alcohol impairment. Sobriety checkpoints were recommended in 2001 by the Community Preventive Services Task Force for reducing alcohol-impaired driving, based on strong evidence of effectiveness. Since the 2001 review, attention to alcohol-impaired driving as a U.S. public health problem has decreased. This systematic review was conducted to determine if available evidence supports the effectiveness of publicized sobriety checkpoint programs in reducing alcohol-impaired driving, given the current context. The economic costs and benefits of the intervention were also assessed. EVIDENCE ACQUISITION This review focused on studies that evaluated the effects of publicized sobriety checkpoint programs on alcohol-involved crash fatalities. Using Community Guide methods, a systematic search was conducted for studies published between July 2000 and March 2012 that assessed the effectiveness of publicized sobriety checkpoint programs. EVIDENCE SYNTHESIS Fourteen evaluations of selective breath testing and one of random breath testing checkpoints met the inclusion criteria for the systematic review, conducted in 2012. Ten evaluations assessed the effects of publicized sobriety checkpoint programs on alcohol-involved crash fatalities, finding a median reduction of 8.9% in this crash type (interquartile interval=-16.5%, -3.5%). Five economic evaluations showed benefit-cost ratios ranging from 2:1 to 57:1. CONCLUSIONS The number of studies, magnitude of effect, and consistency of findings indicate strong evidence of the effectiveness of publicized sobriety checkpoint programs in reducing alcohol-involved crash fatalities. Economic evidence shows that these programs also have the potential for substantial cost savings.