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Connecticut's 2003 Impaired-Driving High-Visibility Enforcement Campaign
INJURY PREVENTION/NHTSA NOTES
National Highway Traffic Safety Administration (NHTSA) Notes Commentator Chris Kahn, MD, MPH Section Editors Mary Pat McKay, MD, MPH Todd Thoma, MD Chris Kahn, MD, MPH Catherine S. Gotschall, ScD
From the Department of Emergency Medicine, University of California–Irvine, Center for Trauma and Injury Prevention Research, Irvine, CA.
Department of Emergency Medicine, Center for Injury Prevention and Control, The George Washington University Medical Center, Washington, DC Department of Emergency Medicine, Louisiana State University, Baton Rouge, LA Department of Emergency Medicine, University of California-Irvine, Center for Trauma and Injury Prevention Research, Irvine, CA National Highway Traffic Safety Administration, Washington, DC
Reprints not available from the editors.
Connecticut’s 2003 Impaired-Driving High-Visibility Enforcement Campaign [National Highway Traffic Safety Administration. Connecticut’s 2003 impaired-driving high-visibility enforcement campaign. Ann Emerg Med. 2008;51: 765-766.] In 2003, the state of Connecticut initiated a publicity and enforcement campaign to reduce impaired driving and alcoholrelated fatalities, particularly among men 21 to 34 years old. The campaign consisted of 3 components: (1) media with an enforcement message; (2) enhanced periods of enforcement surrounding the July 4th and winter holidays, focusing on the use of sobriety checkpoints; and (3) sustained enforcement between holiday enforcement periods. The campaign began during the July 4th holiday period, was sustained during the summer and fall, and peaked during the Thanksgiving and Christmas holiday period, costing nearly $4 million. Connecticut’s efforts followed the National Highway Traffic Safety Administration (NHTSA) impaired driving highvisibility enforcement model and were a test of NHTSA’s model, which includes paid and earned media in support of statewide high-intensity enforcement crackdowns and planned, sustained enforcement efforts between crackdowns. The focus of the media campaign was primarily young men 21 to 34 years old because of their high rate of involvement in alcohol-related crashes. The media campaigns focused on 2 holiday periods during 2003 and were also designed to create the perception of sustained enforcement between these 2 holiday periods. Some media components continued throughout the campaign. The media campaign spanned 11 months, beginning in March 2003, at a cost of $2,199,533. The enforcement component involved commitment to sustained driving while intoxicated enforcement throughout the year and 2 enhanced enforcement crackdowns covering the Independence Day and Thanksgiving/Christmas holiday periods. NHTSA’s model focuses on crackdowns that cover Volume , . : June
85% of the states’ populations and involve high-visibility sobriety checkpoints or saturation patrols during 3 weekends (16 days) of these holiday periods. It also encompasses public awareness efforts involving state-earned media, state-funded paid media, and NHTSA-paid media. Sobriety checkpoints constituted the main focus of the enforcement effort. In total, the state funded 24 sobriety checkpoints during the July 4th holiday period. Fifteen towns held at least 1 sobriety checkpoint during the July 4th holiday period. Under the expanded grants, a total of 18 towns and the state police conducted a total of 89 sobriety checkpoints. Twenty-eight police agencies and the state police conducted a total of 51 sobriety checkpoints during the winter holiday period, more than twice as many as conducted during the July 4th holiday period. Twenty additional sobriety checkpoints included an evaluation research component after the normal portion of the sobriety checkpoint in which researchers collected direct observations of drinking and driving by obtaining breath alcohol concentration (BAC) information from a random sample of drivers passing through the sobriety checkpoint. Statewide telephone surveys were conducted before and after each holiday period. The sampling plan was designed to ensure a representative sample of Connecticut drivers and used a random-digit dialing approach to interview a total of 2,430 drivers during the course of the campaign. The surveys indicated that drivers reported significantly more often after the campaign that they had heard about impaired driving in Connecticut and had been through or knew someone who had been through a sobriety checkpoint. Telephone surveys also indicated that more drivers thought state and local police were strict about enforcing the laws against drinking and driving and that a driver who had been drinking was likely to be stopped by police. Patterns were similar for men 21 to 34 years old. Driver BACs were collected at sobriety checkpoints in 9 towns before and after the holiday enforcement periods as a direct measure of the effect of enforcement and publicity on drinking and driving. A geographically diverse set of sites in the state, focusing on towns with particularly high alcohol-related fatal and injury crash rates, was selected. The research team Annals of Emergency Medicine 765
NHTSA Notes obtained voluntary, anonymous BAC measurements from randomly selected drivers on handheld breath-testing devices. Approximately 92% or more drivers agreed to the BAC test. The team collected 1,249 BAC samples from drivers before and after the July 4th holiday enforcement period and 2,115 BAC samples from drivers before and after the winter holiday enforcement period. Roadside surveys of driver BAC indicated a significant decrease in the proportion of drivers with a positive BAC result at the end of the campaign compared with the previous year. Autoregressive Integrated Moving Average (ARIMA) analyses of the alcohol-related fatality trend for the state and for men aged 21 to 34 years indicated that both rates decreased significantly, by an estimated 2.6 and 1.6 fewer fatalities each month. The total lives saved amounted to 47 statewide and 29 for men aged 21 to 34 years in the year and a half after the campaign’s start. Alcohol-related fatality data were taken from the NHTSA’s Fatality Analysis Reporting System for 2000 through the preliminary 2004 data. The overall alcohol-related fatality trend for the state and the alcohol-related fatality trend for fatalities involving men 21 to 34 years old were analyzed with the ARIMA technique. The analyses indicated that there was a significant decrease in the alcohol-related fatality trend for the 18-month period after the beginning of the impaired driving high-visibility enforcement campaign. The intervention period trend from July 2003 through December 2004 was evaluated in comparison with the trend from 2000 through the first 6 months of 2003 (P⫽.042). When alcohol-related fatalities from contiguous counties in New York, Rhode Island, and Massachusetts were used as a covariate, the significant decrease in the estimated monthly average number of alcohol-related fatalities in Connecticut during the second half of 2003 through December 2004 was stronger (P⫽.01). The estimated reduction in the number of alcohol-related fatalities determined by the ARIMA analysis was about 2.6 lives each month for the 18 months after June 2003. Thus, if there were no campaign, there would have been an estimated 47 additional alcohol-related fatalities. Copies of the 68-page report “Connecticut’s 2003 ImpairedDriving High-Visibility Enforcement Campaign” can be obtained from the National Center for Statistics and Analysis, NHTSA, 1200 New Jersey Avenue, SE, Washington, DC 20590 or downloaded from the NHTSA Web site at: http:// www.nhtsa.dot.gov/people/injury/alcohol/StopImpaired/ 3025ConnImpDriving/. doi:10.1016/j.annemergmed.2008.04.006
COMMENTARY: PRIMARY PREVENTION OF DRUNK DRIVING: OVER THE AIRWAVES, UNDER THE RADAR [Kahn CA. Commentary: primary prevention of drunk driving: over the airwaves, under the radar. Ann Emerg Med. 2008;51:766-768.] 766 Annals of Emergency Medicine
As emergency care providers, most of us have had the misfortune to tell a stunned family that their young son or daughter has been killed in a car crash. All too often, that death is the preventable result of risky behavior. In mid-February of this year, one of us had to deliver that news in Las Vegas, after a car filled with 4 teenagers who had spent the night in the local mountains overturned on a freeway in the early morning hours while the teens were returning home; 2 teens not wearing their seatbelts (a topic for another day) were ejected, and both died. The drunk driver had only minor injuries, whereas the fourth teenager required reconstructive surgery.1 Drunk driving continues to be one of the top killers in our society. Despite years of policymaking, legal enforcement, and technologic advances, the decrease in deaths from drunk driving observed from 1982 to 1994 has nearly ceased, with no significant change in alcohol-related fatalities since that time.2 Each year, more than 17,000 people are killed as the result of drunk driving, with many more injured.2 Clearly, any new idea with the ability to change these staggering statistics for the better is worth our serious attention. In 2002, the NHTSA proposed a new model of drunk driving enforcement, known as the “high-visibility enforcement” (HVE) approach. In 2003, Connecticut implemented this model.3 The results show statistically significant change toward the reduction of drunk driving fatalities, controlled for confounders such as weather, changes in contiguous nonstudy areas, and secular trends. The HVE model relies on 3 major components: an intensive media campaign, statewide high-intensity crackdowns using saturation patrols or sobriety checkpoints (centered on holiday periods in this study), and planned, sustained enforcement between crackdowns. With an overall cost to the state of just under $4 million for the 11-month intervention period, the program saved an estimated 47 lives during 18 months (including the 7 months after the intervention period, in which a sustained effect was observed). Although a detailed costbenefit analysis is best left to economic statisticians, simple math suggests that each life saved cost the state approximately $80,000. A common reference for cost analyses uses the concept of dollars per quality-adjusted life-year, or QALY. The QALY concept incorporates both mortality and morbidity during the years of life saved to give an overall sense of cost and utility, with anywhere from $20,000 to $100,000 per QALY often accepted as a cost-effective intervention; recent studies from the cardiology literature cite ratios of anywhere from $11,000 to $48,000 per QALY for cardiac stents, a commonly performed procedure generally considered to be worth the cost.4,5 Screening mammograms, another commonly performed procedure generally considered to be cost-effective, have been estimated to cost up to $58,000 per QALY.6 Given that the basic analysis in this paragraph of $80,000 per life saved ignores the huge cost of injured (but not killed) persons and that these lives saved are generally those of young healthy persons with many years of productive living ahead, it is intuitive that this Volume , . : June
National Highway Traffic Safety Administration (NHTSA) Notes Commentator Chris Kahn, MD, MPH Section Editors Mary Pat McKay, MD, MPH Todd Thoma, MD Chris Kahn, MD, MPH Catherine S. Gotschall, ScD
From the Department of Emergency Medicine, University of California–Irvine, Center for Trauma and Injury Prevention Research, Irvine, CA.
Department of Emergency Medicine, Center for Injury Prevention and Control, The George Washington University Medical Center, Washington, DC Department of Emergency Medicine, Louisiana State University, Baton Rouge, LA Department of Emergency Medicine, University of California-Irvine, Center for Trauma and Injury Prevention Research, Irvine, CA National Highway Traffic Safety Administration, Washington, DC
Reprints not available from the editors.
Connecticut’s 2003 Impaired-Driving High-Visibility Enforcement Campaign [National Highway Traffic Safety Administration. Connecticut’s 2003 impaired-driving high-visibility enforcement campaign. Ann Emerg Med. 2008;51: 765-766.] In 2003, the state of Connecticut initiated a publicity and enforcement campaign to reduce impaired driving and alcoholrelated fatalities, particularly among men 21 to 34 years old. The campaign consisted of 3 components: (1) media with an enforcement message; (2) enhanced periods of enforcement surrounding the July 4th and winter holidays, focusing on the use of sobriety checkpoints; and (3) sustained enforcement between holiday enforcement periods. The campaign began during the July 4th holiday period, was sustained during the summer and fall, and peaked during the Thanksgiving and Christmas holiday period, costing nearly $4 million. Connecticut’s efforts followed the National Highway Traffic Safety Administration (NHTSA) impaired driving highvisibility enforcement model and were a test of NHTSA’s model, which includes paid and earned media in support of statewide high-intensity enforcement crackdowns and planned, sustained enforcement efforts between crackdowns. The focus of the media campaign was primarily young men 21 to 34 years old because of their high rate of involvement in alcohol-related crashes. The media campaigns focused on 2 holiday periods during 2003 and were also designed to create the perception of sustained enforcement between these 2 holiday periods. Some media components continued throughout the campaign. The media campaign spanned 11 months, beginning in March 2003, at a cost of $2,199,533. The enforcement component involved commitment to sustained driving while intoxicated enforcement throughout the year and 2 enhanced enforcement crackdowns covering the Independence Day and Thanksgiving/Christmas holiday periods. NHTSA’s model focuses on crackdowns that cover Volume , . : June
85% of the states’ populations and involve high-visibility sobriety checkpoints or saturation patrols during 3 weekends (16 days) of these holiday periods. It also encompasses public awareness efforts involving state-earned media, state-funded paid media, and NHTSA-paid media. Sobriety checkpoints constituted the main focus of the enforcement effort. In total, the state funded 24 sobriety checkpoints during the July 4th holiday period. Fifteen towns held at least 1 sobriety checkpoint during the July 4th holiday period. Under the expanded grants, a total of 18 towns and the state police conducted a total of 89 sobriety checkpoints. Twenty-eight police agencies and the state police conducted a total of 51 sobriety checkpoints during the winter holiday period, more than twice as many as conducted during the July 4th holiday period. Twenty additional sobriety checkpoints included an evaluation research component after the normal portion of the sobriety checkpoint in which researchers collected direct observations of drinking and driving by obtaining breath alcohol concentration (BAC) information from a random sample of drivers passing through the sobriety checkpoint. Statewide telephone surveys were conducted before and after each holiday period. The sampling plan was designed to ensure a representative sample of Connecticut drivers and used a random-digit dialing approach to interview a total of 2,430 drivers during the course of the campaign. The surveys indicated that drivers reported significantly more often after the campaign that they had heard about impaired driving in Connecticut and had been through or knew someone who had been through a sobriety checkpoint. Telephone surveys also indicated that more drivers thought state and local police were strict about enforcing the laws against drinking and driving and that a driver who had been drinking was likely to be stopped by police. Patterns were similar for men 21 to 34 years old. Driver BACs were collected at sobriety checkpoints in 9 towns before and after the holiday enforcement periods as a direct measure of the effect of enforcement and publicity on drinking and driving. A geographically diverse set of sites in the state, focusing on towns with particularly high alcohol-related fatal and injury crash rates, was selected. The research team Annals of Emergency Medicine 765
NHTSA Notes obtained voluntary, anonymous BAC measurements from randomly selected drivers on handheld breath-testing devices. Approximately 92% or more drivers agreed to the BAC test. The team collected 1,249 BAC samples from drivers before and after the July 4th holiday enforcement period and 2,115 BAC samples from drivers before and after the winter holiday enforcement period. Roadside surveys of driver BAC indicated a significant decrease in the proportion of drivers with a positive BAC result at the end of the campaign compared with the previous year. Autoregressive Integrated Moving Average (ARIMA) analyses of the alcohol-related fatality trend for the state and for men aged 21 to 34 years indicated that both rates decreased significantly, by an estimated 2.6 and 1.6 fewer fatalities each month. The total lives saved amounted to 47 statewide and 29 for men aged 21 to 34 years in the year and a half after the campaign’s start. Alcohol-related fatality data were taken from the NHTSA’s Fatality Analysis Reporting System for 2000 through the preliminary 2004 data. The overall alcohol-related fatality trend for the state and the alcohol-related fatality trend for fatalities involving men 21 to 34 years old were analyzed with the ARIMA technique. The analyses indicated that there was a significant decrease in the alcohol-related fatality trend for the 18-month period after the beginning of the impaired driving high-visibility enforcement campaign. The intervention period trend from July 2003 through December 2004 was evaluated in comparison with the trend from 2000 through the first 6 months of 2003 (P⫽.042). When alcohol-related fatalities from contiguous counties in New York, Rhode Island, and Massachusetts were used as a covariate, the significant decrease in the estimated monthly average number of alcohol-related fatalities in Connecticut during the second half of 2003 through December 2004 was stronger (P⫽.01). The estimated reduction in the number of alcohol-related fatalities determined by the ARIMA analysis was about 2.6 lives each month for the 18 months after June 2003. Thus, if there were no campaign, there would have been an estimated 47 additional alcohol-related fatalities. Copies of the 68-page report “Connecticut’s 2003 ImpairedDriving High-Visibility Enforcement Campaign” can be obtained from the National Center for Statistics and Analysis, NHTSA, 1200 New Jersey Avenue, SE, Washington, DC 20590 or downloaded from the NHTSA Web site at: http:// www.nhtsa.dot.gov/people/injury/alcohol/StopImpaired/ 3025ConnImpDriving/. doi:10.1016/j.annemergmed.2008.04.006
COMMENTARY: PRIMARY PREVENTION OF DRUNK DRIVING: OVER THE AIRWAVES, UNDER THE RADAR [Kahn CA. Commentary: primary prevention of drunk driving: over the airwaves, under the radar. Ann Emerg Med. 2008;51:766-768.] 766 Annals of Emergency Medicine
As emergency care providers, most of us have had the misfortune to tell a stunned family that their young son or daughter has been killed in a car crash. All too often, that death is the preventable result of risky behavior. In mid-February of this year, one of us had to deliver that news in Las Vegas, after a car filled with 4 teenagers who had spent the night in the local mountains overturned on a freeway in the early morning hours while the teens were returning home; 2 teens not wearing their seatbelts (a topic for another day) were ejected, and both died. The drunk driver had only minor injuries, whereas the fourth teenager required reconstructive surgery.1 Drunk driving continues to be one of the top killers in our society. Despite years of policymaking, legal enforcement, and technologic advances, the decrease in deaths from drunk driving observed from 1982 to 1994 has nearly ceased, with no significant change in alcohol-related fatalities since that time.2 Each year, more than 17,000 people are killed as the result of drunk driving, with many more injured.2 Clearly, any new idea with the ability to change these staggering statistics for the better is worth our serious attention. In 2002, the NHTSA proposed a new model of drunk driving enforcement, known as the “high-visibility enforcement” (HVE) approach. In 2003, Connecticut implemented this model.3 The results show statistically significant change toward the reduction of drunk driving fatalities, controlled for confounders such as weather, changes in contiguous nonstudy areas, and secular trends. The HVE model relies on 3 major components: an intensive media campaign, statewide high-intensity crackdowns using saturation patrols or sobriety checkpoints (centered on holiday periods in this study), and planned, sustained enforcement between crackdowns. With an overall cost to the state of just under $4 million for the 11-month intervention period, the program saved an estimated 47 lives during 18 months (including the 7 months after the intervention period, in which a sustained effect was observed). Although a detailed costbenefit analysis is best left to economic statisticians, simple math suggests that each life saved cost the state approximately $80,000. A common reference for cost analyses uses the concept of dollars per quality-adjusted life-year, or QALY. The QALY concept incorporates both mortality and morbidity during the years of life saved to give an overall sense of cost and utility, with anywhere from $20,000 to $100,000 per QALY often accepted as a cost-effective intervention; recent studies from the cardiology literature cite ratios of anywhere from $11,000 to $48,000 per QALY for cardiac stents, a commonly performed procedure generally considered to be worth the cost.4,5 Screening mammograms, another commonly performed procedure generally considered to be cost-effective, have been estimated to cost up to $58,000 per QALY.6 Given that the basic analysis in this paragraph of $80,000 per life saved ignores the huge cost of injured (but not killed) persons and that these lives saved are generally those of young healthy persons with many years of productive living ahead, it is intuitive that this Volume , . : June