Alcohol-related Crashes

Objectives

Strategies

5.1 A—Reduce Excessive Drinking and Underage Drinking

5.1 A1—Increase the State Excise Tax on Beer (T)

5.1 A2—Require Responsible Beverage Service Policies for Alcohol Servers and Retailers (P)

5.1 A3—Conduct Well-Publicized Compliance Checks of Alcohol Retailers to Reduce Sales to Underage Persons (T)

5.1 A4—Employ Screening and Brief Interventions in Health Care Settings (T)

5.1 B—Enforce DWI Laws

5.1 B1—Conduct Regular Well-Publicized DWI Checkpoints (P)

5.1 B2—Enhance DWI Detection Through Special DWI Patrols and Related Traffic Enforcement (T)

5.1 B3—Publicize and Enforce Zero Tolerance Laws for Drivers Under Age 21 (P)

5.1 C—Prosecute, Impose Sanctions on, and Treat DWI Offenders

5.1 C1—Suspend Driver’s License Administratively Upon Arrest (P)

5.1 C2—Establish Stronger Penalties for BAC Test Refusal Than for Test Failure (T)

5.1 C3—Eliminate Diversion Programs and Plea Bargains to Non-Alcohol Offenses (T)

5.1 C4—Screen All Convicted DWI Offenders for Alcohol Problems and Require Treatment When Appropriate (P)

5.1 D—Control High-BAC and Repeat Offenders

5.1 D1—Seize Vehicles or Vehicle License Plates Administratively Upon Arrest (P)

5.1 D2—Require Ignition Interlocks as a Condition for License Reinstatement (P)

5.1 D3—Monitor All Convicted DWI Offenders Closely (P)

5.1 D4—Incarcerate Offenders (P)

Technical Attributes

Target

All beer drinkers (most of whom presumably drive).

Expected Effectiveness

The relationship between excise tax rates on beer and motor vehicle crashes is well-documented. One recent study, using more sophisticated analyses than earlier studies, found a clear relationship between higher excise taxes and decreased alcohol-related traffic fatalities (Ruhm, 1996). Based on a best-fitting model of the relationship between fatal crashes and alcohol costs, Kenkel (1993) estimated that increasing the federal excise tax on beer in 1988 to adjust for the effects of inflation since 1975 (a 78 percent increase in the tax—not the total price) would have saved approximately 3,500 lives annually in the United States. Other studies confirm that even though alcohol can be addictive for some individuals, heavy drinkers are affected by alcohol prices (Sloan et al., 1995; Cook & Moore, 2002).

Keys to Success

Any increase in excise tax on beer is likely to reduce the total amount of alcohol consumed by drinkers in a state and, as a result, alcohol-related traffic fatalities. However, the larger the increase, the greater the expected benefits. Because it can be challenging to pass any tax increase, states that pursue this strategy should also consider indexing the beer tax to inflation by basing the beer tax on the retail price (as is the case with liquor) rather than on volume as is currently done with the excise tax. This indexing will prevent the need to periodically revisit this issue to address erosion of the excise tax in the future. See Appendix 1 for further discussion of this issue.

It is also important that the general public see the tax increase as a public health and safety measure, rather than as simply a revenue generator. Relating the amount of revenues expected to the estimated cost from DWI crashes (and other alcohol-related public health costs) may help make the case. Reserving all or a part of the revenues for specific DWI reduction programs will help maintain the appropriate message about this strategy, as well.

It will be helpful to form a coalition of support groups from among the stakeholders to help bring resources to bear in gaining public and legislative support.

Because legislation is required to implement this strategy, it will be important to the success of the effort to identify at least one legislator who will "champion" the effort. Support of other public figures will also be valuable.

Potential Difficulties

This strategy requires legislative action. This requirement will be a major obstacle to overcome, despite the substantial public support for this particular tax. Moreover, one can expect active organized opposition to this strategy from the beer and hospitality industries. For further discussion of opponents’ arguments, see Appendix 2.

Appropriate Measures and Data

Unlike many policies, if the excise tax is increased, there is no question that it will be fully implemented. Increasing this excise tax should have a number of measurable outcomes, including reductions in alcohol consumption, alcohol-related traffic crashes and fatalities, and injuries and fatalities arising from other alcohol-related causes (e.g., homicide, suicide, and liver cirrhosis). Exposure measures, such as the actual increase in revenue from the excise tax, will also be helpful.

Associated Needs

PI&E efforts will be needed to explain the purpose of the legislation to the public.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

It will be critical to educate legislators, other stakeholders, and the general public about the societal costs of alcohol-related crashes as well as the potential benefits of increasing the excise tax. This requirement may involve some training for state highway safety officials who are not familiar with the details of alcohol taxation and its effects on drinking-driving.

Responsibility for implementing this strategy will be with the state’s alcohol taxation agency rather than department of transportation personnel.

Issues Affecting Implementation Time

This strategy will require enabling legislation in each state. The primary determinants of how long it will take to implement this strategy are the effectiveness of advocacy efforts in support of this legislation, the prevailing political climate in a state, the degree to which opponents of this legislation are active, and the economic conditions of the state. The time needed to implement this strategy will vary accordingly by state.

Costs Involved

Unlike most strategies, implementing this strategy will substantially increase revenue for states rather than incur costs. Since systems are already in place to collect excise taxes, the costs involved in enacting this strategy are the time and effort that will be required to pass enabling legislation, as well as the cost of any PI&E effort that may be mounted.

Training and Other Personnel Needs

No special training is needed to implement this policy. The excise tax structure and procedures are already in place and should not be affected by an increase in the tax.

Legislative Needs

This strategy requires legislative action.

Other Key Attributes

None.

Technical Attributes

Target

Alcohol retailers and, ultimately, their patrons.

Expected Effectiveness

Research suggests that changes in server behavior can result in fewer patrons being impaired when they leave licensed establishments, thus reducing the subsequent risk of an alcohol-related crash. In Oregon, a law was passed in 1985 requiring all new applicants for beverage service permits to successfully complete a state-approved server training course; existing service permit holders were given 5 years to complete training. Three years after the implementation of this law, single-vehicle nighttime injury crashes—a commonly used proxy measure for alcohol-related crashes because a high percentage of these crashes involve a drinking driver—decreased by 23 percent (Holder and Wagenaar, 1994). Oregon’s server training law (ORS 471.542) is available at http://www.leg.state.or.us/ors/471.html.

Keys to Success

Although voluntary efforts by retailers are helpful, they are insufficient to obtain the cooperation of all retailers in selling alcohol responsibly. Therefore, state law should mandate that all owners, managers, and servers complete a standardized RBS training course as a condition for an alcohol retailer obtaining and maintaining a license (or permit).

The management of establishments must support the training and performance of servers for RBS programs to achieve success.

To be effective, RBS policies should be accompanied by adequate enforcement of laws that prohibit the service of alcohol to intoxicated and underage patrons. In most jurisdictions, serving alcohol to intoxicated patrons is prohibited by state or local law; however, these laws are seldom enforced. Following an enforcement effort in one county in Michigan, the refusals of service to "pseudo-patrons" who simulated intoxication rose from 17.5 percent to 54.3 percent (McKnight and Streff, 1994). Thus, the threat of enforcement is important for ensuring that alcohol retailers follow responsible serving practices.

In addition, state alcohol beverage policies that prohibit sales and marketing tactics that encourage excessive alcohol consumption can further encourage RBS.

Potential Difficulties

Alcohol retailers may resist a state mandate for server training. There is a tendency to react to government control of a business’ practices. Owners should be made aware that, although this requirement may appear to be a burden for alcohol retailers, server training will help reduce the exposure of establishments and servers to lawsuits, especially in the presence of dram shop liability laws (see, for example, http://www.tf.org/tf/alcohol/ariv/dram4.html). Thus, there should be a strong incentive for alcohol retailers to support the policy.

Although employees may initially be unhappy about being required to obtain responsible service training, anecdotal accounts suggest that many leave with a positive attitude about RBS policies and an understanding of how they can increase their tips by being a responsible server. This experience needs to be communicated to persons not yet trained.

Appropriate Measures and Data

The clearest indicator of the efficacy of RBS training is whether it results in the control of excessive drinking in an establishment. This can be assessed by the use of compliance checks by alcohol law enforcement officers. These involve determining how an establishment responds to an individual simulating obvious impairment. In addition, when making arrests for DWI, law enforcement officers can determine where the individual last drank as a way of determining the "problem" retailers in a community. The ultimate measure of success of an RBS policy is a reduction in alcohol-related crashes. However, this may be difficult to adequately assess if RBS policies do not cover all sellers in a jurisdiction.

An important process measure will be the proportion of servers in a jurisdiction who have completed server training. Another measure is the number, timing, and location of compliance checks made.

Associated Needs

Clear guidelines for how to conduct effective compliance checks are needed for local law enforcement agencies that are unfamiliar with this type of operation. Training on how to conduct compliance checks will also be helpful. Finally, in addition to doing such checks, it is important to publicize to the retail community that the checks are routinely conducted (see Strategy 5.1 A3 in this guide).

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

It is important that server training programs meet an explicit set of learning objectives. Classes should describe the need for responsible alcohol service, identify the signs of intoxication, provide information on state alcohol service laws and drinking and driving laws, and present methods for dealing with problem customers (for an example, see http://eeando.unl.edu/rbst/ga/). Although there is currently little empirical evidence on what must be included in a truly effective server training program, simply providing an informational brochure or showing a video to new employees is clearly not adequate. Training programs should include written materials, present realistic scenarios, provide interaction between participants (e.g., role playing), and encourage discussion. Information about Oregon's server training program and requirements is available at the following website: http://www.olcc.state.or.us/.Oregon’s server training rules can be found at: http://arcweb.sos.state.or.us/rules/OARS_800/OAR_845/ 845_016.html.

In some cases, legislative authorization of compliance checks using underage persons may be required. Ideally, server training programs and compliance checks would be established at the state level (see the example of Oregon cited above). Statewide implementation ensures that all alcohol retailers participate in state-approved server training, and it can facilitate monitoring the compliance of alcohol retailers.

Issues Affecting Implementation Time

If a server training program is being administered statewide, it may take several years for all servers and managers to complete the required course. As in Oregon, it may be helpful to have alcohol retailers send their employees to the course as a condition for reinstatement of an alcohol license. This will naturally spread out the number of servers taking the course over a few years (depending on how long licenses are valid within a state). Once the program is in place, all newly hired employees should be required to successfully complete state-approved server training within 1 month of hiring.

If new legislation is required, implementation cannot begin until the law is enacted, further extending the time until most servers are trained.

Costs Involved

RBS courses can be provided either through state agencies or private companies. In either case, the costs of administering server training can be borne by establishments or by individual servers. Requiring individual servers to pay for their own training may not be popular, but has some precedent. As an analogy, drivers typically are required to obtain their own commercial driver’s license before they are qualified for various driving jobs.

Training and Other Personnel Needs

Adequate server education classes typically require at least one full day to complete. To be effective, classes should be conducted by state-certified providers. This program must be ongoing in order to accommodate newly hired servers and new retail establishments. In addition, law enforcement officials need to be trained to establish and conduct an effective compliance check program. This will require a cadre of trained instructors.

Legislative Needs

More than half of the United States currently has dram shop laws that allow persons injured as a result of the service of alcohol to intoxicated patrons to recover damages from licensed establishments. This potential for legal liability has prompted some alcohol retailers to adopt RBS policies. At present, 12 states have laws that mandate at least some employees to complete a server training program (Mosher et al., 2002). Another 11 states offer some form of incentive to alcohol retailers that train their staff. To ensure that RBS practices become widespread, legislative action to mandate server training and other RBS practices is needed. A recent review, however, indicates that server training legislation is generally weak even in states where server training is mandated (Mosher et al., 2002). Sample ordinances for mandatory and incentive-based responsible beverage server training are available at http://www.epi.umn.edu/alcohol/local/servord.shtm.

Other Key Attributes

None.

Technical Attributes

Target

Alcohol retailers directly and underage drinkers indirectly

Expected Effectiveness

A study in Louisiana demonstrates the effectiveness of well-publicized compliance checks in reducing alcohol sales to underage persons (Scribner and Cohen, 2001). In 1995, Louisiana modified its law to allow retailers to be cited for selling alcohol to underage persons. During a first wave of compliance checks in New Orleans, only 11 percent of 143 alcohol retailers asked for age identification before selling to an underage buyer. Five months later, after a media campaign covering the new law and the accompanying compliance checks, a second wave of checks found that compliance had increased to 40 percent. Compliance levels dropped somewhat 1 year later, suggesting the importance of sustained enforcement efforts. The study also found that outlets receiving a citation were more likely to ask for age identification from a young-looking buyer at follow-up compliance checks. Although studies to evaluate community-level interventions are extremely difficult to conduct, one study in Minnesota and Wisconsin found that, as part of a multi-faceted community program, compliance checks showed promise in reducing underage drinking and driving after drinking (Wagenaar et al., 2000c).

Keys to Success

It is essential that compliance checks be accompanied by sustained publicity targeting both retailers and the general public. The goal of compliance checks is to deter retailers from selling alcohol to minors. Although establishments and retailers are punished when caught, the effects of these punishments in some jurisdictions are relatively small compared with the broad effect on all retailers from knowing that compliance checks are routinely conducted. Therefore, compliance checks must be accompanied by sustained publicity targeting both retailers and the general public. In Louisiana, publicity included a press conference attended by the mayor and the state alcohol beverage control (ABC) commissioner. At the press conference, the press conducted "ride-alongs" with law enforcement officers conducting the compliance checks to stimulate TV and newspaper coverage of the compliance check program.

To be effective, the penalties for infractions should be administrative rather than criminal in nature. This increases the likelihood that penalties will be swiftly and consistently levied. In many states, the penalties are currently too lenient to deter retailers from selling alcohol to underage persons. Fines for alcohol retailers may be $300 or less. Furthermore, suspensions of alcohol licenses are infrequent and typically last, at most, only a few days. Considering the revenue that a retailer can generate by selling alcohol to underage persons, a $300 penalty with no suspension is a weak deterrent. Penalties for retailers, including alcohol sales permit suspensions, should be substantial enough to encourage retailers to actively adhere to minimum drinking age laws. Some states have had success employing graduated penalties for license holders who sell to minors so that both fines and suspension periods increase with each conviction.

Finally, to be most effective, minimum drinking age law enforcement should be part of a broad community commitment not to tolerate illegal drinking by young people (Wagenaar et al., 2000b).

Potential Difficulties

The greatest potential difficulty for conducting well-publicized compliance checks is limited resources. Funding for alcoholic beverage enforcement agencies has decreased in many states in recent years. Local police agencies also can conduct compliance checks. In order to do so, however, the police need to divert personnel away from other needs. In most jurisdictions that actively conduct compliance checks, enforcement activities are shared between local police agencies and the state liquor authority.

In some communities, the political power of local retail establishments is an obstacle to conducting compliance checks. Retailers sometimes view law enforcement and public officials who support compliance checks as anti-business. Nonetheless, carefully designed compliance check programs that have law enforcement work closely with retailers can be implemented (see Associated Needs).

Appropriate Measures and Data

Careful implementation of this strategy should result in fewer alcohol-related crashes among young drivers. However, as an important interim measure, the success of well-publicized compliance checks should be measured by the rate of retailer compliance over time. If enforcement is well-publicized and penalties are substantial enough, compliance with minimum drinking age laws should increase significantly.

Associated Needs

Although purchasing alcohol directly from retailers is a common way in which young people obtain alcohol, the most frequent source of alcohol is noncommercial sources, such as older siblings, friends, and co-workers (Wagenaar et al., 1996). Many states have statutes that prohibit adults other than parents from providing alcohol to underage persons; however, these laws are difficult to enforce because the transaction between adult and minor usually takes place in private.

States should also continue to address the use of false age identification by youth. Research has shown that fewer than 10 percent of underage drinkers report using a false identification during the previous month (Wagenaar et al., 1996). The use of false identifications is relatively low because (1) young persons have learned that they are seldom asked for identification when purchasing alcohol and (2) the legal risks are often high if caught with a false identification. Many states are also making it more difficult to duplicate or falsify identifications.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

Compliance checks of alcohol retailers will require political support. This may be hard to obtain in some communities, particularly smaller towns where local merchants have strong influence. However, political support is necessary for law enforcement to carry out a successful program. Therefore, it will be desirable to establish a group of stakeholders in the early stages of the process so that the cooperation and support of all key members of the community can be achieved.

Issues Affecting Implementation Time

Compliance checks can be organized relatively quickly and easily. The primary issue affecting time to implementation is the existence of political and organizational support for this activity. If local community leadership or law enforcement leaders do not see the value of doing compliance checks, then establishing the necessary support can take some time. Media attention can be easy to acquire in the beginning of a compliance check program, since it is a fresh story. As the program ages, resources should be allocated to ensure that the program continues to be effectively publicized, especially to retailers.

Costs Involved

The primary cost associated with this strategy is for local enforcement personnel, especially staff time for conducting compliance checks. Costs will also include training for officers who are not familiar with this kind of activity. Alcohol beverage enforcement officials can often conduct this training at relatively little cost.

Training and Other Personnel Needs

Additional ABC enforcement personnel are needed in most states. At the present time, it is not uncommon for an ABC officer to be responsible for a thousand or more retail outlets. As a consequence, it should come as little surprise that many retailers perceive the risk of selling alcohol to youths as very low. Unfortunately, a number of states are currently decreasing, rather than increasing, their ABC enforcement staff. Information and assistance in training officers for alcohol law enforcement is available from the National Liquor Law Enforcement Association at http://www.nllea.org.

Formal training of employees in retail establishments is also critical. Employees must be familiar with store policies, as well as state laws and penalties for selling alcohol to youths. Employees also need training to learn how to detect false age identification and how to refuse sales to underage persons.

Legislative Needs

Although all 50 states and the District of Columbia prohibit persons under the age of 21 from purchasing or publicly possessing alcohol, states vary considerably in the details of their minimum legal drinking age laws, as well as their procedures for administering and enforcing them and the penalties for violations. Prohibiting persons under age 21 from possessing or consuming alcohol is an important part of a comprehensive approach to underage drinking that requires legislative action. In addition, a law making it illegal for persons under 21 to attempt to purchase (or to actually purchase) alcohol are necessary for effective control of underage drinking. Finally, a law prohibiting the use of false identification to obtain alcohol is needed. For alcohol retailers, the penalties for selling to underage persons should be sufficient to deter retailers from doing so. Administrative penalties are more likely than criminal penalties to be swiftly and consistently enforced. A sample ordinance regarding compliance checks is available at http://www.epi.umn.edu/alcohol/local/adminpen.shtm.

Other Key Attributes

None.

Technical Attributes

Target

Individuals who are drinking at hazardous levels but are not yet alcohol dependent and who have come in contact with the health care system, often in a hospital emergency department as a result of alcohol-related injuries.

Expected Effectiveness

A substantial body of research indicates that brief interventions delivered in primary care settings can reduce the amount of alcohol consumed by persons who are identified as problem drinkers. For example, Monti et al. (1999) randomly assigned 94 young patients (ages 18 or 19) at a hospital emergency department to either a brief motivational interview or standard care. All of the patients either had a positive BAC or reported drinking prior to seeking treatment in the emergency department. In comparison with patients who received the brief motivational interview, those who did not were four times more likely to report drinking and driving at 3 and 6 month follow-up interviews. To date, few studies have examined the effect of brief interventions on motor vehicle crashes. In one recent study in a primary care setting, 226 young patients were randomly assigned to either their usual care or an experimental brief intervention (Grossberg et al., 2004). At a 4-year follow-up, young adults receiving the brief intervention were less likely than their counterparts to have been in a motor vehicle crash involving injuries (9 percent versus 20 percent). These findings are encouraging, but they must be replicated in other health care settings, with different types of brief interventions and larger study samples, before this strategy can be considered proven.

It is noteworthy that in many studies employing randomized, controlled trials, patients in the control condition also show decreases in alcohol consumption at follow-up assessment. This suggests that the assessment procedure itself may serve as a brief intervention. That is, simply asking patients to complete a screening questionnaire about their alcohol consumption may reduce future drinking.

Keys to Success

It is possible for brief intervention programs that do not include a screening component to be effective. However, a program that includes a well-defined screening protocol will identify a larger proportion of patients with mild-to-moderate problems—the type of patient for whom a brief intervention is intended—than a program that does not. When systematic screening is not used, clinicians tend to identify patients with the most severe problems. This type of patient generally needs more intensive, specialized treatment. A screening mechanism that is easy to use and interpret is key to any intervention process, since staff time and resources are limited.

To improve physicians’ use of brief interventions, procedures should be developed and evaluated within entire clinics or hospitals to ensure that brief interventions become a systematic part of routine care. This will require the active participation of all clinical staff, not just individual clinicians.

Potential Difficulties

Even if a systematic program for conducting brief interventions has been established within a health care setting, there are still several difficulties facing effective implementation. Some patients may not speak English, and there may be insufficient bilingual staff to assess and intervene with these individuals. Some patients may have injuries of a severe nature that preclude the opportunity to employ a brief intervention. Other patients who are asked questions about their drinking behavior may be unwilling to participate in the screening process, or they may understate their drinking. Although a number of screening instruments have been developed to identify individuals who may be at-risk or problem drinkers, these instruments are imperfect—some individuals who have problems with alcohol will be missed (Chang et al., 2002). Moreover, not all physicians see the value of conducting brief interventions. In one survey, only 27 percent of emergency department doctors agreed that brief interventions could have a positive effect on reducing alcohol abuse problems (Danielson et al., 1999). Thus, not all physicians can be expected to implement brief interventions as intended.

A major difficulty in establishing a successful intervention program is having adequate staff time to carry out the interventions. Staff must be equipped with sufficient resources and training to initiate and maintain the intervention beyond the initial startup enthusiasm. Another potential difficulty concerns the nature of the medical industry and record keeping. Forty-seven states have laws, intoxication exclusion policies for insurance companies, or precedent-setting court cases that may relieve insurers of liability in instances where an injured individual was "intoxicated" or under the influence of non-prescription drugs (referred to as uniform accident and sickness policy provision laws). Thus, many health care institutions are hesitant to implement alcohol-screening procedures because these procedures could result in insurers denying payment for treatment costs. In practice, this issue pertains only to a relatively small number of individuals seen in emergency departments; many patients either are uninsured or have insurance policies that don’t actively enforce the provisions of these laws. Nonetheless, for reasons of logistic feasibility, health care providers may discourage screening for alcohol problems among patients seen in emergency departments.

Appropriate Measures and Data

Providing brief interventions, especially within the arena of emergency medicine, has the potential to yield a number of favorable outcomes, including reductions in alcohol consumption, alcohol-related traffic crashes and fatalities, and injuries and fatalities arising from other alcohol-related causes (e.g., liver cirrhosis and domestic violence). Indications suggest that while the actual intervention may be brief, the effects of the intervention may be felt across society on a much larger basis.

To ensure that brief interventions are conducted consistently and in the manner intended, useful process measures would include the percentage of patients in the target population who receive an intervention, the percentage of appropriate staff trained to provide brief interventions, and the type of training available to staff.

Associated Needs

Further research is needed. Although brief interventions have been shown to be effective in a variety of medical settings, many research questions remain to be answered. For example, researchers have not yet determined the optimal components of brief interventions, including their content, their length, the number of contacts, and the credentials of the health professional delivering the intervention. Moreover, most studies have employed follow-up assessments within 3 to 12 months of the intervention. The long-term effects of brief interventions are currently unknown.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

To be most effective, screening for alcohol-related problems should be incorporated into the initial emergency department intake or triage process and applied to all individuals seeking medical treatment for an injury. A well-designed intervention will take into consideration the individual’s willingness to cooperate and will allow the provider to take that attitude into account when making subsequent referrals and follow-up plans.

It will be important to gain the support of relevant medical institutions and practitioners for the use of brief interventions. Policies to support this practice and procedures to make staff aware of the latest techniques should be encouraged.

Issues Affecting Implementation Time

Once changes in policy have been made, appropriate staff will need to be trained to carry out the intervention. If training materials must be developed and trainers must be found or trained, the implementation time will be longer.

Costs Involved

The primary costs of this strategy involve adequate training for health care providers and the time that is required to implement brief interventions in practice. In some settings, additional personnel may be needed to provide adequate staff time for these interventions. However, brief interventions should ultimately be a cost-effective benefit because they lower the number of problem drinkers who are hospitalized or who seek treatment for an alcohol-related injury or illness. For example, one study suggested that every $10,000 invested in brief interventions results in a cost savings of $43,000 (Fleming et at., 2002).

Training and Other Personnel Needs

Several recent studies indicate that formal courses with lectures and handouts do little to change physicians’ behavior in practice settings (Davis et al., 1995). These studies suggest that peer education, role-playing, and hands-on training are needed to help medical professionals learn how best to communicate with patients to improve success rates of brief interventions. To improve the use of brief interventions, it will also be important to educate health providers about the potential value of this intervention to problem drinkers and society.

Legislative Needs

In states with uniform accident and sickness policy provision laws or intoxication exclusions, revision or repeal of those laws and exclusions would be helpful in encouraging widespread implementation of this strategy. In states where health care providers may, in effect, be penalized for obtaining information on alcohol use during patient screening, providers are unlikely to obtain this information.

Other Key Attributes

None.

Technical Attributes

Target

The general public (all potential drinking drivers) and actual drinking drivers.

Expected Effectiveness

DWI checkpoints can have a significant deterrent impact on drinking-driving. Several studies have shown that the use of well-planned checkpoints, coupled with campaigns to publicize them, can reduce alcohol-related crashes from 10 to 30 percent (Jones and Lacey, 2001; Ross, 1992; Shults et al., 2001). NHTSA estimates that the routine use of high-visibility checkpoints would reduce alcohol-related fatalities by 15 percent, at a cost saving of approximately $62,000 per checkpoint (NHTSA, 2004a).

Keys to Success

DWI checkpoints are most effective as part of a sustained effort to deter impaired driving. Ideally, checkpoints would be scheduled every weekend of the year in several counties or jurisdictions within a state or region. Regardless of how wide a region is covered, or how frequently checkpoints are conducted, in order to have a clear safety benefit, it is critical that the checkpoint program be widely publicized. Checkpoints not only catch drinking drivers but also, more importantly, deter individuals from driving after drinking because they are more likely to believe they will be detected and apprehended if they know a checkpoint program is in progress.

Potential Difficulties

One of the main difficulties associated with DWI checkpoints is staffing and associated costs (Fell et al., 2003). Conducting checkpoints often involves overtime work for police officers, and enthusiasm for overtime work may wane over time. Hence, scheduling checkpoints and staffing them can become a challenge. Using small-scale checkpoints that require fewer officers can help to alleviate this problem. Research suggests that smaller checkpoints using three to five officers can have just as great a deterrent effect as larger, more costly checkpoints (Stuster and Blowers, 1995). To assist with staffing needs, jurisdictions can combine resources. This is especially important in less populated and rural areas. Finally, it can be difficult to obtain political support and media interest for a sustained checkpoint program. There is often considerable excitement at the outset of a checkpoint program; however, media interest in the program may diminish over time as the program is no longer new.

Appropriate Measures and Data

Police should routinely collect and report process data from checkpoint activities, including the number of agencies involved, the number of vehicles stopped, and the number and types of arrests made as a way of tracking how well a checkpoint program is implemented. However, the actual effectiveness of a checkpoint program should be measured by the reduction in alcohol-related crashes in the community. Gauging the success of a checkpoint operation simply by the number of drinking drivers arrested or the number of checkpoints conducted is inappropriate. At least one study suggests that program effectiveness is not predicted simply by the number of checkpoints conducted (Mercer, 1985). The deterrent effect of a well-designed and carefully implemented checkpoint program will reduce the number of drinking drivers on the road far more than the actual arrests made at checkpoints will.

Associated Needs

DWI checkpoints require time and sustained commitment by law enforcement agencies (i.e., local police, sheriff’s departments, and the highway patrol). Some equipment will be necessary, including traffic cones, warning signs, passive alcohol sensors (ideally), portable breath-testing devices, and readily available evidential breath-testing equipment.

A number of states have funded DWI enforcement vans to assist with these efforts. Although costly, these vans contain and transport all necessary equipment for conducting a DWI checkpoint, including evidential BAC test equipment. These vans can dramatically reduce the time required to process arrests and can draw attention to the checkpoint program. Finally, officers should provide educational materials to every stopped driver explaining the purpose of checkpoints and the dangers caused by drinking-driving.

Publicity in support of the program should include a wide variety of both "earned" and paid media coverage. Press releases should be issued the week before and day before to announce a checkpoint. Local television stations should be contacted in advance and informed of the checkpoint program, and media coverage of the checkpoints themselves should be encouraged. When checkpoints are part of a continuous program, it may be difficult to obtain sustained media coverage. Therefore, paid media (e.g., billboards, radio, and TV ads) may be necessary to ensure that awareness for the program remains high.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

Political support is essential for implementing an effective and sustainable checkpoint campaign. The top political official (i.e., the governor and/or mayor) and other political leaders must understand the value of and endorse the campaign. Additionally, local prosecutors must support the use of checkpoints, and the heads of law enforcement agencies, including the state highway patrol, must make DWI checkpoints a priority if the checkpoints are to achieve their potential. Judges who will handle the arrest cases should be informed of the objectives and effectiveness of this strategy and the importance of their role in its success.

Issues Affecting Implementation Time

The primary factor affecting implementation time is the scope of the program and whether a supportive political climate exists for conducting checkpoints. A statewide program will require a considerable amount of planning and coordination between agencies. This process will take several months before the checkpoint operation can begin. Local checkpoint programs can be organized more quickly. However, it will still take time to ensure the appropriate and necessary media coverage for the program to produce the desired effect. In all cases, a good first step is to assign a senior law enforcement officer as the manager and primary contact for the checkpoint operation.

Costs Involved

Funds are needed to cover law enforcement salaries, publicity costs, and other program expenses. Although checkpoints entail time and resources, considerable savings can be achieved through the associated reduction in alcohol-related crashes and fatalities. Examples of the costs for conducting a DWI checkpoint are available from NHTSA at http://www.nhtsa.dot.gov/people/injury/alcohol/impaired-drivingusa/US.pdf. See also the report on "Checkpoint Tennessee," which provides an example of a comprehensive, statewide checkpoint campaign (http://www.nhtsa.dot.gov/people/injury/research/ChekTenn/ChkptTN.html).

A variety of federal and state funding is available to law enforcement agencies to assist with the cost of conducting checkpoints. These funds are generally administered through each state’s highway safety office. Information on the NHTSA assistance grants may be found at http://www.nhtsa.dot.gov/people/injury/alcohol/StopImpaired/funding.html.

Training and Other Personnel Needs

Establishing an effective DWI checkpoint program may require some specialized training of law enforcement personnel. Officers may need some training in detecting drivers’ alcohol use based on the minimal amount of information available from a driver sitting in a stopped vehicle, a task more difficult than most officers tend to believe. For this reason, the use of passive alcohol sensors as screening devices is highly recommended, and training in the use of these devices is important. Officers who work checkpoints should also be trained in administering standardized field sobriety tests to suspected impaired drivers. Furthermore, officers should be aware of the need to follow all requirements of statutory and case law when conducting checkpoints.

Legislative Needs

In 1990, the U.S. Supreme Court ruled in Michigan v. Sitz that DWI checkpoints do not constitute illegal search and seizure. The Court decided that the brief intrusion of a checkpoint is justified by the public interest in reducing drinking-driving. Currently, Idaho, Iowa, Michigan, Minnesota, Oregon, Rhode Island, Texas, Washington, Wisconsin, and Wyoming prohibit law enforcement officers from conducting checkpoints for the purposes of apprehending drinking drivers. Alaska does not currently conduct checkpoints as a matter of policy. In states where checkpoints are not permitted (usually by provisions in the state constitution or by enacted statute), efforts should be made to remove this legal barrier to the use of a proven effective approach to reducing driving after drinking. More information regarding the legality of DWI checkpoints is available at http://www.nhtsa.dot.gov/people/injury/alcohol/SobrietyCheck/caselaw.html.

Other Key Attributes

In states where checkpoints are not permitted, saturation patrols can be used to reduce impaired driving. Under this approach, teams of law enforcement officers target specific traffic corridors that have a high potential for drinking-drivers (e.g., weekend evenings on roads near bars). Some jurisdictions have developed much larger saturation patrols that cover entire geographic regions, combining efforts of multiple police agencies. As with checkpoints, the effectiveness of saturation patrols depends on extensive publicity about police activity. Some jurisdictions publicize their saturation patrols in the same way as they do DWI checkpoints.

Technical Attributes

Target

The general public (all potential drinking drivers) and actual drinking drivers.

Expected Effectiveness

Most police departments enforce DWI laws at some level. This strategy highlights the importance of conducting DWI enforcement at a high level throughout a broad range of police activities. Measuring both the intensity and extent of enforcement is difficult, as is evaluating the effect of increased intensity or extent on DWI arrests, traffic crashes, or casualties. However, increased enforcement clearly is effective, as the checkpoint studies demonstrate (see Strategy 5.1 B1). A 5-year program was implemented in six Massachusetts communities aimed at reducing drinking and driving as well as speeding, failure to wear safety belts, and other moving violations (Hingson et al., 1996). The program resulted in a 42-percent decrease in fatal crashes involving alcohol, as well as a reduction in the percentage of vehicles observed to be speeding. The primary author also noted that approximately half of the speeders had been drinking and half of the drinking drivers were speeding.

Keys to Success

To be most effective, detection of drinking drivers should be a continuous focus of police enforcement activities. During every traffic stop and every crash investigation, officers should observe the driver for signs of impairment and conduct appropriate follow-up procedures if alcohol is suspected. It is important that all officers who are engaged in traffic enforcement be familiar with signs that a vehicle’s driver may be impaired (Stuster, 2000) and signs that an individual may be impaired (Preusser, 2000), know how to administer standardized field sobriety tests (Burns, 2000), and know the proper procedures for arresting and processing impaired drivers (Simon, 2000).

Potential Difficulties

Many jurisdictions struggle to maintain a consistent level of resources for routine traffic enforcement. In recent years, funding and staffpower have been diverted to other police activities such as homeland security. Because of limited resources, it is especially critical that police include DWI detection as part of their routine enforcement efforts.

Appropriate Measures and Data

This strategy should increase the number of drivers stopped for suspicion of impaired driving, though the data may not be readily available. DWI arrests may increase. As with DWI checkpoints, the number of drinking drivers on the road and the number of alcohol-related crashes both should drop.

Associated Needs

It is important to provide all traffic enforcement officers with equipment to assist in DWI arrests, such as passive alcohol sensors, preliminary breath test devices, and, if appropriate, in-car video cameras. Passive sensors can be highly useful at DWI checkpoints in helping officers determine whether drivers have been drinking and whether a more thorough investigation is needed for a possible DWI or, especially, a zero tolerance violation (Farmer et al., 1998).

A preliminary breath test is a portable breath-testing device that provides a BAC reading from a breath sample. Preliminary breath test results provide evidence to support a driver’s arrest, after which an evidentiary breath test is taken. (Use of preliminary breath tests depends on state law, legal opinion, and judicial findings. Not every state permits use of preliminary breath tests.)

In-car police video recorders can document an offender’s behavior at the time of arrest (including signs of impairment). They also provide evidence that police officers followed the correct procedures during a traffic stop. Although the effectiveness of video recorders has not been fully established, preliminary evidence suggests that they lead to more arrests being resolved in the state’s favor (Jones, 1999). Video cameras also can be used to record the driver’s behavior at the police station after he or she has been arrested.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

In some jurisdictions, it can be difficult and time consuming for police officers to process DWI arrests. This difficulty provides a disincentive for police officers to make an arrest for DWI, and it reduces the amount of time they have available to apprehend offenders. Therefore, it is important that states streamline their processing of DWI arrests through methods such as simplified and standardized forms and computer-based data entry systems (Jones et al., 1998).

It is also important that political and other community leaders support law enforcement officers in their DWI enforcement efforts. Apprehending drinking drivers should be a high priority for law enforcement, policy makers, and the community.

The understanding and support of the judiciary is also important. Ongoing liaison with the courts is highly desirable.

Issues Affecting Implementation Time

This strategy can be implemented relatively quickly in every state.

Costs Involved

Funds will be needed to provide all traffic enforcement officers with both the training and the equipment needed to do effective DWI enforcement. Grants are available for training through state highway safety offices. The funds come from the NHTSA assistance grants. Information on these grants may be found under program number 20.605, "Safety Incentives To Prevent Operation Of Motor Vehicles By Intoxicated Persons," at http://www.nhtsa.dot.gov/people/injury/alcohol/StopImpaired/funding.html.

Training and Other Personnel Needs

Officers whose primary responsibility is traffic enforcement must be given adequate training to detect and arrest impaired drivers and to provide compelling testimony in court. In particular, all officers must have up-to-date training to conduct standardized field sobriety tests.

Legislative Needs

Legislative action may be needed for this strategy to explicitly authorize police officers to use equipment to assist in DWI enforcement, including passive alcohol sensors, preliminary breath tests, and in-car video cameras. In some states, Legislation may also be needed to allow officers to administer an evidentiary breath or blood test after finding positive evidence of alcohol from a passive alcohol sensor or preliminary breath test. Legislation may also need to be changed to simplify the processing of DWI arrests and reduce the time that officers spend away from active patrol duties. States should consider enacting primary seatbelt laws, which allow officers to stop a motorist solely for not wearing a seatbelt. Because of the strong relationship between seatbelt use and impaired driving, seatbelt laws enhance the ability of officers to detect impaired drivers. In addition, states with primary seatbelt laws have higher rates of seatbelt use, thereby protecting more drivers from injury in alcohol-related crashes. For more information, see http://www.nhtsa.dot.gov/people/ injury/ alcohol/ impaired-drivingusa/US.pdf.

Other Key Attributes

None.

Technical Attributes

Target

Drivers under 21 years of age.

Expected Effectiveness

Although a number of studies have shown that zero tolerance laws are effective in reducing drinking-driving among young people, these laws have their greatest targeted effect when combined with well-publicized enforcement. For example, a study of zero tolerance in Maryland found that the law by itself reduced drinking-driving crashes among drivers under age 21 by 21 percent, while the addition of an extensive public information campaign about enforcement of the law reduced crashes by an additional 30 percent (Blomberg, 1992). The importance of publicity is also illustrated by Maine’s zero tolerance law. In 1995, Maine reduced the permissible BAC for young drivers from 0.02 to 0.00. Although substantial decreases were observed in nighttime single-vehicle crashes (a proxy for alcohol-involved crashes), these decreases occurred several months before the law took effect, when there was extensive publicity about the legislative debate and the forthcoming law change (Lacey et al., 2000).

Keys to Success

Publicity about enforcement is key to ensuring that young drivers are aware of zero tolerance and the consequences for violating the law. This publicity can take many forms but should use communication channels that are likely to reach teens. Officers speaking to students in schools, educational materials provided to new license applicants at licensing offices, and ads in popular electronic media are just a few examples.

Publicity without enforcement will likely be viewed by teens as an empty threat. Therefore, it is critical that law enforcement officers be familiar with the law and look for violations when they stop young drivers for any traffic infraction. Well-publicized special enforcement efforts related to zero tolerance can also substantially increase awareness and perceived enforcement of the law.

Finally, zero tolerance is most effective when implemented administratively and when it includes immediate suspension of the young driver’s license. The license is a symbol of independence for young persons, and losing it is a severe penalty. As with any sanction, certainty and swiftness are essential if the desired effect is be realized. Judicial involvement in the license suspension process may delay or decrease the certainty of the sanction.

Potential Difficulties

Drinking drivers are difficult to identify when the BAC is low. Such drivers rarely exhibit any visible signs of impairment and may perform well on the standardized field sobriety tests. One solution is to provide officers with equipment that can help identify potential zero tolerance violations. In particular, passive alcohol sensors could greatly improve officers’ ability to detect drivers with low BAC levels. In some states, officers are not permitted to test young drivers unless they are believed to be over the legal BAC limit for adults. This requirement makes it much more difficult for officers to enforce zero tolerance laws. In other states, the smell of alcohol or an officer suspicion of alcohol consumption by the driver is sufficient cause for administering a breath test.

Another difficulty is that young people may plead guilty to zero tolerance violations as a way to avoid a more serious DWI charge. Similarly, law enforcement officers may decide to "go easy" on young offenders and issue a citation for zero tolerance even when a DWI charge would be more appropriate. Zero tolerance violations should not be issued as a replacement for a DWI charge if the driver has a BAC over the legal limit for adults.

Appropriate Measures and Data

Appropriate outcome measures include increased awareness for zero tolerance laws and greater perceptions of enforcement among young people. The level of enforcement, as demonstrated by a greater number of citations issued for zero tolerance violations, could serve as a process measure. Finally, and most importantly, there should be a reduction in alcohol-related crashes among drivers under the age of 21.

Associated Needs

Passive alcohol sensors can be highly useful in helping an officer determine whether a driver has been drinking and whether a more thorough investigation for a possible DWI or zero tolerance violation is needed. Because low BACs are particularly difficult to detect, more widespread use of these devices would greatly assist officers in detecting zero tolerance violations.

Taking young offenders into legal custody is a major complication that can deter enforcement of zero tolerance laws. The American Probation and Parole Association has created a guide for developing a juvenile holdover program. The guide is available at http://www.nhtsa.dot.gov/people/injury/alcohol/juvenile/index.html.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

It is important that states keep the requirements, evidence, procedures, and paperwork simple. California, for example, allows officers to use a hand-held preliminary breath testing device at the roadside (rather than evidential breath-testing equipment at a police station) as evidence to issue a citation and seize the driver’s license. Enforcement of zero tolerance can be much more difficult—and officers may be disinclined to enforce the law as a result—in states that require extensive procedures and paperwork.

In practice, police officers often have little incentive to enforce zero tolerance. Police officers are seldom rewarded for issuing this type of citation. Support and appreciation from the command level would be helpful for increasing enforcement of zero tolerance laws.

Issues Affecting Implementation Time

The primary issue affecting the time needed to begin active enforcement is simply the minimal training needs for officers. Once begun, publicity and enforcement of zero tolerance must be sustained. Every year, a new group of young people obtain a driver’s license and must be informed about this law and persuaded that it is routinely enforced. Implementation time may be affected by the time to plan and mount a campaign to publicize the program.

Costs Involved

Many forms of publicity can be effective without substantial costs. For example, materials handed to license applicants at licensing offices can be produced at low cost. However, high-visibility publicity (both paid and earned media coverage) is more likely to gain the attention of young drivers. For police, enforcement of zero tolerance should be a part of their routine enforcement activities. Hence, the only cost involved is the diversion of time from other enforcement activities. Passive alcohol sensors can be expensive, costing several hundred dollars, and they require maintenance. Nonetheless, if officers will use the devices when investigating young driver traffic violations, underage drinking-driving can be substantially reduced.

Training and Other Personnel Needs

To encourage active enforcement of zero tolerance, states should implement training programs for law enforcement officers that cover the procedures for enforcing the law (e.g., how to detect low-BAC drivers, special requirements for handling juveniles, and encouragement to file zero tolerance charges). Also important is training to convince officers that using a passive alcohol sensor will dramatically improve their ability to detect violations of their state’s zero tolerance law.

Legislative Needs

All states have enacted zero tolerance laws. However, states should review their laws to ensure that optimal provisions are in place to remove unnecessary obstacles to enforcement and to ensure swift and certain punishment. As mentioned above, zero tolerance laws that are implemented administratively rather than through the courts are more likely to be widely applied. The need to take young offenders into legal custody is a major impediment to enforcing zero tolerance laws; carefully crafted legislation is needed to avoid this problem. Finally, zero tolerance laws are more easily enforced when they specifically stipulate that the smell of alcohol or a reading from a portable breath-testing device or a passive sensor is sufficient evidence upon which to charge an individual.

Other Key Attributes

None.

Technical Attributes

Target

The general public (all potential drinking drivers) and drinking drivers.

Expected Effectiveness

ALR laws have a strong deterrent effect on drinking-driving among the general public. Numerous evaluations have shown that ALR laws reduce alcohol-related fatal crashes. One recent study found that states that implement ALR laws experienced a 13-percent decline in the proportion of fatal crashes involving drivers with a BAC of 0.10 or higher (Voas and Tippetts, 1999).

ALR laws, in combination with other DWI countermeasures, have also been shown to decrease the likelihood that DWI offenders will be re-arrested for drinking and driving. For example, a recent study in Ohio found a 25-percent recidivism rate for repeat offenders before ALR laws and other legislative actions were taken, compared with a 7-percent recidivism rate after these laws were implemented (Voas et al., 2000). For a full description of Ohio’s license suspension law, see http://www.nhtsa.dot.gov/people/injury/research/ohio/toc.html.

Keys to Success

The key to this strategy is that the revocation of the driver’s license is swift and certain. In general, it is far simpler to accomplish this administratively, preferably by the arresting officer, than to accomplish this through the court system. Judicial involvement in the license suspension process almost inevitably involves delays and decreases the certainty of the sanction. Although there is no research on what length of time is optimal, NHTSA recommends that ALR laws include a minimum license suspension of 90 days. Ideally, this suspension should be "hard," meaning that offenders are not eligible for restricted driving privileges or a hardship license.

A fundamental element of this strategy is the existence of an appropriate law. Therefore, it will be important to have at least one champion for this strategy within the legislative system.

Potential Difficulties

ALR laws have been employed as a DWI countermeasure for more than 20 years. Most of the potential difficulties and concerns associated with this strategy have long been resolved. For example, there were early concerns about whether ALR laws lead to loss of employment and economic hardship for offenders who lose their licenses. However, surveys of first-time and multiple-time offenders have shown that ALR laws have a negligible impact on an offender’s job and income (Knoebel and Ross, 1997).

Some potential difficulties may arise if the offender requests a hearing to contest the license suspension. For example, law enforcement officers may fail to appear at hearings or hearings may be used by defense attorneys as opportunities for discovery (Jones et al., 1998). To address these problems, Utah passed a law in 2000 allowing parties involved in ALR hearings to participate by telephone. These hearings resulted in a larger percentage of license suspensions being upheld (Wiliszowski et al., 2003).

Occasionally, ALR laws have been challenged in the court system on the basis that they impose "double jeopardy" on offenders. That is, persons who have had their license administratively revoked are still subject to criminal proceedings that can lead to additional penalties, including further actions against the offender’s license. However, no state Supreme Court has ever upheld such a challenge.

It is well documented that many DWI offenders (70 percent or more, according to Ross and Gonzales [1988]) continue to drive even after their license has been suspended, although they appear to drive less frequently and more carefully. Recently, McCartt et al. (2003) conducted unobtrusive observations of DWI offenders with suspended licenses in Milwaukee, Wisconsin, and Bergen County, New Jersey. Among offenders observed traveling, fully 88 percent in Milwaukee and 36 percent in Bergen County were observed driving. The lower prevalence of driving with a suspended license in New Jersey was attributed, in part, to that state’s stronger laws and greater perceived enforcement. For a detailed discussion of strategies to address unlicensed driving, see the guide for addressing collisions involving unlicensed drivers and drivers with suspended or revoked licenses.

Because of the need for transportation that may prompt some unlicensed driving, several states have begun to issue licenses to convicted DWI offenders that restrict the offenders to driving vehicles equipped with an ignition interlock device (see Strategy 5.1 D1). These devices circumvent the need for alternative transportation while protecting road users from impaired driving by the offender.

Appropriate Measures and Data

To gauge the effectiveness of ALR laws, determine whether the laws deter drinking and driving among the general population. This measure will be reflected in a reduction of alcohol-related crashes and fatalities. Furthermore, ALR laws will reduce the percentage of offenders who recidivate after being convicted for DWI, at least during the period of license suspension.

Associated Needs

None identified.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

It is important that states have good communication systems in place between law enforcement, licensing offices, and the court system so that license suspension systems work efficiently and as intended. If communication is a problem, the formation of a task force, with all stakeholders represented, may be helpful.

Issues Affecting Implementation Time

For states that do not have ALR laws, it may take considerable time to implement this strategy, depending on the speed with which legislators can be persuaded to act on the issue.

Costs Involved

There are costs to establish and maintain an administrative hearing system. In some states, these costs have been a barrier to passage of ALR laws. Many states require offenders to pay a fee at the end of the suspension period to have their license reinstated. A study of ALR laws in Nevada, Mississippi, and Illinois found that revenues from license reinstatement fees can offset the costs associated with the law (National Hardcore Drunk Driver Project, 2003). It is important, however, that these fees be modest; high fees may discourage some offenders from reinstating their license, which may result in higher rates of unlicensed driving.

Training and Other Personnel Needs

States establishing an administrative hearing system will need to hire and train administrative hearing officers. Law enforcement officers will require only minimal training to learn proper procedures for seizing an offender’s license.

Legislative Needs

States that do not currently have ALR laws in place will need to enact ARL laws because DOT officials cannot undertake this issue on their own. Useful information for structuring an ALR law can be found at http://www.highwaysafety.org/safety_facts/ qanda/alcohol_als.htm, and a model ordinance suggested by the National Committee on Uniform Traffics Laws and Ordinances (NCUTLO) is available at http://www.ncutlo.org/1999dwi.htm (see Section 107).

Other Key Attributes

In most states with ALR laws, drivers may appeal their license suspension at an administrative hearing. It is important that this hearing deal only with issues relevant to the administrative suspension (e.g., results of the BAC test and whether there was probable cause to stop the driver). In these cases, hearings are rarely requested and the license suspension is rarely overturned (Rogers, 1995). If ALR hearings are allowed to extend beyond these issues, defense lawyers may use these hearings to discover evidence for the criminal case, thus making it harder to convict the offender of DWI.

Technical Attributes

Target

Individuals stopped by police who are suspected of driving while impaired.

Expected Effectiveness

Given the strong association between refusal rates and the penalties for test refusal, states that establish stronger penalties can expect to see noticeable reductions in refusal rates. As a result, drinking drivers will be more appropriately punished, and those in need of treatment for alcohol problems will be more successfully identified. There is no research to indicate the likely magnitude of effect for this strategy. The size of the effect will depend partly upon the severity of the state’s penalties for test refusal prior to implementing this strategy because this initial severity establishes the baseline against which improvements will be compared.

Keys to Success

The support of key government officials will be important for advocating changing the law, as will be establishing the administrative procedures to implement the law once it is changed.

Informing the public of the potential benefits of the strategy will also be important to encourage the necessary action by the legislative and executive branches of government.

A legislative champion will be important to facilitate the passage of the needed legislation to change penalties for test refusal.

Potential Difficulties

Legislation to increase BAC test refusal penalties may be opposed by some defense attorneys and may also be opposed as an encroachment on civil liberties. However, once enacted and if the legislation is carefully written to avoid loopholes, there should be few difficulties with implementing this strategy.

Appropriate Measures and Data

It will be important to monitor breath test refusal rates before and after this program is instituted to properly measure its effectiveness. By establishing stronger penalties for BAC test refusal than for test failure, states should expect to observe a decrease in refusal rates. In addition, conviction rates in DWI cases will likely improve because prosecutors will have more evidence to present during trial. If the state has an effective system for dealing with convicted offenders, providing adequate sanctions and treatment for those who need it, this strategy should reduce alcohol-related crashes.

Associated Needs

None identified.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

There is strong support among law enforcement, prosecution, and judges for stiffer BAC test refusal penalties. In fact, most prosecutors (73 percent) report that the result of the blood alcohol test is the single most critical piece of evidence for obtaining a conviction in DWI cases (Simpson and Robertson, 2001).

It will be helpful to form a coalition of stakeholders to encourage legislative, policy, and procedural changes. It will be important to include the involvement of representatives of the judicial and sanctioning systems in a coalition.

Issues Affecting Implementation Time

Since this strategy requires legislative action, the time required to implement this strategy may be substantial.

Costs Involved

No specific costs are associated with implementation of this strategy. However, a refusal takes less time than a BAC test for officers to process. If refusals decrease and tests increase, officers likely will spend more time on DWI arrests.

Training and Other Personnel Needs

It may be helpful for officers to receive training in how to obtain cooperation from DWI suspects and overcome refusals. Although strong penalties for test refusal can encourage DWI suspects to take a BAC test, the behavior and demeanor of officers also influences whether individuals are cooperative during the arrest process in general.

Legislative Needs

This strategy requires legislative action to amend existing state DWI statutes. In a few states, refusal to take a BAC test is inadmissible in court. In jury trials, it can make the arresting officer appear careless. (Juries may incorrectly assume that the officer forgot to administer the test or that the officer did not believe there was sufficient evidence of impairment to request a BAC test.) Therefore, when writing legislation to implement this strategy, consideration should be given to including a provision stating that a driver’s refusal to take a breath or blood test to determine BAC is admissible in court. Oregon’s DWI statute provides one of the better examples for how to deal with test refusals (http://landru.leg.state.or.us/ors/813.html; see especially Section 813.130).

Other Key Attributes

None.

Technical Attributes

Target

Individuals charged with an impaired driving offense.

Expected Effectiveness

Most research has shown diversion to be ineffective in reducing recidivism, although a few studies have found positive results (NTSB, 2000). No studies have yet examined the effectiveness of eliminating diversion programs. Participation in these programs is typically voluntary; that is, it may be the most motivated offenders who choose to enter a diversion program rather than contest the DWI charge, and this possibility alone explains the lower recidivism rates observed in a few studies.

There is no clear evidence on how much effect this strategy might have. However, a recent literature review found that restrictions on plea bargaining, when combined with other policies, resulted in crash and injury reductions of approximately 10 percent (Wagenaar et al., 2000d).

Keys to Success

For the DWI countermeasure system to work as it is intended, it is important to ensure that all DWI offenses are retained on a driver’s record. If offenders are allowed to plea bargain a DWI charge to a non–alcohol-related traffic offense, then the driver cannot be identified as a repeat offender if he or she is arrested again. Judicial discretion in determining penalties can be valuable. However, completely removing evidence of a DWI offense from a driver’s record should not be an option. Although treatment for alcohol problems is needed by many offenders, removing evidence of a DWI conviction from the driver’s record, or allowing the offender to avoid other sanctions as a result of obtaining treatment or education, is counterproductive.

Potential Difficulties

Although surveys show that prosecutors support the idea of restricted plea bargaining in DWI cases (Robertson and Simpson, 2002), judges may resist procedures that they perceive will slow the adjudication process. Restrictions on plea bargains and elimination of diversion programs may increase the number of DWI cases that are brought to trial, thus expanding caseloads and lengthening the time required to process cases. However, some states, such as New York, do not permit pleas to a non-alcohol offense, and there is no evidence that this situation creates backlogs.

Appropriate Measures and Data

Ultimately, restrictions on plea bargaining and elimination of diversion programs should reduce alcohol-related crashes and injuries. Following the elimination of diversion programs, the conviction rate for DWI—as measured by the number of arrests resulting in a conviction on the original charge—should increase substantially. Similarly, restrictions on plea bargaining to a non-alcohol offense should increase the number of DWI offenders who are convicted and, as a result, receive interventions that are known to be effective in reducing recidivism, such as a requirement to install an ignition interlock device or to obtain treatment for alcohol abuse or dependency.

Associated Needs

One of the enduring problems in the DWI countermeasure system is that judges sometimes do not follow procedures required by law in deciding and sentencing DWI cases. Court-monitoring programs are one means to increase the consistency of DWI sentencing and reduce plea bargains. In court-monitoring programs, citizens track and report on court activities concerning DWI cases. One study in Maine found that court-monitored cases produced higher conviction rates and stiffer sentences than unmonitored cases (Shinar, 1992).

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

There is another common mechanism by which a first-offense conviction for DWI can be masked from the driver record. Many municipalities and counties have adopted the state traffic law as county or municipal ordinance. The drivers are then convicted of violating a municipal ordinance, and any revenue from fines remains in the county. The state receives no revenue, and there is no record of the event. Only after a second or third offense are violators sent to state court, where more serious penalties can be applied. Hence, a person arriving at state court for the first time is considered to be a first-time offender even though he or she may have two previous convictions in county courts.

Issues Affecting Implementation Time

It may take considerable time to implement this strategy, depending on the speed with which legislators, district attorneys, or other policy makers can be encouraged to act upon the issue.

Costs Involved

No particular costs are involved in implementing the strategy, except in cases where additional court and prosecutorial staffing may be needed to handle a heavier caseload.

Training and Other Personnel Needs

It will be important to educate judges about the reasons for restricting plea bargains and eliminating diversion programs. Mentoring programs to train inexperienced DWI prosecutors by pairing them with an experienced prosecutor can help to ease the overload on prosecutors and ensure more effective prosecution of DWI cases. Establishing a traffic safety resource prosecutor in the state to provide training and serve as an information clearinghouse for prosecutors handling DWI cases can also be helpful.

Legislative Needs

This strategy does not necessarily require legislative action. Jurisdictions can set policies for plea bargaining and diversion programs administratively. District attorneys and state attorney generals can also set these practices. State laws, on the other hand, can mandate procedural changes in handling all DWI cases within the state. At present, only about one-third of U.S. states have laws that place some form of restriction on plea bargaining in DWI cases (NTSB, 2000). States that do not have such laws should strongly consider enacting legislation if they wish to effectively prohibit DWI charges from being reduced to a non-alcohol offense. In addition, to ensure that the DWI control system works effectively, states should consider prohibiting plea bargains in high-BAC cases, where pleading guilty to a lower BAC allows individuals to avoid the more stringent sanctions that a number of states now require for first-time, high-BAC offenders. States with diversion programs that allow dismissal of DWI charges after completion of education or treatment should consider eliminating these programs.

Where municipalities or counties prosecute DWI offenders under local ordinances, states should consider amending their statutes to ensure that alcohol-related convictions of individuals under these ordinances are recorded in state records so that the full prior record of individuals tried for DWI in a state court can be known.

Other Key Attributes

None.

Technical Attributes

Target

Individuals charged with alcohol-impaired driving.

Expected Effectiveness

Assessment, in combination with treatment programs for DWI offenders, is effective in reducing DWI recidivism. A recent review of high-quality studies found that assessment, treatment, and rehabilitation reduced drinking-driving recidivism and alcohol-involved crashes by an average of 7 to 9 percent (Wells-Parker et al., 1995). Treatment was most effective when it combined education, psychotherapy/counseling, and follow-up contacts.

Keys to Success

It is important that all DWI offenders be screened for alcohol problems, not merely repeat offenders. Many first-time offenders have significant problems with alcohol. Recent estimates suggest that offenders make as many as 50 to 200 impaired driving trips before they are first apprehended for DWI (Hedlund and McCartt, 2002). The earlier alcohol problems are detected and addressed, the more likely they can be treated successfully.

Ideally, screening should take place as soon as possible after the arrest so that an appropriate treatment can be identified and initiated. A desirable goal is that all assessments be ordered and completed prior to sentencing. During the sentencing process, assessment and treatment of an offender’s alcohol problems should be considered separately when determining appropriate charges and sanctions against the offender. Treatment should not be offered as a substitute for other sanctions, such as driver’s license suspension. Furthermore, offenders should not be permitted to avoid a DWI conviction by completing an assessment and treatment program (i.e., offenders should not have the option to complete so-called diversion programs; see Section 5.1 C3 of this guide).

No one treatment approach will be suitable for all offenders. Although it might be convenient to assign all first-time offenders to one form of treatment and all repeat offenders to another, matching a treatment program to an offender’s needs will likely result in a treatment that is more likely to reduce recidivism. Matching should be conducted by clinical professionals at an appropriate treatment agency. The strategy seems to work best when the court places broad limits on the length and cost of the mandated treatment, then places the offender in the hands of a competent therapist, allowing individual plans to be developed by the therapist.

Successful implementation will require significant coordination and cooperation among the agencies and organizations involved. Therefore, it will be helpful to create a working group consisting of the major players and other stakeholders to work out necessary details early in the planning process.

Potential Difficulties

Organizing a system to ensure the screening of the large number of offenders for alcohol problems is a serious challenge. This may take several years, depending on the existing treatment system in a state. Ensuring that assessments are conducted and treatment provided by qualified professionals is a major task that will involve the licensing of providers by the state’s mental health services oversight agency.

Adding to the difficulty of this task is the fact that individuals who are mandated to obtain treatment as the result of an impaired driving conviction should be required to show evidence that they have succeeded in addressing problems with drinking before they are allowed to drive again. Merely spending time in treatment should not be considered sufficient to allow the individual to begin driving again.

Another difficulty is that the available screening instruments are only partially successful in predicting who will recidivate and who will not. Recent reviews question the accuracy of even the best-rated screening instruments (Chang et al., 2002). This underscores the importance of assessments being conducted by qualified mental health professionals.

In some jurisdictions, high numbers of caseloads may make it difficult for all assessments to be completed prior to sentencing. In these jurisdictions, an assessment should be made a condition of probation. Delaying assessments until after sentencing has a number of disadvantages. For example, if the offender plea bargains to a non–alcohol-related charge, he or she may be able to avoid assessment and treatment altogether (see Section 5.1 C3 of this guide for a further discussion on problems associated with allowing plea bargains to a non-alcohol offense).

Large courts in urban areas may be able to support large, well-funded treatment agencies to conduct assessments; however, many courts in smaller communities may not have ready access to such treatment providers. Providing for adequate screening and treatment in all areas will be challenging.

Finally, obtaining the cooperation of offenders during the assessment process can be difficult. Some offenders may view screening and treatment as a form of punishment. Individuals may not show up for a scheduled assessment, they may be less than forthright during testing and interviews, or they may underreport their alcohol-related problems and history. This is especially a problem in pre-trial assessments, where the offender may be concerned about self-incrimination.

Appropriate Measures and Data

Under a successful assessment program, every offender should be screened for alcohol problems, ideally prior to sentencing. Careful records should be kept on the number of offenders screened and the referral decisions. A screening program that successfully mandates effective treatment for alcohol problems can be expected to reduce the number of repeat impaired driving offenses and, consequently, the number of alcohol-related crashes, although the effect on crashes in the general driving population may be difficult to detect.

Associated Needs

It will be necessary to have a sufficient number of qualified service providers available to handle the large number of cases resulting from the requirement of screening and treatment for all DWI offenders.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

For this strategy to reach its full potential, an integrated information system is essential so that representatives from all involved agencies can quickly determine where convicted individuals stand in regard to the various requirements placed on them for screening, treatment, punishment, and future requirements such as the application of a lower BAC limit if stopped in the future for suspicion of impaired driving (in states that have such a law).

Mandating treatment for convicted offenders will be most effective if individuals are also required to demonstrate progress before they are allowed to drive. One way to track progress is to require participation in an alcohol interlock program. (See Strategy 5.1 D2 of this guide, as well as Strategy 2.1 C2 of the guide for addressing collisions involving unlicensed drivers and drivers with suspended or revoked licenses). Information available from the computer record created by an interlock device provides one possible indicator of whether an individual is likely to commit a future impaired driving offense. Information from the interlock device indicating that the offender has refrained from trying to drive after drinking is therefore a possible indicator of progress in treatment (Marques et al., 2001b). Individuals with untreated or unyielding drinking problems continue trying to start their vehicle when they have an unacceptably high BAC. Hence, including this information may provide one of the best objective indicators of whether an individual should be allowed to drive again without restrictions.

The lead agency implementing this strategy is probably the best one to assemble a working group of stakeholders who will be involved in the planning and implementation of this program.

Issues Affecting Implementation Time

Most courts currently have a system in place for screening DWI offenders. However, in many states, establishing a system that ensures that all offenders are screened and treated appropriately will likely require substantial time and additional resources to hire additional qualified service providers and to set up an effective tracking system to which all involved agencies have immediate access.

Costs Involved

Funds are needed to pay qualified service providers to conduct assessments. In part, these funds can be subsidized through assessment fees charged to offenders, although many individuals convicted of impaired driving cannot pay fees for screening and especially for extended treatment. Diverting DWI fines to cover the costs of assessment and treatment for those who cannot afford it may be a wise use of funds. One important element of the assessment should be an analysis of the offender’s financial status and his or her access to health insurance that may cover some costs. Service providers should be required to establish fees that will permit reduced charges for those the court finds to be unable to pay full costs.

Training and Other Personnel Needs

To conduct assessments in a timely manner, additional personnel will probably be needed in many states. The additional personnel will require substantial time and training.

Legislative Needs

Although most states have laws in place that mandate screening of offenders following a conviction for impaired driving, improvements can be made in the screening, assessment, and treatment process in most states. It may be useful for states to examine their procedures for how and when offenders are assessed, as well as what incentives are allowed or mandated to encourage offenders to complete the screening and treatment process. It is also important to review required certification for service providers to ensure that individuals who complete the screening and treatment process do not receive inferior care.

Other Key Attributes

None.

Technical Attributes

Target

Repeat offenders and high-BAC first-time offenders.

Expected Effectiveness

A number of studies have demonstrated the effectiveness of monitoring programs. For example, an evaluation of an intensive supervision probation program in Milwaukee County, Wisconsin, found that the program reduced recidivism among multiple DWI offenders by half, from 11 percent to 5.5 percent, after 1 year (Jones et al., 1996).

An evaluation in Los Angeles County, California, found that repeat DWI offenders with home detention and an electronic monitoring program had a recidivism rate that was one-third lower after one year, from 6 percent to 4 percent (Jones et al., 1996).

Although evaluations indicate that drug courts are effective (Belenko, 1998), additional research is underway examining DWI/drug courts specifically. Some anecdotal evidence suggests that DWI/drug courts may reduce re-arrest for impaired driving among multiple-offense drivers.

Keys to Success

One key to success for this strategy is that officers of the court system (typically either judges or probation officers) must maintain frequent individual contact with offenders. This close monitoring helps ensure that offenders satisfy the requirements of their sentence or probation. Moreover, by demonstrating that offenders cannot escape sanctions and treatment if required, this strategy may help to deter drinking and driving among the general public.

The other key is that there must be prompt consequences—often jail time—for failing to satisfy sentence requirements. The monitoring approaches described in this strategy are primarily employed with offenders who face jail sentences. Offenders are allowed to avoid jail if they participate in the intensive monitoring program. Thus, judges must be informed promptly, and must take prompt action, if offenders do not satisfy the terms of their sentence.

Potential Difficulties

The greatest problem with intensive monitoring is probably the substantial costs involved, even though some approaches can be much less costly than others. Decreasing resources coupled with rising numbers of DWI offenders have made it difficult for probation officers to adequately monitor offenders. In many jurisdictions, there are too few probation officers to effectively handle current caseloads. A recent survey of probation officers found an average caseload of 112 offenders, about half of whom were on probation for a DWI offense (Robertson and Simpson, 2003). Not surprisingly, in light of this workload, judges often complain of problems with delayed or inconsistent reports from probation officers. Even more problematic is that some jurisdictions—particularly those in rural areas—do not have a probation department. In these situations, the judge and his or her assistants are responsible for monitoring the compliance of offenders.

Heavy caseloads for judges also can impede effective monitoring. Judges often have limited time to review reports provided by probation officers and treatment facilities. Nearly half of judges report that a heavy caseload is the single most significant problem in monitoring offenders (Robertson and Simpson, 2002). DWI/drug courts address this issue by assigning judges a smaller number of cases, thereby allowing them to maintain much closer contact with offenders. DWI/drug courts also allow judges to specialize in DWI cases, so they come to know the complex law and evidence issues and also understand the frequent underlying influence of alcohol dependency or abuse.

Appropriate Measures and Data

The effects of close monitoring of offenders should be evaluated directly through examination of recidivism rates. A successful monitoring program will reduce the proportion of offenders who are re-arrested for driving after drinking. Alcohol-related crashes and crash rates should also be reduced among this population.

Process measures include the number of cases being monitored, by type, and a measure of time per case spent on monitoring.

Associated Needs

None identified.

Organizational and Institutional Attributes

Organizational, Institutional and Policy Issues

Close monitoring of offenders requires effective communication among judges, probation officers, treatment providers, the department of motor vehicles, and other agencies. A task force of stakeholders should be formed early in the process to help develop a program plan and guide its implementation.

Information must be readily available so that the progress of offenders can be tracked through the system and so that individuals who are not progressing as expected can be quickly identified and dealt with. Where BACs are monitored as part of the program, this information should be shared with therapists to be employed in their counseling program.

Issues Affecting Implementation Time

Creating a system for close monitoring of offenders will take time, resources, and personnel to implement. If a monitoring system is already in place and merely needs additional staffing or new approaches, less time will be required.

Costs Involved

Cost is a major issue in monitoring offenders. Costs include time requirements for judges, parole officers, and in some cases special monitoring equipment such as ankle bracelets (costs for the monitoring equipment are paid by offenders based on their ability to pay). However, many of these strategies have been shown to be more cost-efficient than traditional correctional facilities. Moreover, lower recidivism rates of participants suggest that, over the long term, these programs can save money through reduced alcohol-related crashes and fatalities. NHTSA provides cost estimates at the following website: http://www.nhtsa.dot.gov/people/injury/alcohol/impaired-drivingusa/US.pdf.

Currently, a number of location-monitoring systems can monitor the position of an offender continually. The cost of these systems is declining, and they may offer the most effective, low-cost systems for controlling offenders in the future. Transdermal BAC remote monitoring systems are also being introduced to the courts for use with DWI offenders. They may provide lower-cost, more effective systems for monitoring abstinence than the more labor-intensive approaches that have been used by DWI/drug courts in the past.

Training and Other Personnel Needs

In many jurisdictions, there are too few probation officers to effectively handle caseloads. More probation officers are needed so that close contact can be maintained with offenders.

Some judges and probation officers have limited experience with DWI offenders. As a result, they may be unfamiliar with agencies and treatment providers in the community that are appropriate for DWI cases. Training of judges and probation officers is important to ensure that they are acquainted with the critical features of various intensive monitoring approaches, available resources in their community, and the benefits of intensive monitoring.

Legislative Needs

Legislation will not likely be required to implement this strategy.

Other Key Attributes

None.