ORIGINAL CONTRIBUTION

Female Drivers Increasingly Involved in Impaired Driving Crashes: Actions to Ameliorate the Risk Federico E. Vaca, MD, MPH, Eduardo Romano, PhD, and James C. Fell, MS

Abstract Emergency physicians are confronted daily with the care of traumatically injured patients. A considerable proportion of blunt trauma cases are due to motor vehicle crashes. While men have historically been overrepresented in crash-related injuries and deaths, unfavorable trends for women in alcohol-impaired driving crashes have emerged. This extended commentary with in-depth review presents an examination of the evolving role of sex and gender in alcohol-impaired driving and its outcomes. ACADEMIC EMERGENCY MEDICINE 2014;21:1485–1492 © 2014 by the Society for Academic Emergency Medicine

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he societal effects of injury and its toll on human life viewed through the lens of disease burden is staggering. On the front lines of medicine, emergency physicians (EPs) care for patients who suffer injury due to trauma every day. Most of them suffer injury as a result of blunt trauma, with motor vehicle crashes (MVCs) being the second injury-ranked cause (4% of all annual U.S. emergency department [ED] visits) behind falls for 18- to 64-year-olds who visit the ED.1 In 2012, there were over 2.36 million people officially reported as injured and 33,561 killed in crashes.2 Thirty-one percent (10,322) of all fatal crashes involved alcohol-intoxicated drivers, and these crashes are on the rise.2 Furthermore, even though men remain overrepresented in crash injuries and deaths, there are unfavorable trends for women in alcohol-impaired driving crashes. In concert with the 2014 Academic Emergency Medicine consensus conference, “Gender-Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” we provide this article with in-depth review that highlights the evolving role of sex and gender on alcohol-impaired driving and its outcomes.

THE MAGNITUDE OF THE IMPAIRED DRIVING PROBLEM Each year for the past decade, an estimated 1,400,000 U.S. drivers have been arrested for driving while intoxicated (DWI) or driving under the influence (DUI).3 At best, only about 1 in 300 drivers with illegal blood alcohol concentrations (BACs ≥ 0.08 g/dL) on U.S. roads are arrested for DWI,4,5 and at worst 1 in 1,016 trips by drivers with illegal BACs are arrested for DWI or DUI.6 A nationally representative telephone survey of more than 10,000 licensed drivers showed that U.S. drivers admitted to 85.5 million drinking-and-driving trips in the past 30 days in 2008.7 In 2010, an estimated 1,820,094 reported plus unreported crashes involved drivers with illegal BACs. Not all crashes are officially reported to the police. There are different injury and vehicle damage thresholds used by the police in different states that dictate whether a crash is investigated and reported. These police crash reports have been compared to insurance claims of crash damage and/or injury and hospital records to estimate the number of crashes that go unreported to the police.6 Impaired drivers (BACs ≥ 0.05 g/dL) accounted for at least 12,000

From the Department of Emergency Medicine, Yale University School of Medicine (FEV), New Haven, CT; and the Pacific Institute for Research and Evaluation (PIRE), The Calverton Center (ER, JCF), Calverton, MD. Received March 10, 2014; revision received May 25, 2014; accepted July 2, 2014. The authors have no relevant financial information or potential conflicts to disclose. Supervising Editor: Esther Choo, MD, MPH. Address for correspondence and reprints: Federico E. Vaca, MD, MPH; e-mail: [email protected].

© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12542

ISSN 1069-6563 PII ISSN 1069-6563583

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traffic crash deaths, 3.6 million people injured, and $125 billion in societal costs to the United States annually.6 According to the Healthcare Cost and Utilization Project and National Emergency Department Sample, in 2011, there were nearly 3.2 million ED visits for MVCs and over 75% of these visits occurred at trauma centers.8 Crashes remain a serious public health and safety concern with alcohol being a well-known factor contributing to a substantial portion of crashinjured patients admitted to EDs and trauma centers.9,10 As a result, impaired driving has considerable implications for EDs and injury/trauma care throughout the country. Although remarkable progress was made in reducing impaired-driving fatal crashes between 1982 and 1997 in the United States, since that time progress has stalled (Figure 1).11,12 The proportion of all drivers involved in fatal crashes estimated to have been illegally intoxicated has remained at 20% to 22% from 1998 through 2010.13 The reduction in the prevalence of intoxicated drivers in fatal crashes that occurred in the 1980s through the middle 1990s has been attributed to a variety of countermeasures that were implemented during this period. These included tougher impaired-driving laws enacted by the states,14–19 raising the drinking age to 21 years in all the states,20–24 highly publicized and more frequent enforcement,17,25–28 and changes in attitudes toward impaired driving.7,12 Still, approximately 10,000 to 11,000 people currently are killed each year in alcoholimpaired driving crashes. To explain the current stall in progress, some researchers have begun to pay attention to specific groups of drivers, some of them suspected of becoming increasingly involved in impaired driving events. Women are one of such groups of interest. Research shows that women are safer drivers than men.29–34 Indeed, licensed female drivers are less likely to speed, drive while intoxicated, and crash than their male counterparts.34–37 However, recent data that show an increasing participation of women in alcoholrelated crashes have motivated traffic safety experts to contemplate the need for a revision of extant paradigms.

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THE ROLE OF GENDER Historically, the role that gender plays in traffic safety has been subjected to a paradoxical dichotomy. On the one hand and deeply rooted in our society is the stereotype that women are bad drivers,38,39 a stereotype that has been exploited in advertisements and TV shows over the past 50 years.40,41 Even today, an Allstate commercial42 features a woman who says to her male tablemate, “Remember when you said that men are superior drivers?” Although the commercial’s intent is to debunk this stereotype by depicting a woman who receives a bonus check for driving safely, the premise that a woman has to defend her driving proficiency to a man suggests that the erroneous perception of women as poor drivers persists. On the other hand, and informed by data, researchers and policy-makers have long considered MVCs in general and impaired driving in particular a problem dominated by males. The evidence shows that males account for most of the U.S. traffic fatalities, with population rates of involvement about three times higher than that for females.43 Not surprisingly, males have received most of the researchers’ resources and focus.44,45 But recently, strong evidence has surfaced showing an increase in impaired driving among females,36,46,47 particularly among young women.48 This recent wave of research efforts clearly contradicts the extant paradigm that views traffic safety problems largely as a male domain. The remaining sections of this article focus on the need for a revision of that paradigm. To more clearly highlight the role of gender on impaired driving, we provide data from previously published studies and reports on noncrashed (i.e., from roadside surveys) and crashed drivers, as well as related arrests. Roadside Surveys We first examine drivers on U.S. roads using the recent National Roadside Survey (NRS) findings of alcohol impaired driving.49 The 2007 NRS is the fourth of that kind completed in the United States, following those conducted in 1973, 1986, and 1996 where both self-report and biological measures were taken. Biological measures

Figure 1. Impaired-driving fatal crashes between 1982 and 2010 in the United States.

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included breath alcohol samples from 9,413 drivers, oral fluid samples from 7,721 drivers, and blood samples from 3,276 drivers.50 BACs from preliminary breath-testing units were available on 86% of the eligible drivers. When examining the 1996 versus 2007 NRS survey results, male drivers with BAC ≥ 0.05 g/dL decreased from 8.7% in 1996 to 5.3% in 2007, a 39% reduction in that proportion. Conversely, female drivers with BAC ≥ 0.05 g/dL decreased from 5.8% in 1996 to 3.0% in 2007, a 48% reduction in that proportion. When examining high BACs, male drivers with BACs ≥ 0.10 g/dL went from 3.5% in 1996 to 1.8% in 2007, a 49% decrease in that proportion, while female drivers with BACs ≥ 0.10 g/dL went from 1.5% in 1996 to 1.0% in 2007, a 33% decrease in that proportion. Although by no means definitive, these figures seems to indicate that impaired driving by female drivers on our U.S. roads may not be decreasing at the same rates as male drivers, at least at high BACs. Fatal Crashes Examining fatal crashes in 2010, there were 9,531 drivers who had illegal BACs (≥0.08 g/dL).51 A total of 1,810 were female drivers (19%). This compares to 7,721 intoxicated male drivers (81%), representing 24% of all male drivers involved in those fatal crashes. However, while 69% of intoxicated male drivers (BAC ≥ 0.08 g/dl) had very high BACs (BAC ≥ 0.15 g/dl) compared to 68% of intoxicated female drivers, there remains a 4:1 ratio of male to female drivers with very high BACs in sheer numbers. So the same proportion of intoxicated male and female drivers in fatal crashes have very high BACs (≥0.15 g/dL). However, these figures fail to capture an underlying trend, and that is the increasing participation of women in DWI arrests36,52 and young women in alcohol-related fatal crashes.48,53 The National Highway Traffic Safety Administration (NHTSA) has reported that the number of male drivers killed in fatal crashes dropped from 45,084 in 1975 to 39,739 in 1994 and to 22,860 in 2011. Yet, during the same period and in absolute terms, the number of female drivers in fatal crashes remained stable, from 9,356 in 1975 to 9,499 in 2011, subsequently yielding a relative increase in women’s involvement in crashes (i.e., relative to that by men). Not surprisingly, the estimated involvement rate in fatal crashes per 100,000 licensed male drivers has constantly declined over a 30-year period (from 62 in 1975 to 42 in 2003), but has remained unchanged for female drivers for about 15 years.13 This points to the increasing proportion of female drivers involved in all fatal traffic crashes. Arrests for DUI Given the observed relative increase of women in fatal crashes, perhaps it is not surprising then that the number of women arrested for DWI (of all ages) also has been increasing over the past two decades or so. Between 1998 and 2012, there was a 92.6% increase in the number of females arrested for DUI (126,781 and 244,195 in each of those years, respectively), while arrests of male drivers increased only 8.6% (684,191 and 743,029, respectively).3,54 However, some researchers have pointed out that the increase in women’s arrests may have been related not as much to an

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increase in actual DWI, but rather to an increase in driving mileage (more driving over time),47 as well as changes in social and enforcement perceptions involving the arrest of women (i.e., changes in law enforcement that made officers less likely to pardon female drivers for traffic violations).36 Tougher laws and stricter enforcement directed at less intoxicated offenders may have inadvertently targeted lower BAC female drivers.55 Nevertheless, specialized DUI enforcement activities appeared to arrest deeper into the offender pool and consequently had stronger arrest-producing effects on female drivers who typically drive at lower BACs than male drivers. Still, Schwartz and Davaran56 found that enforcement following the lowering of the illegal BAC limit in the states from 0.10 to 0.08 g/dL was associated with increased arrests for both sexes. In summary, although the evidence coming from roadside surveys, arrests, and crashes clearly show an increase in the participation of women in impaired driving events (young women in particular), the causes and mechanisms for such a change are still unclear. For instance, it is unclear how much of such change is caused by an increase in exposure (miles driven) or by the adoption of risky behaviors by an increasingly larger number of women. Although there is evidence supporting both such arguments, the evidence also signals that young women as a group have become increasingly risk-taking regarding driving behaviors, drinking and driving in particular. To add to these complexities there are differences in the patterns of drinking as well as in drinking and driving between males and females (e.g., compared with men, women are much less likely to be very intoxicated when driving, but such a proportion rises sharply among those fatally injured drivers). Furthermore, changes in law enforcement regarding the likelihood that officers would arrest female traffic violators also have contributed to making the interpretation of extant data difficult. CHANGING ROLES, DRIVING PATTERNS, AND INCREASED EXPOSURE One often-cited explanation for the increasing prevalence of women in alcohol-related crashes and arrests is the increasing level of crash exposure (miles driven) that has taken place among women.57 The number of licensed female drivers has increased steadily from 1975, when there were seven licensed women for every 10 licensed males, to 1994, when it reached parity with males.58 In 2010 there were 105.7 million licensed women and 104.4 million licensed men.59 Data from the 1990 and 2009 National Household Travel Survey (NHTS) shows that annual driving increased across the nation from 1.7 to 2.7 trillion miles in that period.60 Although the increase was evenly split between men and women, the percentage changes were not equivalent. Mayhew et al.47 reported that in 1977, women drove an estimated 378 billion miles; in 1995, that number was 886 billion miles. According to the NHTS, in 2009 men traveled about 10 more miles per day than women, and they also exhibited the greatest decline in miles driven per day since 2001.60 Therefore, not only was there a greater increase in the number of women

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licensed to drive but also a greater increase in their amount of travel. WOMEN, ALCOHOL, AND CRASH RISK The increase in exposure may not be the only reason for the increased prevalence of women in alcoholrelated crashes and arrests. In a 2008 study by Romano et al.,61 the authors examined the issue of why women are increasingly represented in MVCs and arrests. They reported evidence suggesting that increases in both exposure and risk were behind the surge in prevalence. A closer examination of crash risk was conducted recently by Voas et al.53 Comparing data from the Fatality Analysis Reporting System (FARS) and the 2007 NRS, the authors replicated a prior study by Zador et al.62 that used 1996 FARS data and the 1996 NRS to estimate crash risk. The authors reported that the relative risks at any given BAC (i.e., the risk of being involved in a crash at a given BAC > 0.00 relative to the risk of being involved in a crash at BAC = 0.00) were the same for male and female drivers. That differed from what was reported a decade earlier by the same group, who found that compared with their male counterparts, young female drivers were significantly “less risky” at the BAC levels examined (i.e., that at any given BAC > 0.00, the crash risk for female drivers relative to that at BAC = 0.00 was lower than that for males). In their 2012 study, Voas and colleagues53 reported that the relative risk for 16- to 20-year-old female drivers caught up with the risk for male drivers in 2007 compared to 1996, when the risks were lower for young female drivers compared to young male drivers. The still not well-elucidated interaction between gender differences in crash exposure and driving behaviors in shaping impaired driving is further blurred by physiological differences. There is ample evidence showing that alcohol has differing physiological effects on women than on men. In laboratory settings, women are far more affected than men at moderate and high levels of BAC when asked to respond to visual stimuli63 or to perform tasks requiring dexterity.64 In part because of gender differences in body water content and in alcohol pharmacokinetics (i.e., the physiological processing and elimination of alcohol), women tend to reach higher BACs than men under equivalent amounts of alcohol consumption.65 These gender-based differences may increase women’s vulnerability to the deleterious effect of alcohol66 and, therefore, also explain in part the observed high rates of BAC among female crashed drivers. Simply put, because as we have already discussed women are consuming alcohol at increasing rates (young women in particular), the higher vulnerability of women to alcohol (relative to men) may partially explain why women (young women in particular) also are increasingly involved in impaired driving and alcohol-related crashes. TWO KEY OPPORTUNITIES FOR EMERGENCY MEDICINE There are two notable countermeasures worth mentioning that should resonate with EPs and affect female

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drinking drivers: ED alcohol screening with brief intervention and referral to treatment (ED-SBIRT) strategies and lowering the illegal BAC limit for driving from 0.08 to 0.05 g/dL. The first is a specific deterrent and may benefit from a gender-specific approach; the second is a general deterrent to drinking and driving that is likely to improve safety outcomes for both men and women. ED-based Alcohol Screening and Brief Interventions In 2010, U.S. EDs had more than 129 million visits (42.8 ED visits per 100 persons) and nearly 38 million of these visits were for injury.67 A large proportion of ED visits are attributed to alcohol, and there is evidence that alcohol-related ED visits are increasing.68 The disease burden and harm associated with alcohol are well established.69 With the millions of annual alcohol-related injuries and medical comorbidity visits to U.S. EDs, these encounters provide an opportunity to identify, intervene, and initiate treatment in the lives of those with alcohol use disorders.70 Over two decades ago, EM clinicians and researchers recognized the need to systematically identify and intervene in unhealthy drinking ED populations.71 While early alcohol EDSBIRT studies initially provided mixed results,72 today, several scientifically rigorous ED-SBIRT clinical trials empirically demonstrate reductions in drinking and harm.73–75 For example, the Academic ED SBIRT Research Collaborative studied patients who drink over the National Institute on Alcohol Abuse and Alcoholism low-risk limits in 14 national ED sites. At 3-month follow-up, the brief intervention group reported consuming 3.25 fewer drinks per week than the controls.75 Further, a large alcohol ED-SBIRT randomized controlled trial by D’Onofrio et al.73 showed that alcohol ED-SBIRT reduced hazardous and harmful drinking in ED patients with reductions from baseline to 12 months in the mean number of monthly binging episodes of 2.8 (intervention group) and 2.1 (intervention and booster phone call at 1 month by a nurse), compared with the 1.4 in the control group. Several large and rigorous EDbased alcohol screening and brief intervention studies have also shown that brief interventions can improve patient outcomes by decreasing alcohol impaired driving as well as DUI arrests.73,76,77 While to date conclusive and definitive evidence that shows meaningful differential effects based on sex in ED-based alcohol SBIRT is lacking, recent studies do point to the need and importance to clarify this area, and emerging research will focus on the clinical outcomes from alcohol interventions with sex-specific content.78,79 Until that time, we believe that reinvigorating and broadening the implementation of ED-SBIRT could not only potentially help improve the current lag in its use behind national guidelines,80 but could also potentially attenuate the overall all as well as sex- and gender-based negative trends in alcohol-impaired driving. Lowering the Illegal BAC Limit for Driving to 0.05 g/dL On May 14, 2013, the National Transportation Safety Board issued the report, Reaching Zero: Actions to Eliminate Alcohol-Impaired Driving, recommending that states should lower the illegal BAC limit for driving

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from 0.08 g/dL to 0.05 g/dL.81 They provided a sound rationale and concluded that lowering the BAC limit to 0.05 g/dL or lower has a strong evidence-based foundation.81 At least 91 countries around the world have adopted a 0.05 g/dL BAC (e.g., Australia, Austria, France, Germany, Italy, and Spain) or lower limit for driving (e.g., Japan, Norway, Russia, and Sweden have a limit of 0.02 g/dL BAC). Historically, EPs and EM researchers have regularly engaged in local, state, and national advocacy activities that have helped transform policies and improve the public’s safety and health.82,83 While the move to lower the illegal BAC limit for driving is clearly a highly important consideration in the scope of injury prevention and crash-related morbidity and mortality reduction, the rationale for adopting and advocating for a 0.05 g/dL BAC law should be well understood. This can serve to support advocates and further facilitate clear articulation of the evidence for a policy change and its societal benefits. First of all, the driving performance of virtually all drivers is known to be impaired at 0.05 g/dL BAC. Laboratory and test track research shows there are significant decrements in performance in areas such as braking, steering, lane changing, judgment, and divided attention at 0.05 g/dL BAC. Some studies report that performance decrements in some of these tasks are as high as 30% to 50% at 0.05 g/dL BAC.84–86 Next, the risk of being involved in a crash is known to increase significantly at 0.05 g/dL BAC. At each positive BAC level exceeding 0.05 g/dL, the risk of being involved in a crash rises very rapidly, compared to drivers with no alcohol in their blood.87 Recent studies indicate that the relative risk of being killed in a single-vehicle crash for drivers with BACs of 0.05 to 0.079 g/dL is at least seven times that of drivers at 0.00 g/dL BAC (no alcohol) and could be as much as 21 times that of drivers at 0.00 g/dL BAC.53 Lowering the illegal limit to 0.05 g/dL BAC is a proven and effective countermeasure that has reduced alcoholrelated traffic fatalities in other countries, most notably Australia. The evidence is consistent and persuasive that fatal and injury crashes involving drinking drivers decrease at least 5% to 8% and up to 18% after a country lowers its illegal BAC limit from 0.08 to 0.05 g/dL BAC.88–91 If all U.S. states were to adopt the 0.05 g/dL BAC standard and it were enforced, an estimated 500 to 800 lives could be saved each year.92 Moreover, it can easily be argued that setting a 0.05 g/dL BAC is a reasonable standard. A 0.05 g/dL BAC is not typically reached with drinking two standard beers after work, or with a standard glass of wine or two with dinner. It takes at least four standard drinks for the average 170pound male to exceed 0.05 g/dL BAC in 2 hours on an empty stomach (three drinks for the 137-pound female). However, it should be recognized that the BAC level ultimately reached depends on a person’s age, sex, weight, consumption of food, and metabolic rate.93 Finally, from a social marketing perspective in advocating for a 0.05 g/dL limit, it is important to know that there is evidence that the public supports levels below 0.08 g/dL BAC. NHTSA’s surveys show that most people would not drive after consuming two or three

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drinks in an hour94 and believe the limit should be no higher than the BAC level associated with that. That would correlate to 0.05 g/dL BAC or lower for most drivers. While this policy change is not focused specifically to gender, lowering the limit will likely improve driver safety for men and women alike. CONCLUSIONS Alcohol-impaired driving crashes continue to be a formidable public safety and public health challenge. The spectrum of negative consequences in alcohol-impaired driving is clear, and there are unfavorable trends for women engaging in impaired driving. Emergency medicine already possesses tested efficacious tools and skills to identify, intervene, and refer to treatment millions of ED patients who are currently living along the spectrum of active alcohol use disorders. We believe that intentionally broadening the implementation of alcohol screening, brief intervention, and referral to treatment in EDs across the country could yield a multitude of benefits for patients and similarly improve the overall status of alcohol-impaired driving. Further, it has been 30 years since the first two states adopted a 0.08 g/dL BAC limit and 13 years since federal legislation provided a strong incentive to adopt a 0.08 g/dL BAC limit. In this article, we have presented an argument that shows that progress in reducing impaired driving has stalled over the past 10 years. Moreover, we believe that lowering the BAC limit from 0.08 to 0.05 g/dL will serve as an important general deterrent to those who choose to drink and drive. Emergency medicine’s role in advocacy in this context is invaluable. Finally, taking into consideration the most recent national crash injury and fatality statistics, there is increasing concern about the safety of female drivers. Although for many years women were considered safer drivers than men, the evidence suggests that gap is closing. Not only are women driving more (and therefore becoming more exposed to crash risks), but they are also taking more risks when driving (young women in particular). While researchers and policy-makers are attempting to understand and address these increased risks, the rapidly changing landscape of impaired driving makes the acquisition of such information difficult. New and still not well understood sources of impairment (e.g., drugs other than or in combination with alcohol, texting, cell phone use), each suspected of having a different effect on drivers of different age and sex, add further complexity to the goal of addressing the observed increase in the involvement of women in crashes. For researchers and emergency physicians, awareness of this changing landscape will be essential to finding the solutions. References 1. National Center for Health Statistics. Health, United States, 2012: With Special Feature on Emergency Care. Figure 24, p 46. Available at: http://www.cdc. gov/nchs/data/hus/hus12.pdf. Accessed Sep 14, 2014.

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2. National Highway Traffic Safety Administration. Traffic Safety Facts: Research Note, 2012 Motor Vehicle Crashes. Washington, DC: U.S. Department of Transportation, 2013. 3. Federal Bureau of Investigation. Uniform Crime Report: Crime in the United States 2012. Available at: http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/ 2012/crime-in-the-u.s.-2012. Accessed Sep 14, 2014. 4. Beitel GA, Sharp MC, Glauz WD. Probability of arrest while driving under the influence of alcohol. Inj Prev 2000;6:158–61. 5. Hause JM, Voas RB, Chavez E. Conducting voluntary roadside surveys: The Stockton experience. in: Valverius MR, ed. Proceedings of the Satellite Conference to the 8th International Conference on Alcohol, Drugs and Traffic Safety, June 23–25, 1980. Umea, Sweden, Stockholm: The Swedish Council for Information on Alcohol and Other Drugs, 1982: 104–113. 6. Zaloshnja E, Miller T, Blincoe L. Costs of alcoholinvolved crashes, United States, 2010. Ann Adv Automot Med 2013;57:3–12. 7. Moulton BE, Peterson A, Haddix D, Drew L. National Survey of Drinking and Driving Attitudes and Behaviors: 2008 (Volume II: Findings Report). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2010. 8. Healthcare Cost and Utilization Project (HCUP) and National Emergency Department Sample (NEDS). 2011 National statistics. Available at: http://hcupnet. ahrq.gov/HCUPnet.jsp. Accessed Sep 14, 2014. 9. Kufera JA, Soderstrom CA, Dischinger PC, Ho SM, Shepard A. Crash culpability and the role of driver blood alcohol levels. Ann Proc Assoc Adv Automot Med 2006;50:91–106. 10. Ryb GE, Dischinger P, Kufera J, Ho S, Read K, Soderstrom C. Retained risk-taking behaviors among past alcohol dependent trauma patients. Ann Proc Assoc Adv Automot Med 2005;49: 295–309. 11. Dang JN. Statistical Analysis of Alcohol-related Driving Trends, 1982–2005. Washington, DC: National Highway Traffic Safety Administration, 2008. 12. Fell JC, Voas RB. Mothers Against Drunk Driving (MADD): the first 25 years. Traffic Inj Prev 2006;7:195–212. 13. National Highway Traffic Safety Administration. Fatality Analysis Reporting System Data Files, 1982–2010. Available at: ftp://ftp.nhtsa.dot.gov/fars/. Accessed March 10, 2014. 14. Hingson R, Heeren T, Winter M. Lower legal blood alcohol limits for young drivers. Public Health Rep 1994;109:739–44. 15. Hingson R, Heeren T, Winter M. Effects of recent 0.08% legal blood alcohol limits on fatal crash involvement. Inj Prev 2000;6:109–14. 16. Klein TM. Changes in Alcohol-involved Fatal Crashes Associated With Tougher State Alcohol Legislation. Washington, DC: National Highway Traffic Safety Administration, 1989.

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