International policies on alcohol-impaired driving: a review.

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The International Journal of the Addictions, 27(2), 187-208, 1992

International Policies on Alcohol-Impaired Driving: A Review Clifford Peacock, PhD Alcohol Research Group University of Edinburgh Edinburgh, Scotland, UK

Abstract A review is presented of policies to curb alcohol-impaired driving. The principal measure applied against drinking and driving in most industrial countries is the implementation of laws limiting the amount of alcohol which can be legally consumed by a person who subsequently takes charge of a motor vehicle on a public road. This strategy seems to have been the most effective to date, although national variations in legislation, rigor of application, and the extent of public knowledge are reflected in the range of outcomes reported. The effectiveness of “random breath testing” appears to be related to the degree to which drivers believe that the law is enforced. Other strategies aimed at the reduction of drinking and driving are education, publicity, and exhortation; the rehabilitation of convicted offenders; and restrictions on the availability of alcohol. However, due to factors such as the lack of evaluation, or limited scope, or nonspecificity to drinking and driving, these measures appear to have been less successful in curbing alcohol-impaired driving than the application of legal powers.

Key words. Alcohol; Drinking; Drunken driving; Control policies

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Copyright @ 1992 by Marcel Dekker, Inc.

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INTRODUCTION Road traffic accidents are a major cause of injury and death in most countries, and alcohol consumption has long been recognized as a frequent contributory factor (Moser, [Kenya, Mauritius, Nigeria, Swaziland], 1980; &terberg [Finland], 1989; Vogt [Federal Republic of Germany], 1989; Garretson [The Netherlands], 1989). In Great Britain in 1986 almost 1,ooO road users were killed in accidents in which at least one driver or rider was over the legal limit (80 mg/100 ml) for alcohol. These constituted approximately one-fifth of all road accident fatalities. The annual number of casualties in drink-drive accidents may be as many as 25,000-roughly a tenth of total road casualties (Road Traffic Law Review, 1989). In the light of statistics such as these, reflected in many industrial and developing countries, policies have been introduced in an attempt to control what has been described as “A Quiet Massacre” (Dunbar, 1985). For the purpose of this review, policies to curb alcohol-impaired driving are considered under four headings: Laws relating to drinking and driving Education, publicity, and exhortation Rehabilitation of the convicted drink-drive offender Restrictions on the availability of alcohol

LAWS RELATING TO DRINKING AND DRIVING A legal innovation in 1936 has since remained an international model for legislation to control the drinking driver. In that year the Government of Norway introduced what has become known as the per se law under which the need for a driver to be declared “drunk” was no longer a matter of medical observation and assessment; it was a culpable act to drive with a blood alcohol concentrations (BAC) in excess of 50 mg1100 ml (Ross, 1982). The subjective nature of previous methods of determining the fitness of a person to drive after consuming alcohol were replaced by scientific procedures which have become increasingly sophisticated and reliable.

Legal Limits for Blood Alcohol Concentration A World Health Organization (WHO) report (1981) described a “clear decrease in driving safety’’ at a BAC of 50 md100 ml. More recently, Moskowitz and Robinson (1987) reviewed 200 papers which examined a variety of behavioral aspects of drinking and driving. They concluded


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that there is evidence of impairment at a BAC of 70 mg1100 ml in most of the functions examined, and that impairment was reported at concentrations of between 10 and 40 mg/100 ml in 45 studies (20%). There is no international consensus on what constitutes a maximum legal limit for BAC in drivers of motor vehicles. The standards in countries across the world vary from an absolute prohibition to no limit at all, as shown in Table 1. National legal limits for BAC change (in most cases downwards) from time to time, and this list cannot claim to be correct in every case. Its main purpose here, however, is to indicate the wide variations in permitted levels which currently exist. The two extremes of this spectrum must be regarded with some caution. At the lower end, traces of alcohol within the range 1-4 mg1100 ml may be found in the blood or persons who have not drunk intoxicating liquor; this appears to be a metabolite arising from the digestion of fruit (Denney, 1986). In countries where no legal BAC standards exist it is nevertheless an offence to drive while impaired through alcohol. In the USA, maximum legal levels vary from 50 mg/ml to 100 mdml in the 50 states. Countries listed in Table 1 which adopt a two-tier approach to BAC are indicated by an asterisk. The lower of the two levels is intended to deter or identify the more moderate drinker. The upper limit, usually set at or above 100 mg/100 ml and carrying a more severe penalty on conviction, seeks to identify the drinker who is likely to be alcohol dependent. It is clear that as studies of drinking drivers have improved, an increasing awareness has developed of the need to introduce lower BAC limits. Three years ago Dunbar et al. (1987) suggested that the 80 mg/100 ml limit in Great Britain, in force since 1967, should be reduced to 50 mg1100 ml as in most Nordic countries. Further recommendations by these workers included a zero limit for learner and first year motorists, and the introduction of random breath testing (a measure discussed below). In Sweden the maximum permitted BAC for drivers has recently been lowered to 20 mg/100 ml.

Breath Testing Electronic devices are now available which use infrared absorption to give an instant reading of the amount of alcohol present in the exhaled breath (BrAC) of the person concerned. Results are presented as digital displays and on a chart or strip printout. Breath testing is non-invasive and circumvents many of the problems relating to earlier methods of BAC determination from blood or urine samples. It has become established internationally as a reliable means of identifying the driver who has been drinking. BrAC instrument readings are accepted as legal evidence in proceedings relating to alcohol-impaired driving in Canada, Great Britain, New

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Table 1


Legal Blood Alcohol Concentration Limits No alcohol permitted: Czechoslovakia Japan Saudi Arabia Turkey 20 rng/100 rnl: Bulgaria* East Germany Poland Sweden* USSR 50 rng/l00 tnl:

Finland Greece Holland Noway Portugal Australia Yugoslavia 80 rndl00 i d : Austria Belgium Denmark* Great Brimin Greece Iceland* Luxernbvurg New Zealand* Northern Ircland* Spain Switzerland West Germany* 100 rng/100 id: Ireland (Eire)* Puerto Rico

No legal limit: Channcl Islands Cyprus Italy Mdha



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Zealand, and Northern Ireland. Such readings are, it should be noted, influenced by a variety of factors such as gender, weight, health, and age (Paton et al., 1984).Test results are clearly related to driver impairment. Even so, as noted by Johan (1990), there are international legal differences and these imply differences in behavior at various limits. In 1978 New Zealand became the first country to introduce a maximum legal BrAC. A two-tier system operates (see Table 1) with BrAC set at 30 breath mg/lOOml and 5Opg1100 ml of breath (Transport Amendment Act, 1978). In Great Britain the Blennerhasset Report (1976) commented at length on the application of instrumental evidential breath testing. Legislation (Transport Act, 1981) was introduced which laid down a maximum BrAC for drivers of 35pdlOO ml. There is evidence to show that this amount is approximately equivalent to a BAC of 80 mg/100 ml (Paton, 1984). In practice, however, to enhance the probability of conviction, the balance of evidence is often tilted in favor of the suspect. Breath-testing instruments are calibrated to allow for variation in bloodfireath ratios between individuals with the result that the true BrAC is frequently underrecorded. Two tests are normally administered to a suspect, with the lower reading taken as the result. Finally, despite the stipulated legal maximum BrAC of 35 pg/lOO ml, prosecution rarely follows when the instrumental reading is less than 4OpgJ100 ml. The cumulative effect of these measures is such that in Great Britain the minimum BAC of drivers against whom prosecutions are instituted may be of the order of 107 mg/100 ml rather than the statutory limit of 80 mg/100 ml (J. A. Dunbar, personal communication, 1990). The establishment of BAC/BrAC standards and the legal recognition of methods to determine alcohol levels in samples are only the first stages of a comprehensive policy against the drink-impaired driver. It is necessary to establish the circumstances under which a driver can be stopped in the course of a journey and subjected to testing for the presence of alcohol. In addition, punishments must be set for offences which have public and/or political support.

Roadside Screening Driving while impaired by alcohol does not seem to be a universally reprehensible offence. One researcher reports observing a serious three-car accident in Mexico City which had been caused by a driver who was almost stuporously drunk. Police appeared, investigated the accident, and assessed the damage to the cars. No arrests were made and no charges were laid for impaired driving (Smart and Mora, 1984). Differences in attitudes toward the legal regulation of drinking and driving are reflected in the variation of policies adopted by governments. Action, and the literature on the subject, comes predominantly from the Anglophone and Nordic countries whose societies are very vehicle-oriented, worry about drinking and

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young lives, and have strong traditions of social research (Room, personal communication, 1990). In the majority of industrialized countries measures enabling police officers to stop and test drivers for alcohol fall into one of two broad categories, random stopping or random testing.


Random Stopping Under the Road Safety Act, 1967 police officers in Great Britain are authorized to conduct a breath test on any driverinvolvedinan accident, or who has committed a moving-traffic violation, or who gives reasonable cause for suspicion of having alcohol in hisher body. This set of circumstances, cokctive\y known as “due cause,” is a form of “random stopping” of vehicles. In the first year of operation of due cause testing in Great Britain, there were decreases of 15% in fatal casualties and 11% in total casualties (mainly between 10 p.m. and 4 a.m.). These effects were attributed in full to the new law; the measure was hailed as having “had greater demonstrable benefits than any other drinking and driving legislation anywhere in the world” (Department of the Environment, 1976).The initial success was not sustained, however, and the number of casualties associated with drinking and driving began to rise. By 1974the situation was worse than it had been in 1967 (Ross, 1982). This 7-year period was characterized in Great Britain by rises in per capita alcohol consumption and increases in the use of personal transport. There was also a decay in the awareness of the risks incurred by drinking drivers coupled with an appreciation by many of the low risk of detection (Moser, 1980). The random stopping of vehicles on due cause in order to test their drivers has, since its implementation, been regarded by the British Government as an effective measure against the drinking driver. However, it is subject to criticism on the grounds that it may fail to detect the “heavy” drinker and that it carries little impact as a deterrent to future drinking by other motorists. Persons accustomed to the regular consumption of alcohol often appear capable of driving correctly and of presenting a sober demeanor when questioned. Experienced “heavy” drinkers, a group highly represented in alcohol-related vehicle crashes, can therefore evade testing under this system provided they avoid having an accident, commit no traffic offence, and give no indication of having consumed alcohol. As a consequence, the behavior of such persons can become reinforced by the belief that they are able to escape the consequences of driving after drinking to excess (Dunbar, 1985). This is the crucial factor; under random stopping procedures the wrong lesson can be learned by those drivers who most need to control their drinking. The second major criticism of random stopping as a measure against drinking and driving is its failure to serve as a deterrent to others. Under the procedure a single vehicle with a highway patrol car in attendance is occasionally seen stopped



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by the roadside; there is normally nothing to indicate to other motorists that the driver concerned is in fact being breath-tested by the police (Ross, 1982). Random stopping has been conducted in Great Britain by “blitzes” (intensive campaigns) carried out by police officers using discretionary powers to set up roadside checkpoints to stop vehicles; the breath-testing procedure is then applied to any driver considered to have been drinking. The legality of this process under current laws rests mainly on the single decision of a lower court; concern has been expressed that a future case may be decided differently, in which case supplementary action by blitzes will no longer be possible (Josh, 1990). A major difficulty under these circumstances is the need for the preliminary assessment of sobriety to be made quickly in order to avoid traffic hold-ups. Even a highly experienced police officer, in the course of an interview conducted at the open window of a vehicle and lasting only some 30 seconds, cannot be expected to assess correctly in every instance whether or not the driver has been drinking. Reference was made earlier to the ability of many experienced drinkers to present themselves as models of sobriety. A study was conducted in Sweden at simulated roadblocks to assess the chances of detecting drivers smelling of alcohol or showing signs of intoxication. More than 50%of those with a BAC of between 50 and 100 mg100 ml and almost 50% of those with a BAC of between 100 and 150 mgj100 ml failed to arouse suspicion on the part of the police officer carrying out the assessment (J. A. Dunbar, personal communication 1990). Blitz campaigns have been conducted in England in Cheshire (1975) and Sussex (1987) and in Scotland in Fife (1988). Each campaign was associated with media publicity aimed at enhancing drivers’ perceptions of the risk of detection. In Fife during a blitz from mid-October 1987 to the end of January 1988, the number of roadside breath tests increased by 250% while the number of positives fell by 19%.At the same time, all classes of road casualties decreased by 12% with fatal and serious accidents diminishing by 2 1% .These improvements were made in Fife in contrast to a national trend in which casualties remained fairly steady (Moodie, 1988). Unfortunately the success of such campaigns frequently dissipates once they come to an end and the associated publicity and public awareness diminish. This was exemplified in Cheshire where the number of accidents involving fatalities and severe injuries during drinking hours declined by 60%during the campaign but returned to the previous level shortly after it ended (Dunbar, 1985; Moser, 1980; Havard, 1986). Random stopping programs are widely used in the USA. During weekend evenings throughout 1984 the Police Department of the city of Charlottesville, Virginia, mounted 94 checkpoint operations on major roads within the conurbation. In the course of the year over 23,000 vehicles were stopped and 290 (approximately 1%) of the drivers were arrested and charged for driving under the influence of alcohol. The final report on the exercise describes the operation of the checkpoints

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in detail. Due to the small scale and relatively short-term nature of the project, there is no firm evidence to indicate changes in local drink-drive behavior or a reduction in alcohol-related accidents attributable to the checkpoint program. In a review published during the year of the Charlottesville operations, Williams and Lund (1984) concluded that while such enterprises increased drivers’ perceptions of an increased risk of arrest for impaired driving, there was no measurable change in overall drink-drive behavior.

Random Testing The distinguishing feature of random testing is that all motorists stopped at a checkpoint are asked to take a breath test regardless of any evidence that they have been drinking. Random Breath Testing (RBT) has been introduced in Australia, Finland, France, Holland, and Scandinavia. Dunbar (1987) argues forcibly that RBT is successful both in deterring drivers who drink occasionally (the so-called “social drinkers”) and catching those who consume alcohol to excess (the “problem drinkers”). A number of studies have shown that a high percentage of alcohol-related traffic accidents are caused not by social drinkers who drive, but by drivers who are problem drinkers. One-third of a sequence of fatally injured drivers in Australia had BAC of at least 150 mg/100 ml (Johnson, 1976). In Canada, tests on 1,119 fatally injured car drivers showed that 47% had been drinking and of these 80%had a BAC in excess of 80 mg/100 ml. Some 40% of drivers detained for excess BAC as a result of RBT operations show raised gamma-glutamyl transferase (GGT) activity; this is in contrast to only 30% of such drivers detected under due cause testing. Raised GGT levels are indicative of heavy drinking in the recent past. It follows, therefore, that these drivers must have had, and indeed may have driven, with significantly higher BAC at other times; this may account for the elevated alcohol levels found in drivers killed in road accidents (Dunbar et al., 1987). These workers found, on autopsy, liver pathology associated with alcoholic disease in about one hundred fatally injured Finnish and Scottish drivers, thereby substantiating their findings of an association between high accident risk levels and heavy drinking in motorists. In Finland a significant number of alcohol-impaired drivers have been detected in the course of RBT operations conducted in morning traffic within working hours. This group, not surprisingly, includes many motorists who are subsequently shown to have alcohol-consumption-related problems; an elevated BAC in the morning is indicative of “heavy drinking” the previous night or alcohol consumption at an early hour. RBT was introduced into Finland in 1977 with a legal BAC limit of 50 ms/ 100 ml. Checkpoints set up at random in time and place are manned by from eight to twelve police officers, each equipped with a breath-testing kit, standing along the



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center of the road. Every driver traveling in either direction (except those in charge of emergency vehicles) is stopped and a breath test carried out. The procedure, known colloquially as “Blow and GO,”takes only a matter of seconds; the checkpoint functions for half an hour and up to 500 drivers may be tested, with perhaps one or two found to be over the legal limit. Surveys involving the breath testing of 130,000 Finnish drivers were carried out between 1979 and 1985. In 1979 a total of 579 (1.43%) drinking drivers were detected in normal traffic flow, one-third of whom (0.46%)had a BAC in excess of 50 mgllOO ml. By 1985 the frequency of drinking and driving had declined to 0.59% (a reduction of 58% since 1979) and the number with a BAC over 50 mgJ 100 ml had fallen to 0.2% (a reduction of 57%) (Dunbar et al., 1987). RBT legislation was implemented and enforced in New South Wales with a thoroughness and rigor unprecedented in Australia and possibly anywhere else (Homel, 1988). RBT roadblocks normally involve only two officers (the crew of one highway patrol vehicle) who carry out testing for 1 hour in the course of each shift of duty. Its introduction was accompanied by substantial publicity on television, radio, and in the press. In the first 12 months of operation, 923,272 preliminary breath tests were carried out, representing one test for every three licensed drivers in the state (Cashmore, 1985).To put this figure into perspective, only 113,985 tests had been conducted in New South Wales during the previous year; in Sweden it was 3 years after the introduction of RBT before the one millionth test was carried out. In France (where the population is 10 times greater than that of New South Wales), 335,000 tests were carried out in 18 months (Homel, 1988).To match the level of testing in 1983 in New South Wales, the French police would have had to carry out some 5 million tests in 1 year. Fatal crash statistics in New South Wales showed a marked decline coinciding with the inauguration of RBT on 17 December 1982. For the 6 years prior to this date there was a monthly mean of 95.7 fatal crashes. The mean for the 48 months ufer RBT was 76.0, a decline of 20.6% (Homel, 1988).Another important feature is the sustained reduction in total fatalities; this characteristic of the data has been investigated and confirmed by a number of workers (Ross and McCleary, 1983; Arthurson, 1985). The mechanisms by which such reductions were achieved and sustained include changes in drinking and driving behavior as a result of exposure to RBT (Cashmore, 1985). Carseldine (1985) reports a 14% rise (from 26 to 40) in the number of motorists who perceived their chances of arrest as “much higher” following the introduction of RBT; this increasing recognition of the effectiveness of the measure took place in the interval 6 to 20 months after it began. Since December 1989the Australian state of Victoria has been using RBT in a very intensified way with extensive media publicity, highly visible “booze buses,” increased throughput of drivers by the use of passive detectors (which obviate the


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need for the motorist to blow through a mouthpiece), and the involvement of enthusiastic young probationary constables. While formal evaluation of the new program is not yet complete, alcohol involvement in fatal vehicle crashes has been reduced in the state by 20% (an historic low for Australia) with fatal crashes down by 120 from the previous year (Homel, 1990). Some published evaluations (for example, MacLean et al., 1985) have indicated that while the impact of RBT was initially substantial in other Australian states, it was followed by a marked dissipation in effectiveness. This was attributed to an inadequate level of testing. Reference has already been made, and is worth repeating, of the importance of the deterrent effect exerted by RBT upon drivers; the perception of a high probability of being tested is strongly persuasive. Drivers are less likely to drink, and drinkers less likely to drive, when there is a high risk of being detected over the legal limit. This is especially so when, as Ross (1982) states, detection is followed by a punishment which is perceived to be certain, swift, and severe. Hornel (1990) asserts that key elements to success with RBT include, apart from enforcement strategies which maximize the number of impaired drivers apprehended, continuous feedback to police officers on the goals and effectiveness of RBT;intensive publicity in the early stages of implementation; and, again as indicated by Ross, penalties swiftly applied with 100%certainty to apprehended offenders.

Punishment Driving with an excess BAC is usually regarded as a criminal offence which, paradoxically, carries little social stigma (Ross, 1960; Gusfield, 198l), although this attitude is thought to be less prevalent now (J. A. Dunbar, personal communication). Politicians wishing to make symbolic points often advocate an increase in the severity of the punishment laid down for a particular crime. In litigious societies where there are lengthy appeal procedures, for instance in the USA, a draconian sentence may reduce the promptness, and perhaps even the certainty, of its application to the offender (Room, personal communication, 1990). In this connection, Ross (1960) rephrases a basic law of economics in stating that the efficacy of a legal threat is a function of the perceived certainty, severity, and celerity of punishment. A case can therefore be made for the effectiveness of relatively light punishments since they are more likely to be quicker and certain. Legal penalties which may be imposed on a motorist convicted for driving while impaired by alcohol are imprisonment, a monetary fine, and disqualification from driving for a specified period. In Japan the penalties for drinking and driving are severe. There is no legal limit for BAC or BrAC; any driver stopped by the police and found to have been



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drinking is liable to a fine and loss of licence for at least a month, returnable only after satisfactory attendance at a course of lectures. The penalties for driving when judged to be impaired by alcohol are immediate imprisonment, a fine, and the permanent loss of driving license. Convicted individuals who work in the public sector may also be dismissed (Labatt, 1984). In Norway the legal BAC is 50 mg/100 ml. A convicted motorist is imprisoned for at least 21 days and a license suspension imposed for a period depending upon his or her previous history of drink-drive offences (Olsen, 1984). In Great Britain, driving with an excess BAC carries the possibility of a fine of up to f2000, loss of driving licence for between 1 and 3 years, and imprisonment for up to 6 months (Transport Act, 1981). In practice, however, penalties appear to be imposed for first offences in proportion to the measured BrAC or BAC, typically ranging from a 1-year driving ban and a fine of 2120 for a BAC up to 120 mg/100 ml to a 3-year ban and f400 fine at 300 mg/100 ml (Clarke, 1984). Loss of licence is a significant punitive measure. It can remove from the road those guilty of the more serious, and therefore arguably the most dangerous, offences including alcohol-impaired driving. For the offender it is a penalty with heavy consequential financial costs over and above the removal of the legal right to drive. Willett (1990) reports that nearly every offender he interviewed in a survey admitted that “disqualification was the penalty that really hurt.” Ignition interlock devices have become available in recent years and show potential for effectiveness in controlling, in particular, the convicted drink-drive offender. The driver must blow into a breath-testing machine built into the vehicle and register a BAC less than a specified level before the engine can be started (Homel, 1990). Serial devices, requiring the driver to deliver a breath sample at intervals during a journey to prevent ignition cut-out, take account of the possibility of BAC rising in the aftermath of recent drinking. A comprehensive review of ignition interlocks was carried out by the Road Traffic Authority of Victoria (1987), and it was concluded that for the costs to be offset by savings from reduced accident rates, the devices would only need to be 30% effective if applied for the full 6 years of a driving licence. Mackiewicz and South (1989) discuss the fitting of these devices to the vehicles of recidivist offenders as a condition for reinstatement of licence.

EDUCATION, PUBLICITY, AND EXHORTATION In a national survey of 10,000 Canadians (Health Promotion Directorate of Health and Welfare Canada, 1988), there was “strong agreement” in the sample that increased general and driver education programs would be of value in reducing alcohol-impaired driving. These measures received greater support than, for example, harsher laws and stricter enforcement or alterations to the minimum age for

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Table 2


Percentage of Canadians who “StronglyAgree/ Agree” That These Measures Could Be Taken to Reduce Drinking and Driving More driver cducation Educational programs Treatment of drinkers Dcsignated driver programs Stricter law enforcement Mote advertising More roadblocks Stricter sale control Free transport Drinking age up Driving agc up

96.9 92.8 86.7 85.4 84.8 84.7 81.4 66.6 63.4 56.5 50.1

drinking and/or driving. The full results of this part of the survey, based on answers to a multiple-response question, are given in Table 2. While expressions of public opinion of this nature are laudable, there is little evidence to show that such measures are effective in practice. Health education in alcohol aims to inform the individual and to induce the adaptation of hisper behavior into socially acceptable ways of drinking. It is a measure which continues to attract support in terms of both rhetoric and resources in attempts to modify drinking and driving despite the generally unimpressive evidence as to its effectiveness. “Regrettably, much that passes for health education concentrates on negating the values and images portrayed in alcohol advertising at the expense of communicating the positive aspects of alcohol use and patterns of drinking which will not encourage excessive consumption or the creation of alcohol problems” (Davies and Walsh, 1983). In some countries alcohol education is the principal, if not indeed the only, weapon directed toward the problem. While programs may be effective in informing the public of the legal, medical, and social consequences of mixing alcohol and driving, it cannot be assumed that this knowledge will be applied in terms of conduct. “Better informed” is not synonymous with “better behaved” (Moser, 1980). A major difficulty in this area is the lack of scientific information on the effectiveness of programs aimed at the modification of drinking and driving behavior. Almost without exception, such programs are aimed at “social drinkers” since



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“problem drinkers” are sometimes assumed to be too difficult to influence (Organisation of Economic Cooperation and Development, 1978). An example of one apparently successful public education program is, however, reported from New South Wales; it was conducted some eight years prior to the introduction of RBT in the state. Following a campaign to extend knowledge of legislation relating to breath testing, a more ambitious program, known as the “Slob Campaign,” was mounted in 1974, the “ S l o b being defined as a man who drank six middle-sized beers or more in an hour. In a widespread media campaign, emphasis was laid on the need to stop the “Slob” from driving. Significant improvements in attitudes to drinking and driving were reported, and convictions for driving with BAC above the legal limit dropped by 6.3% in 1974as compared with 1973 (Henderson and Freedman, 1976).Attention is, however, drawn in the report to the short duration of these improvements and to the very substantial costs of advertising; doubts are expressed as to the cost-benefit of the program. It must be concluded that despite much excellent work being done in the areas of education in schools and elsewhere, no definite claim can yet be made that such endeavors have reduced alcohol-consumption-relatedaccidents. It has been asserted that it is a complete mystery why alcohol education programs have been pursued for so long when even their potential to reduce accidents, let alone their actual performance, is so limited. “However, when evaluatingthe effects of school based education programs ... it is important to realize that on theoretical grounds there are good reasons for expecting a measure of success provided each program is implemented in a sufficiently wholehearted fashion” (Homel, 1990).Quoting earlier work, Hornel points out that prior to the introduction of RBT in New South Wales there was no evidence that lasting deterrent effects could be achieved. He argues that one of the reasons for the undoubted success of RBT has been extensive and credible publicity. The most appropriate role for education, exhortation, and publicity therefore appears to be as adjuncts to legal measures comprehensively applied. Self-testing of BAC is a measure which can be regarded as appropriate to a review of education, exhortation, and publicity relative to drinking and driving. The provision of self-test machines in bars and hotels is a logical step, and has been described as analogous to fitting speedometersin vehicles. It is estimated that some eight million self-tests are taken worldwide annually. Fixed machines are very accurate (as opposedto the small, hand-held instruments which are also available). In Australia they are officially licensed and checked monthly. Some devices are coinoperated and are reported to produce a net financial benefit to the licensee. In addition to giving a reliable BAC, advice is offered and many drivers are able to learn more about drinking and driving from them. It is claimed that, despite the expression of opinions to the contrary, there is no evidence of intending motorists using self-testing instruments to enable them to drink up to the maximum level permitted prior to driving (Breakspere, 1990).

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REHABILITATION OF CONVICTED OFFENDERS Attitudes toward the rehabilitation of convicted drink-drivers vary widely. In Great Britain the former practice of automatically restoring a driving licence to an offender on completion of a period of imposed suspension was much criticized on the grounds that a pre-existing drinking problem was likely to have intensified rather than resolved in the interim (Homel, 1990; Dunbar, 1987). This was recognized and the law was changed to require a second offender, on application for reinstatement, to undergo a medical examination and satisfy the licensing authorities of the absence of an alcohol problem. The need for rehabilitation courses for drink-drive offenders is clear. Approximately one-third of such offenders show evidence of the chronic ill effects of “heavy” alcohol consumption and one-tenth are known by their doctors to have alcohol problems. This group of drivers is most likely to be involved in road accidents, to be under the influence when vulnerable road users such as children are about, and for whom a conviction for impaired driving is only one of a range of other problems associated with their drinking. Offenders without alcohol problems may drive after drinking because they are unaware of the effects of alcohol and its potential consequences and do not know the strategies for avoiding driving while impaired. These offenders too may benefit from educational programs which help them rationally to choose not to drive after drinking alcohol (Dunbar, 1985). Such programs, however, irrespective of their effectiveness, cannot be expected to have any significant reductive impact upon the number of alcohol-related crashes; they are perhaps more accurately defined as a contribution to the improvement of the personal health of offenders. Recidivism is not a major problem in those convicted for alcohol-consumption-impaired driving. It has been estimated that even if all persons arrested for drinking and driving were prevented from ever driving again, the number of fatal crashes would only be reduced by 3 %, In the USA an evaluation of 18 studies under the Alcohol Safety Action Projects scheme showed no statistically significant reduction in subsequent crashes among convicted drivers who attended educational group sessions (Organisation for Economic Cooperation and Development, 1978). This report also draws attention to the inability of driver rehabilitation programs to produce major reductions in the overall number of alcohol-related traffic accidents since they deal solely with known offenders, a group constituting only a small percentage of those involved in crashes each year. Kern et al. (1977) stated that a study of 855 participants of such programs indicated that many were motivated to attend solely in the expectation of an earlier return of a suspended driving licence. In addition, those considered to be most in need of rehabilitation, the young and those with the highest BAC on arrest, were the most likely to drop out of voluntary programs.


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RESTRICTIONS ON THE AVAILABILITY OF ALCOHOL Laws relating to the minimum age for alcohol purchase and consumption are measures which are used, indirectly, to control drinking and driving. Studies in a number of countries (Tonge, 1972; Kaelber et al., 1985; Clayton et al., 1980) have shown that the combination of inexperience in driving and in drinking places young persons at high risk for alcohol-related traffic accidents: at the low level of 50 mgj100 ml, inexperienced ...drivers are at greater risk than average” (Organisation for Economic Cooperation and Development Report, 1978). In Australia there are lower legal BAC limits for first-year probationary drivers (predominantly in the younger age groups) than for others (Smith, 1986). This measure is reinforced by RBT and a further requirement to display a “P”plate in the first year. This serves to separate driving from drinking at a time when the young would otherwise be likely to experience (and experiment with) both activities simultaneously (Drummond et al., 1986). A second indirect measure against the drinking driver is alcohol taxation. It is almost universal, has historic precedents, and provides governments with a revenue source which is relatively easily collected and readily adjusted. It is ironic, though by no means unprecedented, for unhealthy or “problem” behaviors to be taxed. Countries differ markedly in their taxation policies relating to alcohol, and there are big variations in national cultural, economic, and social perceptions. Fiscal policies vary in their application to wine, beer, and spirits; distinctions are usually made between fermented and distilled liquors (Brewers Association of Canada, 1986). There are indications of an inverse relationship between the real cost of alcohol and per capita consumption in many countries, although some studies show independent fluctuations (Davies and Walsh, 1983). In France, alcohol consumption has been falling since the 1950s despite a decline in the “real” cost of alcohol. A recent review indicated that in the United Kingdom there has been an association between per capita alcohol consumption and alcohol-related problems including motor vehicle traffic accidents (Sales et al., 1989). In the USA it is estimated that if the Federal tax on beer had been indexed-linked to inflation, the number of 18-20 year olds killed in motor crashes in 1975-8 1would have been reduced by 15%; if taxation on alcohol in beer had been equated with that in spirits, the number killed in the same age group would have been 21 % lower. A combination of these two tax policies would have reduced the number killed by 54% (Saffer and Grossman, 1987). This study suggests that tax policies may be a “more potent” instrument than a uniform minimum drinking age of 2 1 for reducing traffic deaths among young people. A third measure to reduce alcohol availability are policies which control the location, density, and distribution of retail outlets, specify opening hours including


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restrictions on sale on certain days, and determine whether alcohol may be consumed on or off the premises or only with meals. These matters are often left to local jurisdictions, with significant variations over small distances (Brewers Association of Canada, 1986). The framework of national policies often reflect cultural aspects of the country concerned. For example, in Finland, Sweden, and Norway there are histories of vigorous temperance movements; today in these countries, extensive government monopoly systems operate to control both the production and distribution of alcohol. In Denmark, where the temperance movement did not develop so fully, and in countries such as Italy and France, the attitude toward alcohol availability is much more relaxed (Davies and Walsh, 1983). In Ontario, Canada, the banning of so-called “happy hours” (periods when drinks are sold in bars and taverns at reduced prices) was investigated by Smart and Adalf (1986) with regard to the impact of this measure on the number of reported drink-impaired driving charges. No firm conclusions can be drawn from this study; the authors state “As with much research evaluating the impact of legislative changes, many of the variables that confound effects are beyond experimental manipulation.” In Australia, Smith (1987,1988) investigated the effects of changes in times of alcohol availability and in the number and types of alcohol outlets on traffic accident mortality. In December 1979 the closing time for hotels in New South Wales from Monday to Saturday was raised from 1O:OO p.m. to 11:OO p.m. Smith (1987) compared the number of accidents between 1O:OO p.m. and 1159 p.m. in the 2 years immediately preceding and following the legislative change. The study, which incorporated a number of controls including a demonstration of a close temporal relationship between changes in variables, shows an increase of 13.2% in the number of fatal and serious injury accidents in the period 1O:OO p.m. to 1159 p.m.: “...it appears reasonable to conclude that the replacing of 1O:OOp.m. ...with 11:OO p.m. closing was the factor responsible for the significant increase ..- ”In his 1988 retrospective study, Smith documents that contrary to previously reported results (Raymond, 1969), the replacement of a 6:OOp.m. closing time with 1O:OO p.m. from Monday to Saturday in the Australian state of Victoria resulted in an 11.5% increase in casualty accidents.

CONCLUSIONS AND DISCUSSION This review has examined measures included in policies aimed at the modification of drink-drive behavior in a range of countries. The literature on the subject is extensive but only a minority of published reports relate to evaluations of policy initiatives. The evidence reviewed above supports the following conclusions:



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Random breath testing (RBT) has a strong deterrent effect on the potential of drivers to drink. This appears to be due to its high visibility to road users, the unpredictability of its timing and location, and the testing of all drivers passing the checkpoint irrespective of whether or not there is a suspicion of alcohol having been consumed. The success of RBT in reducing the number of drink-related crashes arises from vigorous enforcement through frequent large-scale testing, meaningful publicity, the apprehension and conviction of accident-prone “heavy” drinking drivers as well as “social” drinkers, and continuous feedback to police officers on the goals and effectiveness of the procedure. RBT is often conducted in working-day morning traffic, and drivers apprehended at this time include a high percentage with raised gamma-glutymase transferase activity. This indicates the value of RBT as an aid to the identification of those drivers likely to have alcohol-related problems. Random stopping of vehicles, including the due cause procedure, is criticized on the grounds that it is time consuming, inefficient, and can give rise to complaints of selective discrimination. In addition, the procedure is much less obvious to other road users than RBT, resulting in a reduced perception by the drinking driver of the risk of being stopped. The deterrent effect of due cause testing may be enhanced by the rigorous application by police officers of existing drink-drive legislation. In addition, general powers to stop any vehicle may be used; the driver can then be tested for the presence of alcohol if grounds for suspicion exist. These are often difficult to establish in the case of experienced “heavy” drinkers whose misbehavior may thereby become reinforced in the belief that they are able to elude detection. The imposition of penalties for conviction on charges of drinking and driving are most effective when they are certain and swift. The loss of a driving licence is reported to be the penalty that hurts the most. The fitting of ignition interlock devices may become more common as a condition of licence restoration after conviction. There is little evidence to indicate that measures such as health education, publicity (other than that related to RBT), or exhortation succeed in modifying drinking and driving behaviors. These strategies are also expensive. This lack of success is attributed to flaws in the design and presentation of measures previously taken. There are no data to show that “problem drinkers” have been influenced by these means. Voluntary self-testing through the use of machines in bars and hotels merits further investigation and development. The rehabilitation of convicted offenders has not been shown to be a widely successful measure against drinking and driving. In any case, previous offenders represent only a small percentage of those involved in traffic accidents.

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The principal attributes of rehabilitation appear to be its functions as a personal health measure and as a condition which may be attached to the restoration of a driving licence to a convicted offender. Paradoxically, “drop-outs” from voluntary rehabilitation programs in the USA include a large percentage of those most likely to gain benefit from such treatment. Evidence shows that when the minimum age for the purchase and consumption of alcohol on licensed premises has been lowered, there has been a rise in the incidence of drink-related traffic accidents involving young people. Conversely, there is a fall in the incidence when the minimum age is raised. Evidence indicates that per capita alcohol consumption is associated with levels of alcohol-consumption-relatedproblems including alcohol-consumptionimpaired driving. Alcohol taxation might, therefore, be used to influence drink-drive behavior. There is limited evidence documenting that changes in hotel drinking hours have sometimes had an impact on alcohol-related traffic accidents.

The contribution of inappropriate drinking to road accidents is widely acknowledged and has given birth to an extensive literature. Even so, relatively few evaluations have been conducted to assess the effectiveness of specific control policies. As this review indicates, most of the published evidence in the field relates to police powers to deter or detect alcohol-impaired drivers. The most promising approach to deterring alcohol-consumption-impaired driving appears to be Random Breath Testing. The success of this policy in New South Wales, Sweden, and Finland is due to rigor of application, a very high incidence of testing (on average, one in three of all drivers in New South Wales), together with the creation and maintenance of a high level of public awareness and support. Far less evidence is available on the effectiveness of policies based upon education, publicity, and exhortation or on those relating to the rehabilitation of convicted offenders. This is a matter for concern, and it is recommended that these obvious policies should be evaluated rigorously in the future. Limited evidence suggests that several “indirect” policies may have effects on levels of alcohol-consumption-impaired driving. These policies are changes in the minimum legal age for the purchase and consumption of alcohol, taxes on alcohol, and restrictions on the availability of alcohol, specifically the hours of hotel opening. This evidence emphasizes two key issues: First, measures against alcohol-consumption-impaired driving have to be formulated within the overall context of local and national policies on alcohol use and misuse.


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Second, initiatives related to drinking drivers are too often motivated by a political desire to exhibit concern or to symbolize the fact that such behavior lacks social respectability; the issue is one of public health and safety, and policies should reflect this.

In conclusion,a number of promising and obvious approaches have been identified in this paper, and national policies could be usefully guided by the available evidence referred to. Some of the approaches, notably Random Breath Testing, merit far more extensive application.Much more could be done to experiment with promising policies such as ignition interlocks and self-testing. These initiatives need to be adequately evaluated in the future, thereby reversing past trends in which such research has been accorded a low priority.

ACKNOWLEDGMENTS This review was funded by Marks and Spencer plc, with additional support from the Scotch Whisky Association. The Portman Group provides core funding for the Alcohol Research Group. The views expressed are the author’s own and do not necessarily represent those of the funding agencies. The author wishes to thank Ms. Susan Farrell, Director of the Office of Policy Analysis at the National Institute on Alcohol Abuse and Alcoholism, Rockville, Maryland, for her very helpful personal communications.Professor Ross Home1 and Dr. Robin Room read early drafts and made valuable comments and suggestions. The author was fortunate to have Dr. James Dunbar close at hand for advice and guidance; Mrs. Jeanne Wesson provided information which was most helpful, and Mr. Julian Everest is thanked for his critical comments at various stages. Finally the author wishes to acknowledge the support and constant encouragement provided throughout this project by Dr. Martin Plant.

REFERENCES ARTHURSON, R. (1985). Evaluation of Random Breath Testing. Sydney: Traffic Authority of New South Wales, Research Note l0/85. BREAKSPERE, R. (1990).Policies against drink-driving:Some Australian and American experience. In Report of the Drink-Drive Conference. University of Essex, March. BREWERS ASSOCIATION OF CANADA (1986). Alcoholic Beverage Taxation and Control Policies, 6th ed. Ottawa. BRITISH MEDICAL ASSOCIATION (1988). The Drinking Driver. London: Board of Science and Education Report. CARSELDINE, D. (1985). Surveys of Knowledge, Attitudes, Beliefiand Reported Behaviours of Drivers-On the Topic of Drink-Driving and Random Breath Testing. Sydney: Traffic Authority of New South Wales. CASHMORE, J. (1985). The Zmpactof Random Breath Testing in New South Wales. Sydney:Bureau of Crime Statistics and Research.


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CLARKE, K. (1984). J. P.'s given guide to drink-drive penalties. Daily Telegraph, London, February 1. CLAYTON, A. B., el al. (1980). The Male Driver: Characteristics of the Offender and His Offence. Crowthome: Transporl and Road Research Laboratory, Supplementary Report No. 600. DAVIES, P., and WALSH, D. (1983). Alcohol Problems and Alcohol Control in Europe. London: Croon1 Helm. DENNEY, R. C. (1986). Alcohol and Accidents. Cheshire: Sigma Press. DEPARTMENT OF THE ENVIRONMENT (1976). Drinking and Driving-Report of the Departmental Committee (The Blennerhessctt Report). London: HMSO. DRUMMOND, A. E., ct al. (1986). The RiskofAccident Involvement by Time of Week: An Assessment of the Effect of Zero BAC Legislafion and the Potential of Driving Curfews. Victoria, Australia: Road Traffic Authority. DUNBAR, J. A. (1985). A Quiet Massacre. The Institute o f Alcohol Studies. Occasional Paper No. 7, Octohcr. DUNBAR, J. A. (1987). What can we learn from other countries? In DrinkingandDriving: Controlling the Massacre. Institute of Alcohol Studics. DUNBAR, J. A., et al. (1987). Drinking and driving: The success of random breath testing in Finland. Br. Med. J. 295: 101-103. GARRETSON, H. (1989). Alcohol-related problems in high-risk groups. In M. A. Plant (ed.), EURO Reports and Studies 109. World Health Organisation. GUSFIELD, J. K. (1981). The Culiure of Public Problevis. University of Chicago. HAVARD, J. (1986). Drunken driving among the young. Br. Med. J . 293: 774. HEALTH PROMOTION DIRECTORATE OF HEALTH AND WELFARE CANADA (1988). The National Survey 011 Drinking a d Driving. Ottawa: Minister of National Health and Welfare, Canada. HENDERSON, M., and FREEDMAN, K. (1976). Public education as a drink-drivc counter-measure. Aust. J. Alcohol Drug Depend. HOMEL, R (1988). Policing arid Punishing the Drinking Driver. New York: Springer-Verlag. HOMEL, R. (1990). Drink-Driving Countenneasurers in Australia. Drinking and Driving-A Global Perspective. Conference in Edmonton, Canada, March. JOHNSON, I. R. (1976). Alcohol and road accidents-A review of the problem. Aust. J. Alcohoi Drug Depend. 3: 102. JONAH, B. A. (1990). Psychosocial characteristics of impaired drivers: An integrated review in relation to problem behavior theory. In R. J. Wilson and M. E. Mann (eds.), Drinking and Driving. New York Guilford. pp. 13-41. JOSLIN,D. I. (1990). The Police View. Report of the Drink-Drivc Conference, University of Essex, March. KAELBER, C., ct al. (1985). Alcohol and its relations to traffic dcaths among young people. In Proceedings of 9th International Conference. K E R N , J . C., et al. (1977). Drinking drivers who complete and drop out of an alcohol education programme. J. Stud. Alcohol 38: 39. LABA'IT, B. C. (1 984). Drinkers Don 't Drive in Japan. London: Spearhead. MACLEAN,S., ct al. (1985). Survey of Drink-Driving Behnviour, Knowledge and Attitudes in Victoria, December 1983. Melbourne, Australia: Road Traffic Authority. MACKIEWICZ, G., and SOUTH, D. (1989). The Poiential Value of Ignition Interlocksfor Convicted Drinking Drivers. Mclbounie, Victoria: Road? Corporation. MOODIE, W. McD. (1988). Fife DrinvDrive Campaign. Fife Constabulary. MOSER, J. (1980). Prevention ofAlcohol-Related Problems. Toronto: World Health Organisation and Alcoholism and Drug Research Foundation.



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THE AUTHOR Clifford Peacock, MSC, PhD, is a member of the Alcohol Research Group in the University of Edinburgh. He obtained a doctorate in nuclear waste disposal from the University of Dundee. He worked for 10 years as a Senior Lecturer in Community Medicine in the University of Dundee. Before that he worked as a public health engineer in East Africa. His current research relates to policies to control alcohol-impaired driving. He has produced several booklets on health topics for doctors and other health professionals.

An international study of research misconduct policies.

International Hemoglobin Information Center: Policies - IHIC.

Policies and Livestock Systems Driving Brucellosis Re-emergence in Kazakhstan.

Medical marijuana and driving: a review.

Military policies regarding homosexual behavior: an international survey.

International Policies on Sharing Genomic Research Results with Relatives: Approaches to Balancing Privacy with Access.

An international study of the quality of national-level guidelines on driving with medical illness.

Glaucoma and Driving: On-Road Driving Characteristics.

Alcohol Policies and Suicide: A Review of the Literature.

Do Social and Economic Policies Influence Health? A Review.

A review of smoking policies in airports around the world.

Impact of school policies on non-communicable disease risk factors - a systematic review.

Evaluative reports on medical malpractice policies in obstetrics: a rapid scoping review.

Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review.

A health equity lens on government policies.

European policies on tuberculosis prevention in healthcare workers: Which role for BCG? A systematic review.

Bordetella pertussis infection among international travellers: The need for a rigorous implementation of vaccine policies.

Policies on self-poisoning.

Alcohol consumption for simulated driving performance: A systematic review.

Determinants of risky driving behavior: a narrative review.

Policies on self-poisoning.

A study on the effects of fatigue driving and drunk driving on drivers' physical characteristics.

An international survey of assisted reproductive technologies (ARTs) policies and the effects of these policies on costs, utilization, and health outcomes.

Eighth international congress on peer review in biomedical publication.