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Drunk Driving, Distracted Driving, Moralism, and Public Health

Barron H. Lerner, M.D., Ph.D. - N Engl J Med - September 8, 2011

In 1980, Candy Lightner gave a speech about a 13-year-old girl who was killed by a drunk driver with several previous arrests for driving while intoxicated (DWI). She ended by saying, “That little girl was my daughter.”

“The audience gasped,” Lightner later reported. “The press jumped up and ran out the door to call the photographers. Pandemonium broke out.”1 Lightner had launched one of the first salvos of the anti–drunk-driving movement. The organization she started, Mothers against Drunk Driving (MADD), would become a high-profile advocacy organization.

Today, however, drunk driving competes for attention with speeding, road rage, drugged driving, drowsy driving, and texting and cell phone use behind the wheel. Health officials speak of unifying these concerns under the umbrella of improving traffic safety, potentially blending the moral passion of anti–drunk-driving activism with epidemiologically based strategies for saving lives on the roads. An understanding of the history of efforts to prevent automobile crashes can illuminate the benefits and limitations of various approaches and their possible synergy.

Since the automobile´s introduction in the late 1800s, drunk driving has been criticized. In 1904, a writer reviewing “alcohol-related accidents occurring to automobile wagons” remarked that “inebriates and moderate drinkers are the most incapable of all persons to drive motor wagons.”2

Yet despite well-publicized crashes, the development of blood-alcohol measurement devices, and the passage of DWI laws, it proved hard to mobilize a crusade against drunk driving. It became especially problematic after Prohibition was repealed in 1933; scientists began characterizing alcoholism as a disease rather than a sin, and advertisements increasingly equated drinking with the “good life.” As the suburbs grew after World War II, the popularity of fast automobiles came to rival that of alcohol. Although no one advocated drunk driving, U.S. culture promoted it.

Poster by Robert Lachenmann for the Works Progress Administration Federal Art Project, 1937.

One of the earliest scientists to study drunk driving actually saw it as only one of many contributors to highway deaths. William Haddon, Jr., also pushed Detroit to make safer cars, municipalities to remove hazards from the roadside, and drivers and passengers to wear seat belts. His “matrix” was an epidemiologic model that sought to change individual behaviors and environmental factors before, during, and after crashes. Haddon became the first administrator of the National Highway Safety Bureau after Congress passed the 1966 Highway Safety Act. In a 1968 report on drunk driving, Haddon and A. Benjamin Kelley estimated that alcohol was involved in 800,000 crashes annually and led to 25,000 deaths. They called for greater publicity efforts, stricter blood-alcohol laws, and more reliable punishments for drunk drivers.

But a vibrant control campaign didn´t emerge until a decade later, inspired not by public health interventions but by journalist Doris Aiken´s investigation of the 1977 deaths of two Schenectady, New York, teenagers caused by an intoxicated driver. Aiken discovered that drunk drivers routinely received slaps on the wrist, even when they killed someone or had been arrested before. Their victims were seen as having been in the wrong place at the wrong time; after all, drunk-driving crashes were considered “accidents.” Aiken founded an organization called Remove Intoxicated Drivers (RID).

Three years later, Lightner, a California realtor, formed MADD after her daughter Cari, walking along the side of a road to a carnival, was killed by a driver with four prior DWI arrests, including one just 2 days earlier. A police officer told Lightner that the culprit probably wouldn´t go to prison, saying “That´s the way the system works.”1

Aiken and Lightner became passionate activists, and their organizations quickly spread nationwide. Emphasizing victims´ rights, their members sat in on court hearings, “outed” lenient judges and prosecutors, staged protests, and badgered legislators to pass tougher laws. These groups were unabashedly moralistic, deploying tragic stories to right wrongs. Loathing the notion of drunk drivers endangering the lives of innocent people, they worked to replace the “One for the road” mindset with the conviction that “Friends don´t let friends drive drunk.”3

And between 1980 and 1985, states passed more than 700 new drunk-driving laws. Drunk drivers, previously seen as rebels or comic figures, had become outlaws. By 1985, the annual number of U.S. deaths attributed to drunk driving had decreased to 17,000.

But critics of RID´s and MADD´s moralistic, law-and-order philosophy argued that stiffer punishments were not effective deterrents and claimed that the groups were “neoprohibitionist,” opposed to not only drunk driving but drinking itself. They also claimed that the National Highway Traffic Safety Administration (NHTSA) overestimated the number of drunk-driving deaths, since the mere fact that a driver who crashed had imbibed alcohol didn´t prove causality.3

More recently, activists have toned down their moral outrage and sought an approach akin to a public health campaign. They support interventions scientifically proven to reduce drunk-driving deaths, including immediate license revocation, sobriety checkpoints, and zero-tolerance laws for teenage drivers. In addition, noting that more than 10,000 Americans per year still die in alcohol-related crashes, activists and government officials are promoting technologies, such as ignition interlocks, that prevent people from driving drunk rather than trying to persuade them to change their behavior.

Drunk-driving control was also affected by a 1997 research article estimating that using a cell phone while driving was as risky as having a blood alcohol level of 0.08%, the legal limit.4 As cell phone technology improved, texting while driving, which necessitates taking one´s eyes off the road, also became a major concern. The new term “distracted driving” encompasses many behaviors that divert attention from driving, hampering awareness and performance and increasing risk.

The trajectory of activism against distracted driving has echoed that of anti–drunk-driving activism. The media has covered tragic stories, such as the 2007 crash in upstate New York in which a teenage driver distracted by her cell phone killed herself and four schoolmates by driving into an oncoming tractor-trailer. Public service announcements warn that 5000 Americans die each year because of drivers who pay inadequate attention to the road. Again, activists and the public are relying on moral opprobrium to raise consciousness; one man, for example, wrote that the real culprits in the 2007 crash were “the brain dead parents that let a kid drive their SUV while having a phone in the vehicle.”

We still hear about drunk driving when celebrities are arrested for DWI, but attention has largely shifted to distracted driving. Just as Surgeon General C. Everett Koop hosted a workshop on drunk driving in 1988, Secretary of Transportation Ray LaHood convened a conference on distracted driving in 2009. And 32 states now ban texting behind the wheel. What lessons does the earlier crusade hold for the newer one?

First, moral outrage, though often considered inappropriate for public health campaigns, can get the public to appreciate the hazards of certain common behaviors. But moral appeals won´t influence everyone and may lead to a backlash. Thus, promoting technological deterrents may produce additional benefits. Wireless communication companies, for example, are developing devices that disable drivers´ phones when they´re in moving cars, and such innovations should be encouraged.

In addition, it makes sense to unite the campaigns combating various causes of automobile crashes. In the spirit of William Haddon, organizations as diverse as NHTSA, the Insurance Institute for Highway Safety, the Transportation Research Board, the Centers for Disease Control and Prevention, and the United Nations General Assembly are developing comprehensive programs, including improved road design; manufacture of safer vehicles; better regulation of drivers´ behaviors, including seat-belt use; more consistent political support and publicity efforts; and systematic evaluations of interventions´ effectiveness.5

True, such campaigns lack the emotional appeal of previous efforts to rid the roads of drivers who willfully endanger others´ lives. But given the limits of moralizing, it´s worth testing whether a multifaceted public health approach can stop a minority of drivers from making life unnecessarily hazardous for the rest of us.

* Barron H. Lerner, M.D., Ph.D. - N Engl J Med 2011

**Poster by Robert Lachenmann for the Works Progress Administration Federal Art Project, 1937