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Alcohol: the ubiquitous risk factor
  1. I B Pless, Editor

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    This issue includes four papers that draw attention to one of the most important causes of injury in all age groups and in every part of the world—alcohol. In particular, the papers address impaired drivers. The first is an original article pointing to the benefits of laws that penalize drivers whose blood alcohol content (BAC) exceeds 0.08% by weight (p 109). In view of the growing evidence to which this paper adds substantially, it is difficult to understand why so many constituencies tolerate higher limits. It is even more difficult to fathom why, whatever the limits, more impaired drivers are not apprehended or, when they are, why they are not punished more severely.

    These issues are addressed in the second paper—one that we hope will be the first of many written by from a lawyer's perspective (p 96). The senior author, Robert Solomon, is the legal advisor to the Canadian branch of Mothers Against Drunk Driving (MADD). Although the statistics in this paper only reflect the experience in one province, my guess is that the issues these data point to are commonplace, not only elsewhere in Canada but also world wide. In spite of limitations in the data system itself, the findings clearly point to serious flaws in how both the police and the legal system address impaired driving. Set aside the legal subtleties and look at the larger picture the findings present. As someone who has been spared personal experience with drunk driving, I find the results extremely disturbing. Imagine, then, how the families of victims must feel about this “system” that is supposed to deter.

    Because most injury prevention initiatives depend on lay persons for their success, I asked the vice president of MADD in the US, Wendy Hamilton, to present it as a Featured Program (p 90). Anyone familiar with this amazing program is bound to be impressed with its many accomplishments. Sadly, its origins and continued strength derive almost entirely from needless personal tragedies. There are many such programs in other countries and each deserves similar recognition.

    Finally, because impaired driving is dealt with so differently from one country to another, I asked Kathryn Stewart of the Pacific Institute for Research and Evaluation to write a guest editorial on this issue (p 80). She graciously agreed. Her superb contribution draws attention to how international the effort has been to conquer this problem. Not surprisingly, perhaps, the country with the lowest tolerated level is Sweden, 0.02%. Stewart's editorial also addresses varying sanctions or penalties for violations, and in particular, the contentious issue of the role of previous offenders. As well, she examines licensing policies and experiences with enforcement, especially the use of sobriety checkpoints.

    Before I elaborate further on the issue of alcohol as a risk factor, I feel obliged to disclose my interest. Last year, after publishing the essay by Marielle Olivier about the killing of her sister by a drunk driver, I asked her to keep me informed about the events that followed. I was appalled by her bewilderingly discouraging account of the court case, and how powerless she and the other members of the family felt. Consequently, I became involved with MADD Canada and was recently appointed to its National Board of Directors.

    Injury Prevention readers need no reminding that alcohol is not just a risk factor for road crashes. The risk in almost every other category of injury—unintentional and intentional—especially house fires, drowning, sports, and recreation, is also greatly increased by the presence of alcohol. Thus, alcohol is a pervasive risk factor, frequently compounded, especially in the case of road crashes, by drug use (illicit, prescribed, or over-the-counter).

    It is evident that eliminating or sharply reducing the use of alcohol in risk situations is the most direct route to success. What is much less evident is how best to achieve this goal. Is stronger legislation more effective? Does it really matter how vigorously laws are enforced? Should these strategies remain foremost, or should more emphasis be placed on technological solutions such as driver interlock devices? My instincts tell me that of the alternatives available, better legislation is still the most certain path to success. However, as Solomon points out, legislation that may appear “strong” may be much less so if other aspects of the law make it difficult to enforce. In Ontario, and undoubtedly in many other constituencies, policing and judicial problems remain unresolved. This is also true for helmet laws, seat restraint use, smoke detectors, and life jacket use.

    As in so many other injury prevention issues, it seems that the goal will be reached more quickly and efficiently when health departments play a larger part. Health must join with justice, transport, and many other branches of government, to overcome the obstacles that remain. Whether these involve the reluctance of police to do random breath tests or that of judges to hand out stiff sentences, one underlying explanation is almost certain to include the widespread acceptability of alcohol in most societies. In part this reflects how alcohol is portrayed on TV, in magazines, etc. Nowadays when we see an old movie or video in which it seems everyone is smoking, we are surprised and perhaps disapproving. But we react differently when we see alcohol being consumed or when beer ads are shown during high profile events, especially sporting events.

    The evolution of tobacco control measures is instructive. Focusing on the place of alcohol in society, may, therefore, be the next step. The day may not be too far off when governments will launch class action suits against alcohol manufacturers to recover some of the cost of the care of those injured by this product just as they have done with tobacco. We need to reconsider the logic of allowing the sale of alcohol to remain relatively unrestricted. Without wishing to appear as if I were advocating a return to the days of prohibition, we cannot afford to view this product much differently than we now do its fellow evil spirit, tobacco.

    Would it help if products containing alcohol were better labeled to reflect their dangers, as many countries now do for cigarettes? Whatever the answer, it is evident that conventional preventive measures such as strict enforcement of impaired driving and minimum legal drinking age laws, sobriety checkpoints, and prompt suspension of licenses have brought us only part of the way towards the goal. According to a recent Morbidity and Mortality Weekly Report from the Centers for Disease Control and Prevention in the US, the percentage of alcohol related traffic fatalities in the US remained at about 38% between 1997 and 1998.1 With only the measures now in place, the Surgeon General's target cannot possibly be met in the foreseeable future.

    One way or another, we must act more effectively against alcohol used in excess. It is unlikely that there is any other risk factor that accounts for so many preventable injuries.


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