The article documenting the successful seat belt intervention and attributable increase in wearing in Guanghzhou, China is a substantial contribution to road safety in middle-income and low-income countries. The reported increase in seat belt wearing is particularly significant in the context of documented declines over 3 years (2005-2007) in two other eastern seaboard Chinese cities, Nanjing, Jiangsu Province and Zhoushan, Zhejiang Province. The baseline Nanjing results were described in Injury Prevention (Dec 2007), the 3 year 2 city results are currently available on line.[1,2] The minimal wearing of rear seat belts (consistently below 1%) is an additional noteworthy outcome measure of this latter series of surveys. Considering the substantially documented injury prevention benefits of seat belt wearing and that in China fitting has been required in front seats from 1993 and in rear seats of new vehicles since 2004 (and that laws and regulations are in place), interventions that promote community awareness of the effectiveness of seat belts together with sustained enforcement should be actively encouraged.

References
1. Routley V, Ozanne-Smith J, Li D, et al. "Patterns of seat belt wearing in Nanjing, China." Inj. Prev, 2007, 13(6): 388-393.
2. Routley,V, Ozanne-Smith J, Li D et al. China belting up or down? Seat belt wearing trends in Nanjing and Zhoushan. Accid Anal Prev (in press). Available online 4 September 2008.

Dear Editor,

We are grateful for the letter of Desapriya et al. regarding our recent Special Feature, and agree with the sentiments it expresses. We, too, view our proposal to extend BAC limits to the age of 21 as part of a much larger initiative to reduce traffic crashes among youth. Indeed, we outlined a more comprehensive approach to the issue in our 2006 report, Youth and Impaired Driving in Canada: Opportunities for Progress, which was published by MADD Canada and Allstate Insurance. The report includes proposals not only for graduated licensing and extended BAC restrictions, but also for more effective police enforcement powers and the regulation of alcohol sales. The full report can be downloaded at www.madd.ca.

Regards,

Erika Chamberlain and Robert Solomon

Dear Editor

It is timely that Chamberlain and Solomon [1] are proposing an extended zero blood alcohol limit for young drivers and it will definitely save more young lives; however, we believe that drinking and driving is an important part of this complex problem and we have to streamline all other Graduated Driver Licensing (GDL) components in order to realize the significant impact of GDL in saving our children in the future.

For more than a century alcohol has been recognized as one of the principal risk factors for motor vehicle crashes.[2] Alcohol-related motor vehicle crashes represent a leading cause of morbidity and mortality, particularly in young people, carrying an immeasurable human cost, as well as an enormous burden to society. Eighty-one percent of Canadians have rated drinking and driving as one of the most significant social issues they must face today, placing it ahead of other prominent issues, including health care, pollution, and the state of the economy.[3]

Young drivers continue to be a major traffic safety concern. Several factors contribute to the increased risk of traffic crash-related fatalities among adolescents and young adults including less experience driving, higher rates of drinking and driving, excessive speeding and lower rates of seat belt use. Given the significance of alcohol impaired driving to youth mortality, a key issue is to enhance the effectiveness of prevention policy and programming. Mothers Against Drunk Driving Canada has recommended that the zero BAC limits for young drivers be extended to the age of 21.[1]

Previous studies in other countries have also shown that an increased BAC limit is a difficult transition for young drivers (after GDL from a zero tolerance of alcohol to a dangerously higher BAC limit) and it was a major factor which contributed to their increased crash involvement in Australia. [4] Another recent study showed that new drivers experienced a difficult transition from the zero tolerance policy to the adult driver BAC limit (0.08 percent).This has been compromising overall traffic safety in New Zealand. [5]

In addition, New South Wales introduced extended zero tolerance laws to their new drivers.[6] Young drivers are inexperienced not only in driving but also in drinking and when they combine the two activities, this could be deadly. It is not surprising given that the risks of a fatal crash while driving at the current Canadian legal BAC limit (and in many other motorized countries including New Zealand, UK, USA) are alarmingly high even for experienced mature drivers.

The legal BAC limit in most motorized countries is too high; people often mistakenly believe that they may drive up to a BAC of 0.08 percent, overlooking the fact that driving is still impaired at lower concentrations. To set a blood alcohol limit so high that a 72 kg man can drink four bottles of beer and still be under the legal limit has consequences for drunk drivers, passengers of the vehicle and all other innocent vulnerable road users. Importantly, it may adversely influence a person’s estimates of their relative risk of injury or death while driving. Therefore drinking and driving legislation policies and decisions about enforcement need to be hinged on the scientific evidence. [2]

As Rivara and colleagues (2001) [7] pointed out, one of the most effective enabling factors for injury control is legislation. Importantly, laws must be capable of communicating the public health and traffic safety hazards of drinking and driving. As veteran pediatric injury prevention experts like Simons-Morton and Winston (2006) [8] have shown, laws have the power to change drivers’ perceptions of the value of safety practices.

However, we must understand that the youth traffic crash problem is interwoven with several other factors. [9] Therefore, it is important to have an overall approach that is built on the foundation of GDL laws to prevent young driver crashes. We should push for more comprehensive legislation and better enforcement based on the currently available best evidence.

To achieve the Canadian national road safety strategy target 2010, various road safety strategies for new drivers must receive priority. [10] It is evident that our current GDL laws have been steering young drivers in the right direction. However, in addition to extended zero BAC limits, until a complete cell phone ban, maximum speed limits, and compulsory seat belt laws are incorporated into the graduated licensing system throughout Canada, it is unlikely that the national road safety strategy target for 2010 will be achieved. One of the major reasons teens are killed or seriously injured when involved in traffic crashes is lack of seat belt use. It is well known that when drivers drink and drive, they tend to lack seat belt use. If we have effective policies that separate drinking and driving we could reduce non-belted youth drivers in our communities. In addition, GDL laws that explicitly include requirements for seat belt use in all phases, and sanctions that prohibit “graduation” to the next licensing phase if there is a seat belt citation, could increase teen seat belt use substantially. A zero-tolerance program for nonuse of safety belts, use of cell phone while driving and exceeding safe posted speed limits could be implemented, with immediate loss of license or other administrative penalties resulting for non-compliance. One major step we need to take irrespective of anything urgently is that we need to promote responsible driving among our children.

No policy can be effective unless it is adequately implemented and enforced, and there is awareness of both the policy and the enforcement efforts on the part of the intended targets. As with all above zero-tolerance programs, enforcement and strategic media campaigns to increase youth’s awareness of the law and of its enforcement efforts could significantly increase the effectiveness of these laws.

References

[1]. Chamberlain E, Solomon R. Zero blood alcohol concentration limits for drivers under 21: lessons from Canada. Inj Prev. 2008; 14(2):123-128.

[2].Desapriya EB. Alcohol limit for drink driving should be much lower. BMJ 2004; 328(7444):855-6.

[3]. Beirness, D.J., Simpson, H.M., Mayhew, D.R., et al; The Road Safety Monitor 2005- Drinking and Driving- Traffic Injury Research Foundation 2005

[4]. Senserrick TM. Graduation from a zero to .05 BAC restriction in an Australian graduated licensing system: a difficult transition for young drivers? Annu Proc Assoc Adv Automot Med. 2003;47:215-31.

[5]. Senserrick, T., Harworth, N., Review of literature regarding National International young driver training licensing and regulatory systems. Melbourne: Monash University Accident Research Centre, 2005.

[6]. Keall M.D., Frith W.J., Patterson T.L. The influence of alcohol, age and number of passengers on the night-time risk of driver fatal injury in New Zealand. Accid Anal Prev. 2004;36(1):49-61.

[7]. Rivara FP, Bennett E, Crispin B, Kruger K, Ebel E, Sarewitz A. Booster seats for child passengers: lessons learned for increasing their use. Inj Prev. 2001;7(3):210-3.

[8]. Simons-Morton BG, Winston FK. Translational research in child and adolescent transportation safety. Eval Health Prof. 2006;29:33 DOI: 10.1177/0163278705284442.

[9].Desapriya E, Joshi P, Pike I. Effects of graduated driver licensing on fatalities in 16-year-olds. Pediatrics 2006;118(5):2252-3.

[10]. Canada’s Road Safety Targets to 2010 http://www.tc.gc.ca/roadsafety/tp/tp13736/pdf/CRS_Target.pdf (accessed 15th March 2008)

Dear Editor

Nagata et al. reported effectiveness of Japanese law against alcohol-impaired driving, which would serve as a useful reference to other countries.[1] However, for this paper to be really helpful to policy makers, the description of legislation should be accurate; and changes other than the road traffic law, which might have influenced the results, should also be described.

The authors stated the fine against alcohol-impaired driving (AID) increased from 50 000 yen to 500 000 Yen.[1] This is misleading because there are two types of AID in Japan, to which different penalties are applied. Deshapriya et al. described the differences in details: in their words, driving under the influence (DUI) is determined by breath testing and driving while (heavily) impaired (DWI) is determined by the police officers' judgment on drivers' behaviors.[2] Heavier penalties are applied to DWI which is considered to be more dangerous. Before the law amendment, penalties against DUI and DWI were up to three months imprisonment or up to 50 000 Yen fine, and up to two years imprisonment or up to 100 000 Yen fine, respectively (one was imposed a fine thorough a summary procedure unless the one chose a formal lawsuit instead or was a repeated offender). These penalties were increased in June 2002 to one year or 300 000 Yen and three years or 500 000 Yen, respectively.[3] Heavier penalties against DWI have been seldom applied: in 2001 DWI penalties were applied only to 1 % of drivers charged with AID, which increased to 1.3 % in 2003.[3] Therefore, in most of the cases after the new law was implemented, fines imposed to charged drivers were up to 300 000 Yen.

The authors stated the new law made bartenders and passengers culpable.[1] Actually those who provided charged drivers with alcohol or a vehicle, and passengers had been punished as accomplices with the aid of a criminal law articles 61 and 62 that prescribe punishment against those who support a crime until September 2007 when the road traffic law was amended again. The latest law prescribes punishment against those who provided charged drivers with alcohol or a vehicle and passengers; penalties against DUI and DWI were increased to three years imprisonment or up to 500 000 Yen fine and five years imprisonment or up to 1 000 000 Yen fine, respectively.[4]

The authors discussed that no major change other than the new road traffic law occurred between 1998 and 2003.[1] Although there was no other major change in the road traffic law during this period, there was a big change in the criminal law in December 2001. Before that, penalty against those who hit a person while AID resulting in death was up to five years imprisonment. The new criminal law prescribes up to 20 years imprisonment to those who kill a person while dangerous driving including AID.[3] This implies that crashes due to AID which used to be just a mistake has become a homicide crime. This change cannot be ignored because the reduction of deaths due to AID might be at least partly because of the new criminal law. The number of drivers charged with AID started to decline before the increases of the fines (figure).

Figure 1

Another point that should be considered is a possibility of misclassification of AID as non-AID. The new road traffic law did not increase penalties against refusal of breath testing, which was 50 000 Yen fine until November 2004 when it was increased to fine same as that of DUI. Increased refusal by 52.5% was reported in June 2002 to May 2003 compared to the previous one year.[5] Furthermore, penalties against hit and run, though increased from up to three years imprisonment or up to 200 000 Yen fine to five years or 500 000 Yen in 2002, have been less severe compared to the criminal law prescribing up to 20 years imprisonment against dangerous driving resulting in death. Occurrence of hit and run started to increase concurrently with the decline of charged drivers for AID (figure). Drunk drivers involved in a crash might have chosen to be charged with refusal rather than DUI, or escaped to be charged with hit and run especially when there was a possibility of 20 years imprisonment. Therefore, we suggest that the authors analyze the trend of non-AID fatalities whether there is an upward change.

References

1. Nagata T, Setoguchi S, Hemenway D, Perry MJ. Effectiveness of a law to reduce alcohol-impaired driving in Japan. Inj Prev. 2008;14(1):19-23.
2. Deshapriya EB, Iwase N. Impact of the 1970 legal BAC 0.05 mg% limit legislation on drunk-driver-involved traffic fatalities, accidents, and DWI in Japan. Subst Use Misuse. 1998;33(14):2757-88.
3. National Police Agency. Police White Paper 2005. (in Japanese.) Tokyo: Natioal Police Agency, 2005. 20-21.
4. National Police Agency. Kaisei dorokotsuhono gaiyo. [Amendment of the road traffic law.] (in Japanese.) National Police Agency, 2007. http://www.npa.go.jp/koutsuu/kikaku190906/2_kaisei/Taro10-2.pdf (accessed on 19 Feb 2008)
5. National Police Agency. Inshu untentaisakuno jokyonitsuite. [Countermeasures against alcohol-impaired driving.] (in Japanese.) National Police Agency, 2003. http://www.npa.go.jp/comment/result/koutsuukikaku2/honbun/betu07.pdf (accessed on 19 Feb 2008)