August is high summer here in Seattle and the days are typically glorious. Visitors who have succumbed to the misperception that our skies are chronically grey and wet are astonished at the natural beauty of this region when the sun appears. Green forests frame our waterways with snowcapped mountains in the background. Unsurprisingly, absolutely everybody heads out doors to enjoy it while we can.

The sad corollary of this activity on and around the water is a predictable increase in the number of drowning cases each summer. In high-income countries drowning is typically associated with occupational or recreational exposure. In our state, that recreation tends to happen on open water, while people enjoy boating on our rivers, lakes and coastal waters.1 Drowning prevention in these contexts requires a specific set of behaviours and interventions, often quite distinct from the strategies employed to combat drowning in low or middle income countries, in swimming pools or in bathing facilities. A trio of papers in this issue, along with a forthcoming study in press, identifies key behavioural factors which are modifiable and can improve boating safety.ⁱ I think it is instructive that many of the findings and their implications echo past, successful, experience in the reduction of road traffic injury risk through various mechanisms.

Stempski and colleagues contrast risk factors between boat-related injuries and boat-related fatalities in Washington State.2 Using a case-control methodology, they found associations between fatal outcomes and lack of life jacket use, lack of on-board safety equipment and the use of alcohol on the boat. Interesting, they found an increased risk of death in boating incidents that involved paddle craft users, suggesting that we might want to approach these as a class of ‘vulnerable’ boaters, just as we recognise vulnerable road users among pedestrians and cyclists.

Although we have decent evidence that life jackets reduce the risk of drowning,3 few boaters use them consistently and the prevalence of use among those who drown is very low. Using a cross-sectional observational design, Chung et al4 report that life jacket use was much more likely among boaters required by law to wear a floatation device. Cassell and Newstead take a longitudinal perspective, contrasting life jacket use before and after a statewide legislative mandate in Victoria, Australia.5 They found that use increased from 22% to 63% among boaters on vessels covered by the law, but did not change among those on vessels that were exempt. Finally, Quistberg et al6 interviewed boaters to ascertain reasons for the non-use of life vests. Alcohol use, self-assessed swimming ability and the perception that life jackets were uncomfortable were all associated with low use.

Taken together, these papers suggest real opportunities to improve boating safety. Just as the use of seat belts and child restraints has become second nature in the car, so too should the use of life jackets become a fixture in the boating culture. It is clear that legislation can nudge this along, but so too can positive role modelling. Children and teens are much more likely to be using a life vest when the adults in their vessel are doing so.4

Perceptions clearly matter. No one thinks they should buckle up in the car only when they anticipate a crash, yet many boaters forego the use of safety devices when they perceive risk to be low. Understandably, since most boaters don't head out expecting to crash, capsize, or fall overboard, the use of safety devices remains unacceptably poor. Social marketing campaigns to recast the use of life vests as part of a boating “culture of preparedness” may be required to insure that protective equipment is available and in use for every trip.

Similarly, life vests have come a long way in design, features and comfort but this may not be the perception of many boaters.7 Gone are the bulky, mildewed and bright orange collars that branded the user as a novice boater or poor swimmer. Life vests today are designed for a low profile, ease of movement and comfort. Inflatable models are especially well-received. There may be others features, such as a dry-pocket for phones or cameras, which consumers would appreciate; creative market research should drive product design to optimise use after purchase.

Finally, there is a real need to address the risky mix of alcohol and boating. Safety practices suffer when alcohol is consumed. We know that alcohol contributes both to the risk of an incident and to the risk of drowning death when an incident occurs. And, at the end of the day, a boater who has been drinking on the water becomes a drink driver heading home. The public health messaging, interventions and enforcement around this behaviour will be especially tricky to implement and study. The journal would welcome papers looking at this, or at any applied intervention designed to reduce the risk of water recreation without dampening its considerable appeal.