Primary prevention of drink driving by the large-scale use of alcolocks in commercial vehicles Bo Bjerre 1 Johan Kostela 2

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1 T2007 Seattle, Washington Primary prevention of drink driving by the large-scale use of alcolocks in commercial vehicles Bo Bjerre 1 Johan Kostela 2 1 Associate Professor, Senior Physician, Traffic Medicine, Swedish Road Administration, Borlänge, Sweden 2 Senior Research Scientist, Dalarna Research Institute (Dalarnas Forskningsråd), Falun, Sweden Abstract Objective: Alcolocks are commercial breath test devices that prevent a motor vehicle from starting when a driver s blood alcohol concentration (BAC) is elevated. This report is an evaluation of the experiences and BAC data from the first ever use of alcolocks in commercial vehicles as a primary prevention strategy to prevent drink-driving. In most applications, the alcolock is imposed only after an impaired driving conviction. This study, implemented in Sweden, estimates drink-driving on a large scale in a variety of commercial vehicles. Design: Questionnaire-based interviews and analysis of recorded breath tests with no experimental manipulations. Setting: Commercial firms with fleets of registered vehicles. Participants: Officials from 118 companies with alcolocks were interviewed representing vehicles and professional drivers using alcolocks reflecting an 80% compliance rate. In a contrast group of 230 transport businesses the interview compliance rate was 57%. Intervention: Descriptive surveys of companies which were willing, or not willing, to install alcolock devices in commercial vehicle to reduce suspected drink-driving and also to detect vehicle operators with alcohol problems. Main outcome measures: Survey results probed motivation for and experience with alcolocks. Analysis of BAC test patterns alluded to alcohol consumption problems among employees through prevalence estimates of drink-driving attempts from the rate of BAC the legal limit 0.020%. Results: Survey results determined that before alcolock installation, 64% of the employers suspected alcohol problems among their employees. Their main reason for installing was to improve the transport quality. The costs for installing the alcolock device averaged EURO per vehicle. Several companies had technical problems with the alcolocks; but 92 % of them recommended other companies to install alcolocks. In cohorts of about 600, mainly heavy vehicles, 0.19% of all starts were prevented by elevated BAC; these were most frequently detected during weekends and in the mornings. Daytime Saturday and Sunday mornings 0.72% of the drivers had elevated BAC. Conclusions The prevalence of drink-driving among professional drivers is probably similar to that among drivers in general. The use of alcolocks in commercial vehicles would improve the traffic safety through the prevention of many drink-driving episodes. Introduction In Sweden, as in many other countries, drinking drivers are among the biggest problem in road traffic safety with drink-drivers identified every year. As the risk of detection is

2 very low, it is widely assumed that most people convicted of drinking and driving have driven while under the influence of alcohol on many previous occasions. According to population surveys, 10% to 15% of all men and approximately 5% of all women are estimated to have chronic alcohol dependence, and around a quarter of these are in what can be called an active phase (1). However, we do not know how many of these people and how often they are on our roads while intoxicated. Nor do we know how many people only occasionally drive while intoxicated. In 1999 a primary prevention approach to prevent any kind of drinking and driving was introduced in Sweden by one of the authors. This was the first attempt world-wide to prevent drink-driving in a large scale among a population of drivers who had not previously been identified as having alcohol problems. The primary prevention approach was adopted to overcome the difficult task of detecting vehicle operators with alcohol problems who are employed by various transport businesses. Starting with a pilot project, alcolocks were voluntarily installed in commercial vehicles (buses, trucks, and taxis) (2). Currently about various kinds of vehicles have alcolocks installed in Sweden and some transport companies have had the device installed for as long as six years. The object of the present study was to evaluate the experiences from and attitudes to this primary prevention strategy. This evaluation was based on questionnaires distributed to key informants at companies which installed alcolock devices. To permit a comparison, and to determine reasons for not installing, companies without alcolocks were also interviewed. As the alcolock also records the drivers BAC test data we also had the opportunity to study the prevalence of drink-driving attempts in an unselected population of drivers employed in commercial transport companies. Methods A questionnaire-based interview was sent to transport companies having installed alcolocks. Thus all 118 companies in Sweden that were known by the Swedish Road Administration and by the two main alcolock suppliers to have alcolocks installed in their fleets were included. A similar questionnaire was sent to 230 different transport companies that were not known to have installed alcolocks. Outcome evaluation Breath tests records The information about positive breath tests (BAC=/>0.02%) is sensitive for commercial as well as individual reasons because a positive test reveals a DWI offence that could have occurred had the alcolock not prevented it. We got results from two cohorts of vehicles, where the monitoring program was served by one of the alcolock suppliers; one cohort of 687 vehicles with alcolocks during 2004 and another with 581 vehicles during 2005, where all breath tests were recorded. In these cohorts a larger number of the vehicles were heavy (trucks, buses and some single purpose vehicles) than in the whole population; about 70 and 40%, respectively. The total number of breath test recorded when there was an attempt to start the vehicle and the rate of those that were alcohol positive (BAC>0.02%) were recorded for two years in the two cohorts. We also recorded the number of tests just below the legal limit (BAC ) and those showing high BAC (>.10%). The breath tests were distributed on the seven days of the

3 week and on four different time intervals of the day. Typically after a failed test the driver will perform re-tests until he succeeds in starting the vehicle therefore repeated new positive breath tests usually occur after the first failure. Accordingly for the evaluation we have filtered out the re-tests and only record the first alcohol positive test. Results The response rate was 80% on the questionnaires sent to the companies that installed alcolocks. The response rate on the questionnaires sent to the companies that did not install alcolocks was, as we expected, lower, 57%. Type of transport business Those respondents that installed alcolocks were asked to categorize their company into one of six different categories; truck road carriers (31%), buses (12%), taxis (18%), construction vehicles (5%), public-sector (18%), other (16%; several of these were combined bus and taxi companies). Number and kind of vehicles and number of drivers using alcolocks As shown in table 1 most of the vehicles with alcolocks installed were cars and trucks. Among the different transport companies the median number of vehicles equipped with alcolocks was 12 (range 1-541) and the median number of employed driver was 30 (range ). In total drivers used motor vehicles with alcolocks. Previous experiences of alcohol problems among the employees The answers on the three questions about previous, suspected or observed, alcohol problems among the employed drivers differed between those companies that did install alcolocks and those who did not. In the alcolock group 64% reported previous suspicion of alcohol problems, 35% about suspected drink-driving, and 28% about known DWI offence among the employees. In the group of companies without alcolocks the corresponding figures were just 45%, 23% and 19% respectively. The differences between the two groups was, however, only significant with regard to the reported rate of suspected alcohol problems among the employed drivers (p<0.01). The main reasons for installing or not installing alcolocks Almost all companies reported more than one main reason for installing alcolocks. A majority of the companies (73%) reported that improving the quality of their transports was the main motive for installing and 45% also considered the installation as an important strategy that was in line with their own alcohol policy. About half of the companies without alcolocks reported more than one main reason for not installing them. The high costs for the alcolock was considered the main obstacle for 61% of the companies and another 16% believed that the devices were too troublesome. One fourth of the companies found no reason to install as they had not experienced any alcohol problems among their drivers. Another argument against installation was the fear of having vehicles that would not start or integrity problems. It is noteworthy that almost none of the companies considered resistance from trade unions being an obstacle. The costs for installing and for service of the alcolocks

4 The mean costs for installing the alcolock was Euro and the cost of annual service another 225 Euro. How are alcohol positive breath-tests recorded and handled The procedures for recording positive breath-tests varied among the companies. About 35% answered that they recorded and saved all breath-test logs. The remaining companies merely observed the logs when a failure to start was recorded, or they did not use the logs at all. Observed problems with the alcolocks? The most frequently reported problems were difficulties in starting the vehicle when it was very cold in the winter, the delay to start caused by the alcolock (because the alcohol sampling head must warm up before it is ready to test), and various difficulties with the performance of the breath tests. By contrast, several companies did not experience any major problems with the alcolocks. Attitudes to the alcolocks among the employees and employers? According to the poll 82% of respondents reported a positive attitude among the employees towards the use of alcolocks. Some companies had experienced positive reactions from customers and mass media and altogether 98% of all employers would recommend other transport companies to install alcolocks. It is noteworthy that a majority (76%) of the companies without alcolocks nonetheless considered that installation of alcolocks in commercial vehicles will become important in the future. The rate and pattern of alcohol positive breath tests at start The total number of failures to start due to breath tests measuring BAC above the legal limit at various days of the week was 3.72 of tests. As a large part of these failures were caused by repeated positive tests by the same driver in a short time sequence it was necessary to eliminate these repeated trial and errors. Therefore the data in table 2 which represents only the first attempt to start the vehicle is more reflective of separate attempts to drive and presents the number of individual episodes of drink-driving prevented. We found that among the total of start attempts during two years 1.92 out of failed because the driver had a BAC level above the legal limit. The highest rate of positive breath tests appeared during the weekend where about 5 of tests showed BAC =/> 0.02%. Failures to start were also more common on Mondays and Fridays than on the other days of the week. When studying the pattern of drink-driving attempts for various times of the day (table 3) it becomes obvious that alcohol positive breath tests occur most frequently during the morning (06-10 a.m.). This was particularly apparent on Sunday mornings, when 0.72% of all breath tests were alcohol positive (table 4). It reasonable to suggest that the alcolock has a preventive effect in that sense that drivers avoid drinking or they drink less before driving due to the problem of not being able to start the vehicle when coming to their job. Therefore it is also of interest to study the records of breath tests with BAC levels just below the legal limit (BAC %). We then observed that 2 out of breath tests showed BAC levels in this range. Despite the expected preventive effect 1 out of drivers were found to have a BAC level =/> 0.10% when they try to start their vehicle.

5 Discussion In the present study we have data suggesting that the prevalence of drink-driving among drivers in commercial transport companies is comparable to that among Swedish drivers in general. In two cohorts of professional drivers of mainly heavy vehicles (trucks, buses and some contract working vehicles) 0.19% of the start attempts failed because the driver was found with an elevated BAC level. These cohorts had not previously been monitoring alcohol problems and according to the interviews very few transport companies had installed alcolocks as a consequence of known alcohol problems among their employees. Therefore we have no reasons to assume that these groups of drivers differ from an average population of professional drivers. Rather we suggest that the rate of elevated BAC tests among professional drivers would likely be even higher without alcolocks as the placement of an alcolock in the vehicle has two types of preventive effects. First, knowing that the device will not allow a start if the driver had been drinking, prevents drinking by employed drivers in order to avoid trouble getting started. Second, those drivers who do not know or who do not care if their BAC levels are elevated are prevented from drink-driving as well. The highest number of elevated BAC tests occurred during Monday to Friday between 7 and 9 a.m. with a peak at 8 a.m when people started their cars going to their work. On Saturday and Sunday they found the highest number of positive BAC tests were some hours later at 11 am to 12 noon. In both cases these blocked start attempts were probably due to drinking the prior evening. Based on the knowledge that most Swedes carefully avoid drinking and driving we may assume that a major part of drinking and driving occurs among a limited number of people with alcohol problems. Accordingly, a recent Swedish study demonstrated that alcohol problems, based on AUDIT scores, were found to a high extent independent of the detected BAC levels at general traffic controls (3). Thus 48% of suspected DUI drivers with BAC levels between and 0.099% had dangerous or harmful alcohol habits. The corresponding figure for drivers with BAC levels above 0.10% was 69% and, most surprising, 46% of drivers with levels below the legal limit (0.020%) were also found to have alcohol problems. Thus we conjecture that most of the alcohol positive breath tests found in the present study came from drivers with more or less advanced alcohol problems. In the EC field trial a number of alcohol positive breath tests were recorded among professional drivers and it was found that 0.17% of starts failed due to elevated BAC levels (>0.03%) among 20 drivers employed in German international goods transport companies (4). Among 30 Spanish bus drivers 0.60% of the starts were recorded with BAC levels >0.03%. Even though the number of drivers was limited in that study the range of drink-driving attempts seem to be comparable with the Swedish findings. The above observations and the knowledge of how common alcohol problems are in the population constitute good reasons for further installations of alcolocks in the vehicles of transport companies. It seems logical that a general application of alcolocks would be most efficient in those motor vehicles being most frequently exposed in traffic and in vehicles performing passenger traffic. Moreover, the costs for the installation of an alcolock do not correspond to more than 1-2 % of the entire costs of the vehicle. Therefore it is also logical that the Swedish government has proposed that alcolocks should be installed in all new buses and trucks from 2010 and onwards.

6 We present data that reflects the experiences from the use of alcolocks among professional drivers for up to six years. Of the vehicles having alcolocks 904 were trucks and 236 buses. In the cohorts of about 600, mainly heavy, vehicles where all breath tests were recorded for two years we observed that each vehicle, as an average, was prevented from at least one occasion of drink-driving per year. Provided that the entire fleet of trucks, buses, and taxis in Sweden had installed alcolocks that would correspond to about half a million drink driving trips being prevented every year. Based on the assumption that the prevalence of drink-driving among professional drivers is similar to that among drivers in general and on our findings of a high acceptance of alcolocks among the Swedish transport companies we believe that there are good reasons to install alcolocks in heavy vehicles also in several other countries. A large-scale implementation of alcolocks would probably result in a considerable reduction of alcohol-related traffic crashes world-wide. References 1. Statens Beredning för medicinsk Utvärdering (SBU report, in Swedish). Behandling av alkohol- och narkotikaproblem. En evidensbaserad kunskapssammanställning. ( The Swedish Council on Technolgy Assessment in Health Care: Treatment of alcohol and drug problems. An evidence-based knowledge compilation); 2001 Volume I, II. 2. Bjerre B. Primary and secondary prevention of drink-driving by the use of alcolock device and program. Swedish experiences. Accid. Analysis 2005; 37: Bergman H, Hubicka B, Laurell H. Alcohol problems and BAC among Swedish drivers suspected of driving under the influence. Contempory drug problems. 32/Fall 2005: Silverans P, Alvarez J, Assum T, Drevet M, Evers C, Hagman R & Mathijssen R. Alcolock implementation in the European Union. Description, results and discussion of the alcolock field trial. Retrieved March 7, 2007, from Belgian Road Safety Institute. Table 1. The number and type of vehicles having installed alcolocks. The distribution (percent) of alcolocks among the different type of vehicles. Type of vehicle Number of vehicles with an Percent of total alcolock Official cars Trucks Heavy, single purpose vehicles Taxis Buses Other vehicles In total

7 Table 2. Number of drivers making one or several alcohol positive breath tests when trying to start the vehicle. The repeated positive breath tests are excluded when occurring at the same day. Alcohol positive breath tests (failure to start) include all tests measuring BAC =/> 0.02%. Number of failures to start per attempts are presented for 2004 and 2005 at various days of the week. Day of the week Number of attempts to start Number of failures per attempts Monday Tuesday Wednesday Thursday Friday Saturday Sunday Week in total Table 3. Number of drivers making one or several alcohol positive breath tests when trying to start the vehicle. The repeated positive breath tests are excluded when occurring at the same day. Alcohol positive breath tests (failure to start) include all tests measuring BAC =/> 0.02%. Number of failures to start per attempts are presented for 2004 and 2005 at various times of the day. Time of the day Number of failures Number of attempts to start Day in total Number of failures per attempts Table 4. Number of drivers making one or several alcohol positive breath tests when trying to start the vehicle. The repeated positive breath tests are excluded when occurring at the same day. Number of failures to start per attempts are presented for 2004 and 2005 at various times of the different days of the week. Day of the week Monday Tuesday Wednesday Thursday Friday Saturday Sunday

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