Alcohol problems and blood alcohol concentration among Swedish drivers suspected of driving under the influence

Transcription

1 Contemporary Drug Problems 32/Fall Alcohol problems and blood alcohol concentration among Swedish drivers suspected of driving under the influence BY HANS BERGMAN, BEATA HUBICKA, AND HANS LAURELL The purpose ofthe study was to map alcohol problems in relation to blood alcohol concentration in a large representative sample ofmale andfemale Swedish drivers suspectedofdrunk driving. Twenty-one hundred suspected DUI offenders (drivers suspected ofdriving under the influence ofalcohol) were assessedwith the Alcohol Use Disorders Identification Test (AUDIT). Informationfrom the police regarding BAC, age, gender, and place and time ofthe stop was also collected. More than half(58%) ofthe suspected DUI offenders had alcohol problems, and among these 24% had high levels ofalcohol problems. Ofspecific interest was the observation that almost half (46%) ofthe suspects with a BAC below the Swedish legal limit of 0.02% had alcohol problems, a prevalence that did not increase until a BAC of0.10%-0. 15%. It can be concluded that the mere suspicion ofdrunk driving indicates alcohol problems. KEY WORDS: Screening ofalcohol problems among DUI offenders, DUI (driving under influence), BAC (blood alcohol concentration), AUDIT (Alcohol Use Disorders Identification Test). AUTHORS' NOTE: This study was supported by the Swedish National Road Administration, Borldnge, and approved by the Ethics Committee of Karolinska Institutet. Many thanks go to the cooperating policemen, whose contributions were essential to the project by Federal Legal Publications, Inc.

2 388 ALCOHOL PROBLEMS AND BAC The reported prevalence of alcohol problems among samples of offenders charged with driving under the influence of alcohol (DUI) varies as much as between 4% and 87% in different investigations, depending on the definition of alcohol problems and the methods of assessment (Vingilis, 1983, 1988; Lapham et ai., 2000; Brinkmann et al., 2002). Previous studies were carried out mostly on selected DUI groups-e.g., drivers with a high and illegal blood alcohol concentration (BAC), drivers involved in traffic accidents with or without a fatal outcome (Baker et al., 2002), drivers convicted of a DUI offense or undergoing treatment for alcohol problems (Andren et al., 2002). Using the Alcohol Use Disorders Identification Test (AUDIT), Conley (2001) reported that 80% among a sample of multiple-offender drunk drivers had an alcohol use disorder. However, there is a need for studies of DUI offenders that are more representative of the whole population of drunk drivers. There is also a lack of knowledge about the prevalence of alcohol problems among drivers with a low BAC and among female DUI offenders. Research results and experiences from other countries might not be valid for Sweden, since in most other countries legislation, alcohol use, and attitudes toward drunk driving differ considerably, mostly in a liberal direction (Valverius, 1989). Thus, Swedish DUI offenders might be more deviant from drivers generally than DUI offenders in other countries. The prevailing Swedish attitude toward mixing alcohol and driving is one of condemnation; therefore it can be expected that a greater proportion of social drinkers refrain from drinking and driving, thus creating a high proportion of heavy drinkers among drunken drivers. However, since Sweden became a member of the European Union, the Swedish alcohol policy has been successively liberalized, and during the last years increased alcohol consumption (Bergman and Kallmen, 2002, 2003) and increased alcohol involvement in fatal car accidents (Swedish National Road Administration, 2003) have been reported. The total registered alcohol consumption in

3 389 Sweden increased by 13% between 1996 and 2000, and rose by 7% just during 2003 (Sweden's Statistical Databases, 2003) or by 8% according to other sources (SoRAD, 2003). There is a general opinion that the BAC level indicates the severity of alcohol dependency. Thus a high BAC in a driver is considered a sign of an increased alcohol tolerance and alcohol problems on the basis of longtime heavy drinking. Conversely, a low BAC in a driver might imply the absence of alcohol problems. However, most often it is just a coincidence how long a time has passed between alcohol consumption and the detection of a DUI offense and how much alcohol has been metabolized by then. In a previous study (Bergman et al., 1997) of a selected group of sentenced DUI offenders in treatment, we concluded that BAC per se is a poor identification test of alcohol problems, and we hypothesized that among "low BAC drivers" there are many with alcohol problems. The purpose of the present study was to investigate the prevalence of alcohol problems as assessed by the AUDIT in a large representative sample of male and female Swedish drivers suspected of drunk driving. The results were also compared with the corresponding prevalence of alcohol problems in a sample of control drivers and in the general population. The AUDIT results of drivers with different BAC levels, including drivers below the legal Swedish limit of 0.02%, were also compared. Finally, the validity of BAC used as a screening test of alcohol problems was evaluated in a larger, more representative sample of suspected DUI offenders than in previous studies, taking account of the sex of the driver. Method Samples and procedure The study was carried out during the five-year period Altogether 2,170 drivers suspected of DUI responded to the AUDIT. Since 70 of them responded more

4 390 ALCOHOL PROBLEMS AND BAC than once during the investigation period because of a relapse, only their first AUDIT and BAC results were included. Thus, the final sample investigated comprised 2,100 drivers (including 169 females; 8%) from 17 police stations representatively distributed from the north to the south of Sweden, covering both densely and sparsely populated regions, to enhance the validity of the results for the whole of Sweden. After having been stopped by the police, the suspected DUI offender was taken to a police station for interrogation and assessment of alcohol concentration. Following the interrogation, information about the project and an AUDIT form with a stamped return envelope were given to the suspect, to be responded to at home. All the police stations affirmed that the AUDIT materials were handed out to at least 90% of the suspected drivers. Information about gender, age, BAC (both blood and breath analysis were expressed in percent grams/ioo rnl alcohol in blood), and the circumstances at detection (manner and time of detection, type of road, and kind of vehicle) was also collected from the police. Alcohol concentration was received directly from blood samples in 306 cases and from breath-alcohol instruments (intoxylizers) in 1,788 cases, recalculated afterwards into BAC (six cases missing). In Table 1 the investigated sample is distributed with regard to manner and time of detection and BAC, separately for male and for female drivers. General traffic controls comprise all routine controls, roadside sobriety tests, random spot checks, regular patrols, and roadblocks. By "hints from public" is meant information to the police, usually by telephone, from a witness, a family member or a friend about a person who is driving or intending to drive under the influence of alcohol. Categories of manner of detection---dangerous driving, lack of proper lights, driving against a red light, hindering traffic and other traffic offenses-were merged into the category "other manners" because of the small number of cases. Alcohol problems among the suspected drivers in relation to manner and time of detection will be reported in a forthcoming paper. Mean and median age of the male drivers was 40 years (range: 15-88) and ofthe female drivers 39 years (range: 15-73).

5 391 TABLE 1 Number of suspected DUI offenders, by different manners and times of detection, mean age, and mean SAC, by gender Detection Men Women N Age BAC N Age BAC MANNER General traffic controls "Hints" from public Traffic accidents Unlawful driving ( ) Speed offense ( ) Other ( ) TIME OF DAY NOTE: Information about time of day is missing in 16 cases, about manner in 16 cases, and about BAC in six cases. Furthermore, 1,000 control drivers, not suspected of DUI, recruited at general traffic controls by the same 17 police stations as above, were also given the AUDIT materials during the time period The AUDIT materials were handed out to the driver after the routine traffic sobriety control at the roadside, to be responded to at home. The dropout rate was only 21.5% and resulted in 785 control drivers (519 males, 66%, and 266 females, 34%). Both mean and median age of the male controls was 43 years (range: 17-87) and of the females 40 years (range: 18-80). As an incentive to respond, both the suspected DUI offenders and the control drivers were given 100 SEK (equivalent to $11 US) upon returning the completed AUDIT questionnaire. Dropouts and quality of data Data were collected according to the ethical principle of informed consent. The total population of suspected DUI offenders detected by the 17 police stations during the investigation period comprised about 7,000 persons. Since 2,170 mailed back their AUDIT questionnaire to us, the

6 392 ALCOHOL PROBLEMS AND BAC response rate was about 30%. Population data with regard to the number of DUI offenders, BAC levels, gender and age were received monthly from the 17 police stations. There were no statistically significant differences between the sample investigated and the population of 7000 drivers suspected of DUI with regard to BAC, gender and age according to X"- and t-tests (p>0.05). AUDIT The "Alcohol Use Disorders Identification Test" (AUDIT) is a self-report questionnaire with 10 items. A fast and reliable screening method to identify persons with drinking problems in terms of hazardous or harmful alcohol use, it is recommended by the World Health Organization (Babor et al., 200 I) and also recommended for assessing drunk drivers by Conley (2001). The items give information about hazardous alcohol use (quantity and frequency of use, including binge drinking), dependency symptoms (lack of control and abstinence symptoms), alcohol-related harm (guilt feelings, blackouts, somebody hurt, other people worried). Every item is scored between 0 and 4. The total score varies between 0 and 40 points; high scores indicate a high level of alcohol problems. The AUDIT items and a detailed description are accessible on the web (Babor et al., 2001). The Swedish version has a satisfactory psychometric quality (Bergman and Kallmen, 2002, 2003) and has been tried out in several samples, including two large samples randomly selected from the general Swedish population. Factor analysis of the AUDIT responses of the general population samples resulted in two factors, "Hazardous alcohol use" (items 1-3) and "Alcohol-related problems" (items 4-10), each defining a subscale of AUDIT in terms of squared product-moment correlation. The first subscale explained 74% of the total AUDIT variance, and the second 79%. In samples with a high prevalence of alcohol problems, the second subscale has an even higher explanatory value (Bergman 1998). AUDIT was constructed for screening a wide range of alcohol-problem severity, and here the term "alcohol problem" is used in its

7 393 broad meaning. In the present sample the hazardous-use subscale explained 66% and the alcohol-problems subscale no less than 94% of the total variance. For this reason AUDIT is used as an indicator of alcohol problems in the present study. Babor et al. (2001) suggest that scores in the range of 8-15 represent a medium level of alcohol problems and scores of 16 and above a high level of alcohol problems. We suggest (Bergman and Kallmen, 2002) that the lower cutoff score for women should be reduced to 6+ and the cutoff score for a high level of alcohol problems in women should be set at 14 rather than 16 because of women's higher sensitivity to alcohol (about 25%). Based on the random sample, raw scores can be transformed to age- and gender-corrected non-normalized T-scores (M=50, SD=lO). Results AUDIT and BAC by gender and age More than half of the suspected DUI drivers (58% of the males and 55% of the females) had alcohol problems according to the AUDIT 8+ criterion for men and 6+ for women (see Table 2), compared with 15% of the male and 10% of the female control drivers and 18% of the men and 11% of the women in the random sample from the general Swedish population (Bergman and Kallrnen, 2002). The difference between the suspected DUI offender group and the two comparison groups was of course statistically significant for both men and women (X 2 tests, p<.ooi). The difference between the suspected DUI offenders and the control drivers was particularly large with regard to high levels of alcohol problems according to the 16+/14+ criteria (x2tests, p<.ool). The prevalence of alcohol problems among the 1,249 suspected DUI drivers detected at general traffic controls (routine control, roadside sobriety test, random spot checks, regular patrols, and roadblocks included; traffic accidents and all

8 394 ALCOHOL PROBLEMS AND BAC other serious offenses excluded) was nearly the same as for the whole DUI group (54% for the male drivers and 44% for the female drivers). TABLE 2 Prevalence of medium and high levels of alcohol problems together with AUDIT T-scores among Swedish drivers suspected of DUI offense (N = 2,100) and control drivers (N = 785), by gender Alcohol problems Men DUIs Controls N % T-score N % Tsscore None Medium High level DUIs Women Controls None Medium High level The differences between age groups in BAC were small (ANOVA, p=.042). However, the age differences in AUDIT raw scores (p<.ol), and particularly in age- and gendercorrected AUDIT T-scores (p<.ooi), were much larger; see Figure I. The mean T-score of the youngest age group was no fewer than 10 points lower than that of the older age groups. This is because in the general population of Sweden young people drink much more alcohol than older people (Bergman and Kallmen, 2002). Thus a given AUDIT raw score results in a lower T-score among young persons than among old. There was no difference between male and female drivers in BAC (M=0.103, SD=0.073 and M=0.102, SD=0.078, respectively) but the female drivers scored lower on AUDIT. However, in comparison with the general population the female drivers had more drinking problems than the male; see Figure I. Furthermore, their drinking problems became successively more evident in the older age groups as compared with the females of the general population in

9 395 Sweden. The corresponding trend was not observed among the male drivers. FIGURE 1 AUDIT T-scores, SAC level, and number of investigated drivers suspected of DUI offense, by gender and age groups 95~ ::.»,', [<> ~~-~=_---::.:.::.;.; ~77C 50 N-374 N-415 N=4JO N=443 N-272 TT-scores Males NOTE: fl!i N-U N-35 N_ N-J7 N-JJ Females mj > A T-score of 50 corresponds to value of the general population. Mean BAC levels for each age group are on bars. BAC is missing for six cases. BAC level as a screening instrument of alcohol problems As expected, the mean BAC was higher in cases of blood tests than in cases of breath analysis. For blood tests the mean BAC was 0.153% and for breath analysis 0.094% (N=306 and 1,788, respectively). Blood tests are more often used in cases of traffic accidents and of drivers who refuse the breath analysis. The AUDIT results of the two groups were also significantly different (ANOVA, p<.oo 1). The highest BAC level observed was 0.484% among the male drivers and 0.336% among the female drivers. Among 1,110 suspects with a BAC below 0.10% every second driver (49%) and among 984 with 0.10% or above (the legal limit for

10 396 ALCOHOL PROBLEMS AND BAC severe DUI crime in Sweden) more than two-thirds (69%) scored in the alcohol-problems region on AUDIT. Fifteen percent among suspects below a BAC of 0.10% and 34% among severe offenders (BAC 0.10% or higher) scored in the high level of the alcohol-problems region. The two BAC groups differed significantly (p<.oo 1) in both AUDIT total raw and T-scores. See Figure 2. FIGURE 1 AUDIT T-scores for different SAC levels OControl drillers N=785 mouls below penal BAC (0.02) N=189 rjouis of low BAC ( ) N=922 a OUIs of high BAC (abolle 0.10) N= AUDIT, T-scores (total) NOTE: A T-score of 50 corresponds to value of the general population. BAC is missing for six cases. A particularly interesting finding was that no fewer than 46% of the 189 suspects with a BAC below the Swedish legal limit of 0.02% had alcohol problems according to the 8+/6+ criteria. Furthermore, no fewer than 50% of 36 drivers with a BAC of 0.00% scored in the alcohol-problems region! Thus alcohol problems are common among "low BAC drivers." This trend was particularly evident among the female drivers, where the prevalence of positive cases was about the same (48%-53%) from 0.00% up to a BAC of 0.15%; see Table 3.

11 397 TABLE 3 Mean AUDIT T-scores and proportion of AUDIT-positive cases (score 8+/6+) among suspected DUI offenders at different SAC levels, by gender RAe Men Women Positive Positive N T-scores cases N T-scores cases Mean Median Mean Median % % % 0.02~.099% % % % % % 0.15~.199% % % % % % 0.25~.299% % % % % % The DUI offenders and the severe DUI offenders differ significantly as evaluated by ANOVA with regard to quantity of alcohol consumed per drinking occasion, item 2 in AUDIT p<.ool), and frequency of binge drinking, item 3 (p<.ool), but not with regard to frequency of consumption, item 1. Thus, the severe DUI offenders generally do not drink more often than the other DUI offenders, but they drink more per occasion and binge drink more often. Furthermore, they also score much higher on the alcohol-problems subscale (items 4-10, p<.ool). Using the Swedish legal BAC limit of 0.02% as a screening test for identifying alcohol problems (as defined by AUDIT 8+/6+) among suspected DUI offenders resulted in acceptable sensitivity (0.93) but very low specificity (0.12) and low positive prediction value (0.60) among the male drivers. The corresponding values among the female drivers were even lower. In other words, a high proportion of true positive cases (with alcohol problems) were identified, while true negative cases could not be excluded. A cutoff point of 1.0% BAC further reduced the sensitivity, to 0.56, but increased the specificity to 0.65 and the positive prediction value to 0.69 among the men. This is still an unsatisfactory screening result. The highest positive prediction values were observed

12 398 ALCOHOL PROBLEMS AND BAC at 0.20% for the female drivers and 0.25% for the male drivers. However, at these high BAC levels the sensitivity was very low but the specificity approached 1.0. Thus at these high BAC levels one can be pretty sure that the drivers identified really have alcohol problems, but one fails to identify the majority of true positive cases; see Table 4. In sum, using low BAC levels-e.g., the Swedish legal limit of 0.02%-as a cutoff point to identify whether a driver has alcohol problems is not a valid screening method. TABLE 4 Sensitivity, specificity, and positive predictive values for identifying alcohol problems at different BAC levels, by gender (AUDIT 8+/6+) RAC Men Women Pas. Pas. pred. pred. Sensitivity Specificity val. Sensitivity Specificity val. 0.00% % % % % % % % NOTE: BAC is missing for six cases. Discussion In studies of DUI offenders, the quality of data and the influence of dropouts on the generalizability of the results are important to consider. Despite being low, our response rate of 30% is comparable with that of other studies of a similar type reporting rates varying between 20% and 50% (Vingilis, 1983, 1988). Comparisons between the 2,100 suspected DUI offenders investigated and the total population of about 7,000 suspected drivers with regard to BAC, age and gender speak

13 399 in favor of the representativeness of the sample investigated for the whole population of DUI suspects of Sweden in these respects and the generalizability of the results. Of course, our sample might be selected with regard to other characteristics -e.g., psychosocial status, criminality, and other factors of relevance for responding to AUDIT. The sample of 2, I 00 suspected DUI offenders was investigated during the five-year period During that period there were no significant changes in chronological age, alcohol use, proportion of positive cases, or any other AUDIT results among the investigated drivers despite a minor decrease in average BAC. However, during the same period there was a trend of higher AUDIT scores and an increased prevalence of positive cases identified in the general Swedish population that was statistically significant among females, particularly those years old (Bergman and Kallrnen, 2003). Corresponding changes were not observed among the investigated DUI offenders. Eight percent of the suspected DUI offenders investigated were females. This prevalence is comparable to similar studies in Norway (Skurtveit et ai., 1995), Germany (Iffland et al., 1995) and other countries (Valverius, 1989). The female proportion of DUI offenders has increased steadily in Sweden (in 1967 it was 1.5%, in %, in %, and in %). This trend has also been observed in other countries (Valverius, 1989; National Commission Against Drunk Driving, 2002). Comparisons between male and female DUI offenders on age- and gender-corrected AUDIT T-scores indicate more severe alcohol problems among the female drunk drivers, particularly among the middle-aged and older. However, the small number of subjects in each of the female age categories makes the percentages unstable, and these should be interpreted with caution. When compared with the general Swedish female population, the drinking problems of the female suspected DUI offenders are remarkable. Special attention should be

14 400 ALCOHOL PROBLEMS AND BAC paid to this group for several reasons. First, much less is known about female drunk driving than about male (Wilsnack et al., 1984), both in Sweden and abroad. Second, their DUI offense seems to be a symptom of more complex psychosocial problems (Waller and Blow, 1995) than in the case of male offenders. Third, as mentioned above, Swedish women, particularly those years old, scored significantly higher on AUDIT in 2001 than just a few years previously and will probably increasingly show up among the Swedish DUI population. Being a minority group, female DUI offenders might need interventions and treatment models designed specifically for them (Parks et al., 1996). The problems and the treatment needs of female offenders as compared with male offenders with regard to a number of relevant psychosocial domains as assessed by the Addiction Severity Index (ASI) will be further studied in a subsample of drivers taken from the present sample in a forthcoming paper. According to the generally accepted cutoff score of 8+ for men and the suggested 6+ for women on AUDIT, alcohol problems were four times more common among the male (58%) and five times among the female (55%) suspected DUI offenders as compared with 785 control drivers (15% and 10%, respectively). Every fourth DUI suspect (24%) had high-level alcohol problems according to the 16+/14+ score criteria as compared with 1% in each of the two genders among the control drivers. Our results are similar to those of previous DUI studies, with the number of cases with alcohol problems varying between 48% and 74% according to the Michigan Alcoholism Screening Test (MAST) (Lapham et al., 2000; Rumpf et al., 2002). In a study based on spouses' and/or other relatives' reports of drinking histories of fatally injured drivers with a recorded BAC, problem drinking was reported in 41% of those with a BAC between 0.10% and 0.15%, and in 68% of drivers with a BAC of at least 0.15% (Baker et al., 2002). The suspected DUI offenders (BAC below 0.10%) and the suspected severe DUI offenders (BAC 0.10% or higher) had

15 401 somewhat different AUDIT profiles. Thus, the suspected severe DUI offenders scored about the same as the suspected offenders with a BAC below 0.10% on "hazardous alcohol use" (items 1-3) but twice as high on items In other words, suspected DUI offenders and suspected severe DUI offenders have about the same drinking habits, but the severe DUI offenders report more problems in terms of dependency symptoms and alcohol-related harm. The mean alcohol consumption level according to the sum of the first three AUDIT items was the same for the age group but significantly lower among drivers and older than 55 years. Conversely, the youngest age group (ages 15-25) scored significantly lower than the other age groups on the three items indicating alcohol dependence (p<.ol). Thus the youngest drivers had not yet developed dependency symptoms. As expected, there was a modest positive correlation between AUDIT scores and BAC (r xy =.33; p<o.oi). However, less trivial was the finding that almost every second driver below the legal limit of 0.02% BAC had alcohol problems according to the 8+ (men) and 6+ (women) AUDIT criteria. In other words, alcohol problems (particularly medium levels) are very common even in "low BAC drivers" released by the police without further consequences. Furthermore, the prevalence of positive cases does not seem to increase until a BAC of 0.10% or above-i.e., severe DUI crime. The BAC level per se was found to be a poor screening instrument for alcohol problems, particularly at low BAC levels. As expected, at high BACs like 0.20%, the specificity was very high, and the suspected DUI offenders identified had alcohol problems in the majority of cases. At the same time, the sensitivity was very low, and the majority of true positive cases could not be identified. The validity in terms of sensitivity, specificity and positive prediction value of BAC as a screening instrument for high levels of alcohol problems was even lower than the validity for detecting medium levels of alcohol problems.

16 402 ALCOHOL PROBLEMS AND BAC From both a traffic-safety and a general-health point of view, it would be desirable to use the detection of drivers suspected of DUI for preventive efforts in order to counteract a possible escalation of drinking problems in the released group. This can be achieved by involving local social services and/or health care units treating patients with substance abuse directly in connection with the detection. Such a model has been tried out in the northern part of Sweden (the "Skelleftea model") and is being implemented in Stockholm. In Sweden, it is compulsory for drivers who have committed a severe drunk-driving offense (0.10% or above) to submit to a re-licensing evaluation of alcohol and drug problems. On the basis of our results, it can be argued that this level should be reduced and applied in all cases of a DUI offense. Furthermore, our results do not speak in favor of the Swedish 0.02 BAC legal limit as compared with a zero limit from a public-health point of view, since the prevalence of alcohol problems is about the same for all BAC levels up to the BAC level of severe DUI offense. An impaired ability to divide attention between two or more visual stimuli while driving, even at a BAC of 0.02% or lower, has been reported, particularly among persons below 21 years old and above 65 years old (NIAAA, 2001). Both BAC and AUDIT scores are different for different times of day and night and for manners of detection of DUI. This will be the subject of a forthcoming paper, together with analyses of the influence of geographical region, particularly sparsely vs. densely populated regions, on these parameters. Besides increasing the general knowledge about the relationship between DUI and alcohol problems, in Sweden in particular, we expect that the results of the present study might have implications for the legal BAC limit for a DUI offense and the conditions for the mandatory certificate of sobriety in connection with the driving license retrieval. We hope the results will also be valuable when discussing the problems and prospects of identification and secondary prevention of alcohol problems among DUI offenders.

17 403 References Andren, A., Bergman, H., Schlyter, F. and Laurell, H. (2002) Treatment of DUI's-a Swedish Evaluation Study. In Proceedings of the 16th International Conference on Alcohol, Drugs and Traffic Safety, 72002, Montreal, Vol. 3. Mayhew, D.R. and Dussault, C; eds., pp Montreal: ICADTS. Babor, T.F., Higgins-Biddle, J.e., Saunders, J.B. and Monteiro, M.G. (2001) AUDIT: The Alcohol Use Disorders Identification Test; Guidelines for Use in Primary Care. Geneva: World Health Organization. httpr// Baker, S.P., Braver, E.R., Chen, L.-H. and Williams, A.F. (2002) Drinking histories of fatally injured drivers. Injury Prevention 8, 22I-226. Bergman, H., Hillner, E.B., Moberg, T., Rydberg, U., Irvell, P., Englund Nilsson, M. and Tornros, J. (1997) Rattfyllerister far vard istallet for fangelse (DUI offenders get institutional care instead of a prison sentence). Ldkartidningen 94, I. Bergman, H., Kallmen, H., Rydberg, U. and Sandahl, e. (1998) Tio fragor om alkohol identifierar beroendeproblem-psykometrisk provning pa psykiatrisk akutmottagning (ten questions about alcohol identify dependency problems-psychometric evaluation in a psychiatric emergency ward).liikanidningen 95, Bergman, H. and Kallmen, H. (2002) Alcohol use among Swedes and a psychometric evaluation of the Alcohol Use Disorders Identification Test. Alcohol and Alcoholism 37, Bergman, H. and Kallmen, H. (2003) Svenska kvinnor har fau mer riskfyllda och skadligare alkoholvanor. Undersokning av forandringar i svenskarnas alkoholvanor aren 1997 och 2001 (Swedish women drink in a more hazardous and harmful way. A study of changes in alcohol use between 1977 and 2ool).liikartidningen 100, Brinkmann, B., Beike, J., Kohler, H., Heinecke, A. and Bajanowski, T. (2002) Incidence of alcohol dependence among drunken drivers. Drug and Alcohol Dependence 66, Conley, T.R. (2001) Construct validity of the MAST and AUDIT with multiple offender drunk drivers. Journal ofsubstance Abuse Treatment 20, Iffland, R., Balling, P., Grassnack, F. and Krambrich, T. (1995) Indicators for alcohol abuse in female drunk drivers (Comparative study with alcohol intoxicated male automobile drivers). Blutalkohol32, Lapham, S.c., Chang, I., Skipper, B.J. and Berger, L. (2000) Blood alcohol concentrations at arrest and the subsequent diagnosis of alcohol dependence. Proceedings of the 15th International Conference on Alcohol, Drugs and Traffic Safety, Laurell, H.and Schlyter, F., eds. Stockholm, Sweden: ICADTS.

18 404 ALCOHOL PROBLEMS AND BAC National Commission Against Drunk Driving (2002) What the Research Says About Chronic Drinking Drivers and Ways to Apply This Research. National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2001) Alcohol and transportation safety. Alcohol Alert, No. 52. Parks, K.A., Nochajski, T.H., Wieczorek, W.F. and Miller, B.A. (1996) Assessing alcohol problems in female DWI offenders. Alcoholism: Clinical and Experimental Research 20, Rumpf, H.J., Hapke, U., Meyer, C. and John, U. (2002) Screening for alcohol use disorders and at-risk drinking in the general population: Psychometric performance of three questionnaires. Alcohol & Alcoholism 37, Skurtveit, S., Christophersen, A.S. and Morland, J. (1995) Female drivers suspected for drunken or drugged driving. Forensic Science Intemational TS, SoRAD (2003) (Centre for Social Research on Alcohol and Drugs at Stockholm University), httpr/rwww.sorad.su.se/. Sweden's Statistical Databases (2003) httpr/rwww.scb.se. Swedish National Road Administration (2003) Statistiken visar inte sanningen (Statistics do not always show the truth). Borlange, Vagverket. Valverius, M.K., ed. (1989) Women, alcohol, drugs and traffic. Proceedings of the International Workshop, 1988, Stockholm, Sweden. Stockholm: Almquist and Wiksell. Vingilis, E. (1983) Drinking drivers and alcoholics: Are they from the same population? In Research Advances in Alcohol and Drug Problems, Volume 7. Smart, R.G. et al., eds., pp New York: Plenum Press. Vingilis, E. (1988). Are Drinking-Drivers Alcoholics? Presentation for High Alcohol Consumers and Traffic, November 28-30, Paris, France. Waller, P.F. and Blow, F.C. (l995) Women, alcohol, and driving. In Developments in Alcoholism, Volume 12. Galanter, M., ed., pp New York: Plenum Press. Wilsnack, R.W., Wilsnack, S.c. and Klassen, A.D. (1984) Women's drinking and drinking problems: Patterns from a 1981 national survey. American Journal ofpublic Health 74,