Documenting the sustainability of a mature Click It or Ticket program: the North Carolina experience

North Carolina was the first United States jurisdiction to implement a statewide program (called Click It or Ticket) coupling concentrated enforcement with massive publicity to increase seat belt use. After a successful pilot program in three very different North Carolina communities, the statewide program was launched in October 1993, and has been most active and productive as well as imitated by many other states over the past decade. This paper explores the combination of ingredients that have been employed and sustained over that period of time. These include: (a) a basic coalition of critical public-private agencies (central to the planning, execution, and publicity of the many Click It or Ticket programs); (b) critical top-down commitments (starting with the governor); (c) pervasive and innovative media events/press releases/ PSAs/ web site information; (d) vigorous and well-publicized law enforcement; (e) feedback on results with solid, updated data; (f) related statewide and local programs/activities; and last but not least (g) continuous funding.     

Self-Reported Seat Belt Use in Four Countries: A Telephone Survey

A telephone survey was conducted in four countries in November 1998 to compare drivers in the United States with those in Australia, Canada, and the United Kingdom regarding their attitudes toward seat belts and belt use laws. More than 90 percent of the 2251 respondents said they thought seat belts are effective, but self-reported belt use was significantly lower in the United States than in the other countries. Respondents in Australia and the United Kingdom had similar views about what they thought were important reasons for using seat belts and had the highest self-reported use. Reasons given for using belts by Canadian and US respondents were quite similar to one another, yet US respondents had significantly lower self-reported use rates, a difference thought to be due to vigorous enforcement of the law in Canada. US drivers were less likely than Australian and UK drivers to say they used belts out of habit, to avoid a ticket, or because it is required by law and more likely to say they used belts for situational reasons. US drivers were least likely to be in favor of belt use laws. Canadian drivers reported the most experience being checked by police for belt use and were most likely to think that nonusers would be caught. US drivers in primary enforcement jurisdictions were more likely than those in secondary jurisdictions to think that drivers not using belts would be caught and more likely to say they always used belts. Results of this survey indicate that seat belt use in the United States could be increased by adoption of primary enforcement laws and highly visible enforcement programs of the type used in Canada, and that seat belt use could be increased in all countries by increasing the penalties for nonuse.     

“Buckle Up NOW!” An Enforcement Program to Achieve High Belt Use

In the mid-1980s, the first formal seat-belt enforcement program in the United States was conducted in Elmira, NY. Front seat-belt use increased from 49% to 80%, and the Elmira program became a model for other such programs. In the spring of 1999, the New York State Police launched a statewide seat-belt enforcement campaign, and the Elmira program was revived as part of this effort. This 3-week program was coordinated by the Chemung County Sheriff's Office, and carried out in cooperation with local police departments as well as the state police. The earlier Elmira program emphasized the health and safety benefits of seat belts and warning periods prior to tickets being issued. The 1999 program featured a strong no-excuses, no-warning enforcement message, 32 belt-use checkpoints, and publicity about the enforcement through a variety of mechanisms, including feedback signs that informed motorists of current belt use rates. Front seat-belt use increased from 69% to 90%. Public opinion surveys indicated the program was well known to Elmira residents, and had the support of 79% of those polled. The 1999 Elmira program demonstrates that high-intensity enforcement programs can increase seat-belt use to very high levels with strong community support.     

Effect on fatality risk of changing from secondary to primary seat belt enforcement

BACKGROUND: Most seat belt use laws originally passed in the United States contained language restricting enforcement to drivers already stopped for some other reason. States that have since removed this secondary enforcement restriction have reported increased seat belt use. The purpose of the present study was to estimate the effect of these law changes on driver fatality rates. METHOD: Trends in passenger vehicle driver death rates per billion miles traveled were compared for 10 states that changed from secondary to primary seat belt enforcement and 14 states that remained with secondary enforcement. RESULTS: After accounting for possible economic effects and other general time trends, the change from secondary to primary enforcement was found to reduce annual passenger vehicle driver death rates by an estimated 7% (95% confidence limits 3.0-10.9). CONCLUSION: The majority of U.S. states still have secondary enforcement laws. If these remaining secondary laws were amended, an estimated 696 deaths per year could be prevented.     

Teens and seat belt use: What makes them click?

ProblemMotor vehicle crashes kill more adolescents in the United States than any other cause, and often the teen is not wearing a seat belt.MethodsUsing data from the 2011 Youth Risk Behavior Surveys from 38 states, we examined teens' self-reported seat belt use while riding as a passenger and identified individual characteristics and environmental factors associated with always wearing a seat belt.ResultsOnly 51% of high school students living in 38 states reported always wearing a seat belt when riding as a passenger; prevalence varied from 32% in South Dakota to 65% in Delaware. Seat belt use was 11 percentage points lower in states with secondary enforcement seat belt laws compared to states with primary enforcement laws. Racial/ethnic minorities, teens living in states with secondary enforcement seat belt laws, and those engaged in substance use were least likely to always wear their seat belts. The likelihood of always being belted declined steadily as the number of substance use behaviors increased.DiscussionSeat belt use among teens in the United States remains unacceptably low. Results suggest that environmental influences can compound individual risk factors, contributing to even lower seat belt use among some subgroups.Practical applicationsThis study provides the most comprehensive state-level estimates to date of seat belt use among U.S. teens. This information can be useful when considering policy options to increase seat belt use and for targeting injury prevention interventions to high-risk teens. States can best increase teen seat belt use by making evidence-informed decisions about state policy options and prevention strategies.     

Seat Belt Use in States and Territories with Primary and Secondary Laws -- United States, 2006

Problem

Motor-vehicle crashes are a leading cause of death in the United States. In the event of a crash, seat belts are highly effective in preventing serious injury and death.

Methods

Data from the 2006 Behavioral Risk Factor Surveillance System were used to calculate prevalence of seat belt use by state and territory and by type of state seat belt law (primary vs. secondary enforcement).

Results

In 2006, seat belt use among adults ranged from 58.3% to 91.9% in the states and territories. Seat belt use was 86.0% in states and territories with primary enforcement laws and 75.9% in states with secondary enforcement laws.

Discussion

Seat belt use continues to increase in the United States. Primary enforcement laws remain a more effective strategy than secondary enforcement laws in getting motor-vehicle occupants to wear their seat belts.     

Belief about seat belt use and seat belt wearing behavior among front and rear seat passengers in the United States

Introduction: Unrestrained drivers and passengers represent almost half of all passenger vehicle occupant deaths in the United States. The current study assessed the relationship between the belief about importance of seat belt use and the behavior of always wearing a seat belt. Method: Data from 2012 ConsumerStyles were analyzed separately for front and rear passenger seating positions. Multivariable regression models were constructed to identify the association between seat belt belief and behavior (i.e., always wears seat belt) among adults. Models controlled for type of state seat belt law (primary, secondary, or none). Results: Seat belt use was higher in front passenger seats (86.1%) than in rear passenger seats (61.6%). Similarly, belief that seat belt use was very important was higher in reference to the front passenger seat (84.2%) versus the rear passenger seat (70.5%). For the front passenger seat, belief was significantly associated with seat belt use in states with both primary enforcement laws (adjPR 1.64) and secondary enforcement laws (adjPR 2.77). For the rear passenger seat, belief was also significantly associated with seat belt use, and two 2-way interactions were observed (belief by sex, belief by region). Conclusions: Despite overall high rates of seat belt use in the United States, certain groups are less likely to buckle up than others. The study findings suggest that efforts to increase seat belt use among high-risk populations, such as those who live in states with secondary or no seat belt laws and those who ride in rear seats (which include people who utilize taxis or ride-hailing vehicles) could benefit from interventions designed to strengthen beliefs related to the benefits of seat belt use. Practical applications: Future research that uses a theoretical framework to better understand the relationship between beliefs and behavior may inform interventions to improve seat belt use.     

State-level seat belt use in the United States, 2011–2016: Comparison of self-reported with observed use and use by fatally injured occupants

Introduction: Despite 49 states and the District of Columbia having seat belt laws that permit either primary or secondary enforcement, nearly half of persons who die in passenger vehicle crashes in the United States are unbelted. Monitoring seat belt use is important for measuring the effectiveness of strategies to increase belt use. Objective: Document self-reported seat belt use by state seat belt enforcement type and compare 2016 self-reported belt use with observed use and use among passenger vehicle occupant (PVO) fatalities. Methods: We analyzed the Behavioral Risk Factor Surveillance System (BRFSS) self-reported seat belt use data during 2011–2016. The Pearson correlation coefficient (r) was used to compare the 2016 BRFSS state estimates with observed seat belt use from state-based surveys and with unrestrained PVO fatalities from the Fatality Analysis Reporting System. Results: During 2011–2016, national self-reported seat belt use ranged from 86–88%. In 2016, national self-reported use (87%) lagged observed use (90%) by 3 percentage points. By state, the 2016 self-reported use ranged from 64% in South Dakota to 93% in California, Hawaii, and Oregon. Seat belt use averaged 7 percentage points higher in primary enforcement states (89%) than in secondary states (82%). Self-reported state estimates were strongly positively correlated with state observational estimates (r = 0.80) and strongly negatively correlated with the proportion of unrestrained PVO fatalities (r = −0.77). Conclusion: National self-reported seat belt use remained essentially stable during 2011–2016 at around 87%, but large variations existed across states. Practical Applications: If seat belt use in secondary enforcement states matched use in primary enforcement states for 2016, an additional 3.98 million adults would have been belted. Renewed attention to increasing seat belt use will be needed to reduce motor-vehicle fatalities. Self-reported and observational seat belt data complement one another and can aid in designing targeted and multifaceted interventions.     

Effectiveness of primary enforcement safety belt laws and enhanced enforcement of safety belt laws: a summary of the Guide to Community Preventive Services systematic reviews

BACKGROUND: The use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor-vehicle crashes. This paper summarizes the systematic reviews of two interventions to increase safety belt use: primary enforcement safety belt laws and enhanced enforcement of safety belt laws. The reviews were previously published in the American Journal of Preventive Medicine. METHODS: We conducted the systematic reviews using the methodology developed for the Guide to Community Preventive Services. RESULTS: These reviews provide strong evidence that primary laws are more effective than secondary laws in increasing safety belt use and decreasing fatalities and that enhanced enforcement is effective in increasing safety belt use. Increases in belt use are generally highest in states with low baseline rates of belt use. DISCUSSION: Primary safety belt laws and enhanced enforcement programs tend to result in greater increases in usage rates for target groups with lower baseline rates. Concerns regarding public opposition to these interventions may impede their implementation in some jurisdictions. However, surveys indicate that a substantial majority of the public supports implementation of both primary laws and enhanced enforcement programs. CONCLUSION: Based on the strong evidence for effectiveness of primary safety belt laws and enhanced enforcement programs, the Task Force on Community Preventive Services recommended that all states enact primary safety belt laws and that communities implement enhanced enforcement programs.     

Recent estimates of safety belt use

The National Occupant Protection Use Survey (NOPUS) has shown that safety belt use in the United States has increased steadily over the past decade. Increases have been consistent since 2000, when the National Highway Traffic Safety Administration, in partnership with the Air Bag & Seat Belt Safety Campaign, increased its encouragement of states to implement highly visible enforcement programs. In 2003, significant increases were found in the South; in secondary law states; in all types of vehicles; during both weekdays and weekends; and during both rush-hours and non-rush-hours. In spite of these increases, use remains significantly lower in secondary law states; pickup trucks; the Northeast; and the Midwest. The differences between primary and secondary law states and between pickups and other passenger vehicles have been consistent from year to year. A controlled intersection study, which is part of the NOPUS, has shown that safety belt use has increased for both sexes, for nearly all age groups, and for all races for which data are available. Finally, the NOPUS suggests that children are 3-4 times as likely to be unrestrained when riding with an unbuckled driver as when driving with a buckled driver.     

Factors related to seat belt use among fatally injured teenage drivers

PROBLEM: In the United States, teenage drivers have a higher crash risk and lower observed seat belt use than other age groups. METHOD: Seat belt use was examined for teenage (16-19 years) drivers who were fatally injured in traffic crashes occurring in the United States during the years 1995-2000. Vehicle, driver, and crash factors potentially related to belt use were examined. State differences in belt use rates among fatally injured teenage drivers were related to states' observed belt use rates for all ages and other state-level variables. RESULTS: During 1995-2000, mean belt use was 36% among fatally injured teenage drivers and 23% among fatally injured teenage passengers. One of the strongest predictors of higher belt use for both drivers and passengers was whether the crash occurred in a state with a primary seat belt law. Belt use rates for 1995-2000 for fatally injured teenage drivers ranged from 20% or less in six states to more than 60% in two states. States with the highest use rates were those with strong primary belt use laws and those with high rates of observed belt use for all ages. Lower belt use among fatally injured teenage drivers was associated with increasing age; male drivers; drivers of SUVs, vans, or pickup trucks rather than cars; older vehicles; crashes occurring late at night; crashes occurring on rural roadways; single vehicle crashes; and drivers with BACs of 0.10 or higher. Teenage driver belt use declined as the number of teenage passengers increased, but increased in the presence of at least one passenger 30 years or older. IMPACT ON TRAFFIC SAFETY: It is suggested that to increase teenage belt use, states should enact strong primary belt use laws and mount highly publicized efforts to enforce these laws. Graduated driver licensing systems should incorporate strong provisions that require seat belt use by teenage drivers and passengers.     

Evaluation of the Reading, PA nighttime safety belt enforcement campaign: September 2004

PROBLEM: Safety belt use rates among front seat occupants of passenger vehicles are substantially lower at night than during the day despite the fact that night driving is more dangerous. METHOD: Recent advances in night vision equipment now make it possible to enforce belt use laws in darkness. Reading, Pennsylvania conducted a night belt use publicity and enforcement campaign during September 2004 using night vision equipment. RESULTS: Front seat occupant belt use at night increased significantly from 50% prior to the campaign to 56% just after the campaign. Daylight belt use also increased though to a lesser extent (56% to 59%). Survey data indicated that motorists had heard about the campaign in newspapers and on television. Belt use increases were not seen during the same time period in a comparison community.     

Characteristics of drivers not using seat belts in a high belt use state

A study was undertaken in North Carolina to determine the characteristics of the minority of drivers who were not using seat belts following an extensive publicity/enforcement campaign, which had increased statewide use to 80%. Vehicles and drivers whose seat belt use was observed at sites across North Carolina were matched against Division of Motor Vehicles registration and driver history files for vehicle owners. The study file consisted of those observed drivers who matched the owners with respect to sex, race, and approximate age. The results of this investigation indicate that nonuse of seat belts was associated with males; younger age (<35); older vehicles (pre-1985); vehicles other than cars, especially pickups; and poor driving records. Telephone survey information indicated that nonusers were less likely to have health care coverage, more likely to acknowledge having consumed large amounts of alcohol in the past year, and more likely to have an arrest record. When asked about enforcement of the belt use law, many nonusers said that they would not respond to higher fines but they would respond to driver license points. To change the belt use behavior of this hard-core nonuser population, it well may be necessary as was done in Canada to combine publicity/enforcement campaigns with driver license points as a penalty for nonuse.     

Encouraging compliance with graduated driver licensing restrictions

PROBLEM: Although graduated driver licensing (GDL) programs have reduced the high crash rates for 16-and 17-year-old drivers, research suggests that some teenagers fail to comply with restrictions on nighttime driving and carrying passengers. METHOD: A program to encourage compliance with GDL restrictions and seat belt requirements was implemented in Guilford County, North Carolina. The program combined increased enforcement with a multi-faceted publicity campaign drawing attention to the enforcement activity. A comparison community was studied to assess whether changes over time could be reasonably attributed to the program. RESULTS: Several measures indicate that greater enforcement did occur in the intervention community and that teenagers perceived the increase. However, self-reported data and direct observations of young drivers in the intervention and comparison communities showed the program resulted in only modest changes in compliance with GDL restrictions. DISCUSSION: The program put in place the mechanisms known to produce changes in driver behavior, but these may have been insufficient to alter the behavior of the minority of teenagers (and parents) who were not already complying with restrictions. However, the modest changes in young driver behavior plus the clear changes in both actual and perceived enforcement suggest that high visibility enforcement programs merit further use and evaluation in other communities, particularly those where compliance with GDL provisions is lower than in Guilford County.     

Requiring belt use as part of a school parking permit program: does it increase students' belt use?

OBJECTIVE: Teenagers have very high motor vehicle crash rates, and their use of seat belts is generally lower than that of adults. A potential school-based strategy to increase teenagers' belt use is a policy making parking privileges contingent on belt use by student drivers and their passengers. This study evaluated the effects of implementing a school belt policy. METHODS: The effects of a belt policy were evaluated during the 2003-2004 school year at high schools in two states: Connecticut, a state with a primary enforcement belt law and high belt use rates, and Mississippi, a state with a secondary enforcement law and generally low use rates. Both schools enforced the policy, and violations resulted in a graduated set of penalties leading to the potential loss of parking privileges. Baseline and post-policy belt use rates were obtained from observation surveys of student drivers and their teenage passengers coming to and from school. Changes in belt use were examined relative to belt use trends at comparison schools without a belt policy. Implementation of the policies also was monitored. RESULTS: In Mississippi, among students arriving at school in the morning, driver belt use increased from 42% before the policy to 67% about 6 months after; passenger belt use increased from 16% to 61%, although sample sizes were small. These increases were significantly larger than expected, based on belt use trends at the comparison school in Mississippi. In Connecticut, where 86% of drivers and 79% of their passengers already were belted prior to the policy, there was no significant change. Both schools publicized and monitored the belt policy, and most enforcement occurred in the morning as students arrived at school. CONCLUSIONS: Based on a small-scale application of a belt policy at two schools in different states, a school belt policy may have stronger effects in states where belt use is low. Strong penalties and enforcement are essential elements of an effective policy. Adequate resources and commitment are needed for schools to implement and monitor the type of strong policy needed to sustain high belt use rates. Replication of this study in additional schools appears warranted.     

Ninety five percent: an evaluation of law, policy, and programs to promote seat belt use in Washington state

Seat belt use in Washington state was 83% in 2001. In 2002, a series of law, policy, and program initiatives coalesced to produce a dramatic increase in seat belt use. Washington enacted a primary enforcement seat belt, the Chief of the Washington State Patrol made safety belt enforcement one of the core missions of that agency, and Washington participated in the national Memorial Day Click It or Ticket program during May 2002 and continued the program into 2003. Evaluation of these initiatives was accomplished through observation surveys of seat belt use, analysis of seat belt violation data, and analysis of data on traffic deaths of motor vehicle occupants. The major findings were that there was a two- to three-fold increase in enforcement of the seat belt law, belt use rates increased to 93% in 2002 and again to 95% in 2003, and motor-vehicle occupant fatalities decreased by 13%. IMPACT ON PRACTICE AND POLICY: The primary seat belt law and Click It or Ticket program activities were critical factors in increasing belt use in Washington state. Media and enforcement programs targeting seat belt use can be very effective in raising the belt use rate, but a long-term commitment to continuation of these program activities is essential. Other states implementing new primary seat belt laws should consider delivering a Click It or Ticket campaign prior to the effective date of the primary law and continuing these activities during subsequent months and years.     

Self-reported seatbelt use,United States, 2002–2010: Does prevalence vary by state and type of seatbelt law?

ProblemMotor-vehicle crashes are a leading cause of death in the United States. Seatbelts are highly effective in preventing serious injury and death in the event of a crash. Not all states have primary enforcement of seatbelt laws.MethodsData from the 2002, 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System were used to calculate prevalence of seatbelt use by state and type of state seatbelt law (primary vs. secondary enforcement).Results and discussionSelf-reported seatbelt use among adults in the United States increased steadily between 2002 and 2010, with the national prevalence reaching 87% in 2010. Overall, seatbelt use in 2010 was 9 percentage points higher in the states with primary enforcement laws than in the states with secondary enforcement laws (89% vs. 80%). Impact on industry: Primary enforcement seatbelt laws and enhanced enforcement of seatbelt laws are proven strategies for increasing seatbelt use and reducing traffic fatalities.     

Sobriety checkpoints: evidence of effectiveness is strong, but use is limited

There is substantial and consistent evidence from research that highly publicized, highly visible, and frequent sobriety checkpoints in the United States reduce impaired driving fatal crashes by 18% to 24%. Although checkpoints are not conducted in 13 states for legal or policy reasons, there is strong evidence that if conducted appropriately, checkpoints would save lives in the other states. However, a recent survey of checkpoint use has demonstrated that despite the efforts of the U.S. Department of Transportation to encourage checkpoint use through publications, providing funds for equipment, and for officer overtime expenses, only about a dozen of the 37 states that conduct checkpoints do so on a weekly basis. The survey found that lack of local police resources and funding, lack of support by task forces and citizen activists, and the perception that checkpoints are not productive or cost effective are the main reasons for their infrequent use. This article discusses each of these problems and suggests a method for local communities to implement checkpoints without depending on state or federal funds. Low-staffing sobriety checkpoints conducted by as few as three to five officers have been shown to be just as effective as checkpoints conducted by 15 or more officers. A modified sobriety checkpoint program using passive alcohol sensors ("PASpoints") can be implemented by small- to moderate-sized communities in the United States to deter impaired driving. If implemented in a majority of communities, this strategy has a potential level of effectiveness similar to the high level achieved by several Australian states in their random breath-test (RBT) programs. The PASpoint system calls for a small group of three to five officers on traffic patrol duty to converge on a preset site and conduct a mini-checkpoint, returning to their standard patrol duties within two hours. Within this framework, the PASpoint operation would become a standard driving under the influence (DUI) enforcement technique regularly used within the community's jurisdiction. As a standard traffic enforcement activity, the cost would be covered by the normal enforcement budget.     

Drivers' opinions of enforcement and incentive strategies to promote safety belt use

During a nationwide campaign to promote safety belt use among military personnel, a field study was conducted at 12 military bases in the Netherlands. Enforcement and incentive programs were varied among military bases. A written survey was administered to personnel of these bases. The survey contained items concerning reported belt use, motivation to use a safety belt, attitudes toward legislation, public information, enforcement and incentive strategies, and awareness of the campaign. The results showed that enforcement was clearly a better accepted countermeasure than rewarding drivers for the use of safety belts. Respondents from bases exposed to the incentive treatment tend to have relatively more positive opinions of incentives than those exposed to the enforcement treatment. Two independent dimensions were present in the response patterns: one representing opinions of enforcement and the other of incentives/rewards.     

Taking the Click It or Ticket model nationwide

Click It or Ticket is an occupant protection Selective Traffic Enforcement Program (sTEP) combining intensive paid and earned publicity with enforcement during a brief two to four week period. North Carolina demonstrated substantial increases in safety belt use associated with their implementation of the first statewide Click It or Ticket program in 1993. In 2000, Click It or Ticket was implemented in South Carolina. In 2001, Click It or Ticket was implemented across all eight states of the southeast. In 2002, ten states in various parts of the country implemented Click It or Ticket; four states implemented parts of the full Click It or Ticket program; and four states were used as comparisons. Belt use increases were greatest in the full implementation states. Click It or Ticket was implemented nationally in 2003. This paper presents a historical perspective on the implementation and evaluation of Click It or Ticket programs.