Challenging Dogma - Spring 2011

Tuesday, May 10, 2011

Take Me Home Tonight: A critique of the current approach to drunk driving interventions in the United States and ideas for improvement - Sara Munson

An Introduction to Drunk Driving:

During the early 1980s through 1994, the United States saw a dramatic decline in the percentage of car accident fatalities related to intoxication from 60% to 43% (1). Yet from 1995 to the present, this number has virtually become stagnant around 40%(1). This equates to around 15,000 people every year. All of these deaths are preventable. There are plenty of public health campaigns against drunk driving yet the numbers speak for themselves as a sign that these advertisements are not effective. So we must ask, why not? What are we doing wrong and what can we be doing better in order to get the total alcohol related fatalities in the United States to zero? These questions can be answered by taking a closer look at current campaigns and the ideology behind them. Most current public health interventions focus on using shock and awe tactics in order to scare and guilt people into not driving drunk. The negativity and extreme situations we see in these ads are not relatable and do not stick with us; some advertisements do not even make sense. Instead, to create a campaign in order to get people to engage in safer drinking behaviors, a multi-tiered approach must be taken that includes relatable and memorable visuals and text that will not just become another parody on youtube. Together with alcohol education and police diligence, improvements to public health interventions against drunk driving could save thousands of lives every year.

What advertisements we are seeing:

Though there are many poor campaigns against drunk driving, for the purposes of this argument we will focus on a 2009 campaign from the AdCouncil which features the slogan “Buzzed Driving is Drunk Driving” (2) (for those who were not sure of the terminology for their intoxicated condition). One commercial from this campaign shows a hospital emergency room and an unconscious female being attended to by doctors with a distressed man standing over them stating “I was just buzzed.” As the statement is uttered, doctors stop working, “well sir you didn’t tell us that, in that case she’s fine” and the patient looks up, “I’m fine.” “Really?” “No, not really” and the patient hits the table once more, ending with the statement “buzzed driving is drunk driving.” (3) A billboard featured in this same campaign displays a note left on a car windshield stating, “Thank you for not driving buzzed last night. You saved my life.”(2) The note leaves us wondering, who are you and how do you know whether or not I was drinking last night? Why these are ineffective:

The ideas behind these advertisements stem from common theories in the public health world, theories that do not necessarily hold true to real life. The ideas are based on the Health Belief Model, the Theory of Reasoned Action, and (in an attempt to be engaging and relevant to the times) some sarcasm is thrown into the mix. The theories used to promote safe driving are based on individual behaviors and the idea that people behave rationally which is great in theory but does not translate into action. Taking a closer look at these theories and how they relate to this public health campaign will prove the inability of such a campaign to promote safe behaviors.

The Health Belief Model:

“Alcohol's adverse public health impact includes disease, injury, violence, disability, social problems, psychiatric illness, drunk driving, drug use, unsafe sex, and premature death. Furthermore, alcohol is a confirmed human carcinogen.”(4) We are well aware of the diseases and other risks associated with alcohol use yet we continue to engage in risky behavior. So why do public health campaigns continue to focus on just these risks? Even though great research has been done in the field of treating alcohol related illness, “alcohol problems continue to present a major challenge to medicine and public health, in part because population-based public health approaches have been neglected in favour of approaches oriented to the individual that tend to be more palliative than preventative.”(5) The “buzzed driving” campaign is a perfect example of approaches oriented to the individual as we see by the use of the health belief model and the theory of reasoned action.

The campaigns are built largely around the individual behavior change model known as the health belief model which balances perceived benefits with perceived barriers that leads to intention and behavior choices.(6) The model assumes that rational thinking is taking place before actions are taken. However the intent is not always followed through, especially when thinking has been impaired by alcohol. “As a consequence of both acute alcohol intoxication (alcohol 'priming' effects) and exposure to environmental alcohol-related cues, we suggest that a number of changes in cognitive processes are likely. These include increased subjective craving for alcohol, increased positive and arousing outcome expectancies and implicit associations for alcohol use, increased attentional bias for alcohol-related cues, increased action tendencies to approach alcohol, increased impulsive decision-making, and impaired inhibitory control over drives and behavior”(7) Just because we believe early on in the night that we will give up our keys and take a cab home or keep our blood alcohol level below the legal limit does not mean we actually will. After all, people are irrational beings. The man in the commercial is aware that he had drunk enough alcohol to be effected by it, yet he still drove. The use of the health belief model in this case is a contradiction within the advertisement itself.

The Theory of Reasoned Action:

Much like the Health Belief Model, the Theory of Reasoned Action (TRA) relies on a series of perceived outcomes and norms that result in intention and thereby behavior. This theory takes into account how other people think of you and how important their opinions are to you. But similarly, intent does not always lead to action, especially when drinking is involved. A study that asked questions of intoxicated subjects versus sober subjects found that “when a contingency was embedded in the question (e.g., "would you drink and drive only a short distance?"), intoxicated participants were significantly less negative about drinking and driving. These results are consistent with alcohol myopia—the notion that alcohol intoxication decreases cognitive capacity so that people are more likely to attend to only the most salient cues.”(8) This demonstrates the difference between intent and action as though the subjects in general had negative thoughts towards drinking and driving, small cues such as implying it is only a short distance changed their attitude. When one is in an actual situation when they are intoxicated and deciding whether to drive, they are likely to think in these terms of “it isn’t very far” and therefore the Theory of Reasoned Action is negated.

The campaign in question also ties in the social cues that are involved with the TRA by assuming that the buzzed driver cares about what the doctors and EMTs think of his behaviors. He is ashamed by their judgment against his actions and his explanation that he was only buzzed. However this idea does not apply universally. We cannot assume that anyone who would drink and drive is going to take into account how medical professionals and law enforcement officers will judge them assuming something bad happens. Most of us would not even think about these people as a possible presence in our lives which negates the generalizability of this theory.

The TRA used in these advertisements also leaves out self-efficacy which is included in the Theory of Planned Behavior (TPB). Self efficacy is a key factor in the fight against drunk driving. One “study suggested that perceived control over drinking behaviour was the most important factor in determining whether someone will binge drink. This variable is important as it links to the model described here, particularly in terms of drinking refusal self-efficacy (DRSE), the perceived ability to refuse a drink”(9) and further a 1998 study by Norman, Bennet, and Lewis stated that “[binge drinkers] were less likely to believe that binge drinking leads to negative consequences and that they had control over their drinking.”(9) The belief that one has control over their drinking is extremely important and yet completely ignored by this ad campaign. In further support of TPB, a study conducted in China looked at the Theory of Planned Behavior (TPB) and “present findings highlight irrational beliefs of invulnerability and the three TPB components as potentially valid targets for prevention and intervention efforts against drinking and driving”(10). Therefore self-efficacy must be taken into account in public health campaigns which this campaign fails to do.

Social Relevance and Scare Tactics:

“Government messages aimed at decreasing binge drinking are generally created for an undifferentiated audience, a problem exacerbated by the fact that adolescent and young adult audiences are hardest to reach”(9) It is no secret that the United States is full of cynics and overly sarcastic individuals. But to focus an entire public health commercial campaign on this idea is absurd. The script mocks the listener for believing that buzzed driving and drunk driving are different and that it is acceptable to drive if you are only feeling buzzed. Overall the tone of the commercial comes off as condescending and the idea to be relevant backfires. We can compare this rebellion to those who patronize us to psychological reactance theory. When there is a threat to our freedom, in this case a threat to our intelligence and ability to distinguish how intoxicated we may actually be, we will act out against this idea. This ties in with scare tactics which when confronted with we resort to the Terror Management Model which states that the more you remind people about death, the more they will ignore it and continue to engage in unhealthy behaviors(6). Thus two theories that apply greatly to this situation show the campaign to be ineffective.

Further argument against scare tactics is that we are under the impression that we are untouchable: “Thus drinking and driving may continue to be so prevalent in a college population because they erroneously believe that they are still safe drivers and effective at controlling the attendant risks.”(11) To use a model that focuses on extreme situations will be completely ineffective for most young adults. Additionally, a study that used an emotional intervention by Mothers Against Drunk Driving (MADD) against another less emotional approach showed similar results in the argument against scare tactics: “There was no additional effect of the MADD VIP, a relatively emotional intervention, over that of the DWI school, a relatively informational approach, on DWI behavior.” (12)

The time is now:

Multiple studies around the world as seen here have proved the models used in this public health intervention, the health belief model, the theory of reasoned action, and scare tactics to be ineffective in just such a campaign. Self-efficacy, a vital part of the fight against drunk driving is completely ignored. So why do we keep using these types of campaigns? Why has the number of people killed by drunk drivers remained steady for the past 16 years? It is time to do something about it, to educate and enforce but to also design a new campaign that will be relatable to the general public, to those at risk for drunk driving, and those capable of making the decision for themselves to behave responsibly and save lives. 100% of deaths caused by drunk drivers are preventable, so it is time to change the way we run public service campaigns against driving drunk and move this number to zero.

A different approach:

Research shows that effective reduction of drunk driving in a community relies on a combination of factors and cues. “According to Community Guide rules of evidence, the studies reviewed here provided strong evidence that carefully planned, well-executed multicomponent programs, when implemented in conjunction with community mobilization efforts, are effective in reducing alcohol-related crashes.”(13) The three factors important in a successful campaign are beverage service training, social marketing and media advocacy, and police presence.(14) Agreeing with these factors, I propose that further hands on measures be taken to reduce drunk driving, going right to the source. By directly working with bars, cab companies, college dormitories, and college social groups such as fraternities, further improvements can be made in social marketing tools and media advertising to reduce accidents caused by drunk driving.

My proposal is to combine forces with these sources, mainly cab companies and local drinking spots. Unfortunately in our country, drinking is seen as taboo and thus becomes an appealing behavior. Rather than being taught from a young adult age to drink responsibly, we are told to avoid alcohol and become drawn to it instead. In order to help fix the problem, this must be taken into account and drinking must not be viewed in such a taboo light. The approach needs to be a more positive one, not telling people what they can and cannot do but suggesting ways to end their evening on a positive note. To do so, signs can be hung in doors, bathrooms, and around bar areas suggestively encouraging people to take a safe ride home. Slogan ideas include:

“Go home with a stranger”

“We think you’re fab, please call a cab”

“Make new friends tonight, share a cab home”

“See Jane go to a bar, See Jane call a cab, See Jane get home safe”

Each one of these would include the name and phone number of a cab company. By distributing these on cards and displaying them around bars, people would take notice and be reminded of an alternate route home rather than driving themselves. The idea is to allow people to have fun while being safe and associate getting home safely with having fun. Likewise, billboard advertisements could be changed to a similar yet more fun approach. Instead of a note on a windshield reading, “Thanks for not driving buzzed last night. You saved my life.” Why not a note on a bedside table reading, “Thanks for sharing a ride last night! You really saved the night –(insert random girl’s name and phone number here)”. Sure it is a little racy, but that is what sells ideas.

At the same time we must continue to educate on campuses about what actually happens to your body and mind when you are drinking. During freshmen orientation at Boston University in 2007, around 400 incoming students were all handed a solo cup and told to enter a small room. There were signs placed around the room announcing that the only bathroom was broken and that the kegs were empty. This was Boston University’s way of discouraging freshmen from attending house parties because obviously they were all like this, but again this portrayed the over the top and laughable education model. Instead, education needs to be relatable and honest. “Listen, we know that many students are going to drink in college, here is what you can do to protect your body and stay safe.”

In support of higher law enforcement crackdown, in 2003 Connecticut implemented the “high visibility enforcement” model which increased police checkpoints and crackdowns throughout the state. For 11-months of work, an estimated 47 lives were saved (including several within a 7-month sustained effect period when the intervention ended.)(15) As this multi-component approach is looked at, we must take into account the roll of law enforcement. People are irrational and thus we must assume that sometimes, bad decisions will be made despite our best efforts. In order to keep deaths and injuries from alcohol related crashes to a minimum we must also rely on a diligent police enforcement effort, stationing sobriety checkpoints at key targeted areas where the biggest problems are located.

Keeping Things Positive:

Psychological reactance is the brain’s reaction to threats to our freedoms. When we feel threatened we react by lashing out against this threat. This is especially prevalent “when individuals feel obliged to adopt a particular opinion or engage in a specific behavior.”(16) If we are told not to do something we want to do it more. Negative messages have this effect on our brains. In a study on PSAs for smoking cessation, it was found that “fear also had a negative indirect impact on persuasion by activating psychological reactance, while state empathy also had a positive indirect effect by inhibiting psychological reactance.”(17) Therefore when designing a new study it is important to use positive messages to lead people to adopt certain behaviors, not tell them what they can and cannot do.


One of the biggest flaws in the “Buzzed Driving” campaign is that it did not include self-efficacy as a design factor. The man was drunk and the situation was completely out of his control. In the campaign proposed here, self-efficacy is a huge component as people are taking into their own hands the decision to call themselves a cab or go with a designated driver thereby getting home safely. There is no one there telling them not to drive, yet the suggestion is made and we must hope that the previous education component will lead them to make the right decision. However if that decision is not made, there is the police enforcement component to check people before they get very far.

The importance of selling your idea:

For years, advertising executives have been able to sell us products, services, and ideas. So why are public health officials not able to do the very same? The key to successful advertising is to make a promise and support that promise with core values, symbolism, invoking music, relatable images, etc.(18) A text on basic marketing both praises the advantages of advertising and stresses the importance of purpose in that each ad “must be effective not just for one customer but for thousands, or millions, of them.”(19) The problem with most public health campaigns is that they fail to make this promise and appeal to a wide range of people. If advertising firms use freedom, fun, and sex to promote their products, we should too. This alternative campaign would add these things into the mix from a public health perspective. Suggestive slogans and actual relatable context will help promote safe behaviors more than scare tactics and extreme situations ever could.

In conclusion:

Thousands of people die every year from accidents involving drunk drivers. All of these deaths are preventable. “Public health experts have long lamented a national policy that spends well under 5% of our health budget on prevention efforts. Given the widely accepted dictum that prevention efforts are much less expensive during the long term than treatment efforts, and in light of our ever-decreasing availability of health care and economic resources, it is well past time to implement a radical shift in our health spending priorities.”(15) Together with proper education and law enforcement, advertising campaigns can use self-efficacy, positive reinforcement and advertising theory rather than individual based models for behavior change to design successful interventions that promote safe drinking behavior. It is time to put the needed money and effort into an effective campaign technique that will save lives because each life is worth it.


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12. Polacsek M, Rogers EM, Woodall WG, et al. MADD victim impact panels and stages-of-change in drunk-driving prevention. J. Stud. Alcohol. 2001;62(3):344-350.

13. Shults RA, Elder RW, Nichols JL, et al. Effectiveness of multicomponent programs with community mobilization for reducing alcohol-impaired driving. Am J Prev Med. 2009;37(4):360-371.

14. Clapp JD, Johnson M, Voas RB, et al. Reducing DUI among US college students: results of an environmental prevention trial. Addiction. 2005;100(3):327-334.

15. Kahn C. Commentary: Primary Prevention of Drunk Driving: Over the Airwaves, Under the Radar. Annals of Emergency Medicine. 2008;51(6):766-768.

16. Psychological reactance theory - Psychlopedia - Available at: [Accessed May 5, 2011].

17. Shen L. The Effectiveness of Empathy- Versus Fear-Arousing Antismoking PSAs. Health Commun. 2011:1-12.

18. Siegal M. Alternative Models of Behavior Change: Introduction. 2011.

19. Perreault, Cannon, McCarthy. Basic Marketing: A Marketing Strategy Planning Approach. 16th ed.

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