Drowsy driving can be prevented through promoting public awareness, collecting driving accident data, and working with experts in transportation, law enforcement, safety, and health care

“I always nodded off coming home from my girlfriend’s house at 10 pm and never thought anything of it.”

The words of this teenage boy may be a small sign that the warnings about drowsy driving are being noticed and that there is increased awareness of the risks of dozing off at the wheel. However, a recent National Sleep Foundation (NSF) survey reporting that one in five Americans actually fell asleep behind the wheel, and that one half of adults admitted to driving while drowsy, appears to be proof enough for leading experts in law enforcement, transportation, safety, and health to continue the crusade and send the message home. In order for official educational programs to be implemented, actual drowsy driving accident data must be gathered and a reporting mechanism must be put into place.

NSF Goals
NSF is an independent nonprofit organization dedicated to improving health and safety by achieving public understanding of sleep and sleep disorders, and by supporting public education, sleep-related research, and advocacy. NSF has been the leader in raising awareness about drowsy driving through its Drive Alert…Arrive Alive program since 1993. “While everyone agrees that we need more data about drowsy driving, most experts now agree that the problem is significantly larger than we thought a few years ago. While we need to find ways to collect this data, we should not wait to try to save lives now. That is why NSF is looking for ways to significantly increase its commitment to this issue,” says Darrel Drobnich, senior director for Government and Transportation Affairs at NSF.

The NSF recently called for a national consensus to implement solutions. As a first step to prepare for a proposed sleep summit for this summer, the NSF hosted the “Scientific Workshop on Public Health Surveillance for Morbidity and Mortality Associated with Inadequate Sleep” in the fall of 2001. Diverse professionals from a variety of health, safety, injury prevention, and transportation backgrounds recommended processes for better quantifying the effects of sleep deprivation on transportation, the workplace, and public health.

Richard Gelula, executive director of NSF, says, “If you talk to police officers, they will often tell you that the only logical explanation for some crashes is that the driver fell asleep at the wheel. But it seldom becomes an official cause in the crash report. Absent hard accident data, nothing is being done nationally to address what we all know to be an issue. We intend to work with police and others to change that.” Gelula adds that leading experts in transportation, law enforcement, safety, and health would make national policy recommendations.

Workshop participants concluded that the frequency of drowsy driving is a serious public health concern, authenticating findings from the 2001 Sleep in America poll including:

• drowsy driving is most prevalent among males (59% males vs 47% females), and especially young males ages 18-29—a group that is already overrepresented in traffic crashes without factoring in drowsy driving;
• adults with children living at home reported driving drowsy more often (60%) than those without (48%);
• eight out of 10 respondents agreed that information about drowsy dri- ving should be included in driver’s license testing, and that drowsy drivers should be sanctioned if caught;
• approximately 25% of the respon- dents said they drove to or from work at least a few days a month while feeling drowsy and 4% said they drive to work feel- ing drowsy almost every day. The problem is especially acute among shift workers who were even more likely to drive drowsy (36%).

Goals for the proposed 2002 sleep summit, “Many Faces of Drowsy Driving,” include the development of a workable and effective campaign with the following objectives:

• to highlight drowsy driving and sleep deprivation as a public health and safety issue;
• to stigmatize drowsy driving, akin to drunk driving;
• to recommend a national strategy for implementing realistic policy, education, and public health solu- tions.

The agenda for the proposed summit will be shaped by recommendations and reports from existing research, best practices, and expert health, transportation and communications, and industry advice.

NHTSA Report
A report from focus group discussions prepared for the National Highway Traffic Safety Administration (NHTSA) addressed young males, shift workers, and shift work supervisors. The purpose of the project is to identify and provide detailed information about people at risk for fatal fall-asleep motor vehicle crashes and develop educational messages and campaign strategies to help reduce their risk of driving while drowsy—an important contributor to fall-asleep driving deaths.

The report, Development and Testing of Countermeasures for Fatigue Related Highway Crashes, authored by Toben F. Nelson, MS, Nancy E. Isaac, ScD, and John D. Graham, PhD, all of the Harvard School of Public Health in Boston, revealed that young men have a different attitude toward driving while sleepy compared to shift workers. Those interviewed included two groups with young adult males, ages 18 to 25, and two groups with shift workers 30 to 55—male and female. Awareness of the potential problems associated with drowsy driving may not be as real or salient to the young men. The report says that young men also rely heavily on their own ability to avoid crashes and to stay awake and compete against their body’s biological need for sleep.

An excerpt from the report gives statements by those surveyed, and includes those of young males.

• “I wasn’t very well rested, but I pulled through.”
• “People are aware of the problem, but they still tend to push themselves. My brain won’t let me sleep. I have to watch out for others.”
• “I feel mentally strong enough that I can decide when to pull off the road or that I’m able to wake myself up enough to drive.”
• “It doesn’t apply to me. I think I can do something that some body else can’t. I know I’m wrong but it doesn’t matter.”

Young men understand the consequences of being in an automobile crash and even say they are willing to do things to avoid being in a crash, but they discount the possibility of it happening.

Often, they have already tempted fate and come out ahead. From their perspective, the benefits they derive from being out on the road when they are drowsy clearly outweigh the small risk of being in an accident, although they do not appear to think about it directly in terms of weighing the benefits and costs of their actions.

• “People don’t think of it like that. At the time, it’s just I want to go home and go to bed. You don’t think about accidents.”

Even when the young men experienced negative outcomes from driving while drowsy, such as involvement in a crash or a “near-miss,” it did not motivate them to change. The participants openly said that these experiences were not enough to cause them to change. The benefits or the potential to lose something they believe they have (a warm bed or social contacts 50 miles away) keeps them driving even when they know they are at risk for a crash.

• “You don’t change. You just keep pushing. I can go 50 more miles, or 100 more miles.”
• “I know how scary being drowsy is, but at the same time, I’m going to push myself so I can get home and see my family as soon as I can.”

Peer pressure may also play a significant role in pushing the young men to stay awake when their body tells them to go to sleep.

• “My friends are like, ‘I can party all night. I can stay out all night. I guess you can’t hang.’”
• “If others are doing it, I try to push myself.”
• “It affects my decision of when I go to sleep.”
• “You don’t want to fall asleep, cause your friends will mess with you. You have to defend yourself.”

The report for NHTSA concluded that most of the public awareness on this issue appears to come from the news media. To date, there appears to have been little direct targeting of either group to reduce drowsy driving on a broad scale.

The report made the following recommendations:

General
1. Develop strategies that can effectively segment and target each high-risk group and deliver educational messages appropriate to their unique “at risk” behaviors.

2. Initiate development of public education and information materials for testing in the second wave of focus groups. Begin to identify existing dissemination mechanisms for these materials.

3. Other individuals may be promising interveners or persuaders of high-risk individuals to change their behavior. Develop materials for testing that would focus on key, primary intermediaries such as family, friends, and girlfriend/boyfriend/spouse.

4. Develop materials for an awareness campaign with secondary intermediaries who have potential influence. Secondary intermediaries may include employers, law enforcement, emergency medical professionals, personal or company physicians, and sleep researchers.

5. Chronic sleep deprivation is clearly the underlying cause of drowsy driving among young men and shift workers. Consider targeting messages that promote empirically demonstrated effective strategies to prevent drowsy driving (caffeine, naps, and getting off the road to sleep) versus current strategies that have limited effectiveness (listening to the radio, singing, sticking head out of the window, extreme temperatures, and chewing ice).

6. Consider testing messages that promote advance planning (prior to long trips—both leaving and returning; prior to the work shift; and prior to going out for the night) to be sufficiently well rested.

7. Consider testing media-based approaches in the employment setting directly targeted toward high-risk groups (shift workers and young men in entry-level service positions.)

Young Men
1. Conduct qualitative research with law enforcement agencies/representatives who specialize in youth programs to find appropriate resources for identifying and dealing with fatigued driving.

2. Basic educational messages about the consequences of lifestyle choices made by young men that increase risk for automobile crashes should be examined.

3. Further examine the potential overlap between drowsy driving and other high-risk driving behaviors (drunk driving and aggressive driving) or underlying motivations for choosing such risky behavior in young men.

4. Young men have high social needs and few responsibilities. Consider developing an approach that would reduce the harm associated with being on the road late at night or reducing the appeal of being out late at night.

Shift Workers
1. Conduct additional qualitative research among:

• shift workers;
• shift work organization supervisors;
• shift work organization human resource and safety personnel;
• shift work organization senior management.

The primary objective of this phase is to gain additional information, especially from the new target groups on the potential for workplace-based campaigns and/or programs.

2. Conduct focus groups to further differentiate shift workers with the goal of determining the information needs and intervention potential among various segments of that group (men only, women with young families, and single women with children).

3. Develop creative concepts and/or tactics for testing with shift workers for strategies to be applied outside the workplace (creating a dark room at home by turning off the telephone, scheduling with family, and changing sleep-work patterns).

4. The financial incentives for people to work shifts are strong and motivate people to work late night and rotating shifts. However, changing the structure of such incentives is unlikely, since covering those hours is necessary for employers. A more feasible intervention is to work with people to alter how they schedule sleep time and to help them set priorities in how to best use their time.

5. Consider developing strategies to improve the sleep hygiene of shift workers. These strategies could include:

• targeting family members to encourage them to get better sleep;
• providing suggestions about how to reduce distractions and improve sleeping conditions when they can sleep;
• encouraging sleep before working a night shift rather than sleeping directly following work;
• time management strategies to help shift workers set priorities and become more efficient with awake hours and clearing away time for proper sleep.

Theresa Shumard is a member of the national consensus group that prepared drowsy driving solutions at the NSF-hosted “Scientific Workshop on Public Health Surveillance for Morbidity and Mortality Associated with Inadequate Sleep”; she is also a member of Sleep Review’s Editorial Advisory Board; communications director for the Association of Polysomnographic Technologists (APT); and editor of the APT’s international news magazine, The A2Zzz.