Adopted by the 44th World Medical Assembly Marbella, Spain, September 1992

PREAMBLE

Death and injury from road crashes and motor vehicle collisions with pedestrians constitute a major public health problem. Because so many of those killed and maimed on the roads are young, the years of expected life lost as the result of motor vehicle crashes and collisions rival what occurs with the major modern epidemics of cardiovascular disease and cancer.

In many countries, where the consumption of alcohol is accepted as part of everyday life, it has been shown that alcohol impaired drivers of motor vehicles are responsible for about half of all motors vehicle related deaths and serious injuries.

From this it follows that measures ensuring that alcohol impaired persons never drive will result in a very significant improvement in road safety, and a marked reduction in those killed or maimed on the roads.

Driving a vehicle involves accepting a degree of risk. Prudent drivers constantly monitor the risks they are meeting, and act to ensure that the level of risk never becomes subjectively unacceptable. Alcohol alters the driver's subjective estimate of risks, so that risk taking behaviour becomes more likely, at the same time as objectively measured driving skills are deteriorating due to sedation. This is what leads to alcohol related road crashes.

The person who has been drinking and is making a decision to drive is faced with an analogous decision about risks. The risks to be considered include negotiating the roads safely. The subjective assessment of such risk is progressively distorted by the effects of alcohol. It is therefore necessary to ensure that drivers consider whether they will drive or not before sufficient alcohol has been consumed to materially affect such judgments. This implies that legal limits on blood alcohol concentration in drivers must be set low, at the level indeed where subjective assessment of risks remains realistic in virtually all people.

Serious public health problems demand coordinated approaches. The detail of any successful approach must be based upon an analysis of the problem as it affects a particular country and culture. In most countries road crashes involving alcohol involve adolescents and young adults disproportionately and special efforts to reduce alcohol consumption by this group will be relevant. In many such examples the problems of alcohol on the road are mirrored by problems associated with alcohol in the workplace or in social or domestic environments.

Successful programmes will involve:
 - education of the population concerning the seriousness of the problem and of the reasons why alcohol is dangerous to the driver, with the aim of changing the attitude of the population to drinking and driving;
 - underpinning these attitudes with appropriate enforcement policies and legal sanctions; and
 - identification of problem drinkers in whom additional measures may be required.

RECOMMENDATIONS

The World Medical Association urges all National Associations to promote the following principles:

1. Alcohol related road traffic crashes constitute a major preventable public health problem. Public health resources commensurate with its seriousness must be directed to this problem.
   
   
2. Detailed prevention measures necessitate a good understanding of the age and social groups involved and the social forces that prevail to create the problem in these groups. Research that details these issues must be undertaken. Where particular social groups are found to be involved, comprehensive strategies must be undertaken to deal with their problem. This may involve limiting the availability of alcohol to that group and ensuring that those involved in the sale of alcoholic beverages share some liability for the consequences of the sale. There must be education aimed at attitudinal change, backed by sanctions if necessary, and attention given to the elimination of alcohol from the workplace.
   
   
3. An alcohol related road crash must be seen as one of the inter-related alcohol problems that may affect an individual, the others include work accidents, domestic disharmony and violence, and personal alcoholic disease. The legal and medical treatment of individuals must reflect this.
   
   
   1. No opportunity to rehabilitate a person who abuses alcohol should ever be lost. Any driver convicted of driving under the influence of alcohol or with excessive blood (or breath) alcohol should be assessed for other alcohol related problems, and where appropriate, entered into a rehabilitation programme.
      
   2. Rehabilitation programmes for such purposes should be publicly funded, in view of the significant risk to the public wellbeing of unresolved alcohol dependence.
      
      
4. Education of the population must ensure that the progressive effect of alcohol on both driver skills and the assessment of risks is well understood. The effects of alcohol abuse on health generally must not be forgotten, and there should be a better appreciation by the public of the greater likelihood of medical complications when a drunk person is injured.
   
   
   1. The primary health message should be that the drinking of alcohol should always be in moderation.
      
   2. The specific message should be that driving should not be undertaken by one who has been drinking.
      
   3. The special problem of adolescent and young adult drivers who drink must be addressed by educational programmes on the effects of alcohol that extend through school years and promote responsible attitudes to drinking and driving. Other issues to do with alcohol should be simultaneously addressed.
      
      
5. Doctors should endorse the need for a low legally permissible blood alcohol concentration in drivers, certainly not greater than 50mg/100ml of blood, or comparable breath concentrations.
   Low legal limits are of limited effect if enforcement is uncertain. National Associations should carefully consider the advisability of insisting:
   
   
   1. that every driver involved in a significant crash be tested for blood (or breath) alcohol concentrations.
      
   2. that there be random testing of drivers, either generally, or at those times when research has indicated that alcohol related crashes are particularly likely to occur.