SURGEON GENERAL'S WORKSHOP ON DRUNK DRIVING Background Papers Washington, D.C. * December 14-16, 1988 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Office of the Surgeon General 5600 Fishers Lane Rockville, Maryland 20857 ACKNOWLEDGMENTS The Surgeon General’s Workshop on Drunk Driving was supported by the follow- ing organizations: . US. Department of Defense US. Department of Education U.S. Department of Health and Human Services US. Public Health Service : Alcohol, Drug Abuse, and Mental Health Administration National Institute on Alcohol Abuse and Alcoholism Office for Substance Abuse Prevention Centers for Disease Control Health Resources and Services Administration Bureau of Health Care Delivery and Assistance Bureau of Maternal and Child Health and ; Resources Development Indian Health Service U.S. Department of Justice Office of Juvenile Justice and Delinquency Prevention U.S. Department of Transportation National Highway Traffic Safety Administration Editorial support and camera-ready.copy were provided by Janus Associates under contract 85080-001. All material in this volume ts in the public domain and may be used or reproduced without permission from the Office of the Surgeon General or the authors. Citation of the source is appreciated. The opinions expressed herein are the views of the authors and participants and do not necessarily reflect the official position of the Office of the Surgeon General or any other sponsoring agency of the U.S. Government. Printed 1989 FOREWORD The combination of drinking and driving claims one life every 20 minutes and injures hundreds every day. Tragically, the major casualties are the youth of our Nation. Daily —as a society and as individuals — we make decisions about drinking, about serving. alcoholic beverages, about driving, and about “having fun.” These decisions affect our own lives as well as those of our families, friends, and neighbors. Choices about drinking and driving can protect our lives or destroy them. This serious health and safety problem is preventable. Many individuals and concerned groups have campaigned to end this devastation, but it cannot be reduced without national leadership. The Surgeon General’s Workshop on Drunk Driving was held in December 1988 to devise a combination of strategies for addressing the problem at the local, State, and National levels. Experts in diverse fields related to drinking and driving were invited to the workshop to share their expertise and experiences. Their recommendations, made after 3 days of intense discussion, can be found in the Proceedings. The background papers in this volume were commissioned to provide a foundation for and launch the discussion of the 11 expert panels of the workshop. The authors presented the state of the art in the different fields and describe the various attempts throughout the country and the world to prevent alcohol-impaired driving — the trials, the errors, the successes, and the obstacles. With up-to-date knowledge about the problem and proposed solutions, and a coordinated comprehensive plan, we are ready to enlist our country’s help in preventing this major threat to our health and well-being. - C. Everett Koop, M.D., Sc.D. Surgeon General Workshop Planning Committee Jerald H. Anderson Chairperson Intoxicated Driving Prevention Task Force Office of the Assistant Secretary of Defense Force Management and Personnel Safety and Occupational Health Policy US. Department of Defense Loran Archer Deputy Director National Institute on Alcohol Abuse and Alcoholism Alcohol, Drug Abuse, and Mental Health Administration U.S. Department of Health and Human Services Amy Barkin . Coordinator for the Drunk Driving Workshop Office of the Surgeon General U.S. Department of Health and Human Services Maura Daly Senior Policy Analyst ’ Office of the Secretary U.S. Department of Education Roberta Dorn Director Concentration of Federal Effort Program Office of Juvenile Justice and Delinquency Prevention U.S. Department of Justice Robert W. Denniston Director Division of Communication Programs Office for Substance Abuse Prevention Alcohol, Drug Abuse, and Mental Health Administration U.S. Department of Health and Human Services Arthur S. Funke, Ph.D. Chief Psychologist Child and Adolescent Branch Bureau of Maternal and Child Health and Resources Development Health Resources and Services Administration U.S. Department of Health and Human Services vi Mary L. Ganikos, Ph.D. Program Director Community Prevention and Late Life Alcohol Abuse National Institute on Alcohol Abuse and Alcoholism Alcohol, Drug Abuse, and Mental Health Administration US. Department of Health and Human Services Jan Howard, Ph.D. Chief _ Prevention Research Branch National Institute on Alcohol Abuse and Alcoholism Alcohol, Drug Abuse, and Mental Health Administration U.S. Department of Health and Human Services Michael T. Impellizzeri Chief Special Programs Division Office of Alcohol and State Programs National Highway Traffic Safety Administration U.S. Department of Transportation Steve Moore Associate Chief of Staff Office of the Surgeon General US. Department of Health and Human Services James L. Nichols, Ph.D. Deputy Director, Scientific and Technical Affairs National Highway Traffic Safety Administration U.S. Department of Transportation Joan White Quinlan ; Prevention Program Coordinator Special Programs Division Office of Alcohol and State Programs National Highway Traffic Safety Administration U.S. Department of Transportation Richard J. Smith III Manager Injury Prevention Program Indian Health Service U.S Department of Health and Human Services Federal Advisory Group on Followup Activities for the Workshop U.S. Department of Defense Jerald H. Anderson Chairperson, DOD Intoxicated Driving Prevention Task Force Office of the Assistant Secretary of Defense Force Management and Personnel , Safety and Occupational Health Policy Room 3A272 The Pentagon, Washington, DC 20301-4000 U.S. Department of Education Maura Daly Senior Policy Analyst Office of the Secretary, 400 Maryland Avenue, S.W. Room 4145, Washington, DC 20202 U.S. Department of Health and Human Services U.S. Public Health Service Robert W. Denniston Director, Division of Communication Programs Office for Substance Abuse Prevention Alcohol, Drug Abuse and Mental Health Administration Room 13A-54 Parklawn Building, 5600 Fishers Lane Rockville, MD 20857 Arthur S. Funke, Ph.D. Chief Psychologist, Child and Adolescent Branch Bureau of Maternal and Child Health and Resources Development Health Resources and Services Administration Room 9-21 Parklawn Building, 5600 Fishers Lane Rockville, MD 20857 Mary L. Ganikos, Ph.D. Program Director Community Prevention and Late Life Alcohol Abuse National Institute on Alcohol Abuse and Alcoholism Alcohol, Drug Abuse and Mental Health Administration Room 16C-03 Parklawn Building, 5600 Fishers Lane Rockville, MD 20857 vii U.S. Department of Health and Human Services U.S. Public Health Service (continued) Susan J. Lockhart _ Program Specialist Office of the Surgeon General Office of the Assistant Secretary for Health Room 18-67 Parklawn Building, 5600 Fishers Lane Rockville, MD 20857 Richard J. Smith ITI Manager, Injury Prevention Program Indian Health Service 5600 Fishers Lane, Rockville, MD 20857 Bob Vollinger Presidential Management Intern Office of the Surgeon General Office of the Assistant Secretary for Health Room 18-67 Parklawn Building, 5600 Fishers Lane Rockville, MD 20857 U.S. Department of Justice John Dawson Program Manager Office of Juvenile Justice and Delinquency Prevention Room 758, 633 Indiana Avenue, N.W. Washington, DC 20531 Donni Hassler, Ed.D. Social Science Analyst Office of Juvenile Justice and Delinquency Prevention Room 742, 633 Indiana Avenue, N.W. Washington, DC 20531 U.S. Department of Transportation James L. Nichols, Ph.D. Deputy Director Scientific and Technical Affairs National Highway Traffic Safety Administration 400 Sth Street, S.W. Room 5130, Washington, D.C 20590 Joan White Quinlan Prevention Program Coordinator, Special Programs Division Office of Alcohol and State Programs National Highway Traffic Safety Administration 400 7th Street, S.W. Room 5130, Washington, DC 20590 viii Abbreviations 402 Programs 408 Programs 410 Programs ABC ADAMHA ASAP ASTHO BAC BIA CDC CPL DDP DHHS DOJ DOT DUI DwI EMS FARS FBI FCC IACP THS Illegal per se MADD MCD NAB . NAGHSR NCADD 23 U.S.C. 402 Highway Safety Programs. These formula grants to the States for highway safety programs are administered by the Governors’ Representatives for Highway Safety. 23 U.S.C. 408-I incentive grants to States for alcohol traffic safety programs 23 U.S.C. 410-1 incentive grants to States for drunk driving prevention programs Alcohol Beverage Control Alcohol, Drug Abuse, and Mental Health Administration Alcohol Safety Action Projects Association of State and Territorial Health Officers Blood Alcohol Concentration Bureau of Indian Affairs Centers for Disease Control Certified products list Designated driver programs Department of Health and Human Services Department of Justice Department of Transportation Driving Under the Influence Driving While Intoxicated The terms DWI and DUI are synonymous, meaning either driving while intoxicated or driving while under the influence. These are general terms referring to the criminal action of driving a motor vehicle either (1) while “illegal per se” or (2) while impaired, under the influence, or intoxicated by alcohol or other drugs. Emergency Medical Systems Fatal Accident Reporting System Federal Bureau of Investigation Federal Communications Commission International Association of Chiefs of Police Indian Health Service . Refers to State laws that make it an offense to operate a motor vehicle while at or above a specified blood alcohol level. ' Mothers Against Drunk Driving Multiple Cause of Death file taken from death certificate data by National Center for Health Statistics National Association of Broadcasters National Association of Governor’s Highway Safety Representatives National Commission Against Drunk Driving NCADI NCIC NHTSA NIDA NSA OJJDP OSAP PBT PHS PIKE PSA RADAR RFP RID RWID SRP TEAM TIPS National Clearinghouse for Alcohol and Drug Information National Crime Information Center ~ National Highway Traffic Safety Administration National Institute on Alcohol Abuse and Alcoholism National Institute on Drug Abuse , National Sheriffs Association Office of Juvenile Justice and Delinquency Prevention (Office for Substance Abuse Prevention Preliminary breath tester Public Health Service Public information and education Public service announcement Regional Alcohol and Drug Awareness Resource Network Request for proposals . Remove Intoxicated Drivers Riding With Intoxicated Driver Safe ride programs Techniques of Effective Alcohol Management Training for Intervention Procedures by Servers of Alcohol List of Participants Ritchie Aanderud. President, Remove Intoxicated Drivers, Washington State, Puyallup, WA. Doris Aiken. President, Remove Intoxicated Drivers, Schenectady, NY. John Allen, PhD. Chief, Treatment Research Branch, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, U.S. Public Health Service, Rockville, MD. Gloria Ames, CDR. Immigration and Naturalization Service, Health Care Program, Washington, DC. David Anderson, PhD. Substance Abuse Specialist, Arlington, VA. Robert Apsler, PhD. Harold Russell Associates, Inc., Winchester, MA. Loran Archer. Deputy Director, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, USS. Public Health Service, Rockville, MD. Katherine Armstrong, PhD. Coordinator, Children and School Programs, Office of Disease Prevention and Health Promotion, U.S. Public Health Service, Washington, DC. Charles K. Atkin, PhD. Professor, Department of Communications, Michigan State University, East Lansing, MI. Darryl Bertolucci. Mathematical Statistician, Division of Biometry and Epidemology, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD. Harold Brandt, MD. Mothers Against Drunk Driving, Baton Rouge, LA, Rebecca Brown. National Public Policy Committee Chairman, Mothers Against Drunk Driving, New Port Richey, FL. Johnny Mack Brown. Sheriff, Greenville County Sheriff's Office, Greenville, SC. Raul Caetano, MD, PhD. Alcohol Research Group, Berkeley, CA. Beverly Campbell. Church of Jesus Christ of Latter Day Saints, Washington, DC. Kay Chopard. Staff Attorney, Prosecuting Attorneys’ Training Council, Des Moines, IA. Marlene Cole, LCDR. Veterinary Resources Branch, Division of Research Services, National Institutes of Health, U.S. Public Health Service, Bethesda, MD. Ricky Davidson. Chief, Emergency Medical Services Committee, International Association of Firechiefs, Shreveport, LA. Galen Davis. Special Assistant to the Governor, Topeka, KS. Delores Delaney. Member, National PTA, Committee on Health, Virginia Beach, VA. Robert W. Denniston. Director, Division of Communication Programs, Office for Substance Abuse Prevention, Alcohol, Drug Abuse, and Mental Health Administration, U.S. Public Health Service, Rockville, MD. Ted Doege, MD. American Medical Association, Chicago, IL. John Donovan, PhD. Research Associate, Institute of Behavioral Sciences, University of Colorado, Boulder, CO. xi xii James P. Donovan. Chief, Division of Law Enforcement Services, Bureau of Indian Affairs, Washington, DC. Martin R: Eichelberger, MD. Director, Emergency Trauma Service, Children’s Hospital, National Medical Center, Washington, Dc. Vernon Ellingstad, PhD. Department of Psychology, University of South Dakota, Vermillion, SD. . Ann Esch. North Carolinians Against Intoxicated Drivers, Winston-Salem, NC. James A. Farrow, MD. Director, Division of Adolescent Medicine, Director, Reduce Adolescent Drinking and Driving Project, Department of Pediatrics, University of Washington, Seattle, WA. Howard Filston, MD. Duke University Medical Center, Durham, NC. Mary L. Ganikos, PhD. Program Director, Late Life Alcohol Abuse, Prevention Research Branch, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, Mental Health Administration, U.S. Public Health Service, Rockville, MD. Dean Gerstein. Study Director, National Academy of Sciences, Washington, DC. Mark Goldman, PhD. Professor of Psychology, Director, Clinical Program, University of South Florida, Tampa, FL. Michael Goodstadt, PhD. Director, Division of Prevention, Rutgers Center for Alcohol Studies, Rutgers University, Piscataway, NJ. Lawrence’A. Greenfeld. Deputy Associate Director, Bureau of Justice Statistics, Department of Justice, Washington, DC. Joseph Gusfield, PhD. Professor, Department of Sociology, University of California at San Diego, La Jolla, CA. Frank Hamilton, MD, CAPT. National Institutes of Health, U.S. Public Health Service, Bethesda, MD. Maury Hannigan. Deputy Commissioner, California Highway Patrol, Sacramento, CA. John Harvey. Elementary and Traffic Safety Education Consultant, State Department of Education, Montpelier, VT. William Hayes. Manager, New Jersey Highway Safety Office, Trenton, NJ. Anthony J. Heckemeyer. Presiding Circuit Judge, 33rd J udicial District, Benton, MS. Sandy Heverly. Mothers Against Drunk Driving, Las Vegas, NV. Ralph Hingson, ScD. Professor, Chief of Social and Behavioral Sciences, School of Public Health/College of Medicine, Boston University, Boston, MA. Harold Holder, PhD. Director, Prevention Research Center, Berkeley, CA. Jan Howard, PhD. Chief, Research Prevention Branch, National Institute on Alcohol Abuse and Alcoholism; Alcohol, Drug Abuse, and Mental Health Administration, U.S. Public Health Service, Rockville, MD. Michael Impellizzeri. Chief, Special Programs Division, National Highway Traffic Safety Administration, Washington, DC. Michael Jacobson, PhD. Director, Center for Science in the Public Interest, Washington, DC. Paul Kamenar. Executive Legal Director, Washington Legal Foundation, Washington, DC. Jean Kilbourne, EdD. Board Member, National Council on Alcoholism, West Newton, MA. Michael Klitzner, PhD. Pacific Institute of Research and Evaluation, Bethesda, MD. John H. Lacy, PhD. Director for Alcohol Studies, The University of North Carolina, Highway Safety Research Center, Chapel Hill, NC. Ray Larson, Commonwealth’s Attorney, Lexington, KY. Patricia D. Mail, CAPT. Division of AIDS Programs, U.S. Public Health Service, Rockville, MD. Philip May, PhD. Professor, Department of Sociology, University of New Mexico, Albuquerque, NM. Michael Mazis, PhD. Professor and Chair, Department of Marketing, American University, Washington, DC. Katherine McCarter. Associate Executive Director, American Public Health Association, Washington, DC. John McCarthy, PhD. Department of Sociology, C Catholic University, Washington, DC. George McCarthy. Chairman, Alcoholic Beverage Control Commission, Boston, MA. Susan McLoughlin, MSN, RN. Senior Staff Specialist, Center for Nursing Practices, American Nurses Association, Kansas City, MO. Allan Meyers, PhD. Associate Dean, College of Liberal Arts, Boston University, Boston, MA. John Moulden. National Transportation Safety Board, Washington, DC. Joyanne Murphy, LCDR. National Institutes of Health, U.S. Public Health Service, Bethesda, MD. Dennis Nalty, PhD. Director, Office of Policy Analysis and Development, South Carolina Commission on Alcohol and Drug Abuse, Columbia, SC. Carl E. Nash. Chief, Accident Investigations Division, National Center for Statistics and Analysis, National Highway Traffic Safety Administration, Washington, DC. James Nichols, PhD, Deputy Director, Scientific and Technical Affairs, National Highway Traffic Safety Administration, Department of Transportation, Washington, DC. Perla Niguidula. Club Operations Specialist, Recreation Services Department, Naval Military Personnel Command, Arlington, VA. Robert Niven, MD. Harper Hospital, Department of Psychiatry, Detroit, MI. Peter O’Rourke. Director, Office of Traffic Safety, Business and Transportation Agency, Sacramento, CA. Howard P, Patinkin. Assistant Deputy Superintendent, Chicago Police Department, Traffic Division Administration, Chicago, IL. Terry Pence. Traffic Safety Section, State Department of Highways and Public Transportation, Austin, TX. M.W. Perrine, PhD. Director, Vermont Alcohol Research Center, Burlington, VT. James Peters. Responsible Hospitality Institute, Springfield, MA. Charles Phelps, PhD. Professor of Economic and Political Science, Director, Public Policy Analysis Program, University of Rochester, Rochester, NY. Joan White Quinlan. Coordinator, Prevention Program, Special Programs Division, National Highway Traffic Safety Administration, Department of Transportation, Washington, DC. George L. Reagle. Associate Administrator for Traffic Safety Programs, National Highway Traffic Safety Administration, Washington, DC. Nancy Ricci. President, Remove Intoxicated Drivers, Connecticut, Wallingford, CT. Mary Beth Robinson. Director of Public Relations, National Automobile Dealers’ Association, McLean, VA. James D. Rogers, Judge. Fourth Judicial District Court, Minneapolis, MN. H. Laurence Ross, PhD. National Institute of Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, U.S. Public Health Service, Rockville, MD. xiii xiv Wes Roy. Representative, City of Radcliff, Radcliff, KY. Sue Rusche. National Drug Information Center of Families in Action, Atlanta, GA. Micky Sadoff. National President, Mothers Against Drunk Driving, Hurst, TX. Robert Saltz, PhD. Assistant Director, Prevention Research Center, Berkeley, CA. Lawrence Schneider. Health Services and Facilities Consultant, Office of Emergency Medical Services, Department of Health and Rehabilitative Services, Tallahassee, FL. . William Scott. Director, Office of Alcohol and State Programs, National Highway Traffic Safety Administration, Washington, DC. — Jerri Shaw. Johnson, Bassin and Shaw, Inc., Silver Spring, MD. Harvey Siegel, PhD. Professor and Director, Wright State Substance Abuse Intervention Programs, School of Medicine, Wright State University, Dayton, OH. Bruce Simons-Morton, EdD, MPH. Associate Professor, Center for Health Promotion Research and Development, University of Texas, Health Science Center at Houston, Houston, TX. David A. Sleet, PhD. Professor, Department of Health Science, Graduate School of Public Health, San Diego State University, San Diego, CA. Phillip Smith, MD, CDR. Indian Health Service, U.S. Public Health Service, Rockville, MD. Richard J. Smith II], CDR. Manager, Injury Prevention Program, Indian Health Service, U.S. Public Health Service, Rockville, MD. Carl Soderstrom, MD. Assistant Professor of Surgery, Associate Director of Physician Education, University of Maryland, Maryland Institute for Emergency Medical Services Systems, Baltimore, MD. Dorothy Stephens, LTJG. Health Resources and Services Administration, U.S. Public Health Service, Rockville, MD. Alvera Stern, PhD. Administrator, Division of Prevention and Education, Illinois Department of Alcoholism and Substance Abuse, Chicago, IL. Kathryn Stewart. Pacific Institute for Research and Evaluation, Vienna, VA. James W. Swinehart, PhD. President, Public Communication Resources, Inc., Pelham Manor, NY. Elsie Taylor. Public Health Advisor, Prevention Research Branch, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, U.S. Public Health Service, Rockville, MD. John M. Templeton, Jr., MD. Childrens Hospital of Philadelphia, Philadelphia, PA. Stephen Teret, JD, MPH. Director, Johns Hopkins Injury Prevention Research Center, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD. Rae Tyson. USA Today, Arlington, VA. Chauncey Veatch, III. President, National Association of State Alcohol and Drug Abuse Directors, Department of Alcohol and Drug Programs, Sacramento, CA. Robert B. Voas, PhD. Pyramid Planning, Bethesda, MD. Alexander Wagenaar, PhD. Associate Research Scientist, University of Michigan, Transportation Research Institute, Ann Arbor, MI. Lawrence Wallack, Dr.P.H. Associate Professor, School of Public Health, University of California, Berkeley, CA. Julian Waller, MD, MPH. Professor, Department of Medicine, University of Vermont, Burlington, VT. Patricia Waller, PhD. Associate Director for Driver Studies, Highway Safety Research Center, University of North Carolina, Chapel Hill, NC. Joel Watne. Special Assistant, Attorney General, State of Minnesota, Roseville, MN Clark Watts, MD, MPH. Professor of Neurosurgery, University of Missouri Arlington, VA. Richard Waxweiller, PhD. Chief, Epidemiology Branch, Division of Injury Epidemiology and Control, Center for Environmental Health, Centers for Disease Control, U.S. Public Health Service, Atlanta, GA.. Elizabeth A. Weaver. Director of Education, Motorcycle Safety Foundation Irvine, CA. , Allan F. Williams, PhD. Senior Researcher, Insurance Institute f i Washington, DC. aa "9 a Marsha Woodward. President, Remove Intoxicated Drivers, Allen County Scottsville, KY. Judy Zundel. Special Assistant to the Deputy Assistant Secretary, Indian Affairs (Trust and Economic Development), Bureau of Indian Affairs, Washington, DC. XV Contents Foreword 2. ee eee ee eee ee eee Workshop Planning Committee... 2... 2... ee ee ee ee eee Federal Advisory Group on Followup Activities for the Workshop Pricing and Availability Alcohol Beverage Control Policies: Their Role in Preventing Alcohol-Impaired Driving 2.0... 0 0. ee ee es Alexander C. Wagenaar and Susan Farreil Advertising and Marketing Mass Communication Effects on Drinking and Driving Charles K. Atkin Epidemiology and Data Management Epidemiologic Perspectives on Drunk Driving .............-. M.W. Perrine, Raymond C. Peck, and James C. Fell Education Controlling Injuries Due to Dunking and Driving: The Context and Functions of Education Bruce G. Simons-Morton and Denise G. Simons-Morton Judicial and Administrative Processes The Effectiveness of Legal Sanctions in Dealing With Drinking Drivers James L. Nichols and H. Laurence Ross Prosecution, Adjudication, and Sanctioning: A Process Evaluation of Post-1980 Activities James L. Nichols and Kevin E. Quinian Law Enforcement Issues in the Enforcement of Impaired Driving Laws in the United States Robert B. Voas and John H. Lacey — Transportation and Alcohol Service Policies Transportation Alternatives for Drinkers Robert Apsler Server Intervention and Responsible Beverage Service Programs ..... Robert F. Saltz Cr ee Abbreviations 2... 0. ee eee ee ee ens List of Participants ......... Ce ee ee ee ee ee ee ee Ce rd Ce ey 35 93 113 136 157 169 xvii xviii Injury Control _ Injury and Disability Prevention and Alcohol-Related Crashes ........ 180 . Julian A. Waller Youth and Other Special Populations — Youth Impaired Driving: Causes and Countermeasures Michael Klitzner Motor Vehicle Crashes and Alcohol Among American Indians and Alaska Natives 2.0.00. 0c ec ee ee et ee tee 207 Philip A. May Drunk Driving Among Blacks and Hispanics .........-.--+--06> 224 Jan M. Howard, Elsie D. Taylor, H. Laurence Ross, and Mary L. Ganikos Treatment Rehabilitation Countermeasures for Drinking Drivers ............. 234 Kathryn Stewart and Vernon S. Ellingstad Citizen Advocacy Independent Citizen Advocacy: The Past and the Prospects John D. McCarthy and Debra S. Harvey