Issue Report The Facts Hurt: A State-by-State Injury Prevention Policy Report May 2012 Preventing Epidemics. Protecting People. ACKNOWLEDGEMENTS Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need—the Foundation expects to make a difference in our lifetime. For more information, visit www.rwjf.org.     TFAH would like to thank RWJF for their generous support of this report. TFAH BOARD OF DIRECTORS REPORT AUTHORS Gail Christopher, DN Jeffrey Levi, PhD. President of the Board, TFAH Executive Director Vice President — Program Strategy Trust for America’s Health and WK Kellogg Foundation Associate Professor in the Department of Health Policy The George Washington University School of Cynthia M. Harris, PhD, DABT Public Health and Health Services Vice President of the Board, TFAH Director and Professor Laura M. Segal, MA Institute of Public Health, Florida A&M University Director of Public Affairs Trust for America’s Health Theodore Spencer Secretary of the Board, TFAH David Kohn Senior Advocate, Climate Center Senior Communications Manager Natural Resources Defense Council Trust for America’s Health Robert T. Harris, MD Treasurer of the Board, TFAH REPORT CONTRIBUTORS Former Chief Medical Officer and Senior Vice President Rebecca St. Laurent, JD for Healthcare Health Policy Research Manager BlueCross BlueShield of North Carolina Trust for America’s Health David Fleming, MD Rebecca Salay Director of Public Health Director of Government Relations Seattle King County, Washington Trust for America’s Health Arthur Garson, Jr., MD, MPH Director, Center for Health Policy, University Professor, And Professor of Public Health Services REPORT ADVISORY COMMITTEE University of Virginia TFAH worked with a committee of top injury prevention experts from the Safe States John Gates, JD Alliance and the Society for the Advancement Founder, Operator and Manager of Violence and Injury Prevention (SAVIR) to Nashoba Brook Bakery develop the report. Alonzo Plough, MA, MPH, PhD TFAH thanks the experts for their time, Director, Emergency Preparedness and Response Program expertise and insights. The opinions Los Angeles County Department of Public Health and recommendations in the report do Eduardo Sanchez, MD, MPH not necessarily reflect the views of the Chief Medical Officer organizations with which the advisory Blue Cross Blue Shield of Texas committee members are associated. Jane Silver, MPH President Irene Diamond Fund The report’s advisory committee includes: Corinne Peek-Asa, MPH, PhD Professor and Director From The Safe States Alliance College of Public Health, University of Iowa Injury Prevention Amber Williams Research Center Executive Director, Safe States Alliance Keshia M. Pollack, PhD, MPH Lori Haskett Assistant Professor President, Safe States Alliance and Johns Hopkins Center for Injury Research and Policy, Johns Director, Injury Prevention & Disability Programs Hopkins Bloomberg School of Public Health Kansas Department of Health & Environment Director, Occupational Injury Epidemiology and Prevention Training Program SAVIR Board Member Linda Scarpetta Manager, Injury & Violence Prevention Section Fred Rivara, MD, MPH Michigan Department of Community Health Professor, Pediatrics, Adjunct Professor, Epidemiology University of Washington School of Public Health Shelli Stephens Stidham SAVIR President Elect Director, Injury Prevention Center of Greater Dallas Parkland Health & Hospital System Billie Weiss, MPH Associate Director Lisa VanderWerf-Hourigan Southern California Injury Prevention Research Program, UCLA Director, Office of Injury Prevention at the Florida Department of Health Fielding School of Public Health Jamila Porter SAVIR Board Member Assistant Director, Safe States Alliance SAVIR is a national professional organization dedicated to fostering excellence in the Formed in 1993, the Safe States Alliance is the only national nonprofit organization science of preventing and treating violence and injury. Our vision is a safer world comprised of public health injury and violence prevention professionals representing all through violence and injury research and its application to practice. As a membership organization, we provide educational and professional development services to injury U.S. states and territories. Safe States Alliance engages in activities that include increas- researchers in public health and medicine as well as injury practitioners in local, state, ing awareness of injury and violence throughout the lifespan as a public health problem; and national agencies and organizations. SAVIR regularly offers webinars, meetings enhancing the capacity of public health agencies and their partners to ensure effective injury and conferences to foster learning and collaboration. Our members provide mentoring and violence prevention programs by disseminating best practices, setting standards for to new researchers as well as technical assistance and consultation to government surveillance, conducting program assessments, and facilitating peer-to-peer technical as- agencies and private organizations. Educating policy makers is an important part of sistance; providing educational opportunities, training, and professional development for our mission, and we have been an active co-sponsor of many Congressional briefings on those within the injury and violence prevention field; collaborating with other national or- injury and violence. SAVIR works in partnership with other organizations to advance ganizations and federal agencies to achieve shared goals; advocating for public health poli- scholarship in the injury field and to promote evidence informed programs and policies cies designed to advance injury and violence prevention; convening leaders and serving as that can reduce the injury burden in the United States and around the world. the voice of injury and violence prevention programs within state health departments; and Recent highlights of SAVIR activities include sponsoring roundtable discussions with representing the diverse professionals that make up the injury and violence prevention field. a variety of federal agencies to identify opportunities to enhance injury and violence For more information about the Safe States Alliance, please visit www.safestates.org. prevention; preparing a white paper for the National Institute of Child Health and Human Development on research needs to reduce childhood injuries; contributing to the development of the Centers for Disease Control and Prevention’s National Action From The Society for the Advancement Plan on Childhood Injury; and participating on policy development work of the Of Violence And Injury Research (Savir) National Partnership to End Interpersonal Violence. In 2011, for the first time, SAVIR and Safe States Alliance jointly sponsored a national conference on reducing injury Andrea Gielen, ScD, ScM and violence in America. For more information, go to www.savirweb.org Professor and Director Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health ADDITIONAL CONTRIBUTORS SAVIR Past-President Colleen Gallopin, Esq. Shannon Frattaroli, PhD, MPH Director of Training and Technical Assistance Assistant Professor Break the Cycle Johns Hopkins Center for Injury Research and Policy, Johns Rennie W. Ferguson, B.A. Hopkins Bloomberg School of Public Health Kerri McGowan Lowrey, JD, MPH Susan Gallagher, MPH Senior Staff Attorney Director, MS Program in Health Communications Network for Public Health Law’s Eastern Region at the University of Tufts University School of Medicine Maryland Francis King Carey School of Law Co-Chair, SAVIR Advocacy and Public Policy Committee Lindsay Barton Joneigh S. Khaldun, MD Senior Editor Health Policy Fellow, Adjunct Clinical Instructor, MomsTeam.com Department of Emergency Medicine, The George Washington University Co-Chair, SAVIR Advocacy and Public Policy Committee TABLE OF CONTENTS: 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2. State-By-State Prevention Indicators and Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 A. Vehicle Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 n Seat Belts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 s Primary Seat Belt Laws: Report Card Indicator 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 n Driving Under the Influence of Alcohol and Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 s gnition Interlocks Laws: Report Card Indicator 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 I n Motorcycle Helmets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 s Universal Motorcycle Helmet Laws: Report Card Indicator 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 n Child Car Seats and Booster Seats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 s ooster Seats Until Age Eight Laws: Report Card Indicator 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 B n istracted Driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 D n Teen Driving Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 n Older Drivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 n Speeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 n Bicycle and Non-Motorized Vehicle Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 s Bicycle Helmets for Children Laws: Report Card Indicator 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 n Complete Streets Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 B. Violence-Related Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 n Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 s Protection Orders in Dating Relationship Laws: Report Card Indicator 6 . . . . . . . . . . . . . . . . . . 36 n Teen Dating Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 s rade for Teen Violence Prevention Law Review: Report Card Indicator 7 . . . . . . . . . . . . . . . . 38 G n Homicide, Assault and Suicide Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 n Teen Violence Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 s School-Related Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 s ang-Related Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 G s Bullying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 n Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 C. Falls, Drowning and Sports- and Recreation-Related Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 n Concussions and Traumatic Brain Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 s Strong Youth Sport Concussion Safety Laws: Report Card Indicator 8 . . . . . . . . . . . . . . . . . . . . 49 n Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 n Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 D. Injuries from Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 n Prescription Drug Overdose or Misuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 s Active or Pending Prescription Drug Monitoring Program: Report Card Indicator 9 . . . . . . . . . 54 E. Research Tools for Reducing Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 n Data Collection: External Causes of Injury Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 s Coding More than 90 Percent of Injury Discharges from In-Patient Stays in Hospitals: Report Card Indicator 10 F. Fire-Related Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 5 Introduction I njury is a major public health problem in the United States. Injuries — including those caused by accidents and violence -- are the third-leading cause of death nationally — and they are the leading cause of death for Americans between the ages of one and 44.1 One person dies from an injury every three minutes. Every year, 1 S ecti o n injuries generate $406 billion in lifetime costs for medical care and lost productivity.2 While individuals are responsible for taking n otorcycle helmets saved more than 8,000 M steps to stay safe and protect themselves and lives and child safety seats saved around 1,800 their families from injuries, experts have found lives from 2005 to 2009;5 that public education, laws and policies can n obriety checkpoints have been shown to cut S also play a major role in helping keep Ameri- alcohol-related crashes and deaths by around cans healthy and safe. From child safety seats to 20 percent;6 poison control centers, policies and programs can help Americans make healthier and safer n xercise programs for older adults have E choices for themselves and their families. been shown to reduce falls by as much as half among participants;7 and Research has produced strong evidence that shows many different strategies can also signifi- n chool-based programs to prevent violence S cantly reduce the rate of many common injuries. have cut violent behavior among high school As is the case with other areas of health, rigor- students by 29 percent.8 ous scientific studies have led to breakthroughs By adopting policies and laws based on these in understanding patterns of injuries and ways proven approaches, policymakers can help to avoid them. According to the U.S. Centers lower the number of injuries in their states, for Disease Control and Prevention (CDC), re- counties and cities. search has shown that many injuries are “pre- dictable, preventable and controllable.”3 The Trust for America’s Health (TFAH) worked with a committee of top injury prevention ex- For instance, researchers found that seat belts perts from the Safe States Alliance and the can greatly reduce the harm caused to individu- Society for the Advancement of Violence and als in motor vehicle crashes. Today, seat belts Injury Prevention (SAVIR) to create the indi- are standard equipment in all cars sold in the cators to develop this report card to provide United States and are credited with saving an es- the public and policymakers with information timated 69,000 lives from 2006 to 2010.4 Other about the status of some injury prevention poli- research-based prevention strategies have also cies in states, and to provide recommendations helped lead to public education campaigns, for evidence-based strategies to reduce injuries strong, enforced legislation and targeted pro- in the United States. grams that have helped reduce injury rates and save lives, such as: Injury prevention is one of the seven priorities in the National Prevention Strategy (NPS): America’s Plan for Better Health and Wellness, released in 2011. The NPS brings 17 federal agencies together for the first time to move the nation from a focus on sickness and injury to prevention and wellness. 7 INJURIES IN AMERICA Around 50 million Americans — 18 percent of the popula- tion — are medically treated for injuries each year.9 More than 180,000 Americans die annually from injuries, while more than 2.8 million are hospitalized.10, 11 Every year, more than 29 million people are treated in emergency rooms for injuries.12 Injuries disproportionately impact men — males make up more than two-thirds of all injury deaths. More than 12,000 children and teenagers under the age of 20 die from accidental in- juries each year and around 9.2 million were treated in emergency rooms for accidental injuries. Summary of Some Common Types of Injury n Falls: More than eight million Americans suffer falls that Injury Deaths Compared to Other Leading Causes of Death for require medical attention each year.13 One in three Ameri- Persons Ages 1-44, United States, 2007 cans ages 65 and older experiences a fall annually, and falls are the leading cause of injury deaths in adults over 65 years of age.14 Every 15 seconds an older adult is treated in an emergency department for a fall and every 27 minutes an older American dies as the result of a fall.15 n ar and Other Vehicle Crashes: Motor vehicle crashes C are the leading cause death for Americans ages five to 34. Each year, around 38,000 Americans die in motor vehicle crashes and more than 2.3 million adults are treated in emergency departments after being injured in motor vehicle n ires: Fire departments respond to around 380,000 F accidents.16 In addition, bicycle crashes lead to 700 deaths home fires a year. Home fires kill around 2,600 and injure and more than 500,000 emergency room visits a year, and another 13,350 per year.24 injuries sustained from skateboard, scooters and other non- According to CDC, injuries caused by accidents are the leading motorized recreational vehicles are responsible for tens of cause of death for children and teens ages one to 19.25 From thousands of emergency department visits annually.17, 18 2000 to 2009, the rates injuries from accidents decreased by n Violence-related Injuries: More than18,000 Americans 29 percent, from 15.5 to 11.0 per 100,000 individuals. In 2009, are murdered and more than 34,000 commit suicide each child and teen injuries from accidents resulted in approximately year.19 In addition, assaults are responsible for more than a 9,000 deaths, 225,000 hospitalizations and 8.4 million patients million injuries annually. treated and released from emergency room visits. s Violence by intimate partners alone causes more than n otor vehicle traffic-related incidents are the lead- M 2,000 deaths a year. Nearly three in 10 women and one ing cause of death for individuals ages one to 19. While in 10 men in the United States have experienced physical the number of children and teens killed in motor vehicle violence, rape or stalking by a partner.20 crashes decreased by 41 percent from 2000 to 2009, they are still the top cause of death for this age group; s ore than 1,700 children die from abuse or neglect each M year, and 80 percent of those are under four years old. More n uffocation is the leading cause of death for children less S than 15 people ages 10 to 24 die each day from some form than one year of age; of violence and more than 740,000 children and teens visit n rowning is the leading cause of injury deaths for children D emergency rooms for injuries related to violence each year.21 ages one to four; and n oisoning: Nearly 40,000 American die from poisoning P n alls are the leading cause of nonfatal injury for children F deaths and more than 700,000 Americans visit emergency and teens under 15 rooms resulting from poisoning each year.22 Misuse and abuse of prescription drugs has dramatically increased in the past n People between the ages of 25 and 44 — who make up decade. Prescription painkillers are responsible for around 30 percent of the population — account for 44 percent of 15,000 deaths and 475,000 emergency room visits a year.23 injury-related productivity losses.27 8 Annual Lifetime Cost of Injury by Type in Billions26 Annual Lifetime Costs of Injuries, By Cause, in 2000:26 Type of Injury Lifetime Costs of Injury Falls $80.9 Medical Productivity Total Costs Motor Vehicle/Road Related Costs Losses $89.2 Struck by or Against All Injuries $80.2 billion $326 billion $406.3 billion $48.1 Motor vehicle, or other $14 billion $75.1 billion $89.2 billion Firearm $36.5 road-related, accident Other/Unclassified $96.5 Falls $26.9 billion $54 billion $80.9 billion Struck By or Against $11 billion $37.1 billion $48.1 billion Cut/Pierce $3.7 billion $12.7 billion $16.3 billion Fire/Burn $1.3 billion $6.2 billion $7.5 billion Poisoning $25.9 Poisoning $2.2 billion $23.7 billion $25.9 billion Drowning/ Submersion $5.3 Cut/Pierce $16.3 Drowning/Submersion $95 million $5.2 billion $5.3 billion Fire/Burn $7.5 Firearm $1.2 billion $35.2 billion $36.5 billion Other/Unclassified $19.7 billion $76.8 billion $96.5 billion U.S. Investment in Injury Prevention Despite the pervasiveness of injuries, the high ence and the implementation of evidence-based cost of injuries and the growing understanding programs at the state and local level. that policies and programs can greatly reduce NCIPC provides cooperative agreement grants the number of injuries — the U.S. investment in to states and several U.S. territories to support science and public health practice of injury pre- injury prevention programs and activities. Fund- vention is very limited. ing for these programs has decreased over time, According to 2012 For the Public’s Health: Invest- from $104.6 million in FY 2006 down to $88.6 ing in a Healthier America from the Institute of million in FY 2011. This is a 24 percent decrease, Medicine, injury prevention only receives 4.95 adjusting for inflation. NCIPC research funding percent of the CDC’s total budget, yet injuries has also decreased over time. Injury Control have the second highest medical costs of all pre- Research Centers were created by NCIPC in ventable health issues.28 1987 to serve as centers for excellence in injury research, and they include a broad mandate to Public health is focused on preventing injuries conduct leading-edge research, train injury schol- as much as possible and reducing the severity ars and practitioners and ensure that research is of injuries when they do occur. Health experts relevant to practice and is translated into action at identify common types of injuries and conduct state and local levels. There are only 11 centers scientific studies on the most effective ways to in the country, down from 12, and the annual decrease the number of injuries in America. budgets of these centers have decreased. These health professionals work together with experts and officials in other fields, such as trans- Programmatic funding supports a range of pro- portation, fire departments, law enforcement, grams, including the Core Violence and Injury the judicial system, education, social work and Prevention Program, the Rape Prevention and human services to implement policies, programs Education Program and the National Violent Death and practices that have been proven to work. Reporting System. States received an average of $0.28 per capita in federal support for injury preven- At the federal level, the National Center for Injury tion from CDC, with a high of $1.06 per person in Prevention and Control (NCIPC) is the sole federal Rhode Island to a low of $0.10 per person in Idaho. agency with a singular focus and responsibility for injury prevention research and practice. In fiscal n Only 28 states received “core” funding year (FY) 2012, NCIPC received $137.7 million.29 to support injury and violence prevention programs from the Core Violence and Injury Out of these funds, CDC must support a broad Prevention Program. mission that includes research to advance sci- FY 2011 FY 2010 FY 2009 FY 2008 FY 2007 FY 2006 $88,648,854.00 $95,919,713 $97,773,591 $95,135,731 $100,390,981 $104,609,076 9 For the Core Violence and Injury Prevention n Only 31 states (63 percent)had a full-time Program grant amounts for each state by year director for injury and violence prevention — this and for additional FY 2011 injury prevention is down from 2005 when 37 states (76 percent) funding highlights by state, see Appendix C. had a full-time director. However, states with a CDC Core grant are significantly more likely Many states also can use a portion of the funds they to have a full-time director (76 percent vs. 45 receive from the Preventive Health Services Block percent of non-Core funded states). Grant at CDC and the Maternal and Child Health Block Grant at the Health Resources and Services n States reported 402 staff positions focused on Administration (HRSA) to support injury preven- injury prevention. Of those positions: tion activities. Funding for the Preventive Health s 1 percent (366) were paid staff (FT and PT) 9 Services Block Grants was cut by $20 million from s percent (12) were paid interns 3 FY 2010 to FY 2011 (from $96.9 million to $74.3 million). Funding for the Maternal and Child Health s .5 percent (22) were unpaid interns 5 Block Grants was $1.03 billion in FY 2011. s .5 percent (2) were fellows. 0 Limited resources for injury prevention only pro- Despite the enormous toll of injury and vide support for a small number of officials to focus violence, only 39 percent of respondents to on injury prevention in states and communities. the National Association of City and County Health Official’s 2010 National Profile of Local Public health programs are supported through a Health Departments reported injury prevention combination of federal, state and local funds. State activities and only 24 percent reported violence and local funding varies dramatically based on the prevention activities. structure of a state’s public health department. Some departments are centralized, while others In 2009, 36 (80 percent) states indicated that are decentralized. However, states and locali- they provided support to local injury and vio- ties also place different priorities on public health, lence prevention efforts through funding or in- which also accounts for differences in the funding. kind support. This has decreased since 2005 and 2007 (88 percent each year). Local efforts are The Safe States Alliance, a non-profit organiza- also supported by though many of these federal tion and professional association whose mission funding sources, including the Rape Prevention is to serve as the national voice in support of and Education grant (72 percent), as well as the state and local injury and violence preven- Preventive Health and Health Services Block tion professionals engaged in building a safer, Grant (72 percent) and other federal funds. healthier America, conducts a survey of repre- Over half (53 percent) reported using state funds sentatives from each state about their injury and to support local prevention efforts in 2009. violence prevention programs. Some key find- ings from the 2009 survey include that:30 State Health Officials and Injury and Violence Prevention State Health Officials play an important role services, businesses and faith-based organi- in injury and violence prevention and control. zations, are essential for understanding and In 2010, Association of State and Territorial assessing the scope of the issue as well as Health Officials (ASTHO) issued an ASTHO identifying opportunities and barriers. These President Challenge in 2010 for injury and vio- efforts and partnerships can help identify lence prevention and issued the report, Spot- and build support for policy, regulatory and ting Injury and Violence on Your Radar Screen: programmatic strategies for preventing and Creating a Legacy in Public Health — A Guide reducing injuries. for State and Territorial Health Officials.31 The In their guide, ASTHO recommends that report highlights the importance that state state health officials continue to implement health officials have in informing and leading best-practice policies to improve overall pub- efforts within their own states, but also in lic health. The report provides background developing cross-state initiatives to prevent information, rates of injury, overall costs and a injury. Partnerships that state health officials variety of best practices currently in effect to have with other sectors, such as public safety, help state health officials think about how they health care providers, transportation, social can improve injury and violence rates.32 10 State-by-State Injury Prevention Indicators and Scores 1 S ecti o n I njury death rates vary greatly in states, from a high of 98.7 per 100,000 people in New Mexico to a 2007-2009 Injury Fatalities All Causes for All Ages WA MT ND MN low of 36.1 per 100,000 people in New SD WI VT ME OR ID NH Jersey. Mississippi has the highest rate WY IA MI NY MA NE PA RI of childhood fatalities from injuries at NV UT CO IL IN OH NJ CT KS MO WV DE 96.2 per 100,000. Thirteen states have CA KY VA MD DC OK TN NC childhood injury death rates below 20 AZ NM AR SC MS AL GA per 100,000 per year. TX LA This report focuses on a series of 10 indica- AK FL tors of injury prevention across each state that, HI taken collectively, offer an overview of areas of strengths and weakness in the state’s poli- cies to prevent injuries. The indicators were Per 100,00 Population selected based on: n <50% n ­ 50% & <60% n >60% & <75% n >75% > n onsultation with leading experts about key C areas of preventable injury; n epresentation of a range of different types R 2007-2009 Injury Fatalities All Causes of injury; Among Children 19 and Under n vailability of identified interventions that A ND WA MT can help reduce rates of this injury; and MN VT ME SD WI n vailability of data about this indicator in A OR ID WY MI NY NH most or all states. NE IA MA PA RI IL IN OH CT Each state receives a score based on these 10 in- NV UT CO WV NJ DE KS MO dicators. States receive one point for achieving KY VA MD DC CA an indicator or zero points if they do not. Zero OK TN NC AR is the lowest possible overall score (none of the AZ NM SC MS AL policies in place), and 10 is the highest (all of TX LA GA the policies in place). (For more information, please see Appendix A: Data and Methodology for FL AK State Indicators). HI The scores ranged from a high of 9 in California and New York to a low of 2 in Montana and Ohio. n <15% n >15% & <20% n >20% & <25% n >25% 11 Injury Prevention Indicator Map WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA FL AK HI 7 9 8 6 5 4 3 2 (9 states (2 states) (5 states) (10 states) (12 states) (3 states) (7 states) (2 states) & D.C.) California Maryland Connecticut Alabama Arkansas Michigan Idaho Montana New York North Carolina D.C. Alaska Colorado Mississippi Kentucky Ohio Oregon Hawaii Arizona Indiana New Hampshire Nevada Rhode Island Illinois Delaware Iowa North Dakota Washington Kansas Florida Minnesota South Carolina Louisiana Georgia Missouri South Dakota Massachusetts Maine Oklahoma Wyoming New Jersey Nebraska Pennsylvania New Mexico Virginia Texas Tennessee Wisconsin Utah Vermont West Virginia Data for the 10 policies were drawn from a num- Cycle, 2010 State Law Report Cards: A National Sur- ber of sources, including: the Governors Highway vey of Teen Dating Violence Laws; the Network for Safety Association; the National Highway Traffic Public Health Law; the Alliance of States with Pre- Safety Administration; the American Academy of scription Monitoring Programs; and the Agency Pediatrics 2011 State Legislation Report; Break the for Healthcare Research and Quality. 12 INJURY PREVENTION REPORT CARD: KEY INJURY PREVENTION INDICATORS AND KEY FINDINGS Motor Vehicle Injuries Indicator 1: Does the state have a 32 states and Washington, D.C. have primary seat belt law? primary seat belt laws. Motor Vehicle Injuries Indicator 2: Does the state require 16 states require mandatory ignition mandatory ignition interlocks for all interlocks for all convicted drunk convicted drunk drivers, even first drivers, even first time offenders. time offenders? Motor Vehicle Injuries Indicator 3: Does the state have 19 states and Washington, D.C. a universal helmet law requiring have universal helmet laws requiring helmets for all motorcycle riders? motorcycle helmets for all riders. Motor Vehicle Injuries Indicator 4: Does the state require 33 states and Washington, D.C. require car seats or booster seats for that children ride in a car seat or children to at least the age of eight? booster seat to at least the age of eight. Other Vehicle Injuries Indicator 5: Does the state require 21 states and Washington, D.C. bicycle helmets for all children? require bicycle helmets for all children. Violence-Related Indicator 6: Does the state allow 44 states and Washington, D.C. Injuries people in dating relationships to get allow people in dating relationships protection orders? to get protection orders. Violence-Related Indicator 7: Did the state receive 6 states and Washington, D.C. Injuries an “A” grade in the teen dating received an “A” grade in the teen violence laws analysis conducted by dating violence laws analysis conducted the Break the Cycle organization? by the Break the Cycle organization. Falls, Drowning and Indicator 8: Does the state have 36 states and Washington, D.C. Sports- and Recreation- a strong youth sports concussion have strong youth sport concussion Related Injuries safety law? safety laws. Injuries from Poisoning Indicator 9: Did the state enact 48 states have enacted prescription a prescription drug monitoring drug monitoring programs. program? Research Tools for Indicator 10: Did more than 90 23 states reported that more than 90 Reducing Injuries percent of injury discharges from percent of injury discharge of patients hospitals receive external cause- from emergency departments of-injury coding in the state, which received external cause of injury helps researchers and health officials codes, which helps researchers and understand injury trends and evaluate health officials understand injury prevention programs (2009 data)? trends and evaluate prevention programs (2009 data). 13 top ten injury indicators state by state (1) (2) (3) (4) (5) (6) Seat Belts: Drunk Driving: Motorcycle Booster Seats: Bicycle Helmet Intimate Partner Have Mandatory ignition Helmets: Universal Meet AAP Use: Require Violence: Allow primary seat interlocks for all helmet law standards — bicycle helmets people in dating States belt laws convicted drunk requiring helmets require booster for all children relationships to get Source: drivers, even first for all riders seats to at least the Source: American protection orders Governors offenders Source: Governors age of eight Academy of Source: Break the Cycle, Highway Safety Sources: Governors Highway Safety Source: AAP 2011 State Pediatrics, 2011 State 2010 Survey of Teen Association Highway Safety Association Association Legislation Report Legislation Report Dating Violence Laws Alabama 3 3 3 3 Alaska 3 3 3 3 Arizona 3 3 3 Arkansas 3 3 3 California 3 3 3 3 3 Colorado 3 3 3 Connecticut 3 3 3 3 Delaware 3 3 3 3 D.C. 3 3 3 3 3 Florida 3 3 3 Georgia 3 3 3 3 Hawaii 3 3 3 3 3 Idaho 3 Illinois 3 3 3 3 Indiana 3 3 3 Iowa 3 3 Kansas 3 3 3 3 Kentucky 3 Louisiana 3 3 3 3 3 Maine 3 3 3 3 Maryland 3 3 3 3 3 Massachusetts 3 3 3 3 Michigan 3 3 3 Minnesota 3 3 3 Mississippi 3 3 3 Missouri 3 3 3 Montana 3 Nebraska 3 3 3 Nevada 3 3 New Hampshire 3 3 New Jersey 3 3 3 3 3 New Mexico 3 3 3 3 3 New York 3 3 3 3 3 3 North Carolina 3 3 3 3 3 North Dakota 3 Ohio 3 Oklahoma 3 3 Oregon 3 3 3 3 3 31 Pennsylvania 3 3 3 Rhode Island 3 3 3 3 South Carolina 3 South Dakota Tennessee 3 3 3 3 3 Texas 3 3 3 Utah 3 3 Vermont 3 3 3 Virginia 3 3 3 3 Washington 3 3 3 3 3 West Virginia 3 3 3 3 Wisconsin 3 3 3 Wyoming 3 3 Total States 32 and D.C. 16 19 and D.C. 33 and D.C. 21 and D.C. 44 and D.C. 1 Oregon allows people in intimate relationships to get restraining orders. 2 In these states, legislation has been enacted, but the program is not operating yet. 14 (10) (7) (9) Ecodes: More than 90 percent (8) Accidental Prescription Teen Dating Violence: of injury discharges of patients Concussions: Have a Drug Overdose or Use: Receive an A in the of emergency departments strong concussion law. Total Break the Cycle Report Have active prescription received Ecodes Source: Momsteam.com Score Source: Break the Cycle, drug monitoring program Source: HCUP E Code Evaluation and the Network for Public 2010 Survey of Teen Dating Source: Alliance of States with Addendum - Updated Information Health Law Violence Laws Prescription Monitoring Programs for 2009, Agency for Healthcare Research and Quality Alabama 3 3 6 Alaska 3 3 6 Arizona 3 3 3 6 Arkansas 33 32 5 California 3 3 3 3 9 Colorado 3 3 5 Connecticut 3 3 3 7 Delaware 3 3 6 D.C. 3 3 7 Florida 3 3 3 6 Georgia 32 3 6 Hawaii 3 3 7 Idaho 3 3 3 Illinois 3 3 3 7 Indiana 3 3 5 Iowa 3 3 3 5 Kansas 3 3 3 7 Kentucky 3 3 3 Louisiana 3 3 7 Maine 3 3 6 Maryland 3 32 3 8 Massachusetts 3 3 3 7 Michigan 3 4 Minnesota 3 3 5 Mississippi 3 4 Missouri 3 3 5 Montana 32 2 Nebraska 3 32 3 6 Nevada 3 3 New Hampshire 3 3 4 New Jersey 3 3 7 New Mexico 3 3 7 New York 3 3 3 9 North Carolina 3 3 3 8 North Dakota 3 3 3 Ohio 3 2 Oklahoma 3 3 3 5 Oregon 3 3 8 Pennsylvania 3 3 5 Rhode Island 3 3 3 3 8 South Carolina 3 3 3 South Dakota 3 32 3 3 Tennessee 3 3 7 Texas 3 3 5 Utah 3 3 3 5 Vermont 3 3 5 Virginia 3 3 6 Washington 3 3 3 8 West Virginia 3 5 Wisconsin 3 32 3 6 Wyoming 3 3 Total States 6 and D.C. 36 and D.C. 48 23 3 Arkansas does not have a specific youth sports concussion law, but in 2011 it passed a law that requires coaches to receive training that deals with concussions. And it also has a policy that requires coaches, school officials and doctors to closely monitor students who may have concussions. 15 state by state injury data (1) 2007-2009 Injury (3) (4) Fatalities, All Causes Estimated Total Estimated Total (Intentional and (2) Lifetime Medical Lifetime Work Loss States Unintentional) for All Ages State Costs Due To Fatal Costs Due to Fatal (Adults and Children) Ranking Injury: 2005 Injuries: 2005 (Rate per 100,000): Source: WISQARS Source: WISQARS Source: WISQARS1 Alabama 76.5 10 $29.1 million $3.4 billion Alaska 85.8 3 $2.4 million $589 million Arizona 70.7 15 $49.2 million $4.7 billion Arkansas 76.9 9 $17 million $2.2 billion California 47.6 48 $149.5 million $18.1 billion Colorado 67.8 17 $25.6 million $3.0 billion Connecticut 47.9 47 $16.3 million $1.4 billion Delaware 56.9 35 $4.8 million $433 million D.C. 60.2 29 $3.9 million $500 million Florida 66.8 18 $117.7 million $11.9 billion Georgia 61.4 22 $50.4 million $5.5 billion Hawaii 48.3 46 $6.4 million $563 million Idaho 65.3 20 $7.6 million $873 million Illinois 48.7 45 $60.6 million $6.2 billion Indiana 60.4 27 $40.4 million $3.8 billion Iowa 52.5 40 $18.7 million $1.3 billion Kansas 60.4 27 $17.1 million $1.6 billion Kentucky 76.5 10 $26.8 million $3.3 billion Louisiana 80.1 8 $29.2 million $4.4 billion Maine 58.7 31 $7.2 million $703 million Maryland 56.1 37 $25.5 million $3.3 billion Massachusetts 41.1 49 $26.3 million $2.5 billion Michigan 56.8 36 $51.2 million $5.4 billion Minnesota 51.2 42 $31.3 million $2.3 billion Mississippi 84.3 5 $22.6 million $2.6 billion Missouri 70.2 16 $38.4 million $4.0 billion Montana 86.5 2 $6.8 million $725 million Nebraska 51.3 41 $11.2 million $821 million Nevada 71.3 14 $12.4 million $1.9 billion New Hampshire 50 44 $6.1 million $625 million New Jersey 36.1 51 $35 million $3.5 billion New Mexico 97.8 1 $15.4 million $1.7 billion New York 37.1 50 $76.4 million $6.4 billion North Carolina 66 19 $58.4 million $5.7 billion North Dakota 61.1 25 $4.7 million $341 million Ohio 55.9 38 $60.5 million $6.1 billion Oklahoma 83 6 $25.1 million $2.8 billion Oregon 61.2 24 $18.7 million $1.9 billion Pennsylvania 59.4 30 $74.2 million $7.4 billion Rhode Island 50.4 43 $6.4 million $454 million South Carolina 71.7 13 $26.3 million $3.3 billion South Dakota 60.7 26 $5.4 million $502 million Tennessee 75.6 12 $45.7 million $4.6 billion Texas 58.5 33 $115.2 million $13.2 billion Utah 64.8 21 $10.7 million $1.6 billion Vermont 61.3 23 $4.3 million $322 million Virginia 53.4 39 $36.7 million $3.9 billion Washington 58.1 34 $36.4 million $3.4 billion West Virginia 82.2 7 $12.2 million $1.2 billion Wisconsin 58.7 31 $36.9 million $3.1 billion Wyoming 84.7 4 $3.7 million $421 million National Rate 57.9 N/A $1.62 billion $170.6 billion 16 (7) (8) (5) (6) States in which 2007-2009 Averages, 2007-2009 2007-2009 the Poisoning Injury Fatalities All Injury Fatalities, Injury Fatalities, Fatality Rate Causes (Unintentional (9) Motor Vehicle States Poisoning (Rate Exceeds the and Unintentional), State Traffic (Rate per per 100,000): Motor Vehicle Among Children 0 to Ranking 100,000): Source: Traffic Fatality 19 Years Old (Rate Source: Rate per 100,000): WISQARS1 WISQARS 1 Source: WISQARS1 Source: WISQARS1 Alabama 21.7 13.9 25.7 12 Alaska 9.9 20.9 3 33.8 1 Arizona 13.7 16.5 3 21.7 19 Arkansas 21.6 14.2 28.4 7 California 9.7 11.8 3 14.4 43 Colorado 11.2 17.4 3 17.9 30 Connecticut 8.2 12.7 3 11.2 47 Delaware 13.1 15.2 3 16.8 37 D.C. 7.4 8.9 3 28.0 9 Florida 15.3 17.6 3 21.7 19 Georgia 15.5 11 19.1 26 Hawaii 8.6 12.4 3 14.3 44 Idaho 15.8 12.3 21.9 17 Illinois 8.7 11.4 3 17.4 33 Indiana 12.5 15.2 3 21.6 21 Iowa 13.2 9.1 17.1 35 Kansas 14.5 11.5 21.2 22 Kentucky 18.3 19.9 3 23.1 15 Louisiana 20.2 16.6 31.9 3 Maine 12.1 14.8 3 16.3 39 Maryland 10.9 13.6 3 17.5 32 Massachusetts 5.5 13.7 3 8.8 51 Michigan 10.1 14.2 3 19.0 27 Minnesota 9.6 9.3 14.0 45 Mississippi 26.7 12.2 32.9 2 Missouri 15.8 14.9 27.6 10 Montana 23.3 16.8 26.6 11 Nebraska 13.4 7.5 19.8 25 Nevada 12.2 21.3 3 21.9 17 New Hampshire 9.2 13.4 3 11.6 46 New Jersey 6.9 7.4 3 10.6 50 New Mexico 18 27.9 3 29.2 5 New York 6.5 9.2 3 11.0 48 North Carolina 16.5 13.8 20.5 24 North Dakota 17.2 8.3 20.9 23 Ohio 10.1 14.5 3 17.2 34 Oklahoma 19.5 21.1 3 28.2 8 Oregon 10.7 14.4 3 15.6 41 Pennsylvania 11.3 16 3 17.1 35 Rhode Island 7.1 16.7 3 10.9 49 South Carolina 21 14 26.6 11 South Dakota 16.1 7.9 28.8 6 Tennessee 18 16.8 24.2 14 Texas 14.9 10.2 18.9 28 Utah 10.7 21.5 3 17.6 30 Vermont 10.7 11.1 3 16.4 38 Virginia 11.2 9.9 16.1 40 Washington 8.7 16.2 3 15.2 42 West Virginia 19.8 22 3 22.8 16 Wisconsin 10.9 12.6 3 18.4 29 Wyoming 21.7 15.7 3 30.2 4 National Rate 12.4 13.3 31 states and D.C. 18.37 N/A Source: Web-based Injury Statistics Query and Reporting System (WISQARS), CDC 1 All rates are age-adjusted and based on death data from the National Vital Statistics System for the years 2007-2009. 17 A. VEHICLE-RELATED INJURIES Research has shown that a number of strate- departments after being injured in motor ve- gies can greatly reduce the number of injuries hicle crashes.34 Motor vehicle crashes result caused by crashes involving motor vehicles, bi- in around $90 billion in direct medical costs cycles and other vehicles. Public education can and lost productivity annually.35 help people understand how to protect them- n icycle, Skateboard, Scooter and Other Non- B selves and their families, but laws relating to Motorized Vehicle Injuries: Bicycle crashes injury also play a crucial role, providing incen- lead to approximately 700 deaths and more tives for following safe practices and protecting than 500,000 emergency room visits a year, and individuals from harm caused by others, such as skateboard injuries result in another 68,000 drunk drivers or speeders. emergency room visits annually.36, 37 Helmets n otor Vehicle Crashes: Approximately M have been shown to greatly reduce the risk of 38,000 Americans die each year in motor ve- injury. The report card includes one indicator hicle crashes — they are the leading cause of examining requirements for bike helmet use death for people between the ages of five and among children, and also includes informa- 34.33 More than 2.3 million adult drivers and tion about helmet use for skateboard, scooter passengers in 2009 were treated in emergency and other non-motorized vehicles. INDICATOR 1: SEAT BELTS Finding: 32 states and Washington, D.C. have primary seat belt laws. 32 states and Washington, D.C. have primary 18 states do NOT have primary seat belt laws seat belt laws Alaska Arizona Arkansas Colorado California Idaho Connecticut Massachusetts Delaware Missouri District of Columbia Montana Florida Nebraska Georgia Nevada Hawaii New Hampshire* Illinois North Dakota Indiana Ohio Iowa Pennsylvania Kansas South Dakota Kentucky Utah Louisiana Vermont Maine Virginia Maryland West Virginia Michigan Wyoming Minnesota Mississippi New Jersey New Mexico New York North Carolina Oklahoma Oregon Rhode Island South Carolina Tennessee Texas Washington Wisconsin Source: Governors Highway Safety Association38 * New Hampshire is the only state without a primary or secondary seat belt laws 18 Seat belt use is the most effective way to save Thirty years ago, only around 10 percent of lives and reduce injuries in motor vehicle Americans used seat belts. But laws, education crashes.39 According to the National Highway and technology have pushed this rate to nearly 85 Traffic Safety Administration (NHTSA), seat percent. Seat belts reduce serious crash-related belts reduce the risk of fatal injury to front seat injuries and deaths by about half — and seat belts passengers by 45 percent and the risk of moder- have saved an estimated 255,000 lives between ate-to-critical injury by 50 percent.40 1975 and 2008.43 Researchers estimate that in 2009 alone, seat belts saved almost 13,000 lives. Most drivers and passengers killed in motor vehi- cle crashes were not wearing seat belts.41 In 2009, Currently, an estimated one in seven adults 53 percent of drivers and passengers killed in car does not wear a seat belt on every trip.44 In ad- crashes were not wearing restraints. In addition, dition, studies have found that: 45 people not wearing a seat belt are 30 times more n eople between the ages of 18 to 24 are less P likely to be thrown from a vehicle during a crash, likely to wear seat belts than those 35 or older; and more than 75 percent of those who are ejected during a crash die from their injuries.42 According n en are 10 percent less likely to wear seat M to NHTSA, air bags provide added protection but belts than women; and are not a substitute for seat belts — proper seat n dults who live in rural areas use seat belts 78 A belt use is essential for air bags to work as intended. percent of the time. Those in urban and sub- Since the 1960s, state governments and the federal urban areas use them 87 percent of the time. government, have enacted a series of laws that re- According to CDC, if all drivers and passengers quire manufacturers to include seat belts in their wore seat belts, nearly 4,000 additional lives vehicles and drivers and passengers to wear belts. could be saved annually.46 Primary Seat Belt Laws and Reducing Motor Vehicle Crashes The U.S. Task Force on Community Preventive Washington, D.C. levy fines of more than $30 Services, which conducts reviews of all evidence- for adult seat belt violations: Connecticut, Dela- based prevention research, recommends safety ware, Maine, New York, Oregon, Rhode Island, belt laws as a strategy based on strong evidence Tennessee, Texas and Washington. of their effectiveness in increasing safety belt Seventeen other states have adopted “second- use and reducing fatal and non-fatal injuries ary” seat belt laws, which allow law enforcement among adolescents and adults.47 officers to give a seat belt ticket only when there “Primary” seat belt laws allow law enforcement is another traffic offense. New Hampshire is officers to ticket a driver for not wearing a seat the only state not to have either a primary or belt, without any other traffic offense taking secondary seat belt law; it does have a law that place. Thirty-two states and Washington, D.C. requires all drivers and passengers under the have adopted primary seat belt laws, although age of 18 to wear seat belts. these laws can vary based on the age of the In states with primary enforcement laws, 88 driver, whether passengers are riding in the percent of people use seat belts. That is nine front or back seats and the amount of the fines.48 percent higher than states with secondary laws Fifteen of these “primary” states do not cover all or no laws on the subject.49 Experts estimate passengers, both back and front seat, for all ages: that if states with secondary laws had the same Alabama, Arkansas, Connecticut, Florida, Geor- rate of seat belt use as states with primary laws, gia, Hawaii, Illinois, Iowa, Kansas, Maryland, an additional 7.3 million people a year would Michigan, Mississippi, New York, Oklahoma and buckle up. Tennessee. And only nine of these states and 19 RECOMMENDATIONS: According to a study conducted by NHTSA, maximize the effectiveness of primary seat “primary laws, fines and enforcement are im- belt laws, public education campaigns must portant factors in determining seat belt use, be conducted so the public understands that and none of these factors likely has maximum seat belts are important and that the law will potential without the benefit of at least some be enforced. paid media to support it.” 50 In addition, TFAH and the report’s advisory TFAH and the report’s advisory committee rec- committee recommend states use evidence- ommend that: based research from NHTSA to determine the level of fines for lack of seat belt use. A NHTSA n ll states should have primary seat belt laws cov- A analysis found that raising the fine for not wear- ering all ages, and they should apply to everyone ing a seat belt from $25 to $100 can increase belt in the car, not just those in the front seat; and use by more than 10 percent and that boosting n tates must conduct high-visibility enforce- S the fine from $25 to $60 can increase use by ment efforts for primary seat belt laws. To three to four percent. 51 INDICATOR 2: DRIVING UNDER THE INFLUENCE Finding: 16 states require mandatory ignition interlocks for all convicted drunk drivers, even first time offenders. 16 states require mandatory ignition 34 states and Washington, D.C. do NOT require interlocks for all convicted drunk drivers, mandatory ignition interlocks for all convicted even first time offenders drunk drivers, even first time offenders Alaska Alabama Arizona California Arkansas Delaware Colorado District of Columbia Connecticut Florida Hawaii* Georgia Illinois Idaho Kansas Indiana Louisiana Iowa Nebraska Kentucky New Mexico Maine New York Maryland Oregon Massachusetts Utah Michigan Virginia Minnesota Washington Mississippi Missouri Montana Nevada New Hampshire New Jersey North Carolina North Dakota Ohio Oklahoma Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont West Virginia Wisconsin Wyoming Source: Governors Highway Safety Association52 * Hawaii’s requirement is dependent on whether the offender wishes to continue driving53 20 In 2009, nearly 11,000 Americans died in alco- ing and driving and to encourage them not to hol-related crashes.54 About one out of every drink and drive. Many states have passed laws three highway deaths is caused by a drunk to limit happy hours and other practices that en- driver. According to research from the Pacific courage excessive alcohol consumption and have Institute for Research and Evaluation (PIRE), taken measures to penalize bars, restaurants and drunk driving cost the United States $132 bil- stores that sell alcohol to underage drinkers or to lion in 2009: $61 billion in monetary costs, and individuals who serve alcohol to underage drink- $71 billion in quality-of-life losses. Federal, state ers. Setting the federal minimum legal drinking and local governments paid almost $8 billion of age (MLDA) to 21 years has been credited as this, while employers paid almost $11 billion.55 one of the most effective interventions to reduce motor vehicle crash deaths for young people. A 2010 CDC study found that U.S. adults drove under the influence about 112 million times. This In addition, many states use sobriety checkpoints, is down from 161 million in 2006, a 30 percent give breath tests to suspected drunk drivers, per- drop.56 Additional findings from the study include: form BAC tests for drivers in serious crashes and n en were responsible for more than 80 per- M suspend or revoke licenses or require counseling cent of alcohol-impaired driving; or jail time for drunk driving. Beyond checkpoints, a number of states conduct “saturation patrols,” n en between the ages of 21 and 34 make up M which are concentrated enforcement efforts that only 11 percent of the adult population, but target impaired drivers by observing moving viola- they are responsible for almost a third of all tions such as reckless driving, speeding, aggressive drinking and driving; and driving and others. And, some states conduct “rov- n bout 85 percent of drinking and driving epi- A ing patrols,” which targets impaired drivers by ob- sodes are reported by people who also report serving moving violations such as reckless driving, binge drinking. speeding and aggressive driving. All 50 states and Washington, D.C. currently A number of states have outlawed checkpoints, have laws that make it illegal to operate a motor including: Idaho, Iowa, Michigan, Minnesota, vehicle at or above a .08 blood alcohol content Oregon, Rhode Island, Texas, Washington, Wis- (BAC) level. In addition, there are a number of consin and Wyoming.58 other ways that states work to reduce the num- ber of drunk drivers on the road.57 There are about 1.4 million drunk-driving arrests each year in this country. About one million of those There are many national, state and local public arrested are convicted.59 A study by the NHTSA education and designated driver campaigns to found that on average, there was one arrest for every help educate people about the dangers of drink- 88 instances of driving over the legal limit.60 Ignition Interlocks and Reducing Drunk Driving Injuries Ignition interlocks have emerged as one of the Every state and Washington, D.C. have some best evidence-based strategies experts have identi- form of ignition interlock law, but only 16 fied to reduce drunk driving. The U.S. Commu- have laws that apply to first-time offenders. nity Preventive Services Task Force recommends This report uses mandatory first-time offender the use of ignition interlocks for people convicted interlock laws as an indicator. of alcohol-impaired driving on the basis of strong evidence that the devices reduce re-arrest rates.61 Ignition interlocks work by preventing people from driving while under the influence. Before starting a vehicle, a driver must breathe into the device; if a person’s BAC is above the limit programmed into the interlock, the device prevents the vehicle from starting. Researchers have found that without use of interlocks, between half and three quarters of convicted drunk drivers continue to drive, even after having their licenses revoked or suspended.62 CDC’s Community Guide Branch reviewed 15 sci- entific studies on ignition interlocks and found that when these devices were installed, re-arrest rates for alcohol-impaired driving decreased, with reductions ranging from 50 to 90 percent.63, 64 21 In addition, 13 states and Washington, D.C. give The next generation of ignition interlock judges discretion over which offenders must use technology is currently being developed, and interlocks: California, Idaho, Indiana, Iowa, Ken- researchers believe it holds great promise.65 tucky, Maine, Mississippi, Nevada, North Dakota, When ready for market, advanced alcohol sens- Ohio, Rhode Island, South Dakota and Vermont. ing technology systems will be available in new Five states have made interlocks mandatory for cars and will passively sense when the person be- those convicted of drunk driving with a particu- hind the wheel has a blood alcohol level in ex- larly high BAC level: Alabama, Florida, Maryland, cess of a safe level. If the driver is determined to Michigan and New Hampshire; and nine states have a high BAC, the car will not start. Current have made interlocks mandatory for those with re- iterations of this technology include dermal sen- peat convictions or for individuals with particularly sors and breath sensors that sample the air in- high BAC levels: Delaware, Minnesota, New Jersey, side of the car but do not require an individual North Carolina, Oklahoma, Tennessee, West Vir- to blow into a device. ginia, Wisconsin and Wyoming. RECOMMENDATIONS: TFAH and the report’s advisory committee recom- n ake efforts to reduce binge drinking, which M mend that every state require ignition interlocks for is linked to drinking and driving; every convicted drunk driver, including first time n ass primary enforcement seat belt laws that P offenders. In addition, TFAH and the report’s ad- cover all vehicle occupants; visory committee also recommend the following n ave a zero-tolerance policy for underage H evidence-based measures states can take to reduce drivers who are intoxicated; driving under the influence of alcohol and drugs: n eep the federal minimum legal drinking age K n nforce .08 BAC and minimum legal drinking E (MLDA) at 21 in place; and age laws; n equire blood tests when traffic crashes result R n xpand the use of sobriety checkpoints, which E in injury; can reduce impaired driving deaths by one fifth and targeted saturation patrols which can TFAH and the report’s advisory committee also cover a wider area than a checkpoint; recommend: n romptly take away the driver’s licenses of P n nvesting in the research, development and I people who drive while intoxicated; evaluation needed to bring alcohol sensing technology (AST) to the market; and n equire ignition interlocks for everyone convicted R of drinking and driving, even first-time offenders; n xploring the use of DWI Courts, which use a E model of accountability and long-term treatment. How Employers and Health Professionals Can Help CDC provides recommendations that employers can take to help reduce drinking and driving, including to:66 n Set policies that rescind work-related driving privileges for employees arrested for DUI while driving for work purposes; n Use workplace programs to communicate the dangers of drinking and driving, and aim some of this information at employees’ families. And, CDC recommends that health professionals should routinely screen patients for risky drinking behaviors, including binge drinking, and provide a 10 to 15 minute counseling session for patients who screen positive.67   Interlocks in Action: New Mexico New Mexico provides an example of the impact of interlocks. 31 percent; alcohol-related injuries have gone down by 41 per- A decade ago, the state had one of the highest rates of drunk cent; and alcohol-related deaths have gone down by 36 percent. driving fatalities in the country.68 Currently, New Mexico is one of 16 states that have laws requir- In 2005, the state passed a law making interlocks mandatory for ing ignition interlocks for all convicted drunk drivers.69 In 2006, anyone convicted of drunk driving, including first-time offenders. more than 100,000 ignition interlocks were installed nationwide As a result, convicted drunk drivers are 65 percent less likely to on the vehicles of convicted drunk drivers. By the middle of 2011, drink and drive again. Alcohol-related crashes have dropped by the number had risen to nearly 250,000.70 22 INDICATOR 3: MOTORCYCLE HELMETS FINDING: 19 states and Washington, D.C. have a universal helmet law requiring motorcycle helmets for all riders. 19 states and Washington, D.C. have a 31 states do NOT have a universal motorcycle universal motorcycle helmet law requiring helmet law requiring helmets for all riders helmets for all riders. Alabama Alaska California Arizona District of Columbia Arkansas Georgia Colorado Louisiana Connecticut Maryland Delaware Massachusetts Florida Mississippi Hawaii Missouri Idaho Nebraska Illinois Nevada Indiana New Jersey Iowa New York Kansas North Carolina Kentucky Oregon Maine Tennessee Michigan Vermont Minnesota Virginia Montana Washington New Hampshire West Virginia New Mexico North Dakota Ohio Oklahoma Pennsylvania Rhode Island South Carolina South Dakota Texas Utah Wisconsin Wyoming Source: Governors Highway Safety Association71 More than 4,400 motorcyclists were killed in crash in 2009, and five times more likely to be in- 2009, and 90,000 were injured.72 Per vehicle mile jured. Thirty-five percent of all motorcycle riders traveled, motorcyclists were about 25 times more involved in fatal crashes in 2009 were speeding, likely than passenger car occupants to die in a compared to 23 percent of passenger car drivers. Helmets and Reducing Motorcycle Injuries A number of studies have found that helmets that if all motorcyclists had worn helmets, more decrease the severity of head injuries, the num- than 700 additional lives could have been saved. ber of deaths and the overall cost of medical n f motorcycle drivers and passengers who died O care. Some key findings include that: in crashes in 2009, 43 percent of drivers and 57 n HTSA estimates that motorcycle helmets N percent of passengers were not wearing helmets. reduce the likelihood of crash fatalities by 37 n 2009 Cochrane Review of a range of evidence- A percent.73 based studies estimated that helmets were 42 n HTSA estimates that helmets saved the lives of N percent effective at preventing death and 69 nearly 1,500 motorcyclists in 2009. It estimates percent effective at preventing head injuries.74,75 23 In 1967, the federal government required states Dakota, Ohio, Oklahoma, South Dakota, Utah, to enact “universal” motorcycle helmet laws to Wisconsin and Wyoming. Delaware requires rid- qualify for certain highway safety funds. These ers under the age of 19 to wear helmets.76 Eight laws required all motorcycle riders to wear hel- states require riders under the age of 21 to wear mets. By 1975, 47 states had complied. But the helmets: Arkansas, Florida, Kentucky, Michigan, next year, Congress revoked federal authority Pennsylvania, Rhode Island, South Carolina and to penalize states. Since then, many states have Texas. Three states, Illinois, Iowa and New Hamp- weakened their laws. These changes provided shire, do not have any helmet laws. a natural laboratory for researchers to examine According to NHTSA, in states with helmet laws, how different laws affect usage of motorcycle nearly 100 percent of motorcycle riders wore helmets, as well as how rates of helmet use af- helmets, compared to about 50 percent in states fect motorcycle accident injury rates. without helmet laws or laws applying to only some Currently, 19 states and Washington, D.C. have riders.77 According to studies in the American universal helmet laws; 28 states have partial laws, Journal of Public Health and Accident Analysis Pre- usually requiring riders under the age of 18 to vention, motorcycle-related deaths are lowest in wear helmets. Eighteen states require riders under states with helmet laws that cover all riders, and the age of 18 to wear helmets: Alaska, Arizona, lower in states with even partial laws, than in states Colorado, Connecticut, Hawaii, Idaho, Indiana, with no helmet laws.78 States with universal laws Kansas, Minnesota, Montana, New Mexico, North also have lower rates of serious injury. RECOMMENDATIONS: TFAH and the report’s advisory committee rec- riding.79 In addition, ensuring helmets meet ommend every state adopt a universal motor- federal standards, use of protective clothing, cycle helmet law. education and training can help reduce motor- cycle injuries along with highway engineering These laws require all motorcycle riders and and installation of anti-lock breaking systems. passengers of all ages to wear helmets whenever EXAMPLES OF EFFECTIVENESS OF MOTORCYCLE HELMET LAWS IN STATES The experience of individual states also shows n In Texas, the law has changed several times how helmet laws can decrease rates of death over the past four decades. From 1968 to and injury.80 1977, the state had a universal helmet use law. In 1977, the law was changed, to apply only to n In 1992, California imposed a universal law. riders under the age of 18. After the law was Helmet use jumped from 50 percent to 99 passed motorcycle fatalities rose by more than percent, and motorcycle deaths dropped by a third. In 1989, the state reinstated a uni- more than a third; versal law. By the next year, helmet use rate n In 1989, Nebraska reinstated its universal law. jumped to 98 percent, from 41 percent before The state had a 22 percent drop in serious the change. Serious injuries decreased by 11 head injuries among motorcyclists; percent. In 1997, the state legislature weak- ened its helmet law, requiring helmets only for n After Kentucky repealed its universal helmet riders below the age of 21. By the next year, law in 1998, motorcycle deaths rose by 50 helmet use fell to 66 percent, and motorcycle percent. When Louisiana did the same the deaths rose by nearly a third. next year, deaths doubled; and 24 INDICATOR 4: CHILD CAR SEATS AND BOOSTER SEATS Finding: 33 states and Washington, D.C. require that children must ride in a car seat or booster seat to at least the age of eight, meeting the standard set by the National Highway Traffic Safety Administration and the American Academy of Pediatrics. 33 states and Washington, D.C. require car or 17 states do NOT require car seat or booster booster seat use to at least the age of eight seat use to at least the age of eight (the (the standard set by the National Highway standard set by the National Highway Traffic Traffic Safety Administration and the Safety Administration and the American American Academy of Pediatrics). Academy of Pediatrics). Alaska Alabama Arizona Arkansas California Connecticut Colorado Florida Delaware Idaho District of Columbia Iowa Georgia Kentucky Hawaii Louisiana Illinois Mississippi Indiana Montana Kansas Nebraska Maine Nevada Maryland New Hampshire Massachusetts North Dakota Michigan Oklahoma Minnesota South Carolina Missouri South Dakota New Jersey New Mexico* New York North Carolina Ohio** Oregon Pennsylvania Rhode Island Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Source: American Academy of Pediatrics 2011 State Legislation Report81 * New Mexico’s law (Section 66-7-369 NMSA 1978) provides that “children seven years of age through twelve year of age shall be properly secured in a child passenger restraint device or by a seat belt” and defines criteria for when a child is properly secured in a adult seat belt. ** Ohio notes that their booster seat law is not a primary law, so there are gaps in enforcement ability and there is also an exemption for child care provider agencies. 25 Seat belts work by absorbing the energy caused NHTSA and the American Academy of Pediat- by a rapid deceleration in a crash, reducing the rics (AAP) recommend car seats for infants and risk of ejection from a vehicle and spreading the toddlers, typically until a child reaches the age forces from a crash over hard bones rather than of four.84, 85 Child safety seats reduce the risk softer internal organs. But, they only work well if of death in passenger cars by 71 percent for in- they properly fit. fants and by 54 percent for children between the ages of one to four.86 Seat belts are not built to fit the small and ever- changing sizes of growing children. Engineers After that, booster seats are recommended for developed child car seats and booster seats to children who are under the age of eight, so that a better protect children during crashes. Child car seat belt will fit them properly. Without a booster seats provide internal harnesses that can be ad- seat, the seat belt typically will not effectively pro- justed to fit small children, typically children ages tect smaller children. Using booster seats for zero to four, and then booster seats help position children ages four to seven result in 59 percent children so that seat belts will fit them properly. fewer injuries.87 Car seats or booster seats have also been shown to reduce the risk of death for Experts have found that child car seats and children ages two to six by 28 percent compared booster seats are effective ways to reduce the to using seat belts alone.88 number of children hurt in car crashes. From 1975 to 2008, an estimated 8,959 lives were saved There is strong evidence that child safety seat laws, by child safety seats, booster seats and/or seat safety seat distribution and education programs, belts.82 But motor vehicle crashes are still a sig- community-wide education and enforcement nificant cause of death for children ages zero to campaigns, as well as incentive and education three and the leading cause of death for chil- programs, can increase child safety seat use. dren ages three to 14.83 Every day, an average of four children under the age of 15 die in motor vehicle crashes and more than 500 are injured. Booster Seats for Children Both NHSTA and AAP recommend that car Currently, 33 states and Washington, D.C. seats be used for children under the age of four; require booster seat use to at least the age of eight that booster seats be used to help ensure seat or until a child is of the size where a safety belt belts fit children properly be used for children fits correctly. Fifteen additional states require ages four to eight; and that children ride in the booster seat use until the age of six: Alabama, back seat of cars until the age of 13 (depending Arkansas, Connecticut, Idaho, Iowa, Louisiana, on the size of the child.)89, 90 Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, This report uses whether a state requires the Oklahoma and South Carolina. Kentucky use of a booster seat from the age that a child requires booster seat use until the age of seven. has outgrown a car seat until the age of eight as an indicator. RECOMMENDATIONS: TFAH and the report’s advisory committee n elt-positioning booster seats for most chil- B recommend a comprehensive child passenger dren ages four to eight; safety law be passed in every state that would n ap and shoulder seat belts for all children L require: who have outgrown booster seats; and n ge and size appropriate car safety seats for A n hat all children under the age of 13 ride in T most infants and children up to the age of four; the back seat. 26 DISTRACTED DRIVING — INCLUDING CELL PHONES AND TEXTING Experts estimate that in 15 to 30 percent of crashes, at least one n esearchers at the Insurance Institute for Highway Safety R driver is distracted.91 NHTSA estimates that in 2009, 16 percent (IIHS) surveyed more than 1,200 drivers from around the of fatal crashes and 20 percent of crashes that resulted in injuries country. They found that 13 percent of drivers overall involved at least one distracted driver. reported texting while driving; 43 percent of drivers be- tween the ages of 18 and 24 reported texting, compared Drivers who engage in non-driving activities are two to three to two percent of drivers between the ages of 30 and 59. times more likely to experience a near-crash or crash.92 Twelve percent of drivers in states with texting bans re- Cell Phone Use: Around two-thirds of drivers report using ported texting while driving, compared with 14 percent in a cell phone while driving, one-third of those report using states with no ban.98 a cell phone routinely and around one-eighth of drivers re- n survey of nearly 2,000 teen drivers in North Carolina high A port texting while driving.93 NHTSA estimates that between schools found that 30 percent had texted during their last driv- 2000 and 2009, the number of drivers on the road using cell ing trip.  Four percent said they often initiated a text conversa- phones increased from four percent to nine percent; and tion while driving, 11 percent said they often replied to texts, NHTSA has found that talking on a cell phone doubles or and 23 percent said they often read text messages. Among triples the risk of crashes or near-crashes.94, 95 those who texted while driving, 58 percent said they often An academic review of more than 34 cell phone studies found wait until it feels safe to read and reply to text messages.99 that talking on a cell phone increases crash risks, even when n 2010 survey of 348 Kansas drivers between the ages A drivers used hands-free functions.96 of 18 and 30 found that only two percent said they never Texting: Texting while driving increases the risk of a high- texted while driving. Seventy percent said they initiated risk driving event by 23 times compared to non-distracted texts while driving, 81 percent reported replying to texts, driving.97 A number of studies have documented an increase and 92 percent reported reading texts.100 in texting while driving, particularly among younger drivers. Cell and Texting Bans A number of states have passed laws limiting handheld cell use searchers found that the ban also reduced injuries, as well as and texting. However, there is little research to determine the use of hands-free cell phones.103 whether the bans work. A 2010 review of cell phone-driving In California in 2011, more than 460,000 people were con- studies found that bans appeared to reduce use. After New victed of talking on a hand-held cell phone while driving.104 York banned hand-held cell phone use in 2001, studies found that use dropped soon after by about 47 percent. Cell phone Ten states and Washington, D.C. have laws that currently pro- use subsequently increased, but in 2008, use was almost a quar- hibit all drivers from using handheld cell phones: California, ter lower than expected levels had there been no ban. After Connecticut, Delaware, Maryland, Nevada, New Jersey, New Washington, D.C. banned cell phone use in 2004, driver hand- York, Oregon, Washington and West Virginia. In all of these held use dropped by 41 percent. In 2009, use was 43 percent states except for Maryland and West Virginia, the laws are lower than would have been expected without a ban.101 “primary”: officers may cite drivers for using a handheld cell phone without another traffic offense taking place. There is also little data on whether texting bans reduce such behavior. A 2010 study of such bans by the Highway Loss Data Thirty-one states and Washington, D.C. ban all cell phone use Institute found that the measures did not reduce collision claims. by novice drivers: Alabama, Arkansas, California, Colorado, In fact, states that enacted texting bans saw a small rise in claims, Connecticut, Delaware, Georgia, Illinois, Indiana, Iowa, Kan- compared to states without the bans. The researchers offered sas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, two possible explanations. Because the bans are hard to enforce, Minnesota, Nebraska, New Jersey, New Mexico, North Caro- the laws may have no effect on texting rates. Or the bans may lina, North Dakota, Oregon, Rhode Island, Tennessee, Texas, encourage drivers to hide their texting, which may make it more Vermont, Virginia, Washington, West Virginia and Wisconsin. distracting because the act of hiding increases the distraction.102 Thirty-seven states and Washington, D.C. ban text messaging The state of California released a study in March 2012 show- for all drivers: Alaska, Arkansas, California, Colorado, Con- ing that its 2008 ban on cell phones has reduced use and saved necticut, Delaware, Georgia, Idaho, Illinois, Indiana, Iowa, lives. The analysis, by researchers at the University of Califor- Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, nia, Berkeley, examined state crash records two years before Michigan, Minnesota, Nebraska, Nevada, New Hampshire, and two years after the ban went into effect. After the ban, New Jersey, New York, North Carolina, North Dakota, Or- overall traffic deaths declined 22 percent, while deaths caused egon, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, by use of a hand-held cell phones dropped by almost half. Re- Virginia, Washington, West Virginia, Wisconsin and Wyoming. 27 Distracted Driving Countermeasures Researchers, government officials, public health n Public education campaigns to highlight the im- experts and private companies have developed and portance of avoiding distractions while driving; implemented a range of countermeasures designed n Education aimed at new and novice drivers, to reduce distracted driving, as well as the harmful who are more likely to have trouble handling effects of distracted driving. These include:105 distractions while driving; n Roadway countermeasures, such as rumble n Technology that blocks or limits cell phone strips to alert drivers that they are drifting reception when the device is in a moving from their lanes; vehicle; and n aws that penalize distracting behavior such as L n Company policies that discourage employees cell phone use, texting and other non-driving from multitasking while operating company activities; vehicles. RECOMMENDATIONS: NHTSA has recommended that states ban use of n Implement effective distracted driving coun- all portable electronic devices while driving. The termeasures such as edgeline and centerline proposed ban, which was announced in Decem- rumble strips on roads; ber 2011, includes hands-free and hand-held cell n Include “distracted driving” as a category in phones, as well as other devices such as iPods.106 crash reports, to help evaluate distracted In addition, the Governors Highway Safety Asso- driving laws and programs; and ciation recommends that states should take the n Monitor the impact of existing hand-held cell following actions to reduce distracted driving:107 phone bans before passing new laws. States n Enact cell phone and texting bans for novice that have not already passed handheld bans drivers; should wait until more definitive research and data are available on these laws’ effectiveness. n Enact texting bans for all drivers; TFAH and the report’s advisory committee n Enforce existing cell phone and texting laws; recommend that more research should be con- n Introduce programs that publicize existing cell ducted about how to promote drivers being phone and texting laws, and communicate more attentive — including expeditious research how drivers can avoid distractions; on the effectiveness of cell phone and texting bans and campaigns and other ways to reduce n Help employers develop and implement dis- distracted driving. tracted driving policies and programs; 28 TEEN DRIVER SAFETY Motor vehicle crashes are the leading cause of death for U.S. jured drivers over the age of 29, the rate was 48 percent.113 teenagers. A third of deaths among teenagers occurred in n ncreased risk during nighttime driving: 18 percent of teen I crashes. More than 3,000 teens between the ages of 15 and crash deaths occurred between 6 p.m. and 9 p.m.; 17 per- 19 were killed in crashes in 2009. The previous year, more cent occurred between 9 p.m. and midnight; 16 percent than 350,000 were treated in emergency departments for occurred between midnight and 3 a.m. crash injuries.108, 109 Crash-related injuries and deaths in 2005, among teens between the ages of 15 and 19, cost $14 billion s hen driving at night, male drivers between the ages of W in medical care and productivity losses.110 16 and 19 are six times as likely to crash as male drivers between the ages of 30 and 59. Female drivers between Per mile driven, teen drivers are four times more likely than adult the ages of 16 and 19 are three times as likely to crash as drivers to crash. The crash rates are highest during the first year female drivers between the ages of 30 and 59. a teen is licensed.111 For teen drivers, the risk of a crash is high- est at age 16. The crash rate per mile driven is twice as high for n ncreased risk driving with passengers: Compared with I 16-year-old drivers as it is for 18- and 19-year-old drivers.112 driving alone, 16- to 17-year-olds have a 40 percent in- creased risk of crashing when they have one friend in the Some areas of particular concern include: car, twice the risk with two passengers, and almost four n ower rates of seat belt use: Compared with other age groups, L times the risk with three or more teenage passengers.114 teens have the lowest rate of seat belt use. Seat belt use among s Crash rates increase when schools have open campus fatally injured drivers between the ages of 16 and 19 was 41 meal policies, which allow groups of teenagers to drive percent in 2009. Among fatally injured drivers between the away from school for lunch.115 ages of 20 and 29, the rate was 36 percent; among fatally in- Graduated Driver Licenses Graduated driver licensing (GDL) systems are proven to be ef- While 47 states have night driving restrictions on unsupervised fective in reducing crash and injury rates among teen and new teens, only 10 of these states prohibit all unsupervised teen driv- drivers.116 NHTSA and the American Association of Motor ers from driving after 10 p.m. during the entire intermediate Vehicle Administrators developed a three stage program stage of their license: Delaware, Idaho, Michigan, New York, involving a learner’s permit and an intermediate provisional North Carolina, North Dakota, Oklahoma, South Carolina, license before being awarded a full license to help give young South Dakota and West Virginia. Ten states have set the limit at and new drivers more time to learn the skills required to op- 11 p.m. for all intermediate drivers: Arkansas, California, Con- erate a vehicle. As teens move through the stages of GDL, necticut, Hawaii, Louisiana, Montana, New Jersey, Pennsylvania, they are given extra privileges, such as driving at night or driv- Tennessee and Wyoming. And 22 states have set the limit at be- ing with passengers. tween midnight and 1 a.m.: Alabama, Alaska, Arizona, Colorado, Georgia, Iowa, Kentucky, Maine, Maryland, Massachusetts, Mis- States that have adopted graduated licensing have seen crash souri, Nebraska, New Hampshire, New Mexico, Ohio, Oregon, rates among teenage drivers drop by 10 to 30 percent. Re- Rhode Island, Texas, Utah, Virginia, Washington and Wisconsin. strictions on nighttime driving and teen passengers and higher licensing ages have also reduced crash rates.117 Five states and Washington, D.C. have restrictions that vary based on age, amount of driving experience, day of the week or Research has found that: the time of year. Illinois sets a limit of 10 p.m. between Sunday n If every state had a strong graduated driver’s licensing and Thursday and 11 p.m. on Friday and Saturday. Mississippi policy, 175 fewer teens would die in crashes annually and sets a limit of 10 p.m. between Sunday and Thursday and 11:30 about 350,000 fewer would be injured;118 and p.m. on Friday and Saturday. Florida sets a limit of 11 p.m. for 16-year-olds and 1 a.m. for 17-year-olds. Indiana sets a limit of n In states that ban driving at or before midnight, crash deaths 10 p.m. for the first 180 days after a driver receives a license for drivers between the ages of 15 and 17 dropped by 13 and 11 p.m. after that, until the driver turns 18. Minnesota sets percent. a limit of midnight for the first six months after a driver receives All 50 states and Washington, D.C. have adopted a three-tier a license; after that, drivers there do not have a night driving system. All states except New Hampshire and Wyoming re- limit. Washington, D.C. sets a limit of 11 p.m. between Sep- quire a six month learner’s permit. tember and June, and midnight for July and August. 29 RECOMMENDATIONS: CDC, NHTSA and the American Association of 3. A full license, with a minimum age of 18. Motor Vehicle Administrators recommend a three- In addition, NHTSA also recommends: stage graduated drivers’ licensing policy:119, 120 n Prohibiting cell phone use, both talking and 1. learner’s permit with a minimum age of 16 and A texting, for teenage drivers; a mandatory holding period of at least six months. n Allowing teenage drivers to be stopped and 2. probationary license with no unsupervised A ticketed if they or their passengers are not night driving from at least 10 p.m. to 5 a.m. wearing seat belts; and This license would also allow a maximum of one teen passenger to accompany the driver n Vigorously enforcing zero-tolerance policies without adult supervision. This limit would for underage drinking and driving.121 not include family members. GRADUATED DRIVER’S LICENSES: SUCCESS STORIES n A study of Florida’s graduated license law reduced overall crash risks for 16-year-old found that the system reduced reported drivers by 29 percent. It reduced the risk drunk driving, as well as riding with drivers of a fatal crash by 44 percent, and the risk who had been drinking;122 of a nighttime crash by 59 percent;124 and n A study by NHTSA found that states with n study of North Carolina’s graduated A comprehensive graduated licensing pro- driver’s license system found that crash grams had crash rates among 16-year-old rates declined sharply for all levels of sever- drivers that were about 20 percent lower ity among 16-year-old drivers after the pro- than states without graduated licensing pro- gram was implemented. For 16-year-olds, grams;123 fatal crashes declined 57 percent, nighttime crashes decreased by 43 percent and day- n An examination of Michigan’s graduated time crashes decreased by 20 percent.125 licensing program found that the program 30 OLDER DRIVERS Once drivers reach the age of 65, the risk of being injured or had a high BAC, compared to a quarter of drivers between killed in a crash increases. Age-related declines in vision and the ages of 21 and 64. cognitive functioning, as well as physical changes, may affect Limits on Older Drivers the driving ability of some older adults.126 Thirty-three states and Washington, D.C. currently have limits The number of older drivers in the United States has been for mature drivers, including shorter gaps between renew- increasing. There were 33 million licensed drivers over the als, restrictions of online or mailed renewals, required vision age of 64 in this country in 2009. This is a 23 percent increase and road tests and reduced or waived renewal fees. These from a decade earlier. states are: Alaska, Arizona, California, Colorado, Connecticut, Older drivers have relatively low rates of fatal crash involvement Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, per licensed driver, but extremely high rates per vehicle mile trav- Louisiana, Maine, Maryland, Massachusetts, Missouri, Montana, eled, especially after age 75. More than 5,500 older adults were Nebraska, Nevada, New Hampshire, New Mexico, North killed in crashes in 2008, and more than 183,000 were injured.127 Carolina, North Dakota, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Texas, Utah and Virginia. Older drivers are less likely to drink and drive than other driv- ers. Only five percent of older drivers involved in fatal crashes RECOMMENDATIONS: TFAH and the report’s advisory committee recommend that n void passage of reactive, unscientific legislation that overly A more research be conducted to study the issues related to restricts driving privileges of older drivers; older drivers. The group recommends that: n urther investigate the usefulness of older driver training F n esearch needs to be conducted to examine if the laws plac- R programs; ing restrictions on older drivers have scientific merit and the n ncrease communication in and between states about older I quality of life and mental health impact of these restrictions; driver safety; n Steps should be taken to provide seniors with alternative, n evelop and promote evidence-based older driver licensing D convenient modes of transportation such as expanded public programs; transportation options and “neighbor care” ride programs; and n Include medical advisory boards in the creation of these programs; n edical care providers should receive education about older M driver issues and talk to their patients about risks and benefits of n Create a process by which potentially unsafe older drivers continued driving. can be assessed by medical advisory boards; NHTSA recommends that states and municipalities make a n Train DMV personnel to recognize signs of potential cogni- range of changes to reduce risks among older drivers:128 tive or physical impairments in older drivers; and n Improve communications to older drivers, and encourage n Train law enforcement personnel to recognize potentially un- them to adjust their driving habits as they age; safe older drivers and refer them to medical advisory boards. The American Medical Association’s Older Drivers Project The American Medical Association (AMA), in cooperation against serious injuries in the event of a crash. By adopt- with NHTSA, has developed a Physician’s Guide to Assess- ing preventive practices — including the assessment and ing and Counseling Older Drivers. The guide states that counseling strategies outlined in this guide — physicians can “By providing effective health care, physicians can help their better identify drivers at risk for crashes, help enhance their patients maintain a high level of fitness, enabling them to driving safety, and ease the transition to driving retirement if preserve safe driving skills later in life and protecting them and when it becomes necessary.”129 31 SPEEDING Speeding was a factor in nearly a third of all fatal crashes in drivers involved in fatal crashes were speeding at the time 2009; these crashes killed 10,591 people.130 According to of the crash, compared to 15 percent of female drivers. NHTSA the cost of speed-related crashes is more than $40 This finding held true across all age groups. billion annually.131 n rivers who drink are often involved in speeding-related D Age, gender and alcohol are often related to crashes involving crashes. Among drivers involved in fatal crashes in 2009, 43 speeding:132 percent of those who were speeding had high BAC, com- pared to only 17 percent of those who were not speeding. n Of drivers involved in fatal crashes, young males are most likely to be speeding. NHTSA found that of those involved in n Of the speeding drivers under the age of 21 who were in- a fatal crash in 2009, 39 percent of male drivers between the volved in fatal crashes in 2009, 29 percent had a high BAC. ages of 15 and 20, and 37 percent of those between 21 and Just 13 percent of the non-speeding drivers in this category 24, were speeding at the time of the crash. had a high BAC. Just over half of drivers between the ages of 21 and 24 who were involved in fatal crashes, and who n A NHTSA analysis of fatal crashes found that the fatal were speeding, also had a high BAC, compared with only 27 crashes of male drivers were more likely to be speed-re- percent of non-speeding drivers. lated than those of female drivers. Nearly a quarter of male RECOMMENDATIONS: The Department of Transportation recommends that states n dentify and promote effective speed enforcement efforts; and I and municipalities take a range of steps to reduce the risk of n mprove cooperation of stakeholders, including traffic court I speeding-related accidents and injuries:133 judges, prosecutors, safety organizations, health professionals n Identify and promote engineering measures to better man- and policy makers. age speed. Increase the use of speed management tech- TFAH and the report’s advisory committee recommend that niques and technology that can be built into the current more research should be conducted into the link between speed highway system; and safety and new technologies to identify and ticket speeding n Increase public awareness of the dangers of speeding. If drivers, including systems built into roadways and into vehicles. In people are not aware of, or do not understand, the risks of addition, community design principles, such as those outlined in speeding, they are less likely to adjust speeds for traffic and Complete Streets initiative, and health impact assessments can be weather conditions, or to drive within the speed limit; used to inform how to reduce speed and increase road safety. HISTORY OF SPEED LIMITS134 Congress passed a law in 1973 that withheld highway funds A study of the effects of the 1995 repeal found a 15 percent from states that did not adopt a maximum limit of 55 mph. increase in fatalities on interstates and freeways. Another The National Research Council said decreased limits saved study found that states that increased limits to 75 mph had 4,000 lives in 1974, compared with the previous year. 38 percent more deaths per million vehicle miles traveled than expected. States that increased limits to 70 mph saw a Fifteen years later, Congress allowed states to increase 35 percent rise. speed limits on rural interstates to 65 mph. Eight years after that, it repealed the maximum limit altogether. Since then, A study done in 2009 examining the effects of the 1995 every state but Alaska has raised its speed limits in some repeal found a three percent increase in fatalities due way. Many states have since raised speed limits significantly. to higher speed limits on all road types. The scientists estimated that between 1995 and 2005, more than 12,000 Studies by the Insurance Institute of Highway Studies show deaths were caused by the increased speed limits. that deaths on rural interstates increased by 25 to 30 percent when states began increasing limits in 1987. 32 INDICATOR 5: BICYCLE AND OTHER VEHICLE SAFETY Finding: 21 states and Washington, D.C. require bicycle helmets for all children. 21 states and Washington, D.C. require 29 states do NOT require bicycle helmets for bicycle helmets for all children all children Alabama Alaska California Arizona Connecticut Arkansas Delaware Colorado District of Columbia Idaho Florida Illinois Georgia Indiana Hawaii Iowa Louisiana Kansas Maine* Kentucky Maryland Michigan Massachusetts Minnesota New Hampshire Mississippi New Jersey Missouri New Mexico Montana New York Nebraska North Carolina Nevada Oregon North Dakota Pennsylvania Ohio Rhode Island Oklahoma Tennessee South Carolina West Virginia South Dakota Texas Utah Vermont Virginia Washington** Wisconsin Wyoming Source: American Academy of Pediatrics 2011 State Legislation Report135 *Maine’s law is for children up to age 16. ** Washington state notes that while they do not have a state law requiring bicycle helmet use by children, they have cities and counties that have adopted ordinances requiring helmet use by children. Around 700 bicyclists are killed and 52,000 are Bicycle Helmet Use injured each year.136 Males represent 87 per- cent of the bicyclists killed, and 79 percent of According to studies, wearing an approved those injured. The average annual cost of bi- helmet in the proper way provides up to an 88 cycle fatalities in children and teens below the percent reduction in the risk of head and brain age of 20 is around $993 million, and the aver- injury for bicyclists of all ages. Helmets are the age annual cost of nonfatal bicycle injuries for most effective way to reduce death and head in- children and youth is $4.7 billion.137 juries from bike crashes.140 Bicyclists below the age of 16 accounted for Bicycle helmet requirements for children were 13 percent of all bicyclists killed in 2008, and examined as an indicator for this report. Twenty- a quarter of those injured. Children under 15 one states and Washington, D.C. currently re- accounted for 45 percent of bicycle injuries quire children to wear bicycle helmets. Studies treated in emergency departments.138 have found that bicycle helmet use laws — which are mostly focused on children — when com- Traumatic brain injuries account for more than bined with education are effective in increasing 50 percent of bicycle fatalities among children helmet use and reducing head injuries.141, 142, 143 and youth below the age of 20. This report used bicycle helmet requirements Bicycle deaths decreased by 25 percent from for children as an indicator. Twenty-one states 1995 to 2009, and bicycle injuries dropped by and Washington, D.C. currently require chil- 16 percent.139 dren to wear bicycle helmets. 33 In addition, eight states require children to instance, New Jersey issues a $25 fine for first wear helmets when riding scooters and skate- offenses and $100 fines for subsequent offenses boards: California, Delaware, Maryland, Massa- if it can be shown that the parent or guardian chusetts, New Mexico, New York, Oregon and failed to exercise reasonable supervision or Rhode Island. Among children under the age control over the person’s conduct. Penalties of 14, skateboard-related injuries accounted for may be waived if an offender or his parent or more than 68,000 emergency department visits legal guardian presents suitable proof that an and 1,500 hospitalizations in 2009.144 approved helmet was owned at the time of the violation or has been purchased since the viola- A number of states and localities issue fines for tion occurred. violating the bicycle helmet requirements, for RECOMMENDATIONS: TFAH and the report’s advisory committee rec- NHTSA has issued a set of recommendations ommend that every state adopt a law requiring that include a range of public education and bicycle helmet use for all children and teens policy steps including:145 along with education campaigns, and that all n reating “Share the Road” public education C laws relevant to bicycle safety should be en- efforts; forced. In addition, TFAH and report’s ad- visory committee recommend strong public n ncluding components on safe bicycling and I education campaigns about the benefits of hel- sharing the road in driver education programs; met use and adults should also be encouraged n xpanding school-based and community- E to use helmets, and that states and communi- based bicycle safety programs that include in- ties should: creasing access to affordable helmets for both n reate bicycle paths; C children and adults; n ncorporate designated bicycle paths that will I n reating bicycle helmet safety campaigns, at C allow people to travel around the commu- national, state and local levels; nity safely when new communities are being n ncouraging law enforcement agencies to en- E built; and force existing bicycle helmet laws; n onsider how to create a safe environment C n onitoring and evaluate the effectiveness of M for bicyclists when updating or modifying ex- existing helmet laws; and isting roads. n mproving the collection and quality of data I on bicycle accidents and injuries. COMPLETE STREETS INITIATIVES Streets without safe places to walk, cross, catch a bus or bicy- 3. Establishing safe routes to school; cle put people at increased risk for being injured. More than 4. ostering traffic-calming measures (e.g., any transportation F 5,000 pedestrians and bicyclists died on U.S. roads in 2008, design to slow traffic); and and more than 150,000 were injured.146 5. Creating incentives for mixed-use development. Complete Streets are roadways that are designed and operated According to the National Complete Streets Safety Coalition, so users of all ages and abilities — including bicyclists, pedes- Complete Streets policies have been adopted in 315 regional and trians, public transit riders, and motorists — can safely travel local jurisdictions and in 26 states, including: California, Colo- along and across them. There is a growing trend at both the rado, Connecticut, Delaware, Florida, Hawaii, Illinois, Louisiana, state and local levels of government to adopt Complete Streets Maryland, Massachusetts, Michigan, Minnesota, Mississippi, New policies in order to foster safety, physical activity and promote Jersey, New York, North Carolina, Oregon, Pennsylvania, Rhode healthy living and more environmentally friendly transportation Island, South Carolina, Tennessee, Texas, Vermont, Virginia, use. Complete Streets policies require all new and renovated Washington and Wisconsin. streets to be designed and built in a manner safe for all users. A review by the National Conference of State Legislatures RECOMMENDATIONS: identified five state policy options that are most effective at TFAH and the report’s advisory committee recommended encouraging safe biking and walking:147 every state and local jurisdiction adopt Complete Streets poli- 1. Incorporating sidewalks and bike lanes into community design; cies that incorporate safety and physical activity concerns into 2. Providing funding for biking and walking in highway projects; the built environment. 34 B. VIOLENCE-RELATED INJURIES Nearly 17,000 Americans were murdered in caused 2,340 deaths in 2007. Seventy percent of 2009 and more than 37,000 committed sui- these victims were female.154 cide.148 In addition, assaults are responsible for Violent deaths resulted in $47 billion in total more than a million injuries annually.149 medical and work loss costs in 2005.155 The cost Homicide and suicide rates are higher for teens of suicides was $26 billion. The cost of homi- and young adults than other ages. Homicide is cide was $20 billion. the second-leading cause of death and suicide is Experts have developed evidence-based ways to third for this age range.150 help reduce violence and violence-related injuries. Overall, there are more than 740,000 children This report examines two violence-related in- and teenager emergency room visits a year for dicators: the ability of people in dating rela- injuries related to violence.151, 152 Child abuse tionships to get protection orders, and state and neglect, teen dating violence, school- and grades in an analysis of teen dating violence gang-related violence and bullying all contrib- laws by the Break the Cycle organization. In ute to the number of violence-related injuries. addition, this section also reviews information For adults, violence within intimate relation- about homicides, suicide and assaults; teen ships is also significant. More than one in three violence, including gang- and school-related women and one in four men in the United violence and bullying; and child abuse. It also States have experienced rape, physical vio- includes strategies that have been found to be lence and/or stalking by an intimate partner in effective in reducing injuries related to these their life time.153 Violence by intimate partners forms of violence. 35 INDICATOR 6: INTIMATE PARTNER VIOLENCE Finding: 44 states and Washington, D.C. allow people in dating relationships to get protection orders. 44 states and Washington, D.C. allow people 6 states do NOT allow people in dating in dating relationships to get protection orders relationships to get protection orders Alabama* Georgia Alaska Kentucky Arizona Ohio Arkansas South Carolina California South Dakota Colorado Utah Connecticut Delaware District of Columbia Florida Hawaii Idaho Illinois Indiana Iowa Kansas Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania* Rhode Island Tennessee Texas Vermont Virginia* Washington West Virginia Wisconsin Wyoming Source: Break the Cycle, 2010: State Law Report Cards: A National Survey of Teen Dating Violence Laws156 *Alabama, Pennsylvania and Virginia have updated their laws since the release of the 2010 Break the Cycle report to allow individuals in dating relationships to petition for protection orders or stalking protection orders. 36 More than one in three women and one in four n mong victims of intimate partner violence, A men in the United States have experienced more than one in three women experienced rape, physical violence and/or stalking by an in- multiple forms of rape, stalking or physical vio- timate partner in their life time.157 Violence by lence. Ninety-two percent of male victims expe- intimate partners caused 2,340 deaths in 2007. rienced physical violence alone, and 6.3 percent Seventy percent of these victims were females.158 experienced physical violence and stalking; and The medical care, mental health services and n n just the year prior to taking the survey, one I lost productivity cost of violence by intimate in 17 women and one in 20 men experienced partners was nearly $6 billion in 1995. In 2011 rape, physical violence and/or stalking by an terms, that is nearly $9 billion. intimate partner. According to the 2010 National Intimate Part- According to the survey, intimate partner ner and Sexual Violence Survey (NISVS):159 violence risks are higher for some racial and n round one in four women and one in seven A ethnic groups:160 men have experienced severe physical violence n pproximately four out of every 10 Black, A by an intimate partner (e.g., hit with a fist or American Indian or Alaska Native women something hard, beaten, slammed against and one out of two multiracial non-Hispanic something) at some point in their lifetime; women have been the victim of rape, physi- n early one in 10 women has been raped by an N cal violence and/or stalking by an intimate intimate partner in her lifetime, and an esti- partner violence in their lifetime. About one mated 16.9 percent of women and eight percent third of White women, more than a third of men have experienced sexual violence other of Hispanic women and around one-fifth of than rape by an intimate partner at some point Asian or Pacific Islander women have experi- in their lifetime. More than half of all female enced this type of violence; and rape victims were raped by an intimate partner. n round 45 percent of American Indian or A More than four of five women who were raped, Alaska Native men and nearly four out of stalked or subjected to physical violence by an every 10 Black and multiracial non-Hispanic intimate partner reported significant short- or men reported being the victim of rape, phys- long-term impacts, such as post-traumatic stress ical violence and/or stalking by an intimate disorder (PTSD), while 35 percent of men re- partner in their lifetime. Rates for these port such impacts from these experiences; types of violence are nearly 27 percent for n n estimated 10.7 percent of women and 2.1 A Hispanic men and more than 28 percent for percent of men have been stalked by an inti- White men. mate partner during their lifetime; Studies have found that the risk of intimate n early half of all women and men have expe- N partner violence is lower when victims can ob- rienced psychological aggression by an inti- tain final protective orders from courts.161, 162 mate partner in their lifetime; RECOMMENDATIONS: TFAH and the report’s advisory group recom- n ata must include the collection of specific D mend that states, counties and municipalities demographic information, such as race, eth- should take a public-health approach to reduc- nicity, disability status and sexual identity/ ing intimate partner violence by focusing on orientation, which is also consistent with new stopping violence before it happens in the first HHS standards for self-reported surveys, to place, and that: help understand patterns and target preven- tion strategies more effectively; and n ffective services for victims, such as shelters E and legal aid, need to be maintained where n nder the new health reform law, the Afford- U they exist and expanded to serve those still able Care Act (ACA), most private insurance in need; plans must cover many women’s preventive health care services with no out of pocket n ervices and programs must emphasize collab- S costs to the patient. This includes screening oration among federal, state and local govern- and counseling for victims of intimate partner ments and across agencies and types of services; violence. These provisions should be fully sup- n rotection orders must be accessible to pro- P ported, implemented and evaluated for their tect victims and their families; impact on women’s physical and mental health. 37 INDICATOR 7: TEEN DATING VIOLENCE Finding: 6 states and Washington, D.C. received an “A” grade in the teen dating violence prevention laws from an analysis conducted by Break the Cycle. 6 states and Washington, D.C. received an 44 states did NOT receive an “A” grade in the “A” grade in the Break the Cycle, 2010 State Break the Cycle, 2010 State Law Report Cards: Law Report Cards: A Survey of Teen Dating A Survey of Teen Dating Violence Laws. Violence Laws. California Alabama (B/C)* District of Columbia Alaska (B) Illinois Arizona (B) New Hampshire Arkansas (C) Oklahoma Colorado (C) Rhode Island Connecticut (C) Washington Delaware (B) Florida (B) Georgia (F) Hawaii (C) Idaho (C) Indiana (B) Iowa (C) Kansas (C) Kentucky (F) Louisiana (C) Maine (B) Maryland (C) Massachusetts (B) Michigan (C) Minnesota (B) Mississippi (B) Missouri (F) Montana (C) Nebraska (C) Nevada (C) New Jersey (B) New Mexico (B) New York (B) North Carolina (C) North Dakota (D) Ohio (D)* Oregon (D)* Pennsylvania (C)* South Carolina (F) South Dakota (F) Tennessee (B) Texas (C) Utah (F) Vermont (B) Virginia (C)* West Virginia (B) Wisconsin (D) Wyoming (C) Source: Break the Cycle, 2010 State Law Report Cards: A Survey of Teen Dating Violence Laws163 *At least five states have updated dating violence laws since the publication of the 2010 Break the Cycle report that would result in changes to their grades. Alabama: Law change to allow persons in dating relationships to petition for protection orders (Ala. Code § 30-5-2(5)(d)); Pennsylvania: Law changed to include intimate partners in persons eligible for a protection from abuse order (23 Pa. C.S.A. § 6102(a)); Virginia: Law changed to allow persons in dating relationships to petition for stalking protection orders (Va. Code § 18.2-60.3(A)); Ohio: Law Am Sub H.B. 10 allows adolescents or others on their behalf to seek Civil Protection Orders in Juvenile Court against persons under the age of 18 who create an immediate and personal danger and OH Sub HB 19 more broadly addressed school policy and training requirements related to teen dating violence; and Oregon: Law HB 4077 directs each school district board to adopt a policy regarding teen dating violence. 38 Recognition of the high rates of teen dating n quarter of teens in a relationship say they have A violence has grown in recent years. According been called names, harassed or put down by to CDC, a quarter of adolescents are verbally, their partner through cell phones and texting. physically, emotionally or sexually abused by a n iolent relationships in adolescence put victims V dating partner each year.164 One in 10 students at higher risk for substance abuse, eating disor- nationwide report being physically hurt by a ders, risky sexual behavior and suicide. boyfriend or girlfriend in the past year. n tudies have found that a quarter of adoles- S Studies have found that: cent mothers experience relationship vio- n eens who are victims are more likely to be T lence before, during or just after pregnancy. depressed and do poorly in school. n ictimization among teens is as common V among males as among females. Teen Dating Violence Laws While all 50 states and Washington, D.C. have n ccess to civil protection orders; A laws pertaining to interpersonal violence, the n ccess to sensitive services; and A specificity and inclusiveness with respect to mi- nors differ greatly. For instance, states differ n chool response to dating violence. S in whether minors can obtain protective orders This indicator provides a point to states that without adult consent, whether these orders receive an “A” in the Break the Cycle analysis. can be obtained against minors, and what sensi- Seven states met this standard. Fifteen states re- tive services (i.e. STD treatment or testing) are ceived a “B,” 16 states received a “C,” four states available to minors. received a “D,” and nine states received an “F.” Break the Cycle, a group that focuses on The full report card and state by state assess- youth dating violence issues, has developed a ments are available on the Break the Cycle Web report card based on a systematic review of site: http://www.breakthecycle.org/content/ state laws for: teen-dating-violence-state-law-report-cards. The criteria are outlined in Appendix B. RECOMMENDATIONS: TFAH and the report’s advisory committee n llow victims of intimate partner sexual abuse, A support the Break the Cycle recommenda- stalking and harassment to get protection orders; tions that states provide prevention education n llow victims to petition for protection orders A about teen dating violence and pass laws that against minor abusers; provide legal protection and services to ensure their safety.165 n llow youth access to protection orders without A the permission or knowledge of their parent or Break the Cycle recommends that all states guardian; should enact laws that: n llow minors to receive sensitive services A n llow people in dating relationships to get A needed to overcome the effects of abuse, civil protection orders; without parental involvement; n ffer victims of same-sex partner violence O n equire schools to teach evidence-based dat- R access to all civil domestic and dating violence ing violence prevention education; and remedies; n equire school districts to adopt dating violence R n llow minors to get civil protection orders; A policies, and provide resources to students. 39 HOMICIDE, ASSAULTS AND SUICIDE PREVENTION OVERVIEW PREVENTING HOMICIDES AND ASSAULTS Experts in reducing violence and violence-related injuries peat incidents (secondary prevention) is also essential and a have developed sets of evidence-based strategies that have potentially efficient use of resources since the target popu- been shown to be effective. Many of these are focused on lation of offenders is a fraction of the overall population. targeted concerns, such as intimate partner violence, youth n focus on monitoring and tracking data using public health A and gang violence, school-based violence, bullying and child surveillance and other strategies, researching risk and pro- abuse and neglect. tective factors and carefully evaluating interventions. A public health approach, which has support from CDC and n n understanding that cooperation is crucial. Health, A other experts, includes:166, 167 media, business, criminal justice, behavioral science, epi- n n emphasis on primary prevention, that is, preventing A demiology, social science, faith, advocacy and education violence before it occurs. This requires reducing the all can play a role in violence prevention. factors that put people at risk of being victims, as well n A population approach. Violence is a community prob- as increasing factors that keep people from committing lem, and its solutions are in part also community-based as violence. This also includes strategies that promote safe well as individual and societal. communities as well as individual approaches. TFAH and the report’s advisory committee recommend n While stopping violence in the first place (primary preven- taking a public health approach to violence, which focuses tion) is important, stopping individuals from engaging in re- on preventing violence before it happens. FIREARM SAFETY AND CHILDREN Forty-seven percent of Americans report they have a gun in Studies have found in almost three-quarters of unintentional their home or elsewhere on their property, according to a deaths and injuries, suicide and suicide attempts with a fire- 2011 Gallup poll.168 Most Americans who own firearms use arm involving children and teens under the age of 20, the them safely and responsibly. firearm was stored in the home of the victim, a relative, or a friend.175 In addition, an estimated 40 percent of homes Firearms were used in more than 11,400 homicides in 2009, where children are living and guns are stored, there is at and more than 18,700 suicides.169, 170 least one unlocked firearm; in 13 percent the unlocked fire- More than 15,500 children and teens under the age of 20 arm was kept loaded, or was stored with ammunition.176 were injured by a firearm in 2010. More than 3,000 of these injuries were unintentional.171 RECOMMENDATIONS: The firearm-related death rate for U.S. children under 15 To help reduce homicides, injuries and suicides related to is nearly 12 times higher than that for children in 25 other firearms, TFAH and the report’s advisory committee also industrialized nations. The firearm-related suicide rate recommend that states and localities: for American children between the ages of five and 14 is n Educate the public about safe storage of guns, including nearly 11 times higher than that for 25 other developed the use of lock boxes and gun locks and storing guns and countries.172 ammunition separately; Nearly 3,000 children and youth under the age of 20 were n equire private gun sales to be subject to the same back- R killed by firearms in 2009. Around 400 were under the age ground check provisions as sales by licensed dealers. In of 15.173 In addition, more than 13,700 children and teens states where those laws exist, they must be enforced; were injured by firearms in 2009 and more than 20,500 were injured by firearms in 2008. n Ensure existing laws are enforced to keep guns from pro- hibited persons, such as individuals subject to domestic According to a number of studies, including a 2005 article violence restraining orders; and in the Journal of the American Medical Association (JAMA), keeping a gun locked, unloaded and storing ammunition in a n epealing laws that restrict the ability of physicians and R locked and separate location can lower the risk of uninten- other health care providers to talk to families about fire- tional injuries and suicide among youth.174 arms and firearm safety. 40 PREVENTING SUICIDE Suicide is the 10th leading cause of death in the across the lifespan and be fully implemented United States.177 There are nearly 37,000 sui- and evaluated; cides each year, which is nearly 12 suicides per n Encouraging states to mandate suicide preven- 100,000 people. Suicide rates are highest for tion training for teachers and all other school people between the ages of 40 and 59 years old. personnel who interact regularly with students, Nearly one million Americans attempt suicide and when possible, provide training materials each year. Men are nearly four times as likely to as an option to satisfy those mandates; and die by suicide than women, but women attempt n Encouraging states to pass anti-bullying and suicide three times as often as men.178 anti-cyberbullying legislation and promote The American Foundation for Suicide Preven- safe school environments. tion (AFSP) and the Suicide Prevention Action Network (SPAN) are focusing on a number of RECOMMENDATIONS: measures to improve suicide prevention activi- To prevent suicides, TFAH and the report’s ad- ties in states, including: visory committee recommend that states enact n Encouraging states to have suicide prevention suicide prevention plans and programs and sup- plans and initiatives, and that these plans and port school-based education programs, including initiatives should address suicide prevention anti-bullying efforts. TEEN AND YOUNG ADULT VIOLENCE OVERVIEW More than 5,700 people between the ages of Males Between Homicide Rate per 10 to 24 were murdered in 2007, an average of 10 and 24 100,000 16 per day. Eighty-four percent of these were Non-Hispanic Blacks 60.7 killed with a firearm.179 Hispanics 20.6 Youths between the ages of 10 and 17 make up Whites 3.5 less than 12 percent of the U.S. population, yet this group commits about a quarter of serious More than 656,000 people between the ages violent crimes.180 of 10 to 24 were treated in emergency depart- ments in 2008 for violence-related injuries. Homicide is the second-leading cause of death for people between the ages of 10 to 24. It is A 2003 national survey conducted by CDC es- the leading cause of death for Blacks between timated that there were more than 1.5 million the ages of 10 to 24. It is the second-leading violent incidents against adults by perpetrators cause of death for Hispanics in this age group, estimated to be between the ages of 12 to 20.182 A and the third-leading cause of death for Asian/ third of these incidents were serious violent crimes, Pacific Islanders, and American Indians and including rape, robbery and aggravated assault. The Alaska Natives.181 other two-thirds did not involve a weapon, and did not cause an injury requiring more than two days in The homicide rate among non-Hispanic, Black a hospital. Because survey respondents were the males between the ages of 10 to 24 is three victims themselves, murder was not a category. times higher than the rate for Hispanic males in that age group, and more than 17 times Violence prevention efforts targeted toward teens higher than the rate for white males in that and young adults have been shown to help reduce age group: violence. 41 SCHOOL-RELATED VIOLENCE School-based programs to prevent violence have n lmost eight percent said they had been threat- A cut violent behavior among high school students ened with or injured by a weapon on school by 29 percent.183 CDC has found that universal property at least once in the previous year. school-based violence prevention programs are School violence is connected to a range of is- “an important means of reducing violent and ag- sues, such as family and interpersonal dynam- gressive behavior.”184 ics, the environment in any given school, the According to CDC, school violence is a serious larger community that school is in and societal concern:185 attitudes toward violence. According to The Prevention Institute, “Since the causes of violent n Nearly four percent of high school students in behavior in school are multi-faceted, strategies a 2009 national survey said that at least once to address this issue must also operate on a va- in the past year, they had been in a physical riety of levels. Plans that are developed collab- fight that resulted in injuries that had to be oratively by students, teachers, administrators, treated by a doctor or nurse. parents, health professional, law enforcement n Nearly a third said they had been in a physical officers, business and community leaders and fight in the past year. The rates were 39 percent other key community groups are more likely to for males and nearly 23 percent for females. succeed than those prepared by a single group of professionals acting alone.”186 n More than 17 percent of respondents said they had carried a weapon, such as a gun, Since 1999, more than 275 school districts knife or club, at least once in the past 30 days. around the country have received federal grants Twenty-seven percent of males and seven as part of the Safe Schools/Healthy Students percent of females had carried a weapon. Initiative.187 The initiative is jointly sponsored by the U.S. Department of Education, the U.S. n Almost 10 percent of males and 1.7 percent Department of Justice and the U.S. Department of females had carried a gun at least once in of Health and Human Services. Grantees must past 30 days. More than five percent said take a comprehensive approach to reducing they had brought a weapon onto school prop- school violence that includes: erty at least once in the previous 30 days. n Safe school environments and violence n Just over 11 percent of students in the survey prevention activities; — 15 percent of males and 6.7 percent of fe- males — said they had been in a physical fight n lcohol and other drug prevention activities; A on school property in the past year. n Student behavioral, social and emotional supports; n Five percent said they did not go to school n ental health services; and M at least once in the previous 30 days because they didn’t feel safe, either at school or on n Early childhood social and emotional learning their way to or from school. programs. RECOMMENDATIONS: The Prevention Institute has summarized the n Eliminating barriers to communication among characteristics of effective school-based violence groups of students; prevention programs, which includes:188 n Involving students in violence prevention ini- n A strong commitment to reaching all students tiatives as critical and valued partners; and staff with the message that violence, ha- n Collaborating closely and effectively with rassment and intolerance are unacceptable in community, media and policing agencies. the school environment; Effective conflict resolution, peer mediation, full n Involving all students, staff, parents and inter- service schools and peer and adult mentoring pro- ested community members in learning about grams have all shown results in reducing violence. violence and how to prevent it; 42 GANG-RELATED VIOLENCE Gang homicides account for a large number of n n Los Angeles and Oklahoma City, nearly I murders among youths in some U.S. cities.189, 190 a quarter of gang homicides were drive-by Between 2002 and 2009, up to 1,300 homicides shootings, compared with between one per- were estimated to be gang-related in the na- cent and six percent of non-gang homicides. tion’s largest cities. n n Long Beach, gang homicides accounted for I Gang-related homicide appears to occur mostly 69 percent of youth murders. in the largest cities, where there are higher n n Los Angeles, gang homicides accounted for I numbers of gang members. CDC analyzed 61 percent of the murders among people be- gang homicides in Los Angeles, Oklahoma City, tween the ages of 15 and 24. Oakland, Long Beach and Newark, New Jersey between 2002 and 2008. The report found that These estimates may be significant under these cities had 856 gang murders and 2,077 counts, according to some experts.192 non-gang murders during that period.191 The CDC concluded that “gang homicides are report found that the majority of gang homicides unique violent events that require prevention were unrelated to drugs, and concluded that strategies aimed specifically at gang processes. most of these killings were likely “quick, Preventing gang joining and increasing youths’ retaliatory reactions to ongoing gang conflict.” capacity to resolve conflict nonviolently might According to the report: reduce gang homicides.”193 GANGS IN THE UNITED STATES The 2009 National Gang Center Survey n Just over 44 percent of gangs are in large estimates that there were more than 28,000 cities; just over 29 percent are in small gangs in the country with an estimated cities; another 21.4 are in suburban areas, 731,000 gang members in the United while 5.4 percent are in rural counties; and States.194 This is the highest number since n More than 55 percent of gang members live in 1997. According to the survey:195 large cities (population above 400,000); 23.3 n fter declining from 1996 to a 2003, A percent live in suburban counties; 18.3 percent the number of gangs has risen steadily, live in small cities; and 2.7 percent live in rural increasing by more than 28 percent areas. There are reports that gangs and gang between 2002 and 2009; violence is increasing in medium-sized cities. RECOMMENDATIONS: TFAH and the report’s advisory committee n Collaboration with community leaders; recommend that the evidence-based, n Improving educational, vocational and social comprehensive approaches to preventing services as well as programs in schools and and reducing gangs and gang violence be neighborhoods with high rates of violence. implemented across the country. Some key components of a comprehensive approach In addition, TFAH and the report’s advisory com- include: mittee recommend continuing to build on prom- ising research on cross-cutting policy strategies, n Involvement and support of high level local such as a de-concentration of public housing and government leaders; development of business improvement districts. 43 UNITY Policy Platform: What cities need to prevent violence before it occurs196 Urban Networks to Increase Thriving Youth (UNITY) through ing is from an overview of the Platform, the full document is Violence Prevention created “The Unity Policy Platform: What available at: http://www.preventioninstitute.org/component/ cities need to prevent violence before it occurs.” The follow- jlibrary/article/id-290/127.html. What Cities Need on the Ground to Prevent Violence Cities need strategic plans to prevent violence and coordinate Build community capacity so residents can effectively address efforts across multiple sectors. The following strategies should current and future problems, and sustain positive outcomes. be part of a balanced approach and include high-level leader- III. hese strategies reduce risk factors to sustain reductions in T ship and community engagement in planning and implementa- violence over the long term in neighborhoods highly impacted tion. Efforts should be driven by local data and evaluation. by violence: Social connections characterized by trust and I. his strategy can reduce shooting and homicides by up to T concern for one another. Economic development, including 70 percent in neighborhoods highly impacted by violence: youth employment. Conflict resolution: Enhance the skills Street outreach and interruption: Street outreach workers of young people to resolve conflicts without violence. Youth can detect and interrupt violence, prevent imminent death leadership: Support and engage young people in decision- and injury. They can also begin changing community norms making. Quality after-school and out-of-school programming. about violence and create favorable conditions for long-term Mentoring: Provide positive role models who can form strong prevention strategies and the return of business. and enduring bonds with young people. Quality early care and education: Foster social, emotional and cognitive skill de- II. hese strategies reduce community and school violence by T velopment. Positive social and emotional development: Sup- 50 percent in two to five years in neighborhoods highly im- port growing self-awareness and self-regulation. Parenting pacted by violence: Universal, school-based violence preven- skills: Train parents and caregivers on parenting practices and tion at all schools promotes a safe climate for children to learn developmental milestones. Family support services: Provide and fosters positive social and emotional development. Treat integrated family services to promote self-sufficiency. mental health problems and substance abuse, and enhance protective factors among youth to prevent mental illness IV. his strategy reduces recidivism and prevents the re-occur- T and substance abuse. Reduce young children’s exposure to rence of violence: Successful re-entry: Support a successful violence in home and communities. Reduce family violence. transition from incarceration/detention to the community. What Cities Need on the State and National Levels to Maximize Local Efforts Investing in cities to prevent violence pays off, saving dollars n quip people with the necessary skills to build a com- E at the federal, state and local levels in the long term. For local mon language and foster understanding about one’s own efforts to be successful and sustainable, cities need support in role and each sector’s contribution. the following ways: n stablish supportive data, research, and evaluation E n Allocate and align resources: Cities need adequate, systems: A national research agenda on effective preven- flexible financial resources to implement effective strategies tion and disseminating multi-sector surveillance data on key on the ground, bring them to scale and coordinate them. risk and protective factors would inform and enhance local efforts. This information could be used to establish national n Create a high-level focal point for preventing violence baseline measures and standards. in federal and state governments. This would foster ac- countability and coordination across multiple agencies. n evelop a communications campaign to lend local efforts D heightened visibility and added credibility. Convey positive n Establish a mechanism for multi-sector collaboration messages about youth and make the case for prevention. in federal and state governments. This would provide a vehicle for aligning federal initiatives, establishing joint n nhance public health’s capacity and infrastructure at the E funding streams, coordinating data systems and sharing federal, state and local levels to address violence. Public health evaluation strategies. has a track record and proven methodology for changing be- haviors that contribute to poor health and safety outcomes. 44 REDUCING TEEN AND GANG VIOLENCE SUCCESS STORIES The following are examples compiled by The Pre- n n Chicago, the CeaseFire program uses I vention Institute of effective strategies for reducing street-savvy former gang members to work youth and gang violence:197 gangs to reduce violence. The program has reduced shootings and killings by between n Since introducing a “Blueprint for Action” 41 and 73 percent, and eliminated retaliation violence prevention program, Minneapolis has murders. Similar programs now exist in other seen a 40 percent drop in juvenile crime in the cities, including Baltimore and Boston. neighborhoods where the program is active. In addition, a long-term study found that high- n ang violence decreased by 17 percent in San G quality preschool can help reduce violence and Diego in 2009 from a year earlier, and gang- criminal offenses for those individuals as they age: related homicides dropped from 21 to nine percent. The improvement came after the city n The study found that low-income Black chil- implemented a combination of moves: aggressive dren who received a high-quality preschool police efforts, prevention and intervention pro- education at ages three and four were more grams, including extended Friday hours at recre- likely to hold a job, commit fewer crimes and ation centers, summer jobs for 3,000 youths, and graduate from high school by the time they biweekly curfew sweeps in certain areas. were 40. Overall, the research showed that for every dollar spent on the program, society n fter instituting a program to strengthen com- A received more than $16 in benefits; 88 per- munity connections, and to help youth economic cent of the savings came from savings from prospects, a neighborhood in Oakland, California, crime-related expenses.198, 199 reduced violent crime by more than 40 percent — even as rates of violent crime in the city rose. 45 BULLYING Bullying is often defined as an aggressive pattern of behavior Anti-Bullying Laws that involves unwanted, negative actions towards an indi- Forty-nine states have anti-bullying laws as of March 2012, vidual or group perceived to have less power.200 It can have according to the federal government Web site, a long-term negative psychological impact on victims, and StopBullying.gov.208 is also an indication of psychological issues of the individual engaging in bullying behavior. According to a review by the National School Board As- sociation, state anti-bullying statutes direct state educational According to the 2009 Youth Risk Behavior Study from agencies to, among other things: aggregate and report on CDC, nearly 20 percent of high school students report being information received from districts on incidents of bullying, bullied on school property in the previous 12 months.201 provide training or materials to districts, review local policies, According to a 2009 survey by the Associated Press and MTV, develop curriculum and standards for school safety specialist 60 percent of young people who have been bullied online re- training, develop teacher preparation program standards on port destructive behavior, such as smoking cigarettes, drinking identification and prevention, develop model education and alcohol, using illegal drugs or shoplifting (compared to 48 per- awareness programs, and/or provide technical assistance to cent of those not bullied in this way). The survey found that districts. Some of these actions are in the form of administra- those who had been bullied online were twice as likely to re- tive rule-making, to which local school boards will be subject. port having received mental health treatment, and nearly three Of particular importance to local school boards is the re- times more likely to have considered dropping out of school.202 quirement that the state agency issue a model policy that the local board must adopt in some form In addition, research by the Cyberbullying Research Center has found that bullied students are nearly twice as likely to have attempted suicide as those who had not experienced RECOMMENDATIONS: this kind of bullying.203 Stopbullying.gov, managed by the U.S. Department of Health and Human Services (HHS), includes a series of recommen- Other studies have also found that bullying has significant ef- dations for how community, schools, parents, teens and chil- fects on victims: dren and other individuals can help prevent bullying. 209 n A review of studies of bullying and suicide found links be- In terms of developing effective laws, the Anti-Defamation tween the two. Almost all of the studies found connec- League recommends that state laws should:210 tions between being bullied and suicidal thoughts among children. Five studies found that bullying victims were n nclude a strong definition of bullying, including cyberbullying; I up to nine times more likely than other children to have n ddress bullying motivated by race, religion, national ori- A suicidal thoughts. The review found that bullying affects gin, gender, gender identity, disability, sexual orientation between nine and 54 percent of children.204 and other personal characteristics; n A study from 2011 of more than 7,000 ninth-graders n nclude notice requirements for students and parents; I found that high schools with more bullying had lower average test scores. The researchers concluded that a n Set clear reporting procedures; and bullying atmosphere may hinder learning.205 n equire regular training for teachers and for students R n A review study done in 2011 by researchers at the Uni- about how to recognize and respond to bullying and versity of Pittsburgh found that gay, lesbian and trans- cyberbullying. gender youths were significantly more likely to be bullied TFAH and the report’s advisory committee recommend and abused in a range of ways. The scientists concluded taking a public health approach to preventing bullying and that these higher rates may contribute to this group’s also recommend more research be conducted to under- subsequent high incidence of mental health problems, stand cyberbullying, including what constitutes cyberbully- substance abuse, risky sexual behavior and HIV.206 ing, who does it, against whom, how to punish it and how n A survey done in 2010 of more than 2,100 teenagers to stop it. found that 29 percent had been the victim of Internet bullying in the past year.207 46 CHILD ABUSE AND NEGLECT About 754,000 children were abused in 2010, according to a A 2010 national study by HHS found that more than 1.25 mil- study by the Administration for Children and Families (ACF) lion children experienced maltreatment over the course of a at HHS. Rates of abuse and neglect are highest among infants year– one in every 58 children in the United States. For this and young children.211 study, “maltreatment” encompassed both abuse and neglect. Abuse included physical, sexual and emotional abuse, while More than 1,500 children died from abuse and neglect in neglect included physical, emotional and educational neglect. 2010. Of these victims: Some other key findings included:213 n Nearly 80 percent of these children were younger than four n orty-four percent of these children, more than 553,000, F years old. About a third of these deaths were caused solely were abused, while 61 percent, more than 771,000, were by neglect. neglected. Some children were both abused and neglected, n More than 78 percent of victims suffered neglect. More and were counted in both categories. More than five per- than 17 percent suffered physical abuse. Just over nine per- cent of the total, more than 68,000 children, were both cent suffered sexual abuse. abused and neglected; n Forty-five percent were White, 22 percent were Black, and n ifty-eight percent of abused children, about 323,000, were F 21 percent were Hispanic. physically abused. Slightly less than a quarter, about 135,000, were sexually abused, while 27 percent, about 148,000, were n The overall child abuse rate was around 10 per 1,000 emotionally abused. Forty-seven percent of neglected children, children. Some groups had higher rates: Black, American more than 360,000, experienced educational neglect. Thirty- Indian or Alaska Native, and multiple racial descents had the eight percent, more than 295,000, were physically neglected, highest: 14.6, 11, and 12.7 victims per 1,000, respectively. and a quarter, more than 193,000, were emotionally neglected; The total number of perpetrators of child abuse or neglect n The rate of abuse has dropped by 32 percent since 1996; and was more than 510,000 in 2010. Forty-five percent were men, and around 54 percent were women. More than 36 n The study found that state and local child protective ser- percent of perpetrators were between the ages of 20 and 29. vices agencies investigated only 32 percent of cases in More than 84 percent were between the ages of 20 and 49.212 which children experienced maltreatment. RECOMMENDATIONS: In their publication Addressing Common Forms of Child Mal- n mplement respite and crisis care programs, which offer I treatment: Evidence-Informed Interventions and Gaps in Current short-term child care to help parents and other caregivers Knowledge Research Brief, Casey Family Programs, the nation’s in stressful situations; largest operating foundation focused entirely on foster care n mplement programs to reduce and prevent Shaken Baby I and improving the child welfare system, outlines the need for Syndrome, which involves violently shaking an infant or research-based, culturally-competent safety and risk assess- young child. These programs should include education as ment methods, highly trained child protective services staff, well as instruction in coping strategies; and strong networks of alternative/differential response agencies and an array of effective family support agencies offering evi- n Create a statewide child abuse prevention strategy, which dence-based services to address child maltreatment.214 includes a plan for developing family resource centers and enforcement of existing state laws. In addition, the non-profit group Prevent Child Abuse recom- mends that states take a range of actions to reduce and pre- The Department of Justice Office of Juvenile Justice and vent child abuse:215 Delinquency Prevention also recommends that states require basic screening practices, pass laws authorizing criminal n Increase evidence-based education programs for parents and record checks and encourage education and training designed other caregivers, to improve their parenting skills. These to prevent child abuse.216 programs should focus particularly on single parents, teen parents and parents otherwise at greater risk of child abuse; There are additional promising policy strategies to preventing child abuse and neglect that focus on strengthening families n mplement home visitation programs, in which public health I and support for parents, including allowing longer maternity workers visit pregnant mothers and families with new babies leave time and other social and economic supports for parents or young children in order to strengthen parenting skills; and improve access to child care. 47 C. F ALLS, DROWNING AND SPORTS- AND RECREATION- RELATED INJURIES A significant number of accidents and injuries improving responses to limit the impact of are related to daily life and recreational activities. concussions. n RAUMATIC BRAIN INJURIES: There is in- T n FALLS: Falls are the third-leading cause of in- creasing awareness of the number of traumatic jury deaths for all ages. Injuries from falls dis- brain injuries in the United States — which proportionately impact young children and often occur during youth and adult sports and older Americans. One in three Americans recreation. About 1.7 million people sustain over the age of 64 experiences a fall each year a traumatic brain injury (TBI) annually. Each and the number of falls by older Americans is year, traumatic brain injuries contribute to a expected to sharply increase as Baby Boomers substantial number of deaths and cases of per- age.219 Falls can have devastating and long- manent disability. Recent data shows that, on term consequences including reduced mo- average, approximately 1.7 million people sus- bility, loss of independence and premature tain a traumatic brain injury annually.217 TBI- death. There are few legal measures that can related medical costs, as well as indirect costs reduce falls, but there is strong evidence that such as lost productivity, totaled $60 billion in clinical assessment, treatment and/or refer- the United States in 2000. ral by a healthcare provider; exercise that im- proves balance and lower body strength; and TBI is a contributing factor in more than 30 multi-factorial fall prevention programs can percent of all injury-related deaths in this help to significantly reduce the number of country. About three-quarters of all TBIs in falls and the severity of fall-related injuries.220 this country are concussions or other forms of mild TBI.218 n DROWNING: Every day, around 10 Ameri- cans die from drowning. Two children under This report includes an indicator for laws re- 15 die from drowning daily.221 Public edu- quiring coaches of school sports to receive cation and water safety programs have been concussion training, and examines other in- shown to help reduce the risk of drowning. terventions for preventing concussions and 48 INDICATOR 8: CONCUSSIONS AND TRAUMATIC BRAIN INJURIES Finding: 36 states and Washington, D.C. have strong youth sport concussion safety laws. 36 states and Washington, D.C. have strong 14 states do NOT have strong youth sport youth sport concussion laws concussion laws Alabama Georgia Alaska Hawaii Arizona Maine*** Arkansas* Michigan California Mississippi Colorado Montana Connecticut Nevada Delaware New Hampshire District of Columbia Ohio*** Florida South Carolina Idaho Tennessee Illinois Vermont** Indiana West Virginia Iowa Wyoming** Kansas Kentucky Louisiana Maryland Massachusetts Minnesota Missouri Nebraska New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Rhode Island South Dakota Texas Utah Virginia Washington Wisconsin Sources: Network for Public Health Law and MomsTEAM.com222 , 223 * Arkansas does not have a specific youth sports concussion law, but it has a series of laws and requirements that meet the three criteria for having a strong law in place. ** Vermont and Wyoming have concussion laws, but they do not meet the criteria for strong laws.224 *** Maine and Ohio have legislation still under as of consideration in May 2012. 49 Concussions are a form of TBI, often caused by than 29,000 TBI injuries, a rate of .36 per a bump, blow, or jolt to the head or a fall or 1000 athlete exposures); blow to the body. n ales account for almost three-quarters of M Each year, emergency departments treat more all sports- and recreation-related TBI emer- than 173,000 sports- and recreation-related gency department visits. For males between TBIs, including concussions, among children the ages of 10 and 19, sports- and recreation- and youth younger than 19.225 Children and related TBIs occurred most often while bicy- teens between the ages of 10 and 19 account for cling or playing football; and more than 70 percent of sports- and recreation- n or females between the ages of 10 and 19, sports- F related TBI emergency department visits. and recreation-related TBIs occurred most often Over the last decade, emergency department while bicycling, or playing soccer or basketball. visits for sports- and recreation-related TBIs (in- Repeated mild TBIs over a long period can re- cluding concussions) among children and ado- sult in cumulative neurological and cognitive lescents have increased by 60 percent. Some deficits. Repeated TBIs occurring within hours, trends include that: 226 days or weeks can cause serious problems or n BIs occur most often in football (more than T even death. TBIs can cause epilepsy, and in- 55,000 TBI injuries, a rate of .47 per 1,000 crease the risk for degenerative illnesses such athlete exposures) and girls’ soccer (more as Alzheimer’s disease and Parkinson’s disease. Preventing Concussions and Reducing the Impact of Concussions A number of measures — including use of n emoval of a youth athlete who appears to have R proper protective equipment — can be taken to suffered a concussion from play or practice at help prevent concussions or to limit the harm the time of the suspected concussion; and caused by a concussion or suspected concussion. n equiring a youth athlete to be cleared by a li- R The Zackery Lystedt law, passed by Washington censed health care professional trained in the state in 2009, is considered by a number of ex- evaluation and management of concussions perts and organizations, such as MomsTEAM, as before returning to play or practice. setting a standard for strong youth sport concus- Thirty-five states and Washington, D.C. have sion safety laws, based on including three prin- laws that meet this standard. (Arkansas has a set ciple components: of laws and guidelines that meet the standard). n nforming and educating youth athletes, their I Vermont and Wyoming, have youth sport con- parents and requiring them to sign a concus- cussion laws but they do not have all three com- sion information form; ponents of the Zackery Lystedt law. RECOMMENDATIONS: TFAH and the report’s advisory group recom- n equirement that an athlete must obtain writ- R mend that state laws relating to concussions and ten authorization from a medical or health youth sports should contain: care professional before returning to play; n alidated screening tools should be used to V n ducation and training about how to prevent E measure individuals suspected of having a and understand the signs and symptoms and concussion; possible long term consequences of concus- sions for coaches, physical education teach- n emoval from play if an athlete is suspected R ers, parents, athletes and others; and of having a concussion; n ddressing the peer and cultural pressures so A n eferral to a medical professional trained in R it becomes acceptable to sit out games instead the diagnosis and management of concus- of returning to play when injured. sions and TBI; 50 FALLS Among Americans aged 65 and older, the fall death n ost fractures among older adults are caused M rate has risen sharply over the past decade. Falls by falls; are also the most common cause of nonfatal inju- n mericans suffered 264,000 hip fractures in A ries and hospital admissions for trauma. Emergency 2007; over 90 percent were caused by falls. departments treated 2.3 million nonfatal fall injuries The rate for women was almost three times the among older Americans in 2010; about 600,000 rate for men. White women have significantly of these patients were hospitalized. The direct higher hip fracture rates than black women; medical cost of fall injuries among older Americans is estimated to be $28.2 billion (in 2010 dollars).227 n alls are the most common cause of TBI. In F CDC estimates that if the rate of increase in falls 2000, TBI accounted for 46 percent of fatal is not slowed, the annual cost under the Medicare falls among older adults; program will reach $59.6 billion by 2020; n Twenty to 30 percent of people who fall suf- Falls are a particular concern for older Ameri- fer moderate to severe injuries such as lacera- cans. Each year, one in three Americans over tions, hip fractures, or head traumas; and the age of 64 experiences a serious fall.228 Falls n ess than half of older people who fall tell L can cause injuries such as hip fractures and head their healthcare provider. traumas, and can increase the risk of death. The chances of falling, and of being seriously injured Falls are also a problem for children. Each year, from a fall, increase with age. around 100 children under the age of 14 dies from fall-related injuries, and there are around 2.3 mil- Among Americans over the age of 64, falls are lion nonfatal fall-related injuries among children.229 the leading cause of injury-related death — nearly Falls are the leading cause of unintentional injury 20,000 older adults died from unintentional falls for children ages 14 and under. Around 45 per- in 2008. Eighty-two percent of fall deaths in 2008 cent of nonfatal and 56 percent of fatal childhood were among people 65 and older. In 2009, the fall injuries were among kids ages four and under. rate of fall injuries for adults 85 and older was al- Young children are at risk for falls from windows, most four times that for adults between the ages furniture, stairs and playground equipment. Chil- of 65 and 74. dren and teens are also at risk for sports- and n Fall death rates are around 46 percent higher recreation-related falls. Effective ways to protect for men than women; children include window guards, stair gates and having appropriate equipment and energy absorb- n Women are 58 percent more likely than men ing surfacing on playgrounds. to be injured in a fall; Laws to Help Prevent Falls The National Council on Aging has launched the Connecticut, Florida, Maine, Oregon, New York, Falls Free© Initiative, a national collaborative effort Texas and Washington.232 These laws establish to educate the public and support and expand evi- commissions, coalitions and/or other programs. dence-based programs and interventions that help New York and Washington have allocated funds to communities, states, federal agencies, non-profits, address these initiatives.233 businesses and older adults and their families fight Thirty-three states have enacted laws relating to back against falls. Forty-one states are developing osteoporosis prevention programs and 14 have or have Falls Prevention Coalitions in place www. mandated insurance coverage of diagnosis and ncoa.org/FallsMap.230 In 2011, 43 states, Puerto treatment.234 Rico and Washington D.C. participated in pro- moting National Falls Prevention Awareness Day The Affordable Care Act (ACA) implemented http://www.ncoa.org/FPAD.231 annual wellness visits that include screening for fall risks; the Welcome to Medicare visit also As of November 2011, eight states have enacted screens for fall risk. laws to address falls in older adults: California, 51 RECOMMENDATIONS: TFAH and the report’s advisory committee n To prevent childhood falls and fall-related in- recommend additional research should be juries, efforts should be taken by pediatricians, conducted to help create stronger policies and public health professionals and policymakers effective programs to prevent falls. In addition, to communicate information about safety to TFAH and the report’s advisory committee rec- parents and to ensure that local and state or- ommend: dinances include playground safety standards. Some public education and encouragement of n To prevent falls in older Americans, states and safety steps that should be taken include: localities should adopt multi-strategy initia- tives that assess and address known risk fac- n Education about window safety and stair tors, such as problems with gait and balance, safety coupled with access to window guards use of psychoactive medications, severely low and stair-gates, including providing affordable blood pressure and visual or foot problems. options for lower-income families; Effective strategies include exercise pro- n Compliance with baby walker recommenda- grams that address strength, gait and balance; tions from the Consumer Product Safety managing medications; and home hazard Commission; and modification; as well as educating individuals, caretakers, families and healthcare providers n ppropriate equipment and protective surfac- A about ways to reduce risks;235 and ing under and around playground equipment. PREVENTING FALLS IN OLDER AMERICANS CDC recommends older Americans can re- n Having eyes checked at least once a year, duce their chances of falling by:236 and updating eyeglasses to optimize vision. n Increasing exercise levels. Programs that n Adding grab bars in the bathroom, railings focus on improving leg strength and balance along stairs, and additional lighting in unlit have been shown to reduce falls by as much areas. as half among participants. Weight-bearing n Taking steps to decrease hip fracture risk. exercise can strengthen bones. Older adults should check to make sure n Asking health professionals to review medi- that they are getting adequate calcium and cines and identify those that may cause diz- vitamin D, and should be screened and ziness or drowsiness. treated for osteoporosis. DROWNING Nearly 4,000 Americans die each year from settings, lack of life jacket use in recreational drowning.237 Nearly 1,000 children under the boating and alcohol use increase drowning risks age of 19 died from drowning in 2009, 450 of in adults. In addition, individuals with seizure these deaths were among children between one disorders are at an increase risk for drowning. and four years old.238 n atal drowning is the second-leading cause of ac- F RECOMMENDATIONS: cidental injury death for children ages one to 14.239 TFAH and the report’s advisory committee rec- n Nearly 80 percent of people who die from ommend public education and safety campaigns drowning are male.240 to help Americans understand how to reduce the risk of drowning, including the importance A number of factors can increase the risk of of close supervision of children, swimming les- drowning.241 For young children, bathtubs and sons, fences around swimming pools, use of life swimming pools can pose significant risks. Close jackets in recreational boating, the use of cardio- supervision, formal swimming lessons and fences pulmonary resuscitation to improve outcomes in can help reduce these risks. Natural water drowning victims and other measures. 52 D. INJURIES FROM POISONING Around 40,000 Americans die from poisoning each n he lowest mortality rates were among chil- T year.242 In 2009, poisoning surpassed traffic-related dren younger than 15, due to children abus- crashes as the leading cause of injury death in the ing drugs less frequently than adults. United States.243 Poisoning deaths exceeded the n nintentional poisoning deaths increased by U number of motor vehicle-related deaths in 31 states. 145 percent between 1999 and 2007. Every day, nearly 82 people die as a result of Unintentional poisoning is also the cause for sig- unintentional poisoning; another 1,941 are nificant numbers of emergency room visits. Un- treated in emergency departments.244 Between intentional poisoning caused more than 708,000 1999 and 2007, unintentional poisoning deaths emergency department (ED) visits in 2009. More in the United States increased by 145 percent:245 than 150,000 of these visits led to hospitalization n ore than nine out of ten unintentional poi- M or transfer to another medical facility. soning deaths in 2007 were caused by drugs The accidental or intentional misuse of prescrip- and medicines.246 Pain medications that con- tion drugs has become a growing concern, partic- tain opiates were most commonly involved, ularly since the number of painkillers prescribed followed by cocaine and heroin. has tripled in the past decade. Experts have found n en died from unintentional poisoning M that programs to monitor these medications can at twice the rate of women in 2008. Native help reduce the number of injuries related to pre- Americans had the highest death rate, fol- scription drugs. This report examines whether lowed by Whites and Blacks. states have these programs in place as an indicator. 53 INDICATOR 9: PRESCRIPTION DRUG OVERDOSE OR MISUSE Finding: 48 states have an active or pending prescription drug monitoring program. 48 states have an active or pending pre- 2 states and Washington, D.C. do NOT have scription drug monitoring program an active prescription drug monitoring pro- gram Alabama Washington, D.C. Alaska New Hampshire** Arizona Missouri** Arkansas* California Colorado Connecticut Delaware Florida Georgia* Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland* Massachusetts Michigan Minnesota Mississippi Montana* Nebraska* Nevada New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota* Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin* Wyoming Source: Alliance of States with Prescription Monitoring Programs247 * In Arkansas, Georgia, Maryland, Montana, Nebraska, South Dakota and Wisconsin, legislation has been enacted, but the program was not yet operating as of April 2012. **In New Hampshire and Missouri, legislation is pending.248 54 Sales of prescription painkillers tripled from Nearly 15,000 Americans died of overdoses in- 1999 to 2010 — as did the number of fatal volving prescription painkillers in 2008, which poisonings due to prescription pain medica- is more than the combined number who died tions.249 Enough prescription painkillers were from overdoses of cocaine and heroin.254 About prescribed in 2010 to medicate every American half of prescription painkiller deaths involve adult continually for a month.250 at least one other drug, including benzodiaz- epines, cocaine and heroin, and alcohol is also The growth in availability of these medications involved in many overdose deaths. means more individuals are using leftover drugs for non-medical purposes. There has been a sig- The misuse and abuse of prescription painkill- nificant rise in prescription drug abuse — and a ers was responsible for more than 475,000 emer- significant rise in unintentional overdoses. gency department visits in 2009. This is nearly double the amount from 2004.255 n ixteen million Americans over the age of 11 S took a prescription pain reliever, tranquilizer, n mong the 708,000 non-fatal poison-re- A stimulant or sedative for non-medical pur- lated emergency room visits in 2008, opi- poses at least once in 2009.251 About seven oid painkillers and benzodiazepines were million people used prescription psychother- the most frequent reason for treatment. 256 apeutic drugs for nonmedical purposes in The researchers only counted those who 2009; more than five million people abused had used prescription or over-the-counter pain relievers; two million abused tranquiliz- drugs non-medically. ers; about 1.3 million abused stimulants; and n bout 71,000 children and youth below the A 400,000 abused sedatives.252 age of 18 were seen in EDs due to medication n survey funded by the National Institute on A poisoning in 2004 and 2005. More than 80 Drug Abuse found that 2.7 percent of 8th grad- percent of these visits occurred after an unsu- ers, 7.7 percent of 10th graders and 8.0 percent pervised child found and swallowed medicine. of 12th graders had used Vicodin for nonmedi- n hildren visit the ED twice as often for medica- C cal purposes at least once in the year prior to tion poisoning as for poisonings from house- being surveyed. Just over two percent of eighth hold products such as cleaning solutions. graders, 4.6 percent of 10th graders and 5.1 per- cent of 12th graders had abused OxyContin.253 Most Common Prescription Painkillers257 Opioids: Prescription opioids act on the same These drugs can be addictive. High doses can receptors as heroin and can be highly addictive. cause severe respiratory depression. The risk Abuse of opioids, alone or in combination with rises when the drugs are combined with other alcohol or other drugs, can depress respiration and medications or alcohol. lead to death. Injecting opioids also increases the Stimulants are used to treat ADHD and risk of HIV and other infectious diseases through narcolepsy. These drugs can be addictive, use of contaminated needles. and can cause a range of problems, including Central Nervous System Depressants psychosis, seizures and heart ailments. are used to treat anxiety and sleep problems. 55 Prescription Drug Monitoring Programs Prescription Drug Monitoring Programs substance prescriptions, and numbers of pre- (PDMPs) are state-run electronic databases scribers; used to track the prescribing and dispensing s rescribers who clearly deviate from accepted P of controlled prescription drugs to patients. medical practice in terms of prescription They are designed to monitor this information painkiller dosage, numbers of prescriptions for suspected abuse or diversion — that is, the for controlled substances, and proportion of channeling of the drug into an illegal use — doctor shoppers among their patients; and and can give a prescriber or pharmacist critical information regarding a patient’s controlled s DC also recommends that PDMPs link to C substance prescription history. This informa- electronic health records systems so that tion can help prescribers and pharmacists iden- PDMP information is better integrated into tify high-risk patients who would benefit from health care providers’ day-to-day practices. early interventions. CDC recommends that Forty-eight states currently have a PDMP and PDMPs focus their resources on: received a point for this indicator. However, as s atients at highest risk in terms of prescrip- P of February 2012, the programs are not yet in tion painkiller dosage, numbers of controlled operation in seven of those states. Poison Control Centers Poison control centers provide immediate expert n dults 20 and older accounted for 92 percent A treatment advice by telephone when people are ex- of all poisoning deaths. Adults between the posed to hazardous substances or overdoses. They ages of 40 and 49 have the highest number of also serve as an important community educational poisoning deaths. resource in poisoning prevention and treatment. n eventy-two percent of all poison exposures S The nation’s 57 poison control centers handled in 2009 were managed over the phone, with- more than 3.7 million calls in 2010 — an average out a trip to a doctor or hospital.261 of nearly 11,000 per day — and provided treat- ment advice for over 2.4 million human poison n octors and nurses also use the expertise of D exposures.258 Poisonings resulted in $33.4 billion poison centers to guide treatment of patients: in medical and productivity costs in 2005.259 IOM more than 400,000 calls were placed from a estimates that every dollar spent on poison control health care facility in 2009. centers saves $10 in health care costs annually.260 Almost a third of poison control centers report n hildren younger than six accounted for C that they faced the threat of closure in the past about half of all of these calls and account five years.262 Congress cut a quarter of federal for about two percent of the deaths. funding for poison control centers in 2011.263 RECOMMENDATIONS: In 2011, the White House released a new report TFAH and the report’s advisory group recom- Epidemic: Responding to America’s Prescription Drug mend states and municipalities take strong ac- Abuse Crisis.264 Working with states to establish tion and implement PDMPs to reduce the risk effective PDMPs in every state, including lever- of prescription drug abuse and call for more aging state electronic health information ex- research to be conducted on ways to prevent change activities, and to require prescribers and injuries resulting from prescription drug use. 266 dispensers to be trained in their appropriate use CDC recommends that:267 were among the goals and strategies mentioned in the report. In April 2012, the annually up- n DMPs link to electronic health records sys- P dated National Drug Control Strategy was re- tems so that providers have better access to leased and reinforced a public health approach prescription information, which should in- to responding to the national prescription drug clude real-time reporting, interoperability abuse problem, focusing on education, monitor- between states and proactive use of PDMPs ing, disposal and enforcement.265 to identify problem prescribers and patients; 56 n rograms such as Medicaid and workers’ com- P s arrying out continuous quality improve- C pensation monitor prescription claims informa- ment; and tion and PDMP data. For patients whose use of s ntegrating services into the public health I multiple providers cannot be justified on medi- system. cal grounds, such programs should consider reimbursing claims for controlled prescription n oison control centers should collaborate P drugs from a single physician and from a single with state and local health departments to pharmacy. This can improve coordination of develop, disseminate and evaluate public and care and ensure appropriate access for patients professional education activities; who are at high risk for overdose; n HS and the states should establish a Poi- H n tates ensure that providers follow evidence- S son Prevention and Control System that in- based guidelines for use of prescription tegrates poison control centers with public painkillers. Swift action against health care health agencies, establishes performance providers acting outside the limits of ac- measures, and holds all parties accountable cepted medical practice can decrease pain- for protecting the public; killer abuse and overdose; n DC, HRSA, and states should continue to C n tates pass laws to prevent doctor shopping S build an effective infrastructure for all-haz- and the operation of rogue pain clinics, while ards emergency preparedness, including bio- at the same time safeguarding legitimate ac- terrorism and chemical terrorism; cess to pain management services; and n RSA should commission a review focusing H n tates increase access to substance abuse S on organizational determinants of cost, qual- treatment programs, which can reduce over- ity and staffing of poison control centers; dose injuries and deaths among addicts. n ongress should amend the current Poison Con- C Additional promising strategies include: regu- trol Center Enhancement and Awareness Act to lating unlicensed pharmacy technicians; pub- provide sufficient funding to support the pro- lic outreach and education campaigns on the posed Poison Prevention and Control System; dangers of prescription drug abuse; training n ongress should amend existing public C for pharmacists to detect doctor shopping and health legislation to fund a state and local in- use of fraudulent prescriptions; regulating the frastructure to support an integrated Poison online pharmacy industry; and establishing Prevention and Control System; take-back days where patients can return un- used drugs.268 n n external, independent body should be A responsible for certifying poison control cen- TFAH and the report’s advisory group also con- ters and specialists in poison information; cur with the ten recommendations outlined by the IOM for maintaining and improving the na- n he Secretary of Health and Human Services T tion’s poison control center system:269 should instruct key agencies to convene an expert panel to develop a definition of poi- n ll poison control centers should perform a A soning that can be used in surveillance and defined set of core activities supported by fed- data collection; eral funding. These activities include: n HS should increase health providers’ aware- H s anaging telephone-based poison expo- M ness of the importance of keeping informa- sure and information calls; tion on poisoning private, so that callers are s reparing and responding to all-hazards emer- P not reluctant to call, or follow up; and gency needs, especially biological or chemical n DC should ensure that exposure surveil- C terrorism or other mass exposure events; lance data generated by the poison control s apturing, analyzing and reporting expo- C centers and reported in the Toxic Exposure sure data; Surveillance System are available to appropri- ate local, state and federal public health units s raining poison control center staff, in- T and to the poison control centers on a real- cluding specialists in poison information time basis at no additional cost to these users. and poison information providers; 57 E. RESEARCH TOOLS FOR REDUCING INJURIES INDICATOR 10: EXTERNAL CAUSE OF INJURY CODES (E-codes) Finding: In 23 states, more than 90 percent of injury discharges of patients of emergency departments received Ecodes. In 23 states, more than 90 percent of In 27 states and Washington, D.C., LESS than injury discharges of patients of emergency 90 percent of injury discharges of patients of departments received E-codes in 2009 emergency departments in 2009, or the number of E-codes was NOT provided to the Healthcare Cost and Utilization Project E-code Evaluation Arizona Alabama1 California Alaska Connecticut Arkansas2 Florida Colorado3 Georgia Delaware1 Hawaii Washington, D.C.4 Iowa Idaho1 Kansas Illinois5 Maine Indiana Maryland Kentucky5 Massachusetts Louisiana^ Missouri Michigan1 Nebraska Minnesota5 New Hampshire Mississippi^ New York Montana1 North Carolina Nevada4 Rhode Island New Jersey South Carolina New Mexico5 South Dakota North Dakota1 Tennessee Ohio Utah Oklahoma Vermont Oregon5 Wisconsin Pennsylvania1 Texas1 Virginia1 Washington1 West Virginia^ Wyoming Source: Healthcare Cost and Utilization Project (HCUP) E-code Evaluation Addendum — Updated Information for 2009, Agency for Healthcare Research and Quality TFAH worked with researchers at the Johns Hopkins Bloomberg School of Public Health to conduct phone interviews with states that did not report information to the HCUP E-code Evaluation. 1 State indicated no system is in place 2 State indicated system is in place in 2012 for the first time 3 State indicated data is collected for 75 percent of hospitals 4 State or Washington, D.C. indicated they have a unique system in place 5 Illinois noted that in the state, for the first three quarters of 2011, 92 percent of injury discharges of patients of emergency departments received E-codes.  Oregon noted they currently have a statewide hospital based system but not an emergency department data system, but an all pairs, all claims database that include emergency data is expected shortly, which will be for 2010 and forward. Minnesota noted they have a voluntary system, not a mandated system, where they have a 93 percent reporting rate and high quality data, but training and encouragement of Health Information Management Staff in hospitals need to continue. New Mexico notes the state’s interim ED data captures about 60 percent of the E-codes expected in injury discharges from ED’s. The collection of E-coding will increase as ED reporting becomes established in New Mexico. Kentucky noted reporting more than 85 percent of injury discharges in EDs. ^ State did not respond to inquiries 58 Every year, about 50 million people in the United the injury is (for example, a broken bone), but States are injured badly enough to require medi- they do not necessarily indicate why the injury cal attention. Many of these people receive treat- occurred (i.e assault).This data is important be- ment in an emergency department or a hospital, cause it helps researchers and health officials which collect patients’ healthcare data. There understand injury trends and evaluate preven- are currently three injury surveillance systems, tion programs. including 1) the national vital statistics registry, However, the quality of E-coding varies substan- 2) hospital discharge data systems, and 3) local tially from state to state, which limits the use- emergency department data systems. fulness of the data. In many states, hospitals This data is often collected using a standard and clinicians are not required to document method for classifying types of injuries, known E-codes, and E-codes are not required for in- as external cause-of-injury coding, or E-coding. surance reimbursement. In some states that do collect E-codes, the information is incomplete. These codes include information about an in- A 2008 CDC report found that “the majority jury’s cause and whether it was intentional or of states lack policies or adequate resources to accidental. Hospitals and clinicians assign these implement ongoing quality-assurance practices codes to describe patient visits. Other types of that would ensure high quality E-coding.”270 regularly documented codes may describe what E-coding System and Practices in Place Understanding patterns and trends in injuries is The Healthcare Cost and Utilization Project a crucial tool for developing successful and useful (HCUP), which is run by the Agency for Health- policies to reduce accidents, violence and injuries. care Research and Quality (AHRQ), studies the status of state E-coding efforts. It found that 29 HHS has set priority health goals for the country states out of 44 states that provided information in its Healthy People 2020 report and has included to HCUP had statewide hospital discharge data two objectives for E-coding, including to:271 systems that routinely collected E-coding data for n ncrease the proportion of states and D.C. I 90 percent or more of injury-related discharges. with statewide emergency department data It also found that 23 out of 29 states that pro- systems that routinely collect external-cause- vided information to HCUP had statewide of-injury codes for 90 percent or more of emergency department data systems that rou- injury-related visits; and tinely collected E-coding data for 90 percent or n ncrease the proportion of states and D.C. with I more of injury-related visits. statewide hospital discharge data systems that rou- tinely collect external-cause-of-injury codes for 90 percent or more of injury-related discharges. RECOMMENDATIONS: In a 2008 report, CDC offered a series of ideas n onsider the possibility of requiring narrative C to increase the use of E-codes, and improve the documentation and E-coding in electronic quality of E-coding data.272 The report recom- health and patient record systems; mended that the agency should: n emonstrate how E-coding can help health- D n ake the lead in working with other relevant T care businesses; federal agencies to increase the use of E-codes; n xamine the use of financial incentives, en- E n long with the Centers for Medicare and Medic- A forcements and mandates to improve the aid Services (CMS) and state health departments, quality of E-coding; explore the possibility of linking E-codes to uni- n evelop methods that could track this D form billing procedures used for reimbursement improvement; in government health insurance systems; n ork with the International Collaborative W n ork with state public health officials, the in- W Effort on Injury Statistics, as well as other surance industry and medical professional as- international researchers, to share ideas on sociations to examine how E-coding can drive improving E-coding in this country; injury prevention efforts; 59 n ork with the Safe States Alliance, SAVIR W n onduct evaluations to examine the quality C and the Council of State and Territorial Ep- of E-coding in hospitals within their jurisdic- idemiologists (CSTE) to improve E-coding tions. States should provide feedback to hos- through cost-effective quality assurance and pitals on the results; evaluation; n ork with local health departments to high- W n ork with state public health officials to edu- W light injury and injury prevention as public cate healthcare workers, hospital association health priorities; members, health plan staff and the public on n nsure that policymakers, program planners, E the importance of E-codes. researchers, and the public have easy online n n collaboration with the Safe States Alli- I access to E-code data; and ance, SAVIR and CSTE, CDC should develop n ealth departments with an existing state- H training programs for hospitals and medical wide hospital discharge data system should education programs to raise awareness of E- participate in CDC’s Injury Indicators Project coding; and to improve communication among states on n n collaboration with the Safe States Alli- I the use of E-code data. ance, SAVIR and CSTE, CDC should work TFAH and the report’s advisory committee also with medical professional groups to develop recommend the reporting of E-codes be used for incentives and approaches to encourage col- reimbursement of Medicare and Medicaid claims lection of high-quality E-coding data. of injury-related cases as part of the ACA efforts The report also had recommendations for state through Electronic Health Record/Meaningful health departments:273 Use criteria that CMS has established.     60 F. FIRE-RELATED INJURIES In 2010, 3,120 Americans died in fires, not in- n Children under the age of five; cluding firefighters. Home fires were respon- n dults over the age of 64; A sible for 2,640 of these deaths, and they injured another 13,350. Fire departments responded to n lacks and Native Americans; B 384,000 home fires in 2010.274 n he lowest-income Americans; T Deaths from fires and burns are the third-lead- n eople living in rural areas; and P ing cause of fatal home injury. Most fire victims die from smoke or toxic gases, not from burns. n eople living in manufactured homes or sub- P standard housing. Residential fires caused an estimated $7.1 billion in home property losses in 2010. 275 In addition, Cooking is the primary cause of residential fire and burn injuries cost $7.5 billion each year.276 fires. Smoking is the leading cause of fire-re- Fatal fire and burn injuries cost $3 billion a year. lated deaths. Alcohol use contributes to about 40 percent of residential fire deaths. Most resi- Groups at increased risk of fire-related injuries dential fires occur in winter.278 and deaths include:277 Alarms and Sprinklers Smoke alarms have long been recommended as but failed to operate. Smoke alarm failures a way to quickly detect and alert people about are usually caused by missing, disconnected fires so they can immediately vacate a building. or dead batteries. A number of policies exist, such as requiring n n 37 percent of fire deaths, smoke alarms I landlords to install smoke detectors to meet sounded. One percent of the deaths were National Fire Protection Association standards caused by fires too small to activate the alarm. for all rental units and for smoke alarms to be installed in all new residential buildings. Most There is strong evidence that residential sprin- of these policies are city or local ordinances, al- klers are highly effective in quickly dampen- though a few states have detector laws. ing the spread of fires and preventing injuries and deaths related to fires. For more than 100 Working smoke alarms reduce the risk of death years sprinkler systems have been used in com- in a house fire by at least 50 percent. However, mercial properties, and for decades they have while a majority of Americans think they have been used with great success in hotels and working smoke alarms, follow-up home observa- multi-family residences. Sprinklers can help tions show that only about half of them are actu- save the lives of families and firefighters, limit ally working.279, 280 Among homes with smoke the damage and cost-of-damage from a fire and alarms, most have too few alarms, incorrectly are environmentally friendly.282 The 2009 In- placed alarms or non-working alarms. ternational Residential Code (IRC) has adopted Between 2005 and 2009, smoke alarms were this requirement, but currently only three states present in 72 percent of reported home and have adopted the 2009 code (California, Mary- apartment fires. They sounded in 51 percent land and South Carolina) while eight states of these fires.281 have prohibited the adoption of the IRC sprin- kler mandate. Some officials and builders have n hirty-eight percent of home fire deaths re- T expressed concern over the costs of putting in sulted from fires in dwellings without alarms. residential sprinklers. Research by the Fire Pro- n wenty-four percent of deaths were caused T tection Research Foundation indicates that the by fires in which smoke alarms were present cost would not be prohibitive 61 RECOMMENDATIONS: TFAH and the report’s advisory committee rec- and use 10 year lithium batteries instead of ommend that: alkaline ones; and n ll states should adopt the 2009 International A n ll states should require all landlords to in- A Residential Code requirement that all new stall smoke alarms in all rental units; that one- and two-family homes include a residen- these alarms should meet National Fire Pro- tial sprinkler system; tection Association standards; that smoke alarms be mandatory in all new residential n tates should also encourage installing sprin- S buildings; and that smoke alarm installation klers in existing homes; be mandatory before changes in ownership of n here should be widespread public educa- T single family homes.  tion to regularly change batteries regularly CARBON MONOXIDE Carbon monoxide (CO) is an odorless, colorless The average daily number of CO-related deaths gas produced when fossil fuels are burned in a is greatest in January and December, and lowest furnace, vehicle, generator, grill, or elsewhere. in July and August. Nebraska had the highest The gas can build up in enclosed or semi-en- CO mortality rate of any state. closed spaces, and can cause sudden illness and Municipal fire departments responded to an esti- death if enough is breathed in.283 mated 61,100 carbon monoxide incidents in 2005, Unintentional CO exposure in this country an- excluding incidents where nothing was found or nually accounts for about 500 deaths and 15,000 there was a fire. The peak time for these inci- emergency department visits.284 dents was between 6 p.m. and 10 p.m.285 RECOMMENDATIONS: The National Council of State Legislators rec- n equire detectors on all floors in all hotels, R ommends that all states should:286 motels, and other dwellings where occupants are transient; n Require carbon monoxide detectors in child care facilities, schools and hospitals; n equire that detectors be installed in all R homes, condominiums and apartments before n equire detectors on all floors of any housing unit; R these buildings are sold or rented; n Require detectors in all new homes, condo- n equire that detectors in all rental units and in R miniums and apartments; all new homes be powered by both the build- n Require that landlords install detectors in ing’s electrical supply and by battery; and every unit of all rental homes and apartments; n equire state fire authorities to develop a list R n Prohibit tenants from removing or tampering of approved carbon monoxide detectors, and with these detectors; forbid the sale of any devices not on the list. 62 Conclusions T his report details a range of proven, evidence-based policies and strategies for reducing injury rates across the country. Thousands of injuries could be prevented and billions of dollars could be saved in medical costs n ncreased Investment is Needed for Injury I Prevention Research 3 S ecti o n each year with the wider implementation of re- Research has generated strong evidence for a search-based policies and an increased investment number of ways to reduce a wide range of inju- in programs, enforcement and public education. ries. This evidence is generated from surveillance n ncreased Resources and Workforce are I data on injury problems, studies of the risk and Needed for Injury Prevention protective factors, the development and evalua- tion of innovative solutions, and the widespread Currently, public health departments and re- dissemination of effective programs and poli- searchers do not have the support they need to cies. However, limited resources mean limits on fully implement many of these strategies. Instead the ability to collect, analyze and evaluate data of increasing the investment, in the past several to move the field forward. For instance, more years, funding for public health has dramatically information is needed to evaluate whether bans decreased. Injury prevention efforts require ded- of handheld devices and texting help reduce ac- icated resources and staff in place to be effective. cidents or if they are encouraging more distrac- n he nation’s public health system is respon- T tion for drivers to try to hide devices while they sible for improving the health of Americans. continue to engage in these practices. And, when But, the public health system has been chroni- there is a proven, effective policy, what are the cally underfunded for decades. Analyses from most effective methods to implement and dissem- the IOM , The New York Academy of Medicine inate it to the broader population? For instance, (NYAM), CDC and a range of other experts graduated driver’s license policies reduce teen have found that federal, state, and local pub- deaths and injuries but more research can help lic health departments have been hampered better understand what the key ingredients are due to limited funds and have not been able that make them effective and encourage more to adequately carry out many core functions, states to adopt them. Answering these and many including programs to prevent disease and in- other injury prevention questions are essential to juries and prepare for health emergencies.287 more fully protecting the public in the future. In addition, improved data collection through wide- Federal funding for public health has remained spread and standardized use of external cause-of- at a relatively flat and insufficient level for years. injury coding (E-codes) is essential to being able The budget for CDC has decreased from a high to analyze injuries in the United States and the of $6.62 billion in 2005 to $6.12 billion in 2011.288 effectiveness of strategies to prevent them. At the state and local levels, public health budgets n artnerships Between Public Health and Other P have been cut at drastic rates in recent years. Ac- Sectors Must Continue to Be Strengthened cording to a TFAH analysis, 40 states decreased their public health budgets from FY 2009-10 to FY 2010- Injuries have a wide range of causes. While harm to 11, 30 states decreased budgets for a second year in a person’s wellbeing or even death are what defines a row, 15 for three years in a row. A recent study an injury, it takes health experts working with other conducted by the National Association of County fields to identify and implement effective preven- and City Health Officials (NACCHO) found sig- tion strategies. For instance, motor vehicle policies nificant cuts to programs, workforce and budgets and programs involve working with transportation at local health departments (LHDs) around the officials, experts and members of industry, while country. Since 2008, LHDs have lost a total of 34,400 violence reduction efforts can involve community jobs due to layoffs and attrition.289 Combined state organizations, social services, education, law en- and local public health job losses total 49,310 since forcement, judicial system and other areas. These 2008.290 LHDs continue to struggle with budget collaborations are key to success and working to- cuts. In July, 2011 nearly half of LHDs reported re- gether can create win-win policy approaches across duced budgets, which is in addition to 44 percent sectors. Public health officials bring the perspective that reported lower budgets in November 2010.291 of protecting safety and health to the development In addition, more than 50 percent of LHDs expect and implementation of policies and programs and cuts to their budgets in the upcoming fiscal year. should be integral in these decisions. 63 APPENDIX A: RATES METHODOLOGY State death rates from injury include deaths for parison purposes. The data come from the U.S. all ages, for injuries caused by both accidents Centers for Disease Control and Prevention’s and violence (unintentional and violence-related Web-based Injury Statistics Query and Reporting causes). In the rankings, states with a higher System (WISQARS). The data are age-adjusted ranking had a higher rate of injury-related death. using the year 2000 as the reference point. The In other words, a state with the rank of “1” has the use of age-adjusted rates, which is recommended highest rate of injury fatalities, while a state with by CDC, accounts for differences in age distribu- the rank of “51” has the lowest rate (the rankings tion between states. The rates refer to deaths per include Washington, D.C. The rates and rank- 100,000 people. Childhood rates refer to state ings are based on combined data for the years residents under the age of 20. 2007-2009 to “stabilize” the death rates for com- APPENDIX B: METHODOLOGY FOR THE BREAK THE CYCLE TEEN VIOLENCE REPORT CARD 292 Break the Cycle calculated its state grades based n even-and-a-half percent depended on S on a system that analyzes 11 indicators, each of whether a protection order can be granted which received varying weights according to its against a minor accused of abuse. relative importance.  The system was developed by n ive percent depended on the availability of F staff at Break the Cycle in conjunction with public options to minors who cannot file for protec- health researchers at the University of Minnesota. tion orders themselves.  Some states allow n wenty percent of a state’s score depended T protection orders to be filed for minors by on whether or not minors may be granted adults who are not the victim’s parents. protection orders.  States that prohibit mi- n ive percent depended on the types of abuse F nors from receiving protection orders auto- that qualify for protection orders.  The group matically received a failing grade.  focused on whether states include property n wenty percent of a state’s score depended on T damage and the use of technology, such as what kinds of relationships are eligible for pro- texting, as part of their criteria for abuse. tection orders.  States that prohibit people in n ive percent depended on whether or not mi- F dating relationships from receiving protection nors’ cases are heard in courts familiar with orders also automatically received a failing grade.  domestic violence law. n en percent of a state’s score depended on T n ive percent depended on whether a judge F how easy it is for minors to file for a protec- can modify the protection order once it is tion order themselves.  granted, to adjust to new circumstances. n en percent depended on whether a minor’s T n ive percent depended on the types of relief F parents may be notified of the proceedings.  available, such as no-contact orders, orders of n even-and-a-half percent depended on S temporary custody and orders to vacate a home. whether same-sex couples can qualify for pro- tection orders. 65 APPENDIX C: CDC Injury Prevention Funding Over the Years Injury Prevention State 2011 Population 2006 2007 2008 2009 2010 Alabama 4,802,740 $1,647,829 $1,668,784 $1,606,504 $880,800 $702,979 Alaska 722,718 $642,278 $676,061 $716,303 $724,618 $783,728 Arizona 6,482,505 $1,088,401 $888,808 $1,029,715 $826,532 $955,867 Arkansas 2,937,979 $522,485 $604,460 $597,905 $615,312 $360,876 California 37,691,912 $11,978,652 $10,799,878 $10,667,174 $11,309,622 $9,354,024 Colorado 5,116,796 $3,172,098 $2,653,532 $2,651,679 $3,277,852 $2,592,307 Connecticut 3,580,709 $736,656 $1,009,162 $1,015,488 $1,028,270 $720,475 Delaware 907,135 $352,638 $281,785 $938,404 $369,612 $326,220 D.C. 617,996 $1,315,862 $892,053 $1,443,710 $924,164 $2,391,935 Florida 19,057,542 $2,973,747 $2,781,663 $2,493,462 $3,091,803 $3,005,635 Georgia 9,815,210 $3,102,855 $3,564,808 $2,704,239 $3,744,699 $3,761,706 Hawaii 1,374,810 $1,413,011 $1,292,691 $1,278,224 $1,307,462 $289,881 Idaho 1,584,985 $186,607 $181,166 $177,987 $237,903 $175,742 Illinois 12,869,257 $3,202,406 $3,868,633 $3,660,418 $4,544,521 $4,899,876 Indiana 6,516,922 $868,260 $842,236 $827,452 $921,069 $818,171 Iowa 3,062,309 $1,842,645 $1,835,479 $1,800,086 $1,374,088 $1,331,251 Kansas 2,871,238 $1,263,239 $875,405 $901,144 $1,133,151 $896,812 Kentucky 4,369,356 $1,073,024 $1,332,881 $1,025,303 $1,541,605 $1,497,161 Louisiana 4,574,836 $755,525 $671,354 $733,017 $736,631 $727,039 Maine 1,328,188 $300,658 $265,747 $299,528 $501,812 $497,509 Maryland 5,828,289 $5,453,917 $5,744,544 $5,387,689 $3,433,809 $2,538,979 Massachusetts 6,587,536 $4,823,129 $3,546,824 $3,397,499 $3,360,026 $2,401,285 Michigan 9,876,187 $4,545,341 $2,289,724 $1,867,310 $2,936,248 $4,063,644 Minnesota 5,344,861 $1,524,316 $1,521,112 $1,355,836 $1,551,309 $1,241,054 Mississippi 2,978,512 $437,445 $540,227 $533,290 $533,578 $525,788 Missouri 6,010,688 $878,534 $1,118,627 $1,137,008 $2,280,545 $2,145,919 Montana 998,199 $477,171 $347,763 $264,217 $398,673 $389,055 Nebraska 1,842,641 $362,797 $369,679 $358,751 $386,959 $356,924 Nevada 2,723,322 $403,669 $1,668,784 $380,548 $400,949 $395,469 New Hampshire 1,318,194 $178,324 $472,955 $759,452 $769,650 $466,357 New Jersey 8,821,155 $1,473,069 $1,376,050 $1,351,378 $1,446,267 $1,831,255 New Mexico 2,082,224 $574,664 $562,743 $547,132 $562,669 $557,453 New York 19,465,197 $6,191,453 $6,098,930 $5,987,693 $6,291,674 $6,711,930 North Carolina 9,656,401 $4,142,136 $3,706,593 $3,143,141 $3,556,821 $4,920,673 North Dakota 683,932 $362,286 $357,743 $300,651 $415,003 $406,358 Ohio 11,544,951 $2,754,889 $3,052,586 $3,122,255 $4,125,695 $3,463,374 Oklahoma 3,791,508 $1,716,690 $1,498,172 $1,099,710 $1,262,710 $1,135,529 Oregon 3,871,859 $2,295,298 $2,210,149 $2,204,876 $1,367,448 $1,508,716 Pennsylvania 12,742,886 $6,405,867 $7,060,939 $6,646,094 $5,818,679 $5,914,536 Rhode Island 1,051,302 $969,185 $925,777 $688,136 $891,985 $1,053,249 South Carolina 4,679,230 $3,243,390 $2,263,146 $1,996,408 $1,681,488 $1,670,480 South Dakota 824,082 $109,833 $106,574 $104,705 $104,663 $313,183 Tennessee 6,403,353 $1,932,586 $2,002,395 $1,988,161 $1,898,183 $1,886,618 Texas 25,674,681 $3,731,166 $3,168,552 $3,445,513 $3,419,333 $3,236,691 Utah 2,817,222 $889,997 $699,016 $684,230 $729,666 $721,619 Vermont 626,431 $205,798 $218,156 $201,641 $212,177 $208,954 Virginia 8,096,604 $3,199,708 $3,083,717 $2,930,250 $2,604,511 $3,087,972 Washington 6,830,038 $3,308,127 $3,159,094 $2,556,079 $2,023,557 $2,115,388 West Virginia 1,855,364 $1,133,434 $1,121,637 $1,106,200 $1,222,208 $1,355,274 Wisconsin 5,711,767 $2,373,326 $3,041,586 $2,952,773 $2,926,375 $3,138,437 Wyoming 568,158 $72,655 $70,601 $69,363 $69,207 $68,356 U.S. Total 311,591,917 $104,609,076 $100,390,981 $95,135,731 $97,773,591 $95,919,713 66 Real 2011 (adjusting Real % change Nominal % State Nominal 2011 2011 Per Cap for inflation-in 2006 06-11 (adjusting change 06-11 dollars) for inflation) Alabama $543,390 $0.11 -67.0% $486,986 -70.4% Alaska $632,047 $0.87 -1.6% $566,441 -11.8% Arizona $1,010,519 $0.16 -7.2% $905,627 -16.8% Arkansas $327,659 $0.11 -37.3% $293,648 -43.8% California $9,077,880 $0.24 -24.2% $8,135,596 -32.1% Colorado $3,995,468 $0.78 26.0% $3,580,738 12.9% Connecticut $416,711 $0.12 -43.4% $373,456 -49.3% Delaware $310,217 $0.34 -12.0% $278,016 -21.2% D.C. $1,061,078 $1.72 -19.4% $950,938 -27.7% Florida $3,113,286 $0.16 4.7% $2,790,127 -6.2% Georgia $3,401,924 $0.35 9.6% $3,048,804 -1.7% Hawaii $299,856 $0.22 -78.8% $268,731 -81.0% Idaho $159,880 $0.10 -14.3% $143,284 -23.2% Illinois $3,993,832 $0.31 24.7% $3,579,272 11.8% Indiana $742,055 $0.11 -14.5% $665,030 -23.4% Iowa $1,259,040 $0.41 -31.7% $1,128,352 -38.8% Kansas $864,988 $0.30 -31.5% $775,202 -38.6% Kentucky $1,504,002 $0.34 40.2% $1,347,887 25.6% Louisiana $608,683 $0.13 -19.4% $545,502 -27.8% Maine $357,159 $0.27 18.8% $320,086 6.5% Maryland $4,133,961 $0.71 -24.2% $3,704,856 -32.1% Massachusetts $2,205,176 $0.33 -54.3% $1,976,279 -59.0% Michigan $3,826,157 $0.39 -15.8% $3,429,002 -24.6% Minnesota $1,537,645 $0.29 0.9% $1,378,037 -9.6% Mississippi $348,489 $0.12 -20.3% $312,316 -28.6% Missouri $1,988,646 $0.33 126.4% $1,782,225 102.9% Montana $370,152 $0.37 -22.4% $331,730 -30.5% Nebraska $510,330 $0.28 40.7% $457,358 26.1% Nevada $243,043 $0.09 -39.8% $217,815 -46.0% New Hampshire $152,806 $0.12 -14.3% $136,945 -23.2% New Jersey $1,674,222 $0.19 13.7% $1,500,438 1.9% New Mexico $404,234 $0.19 -29.7% $362,275 -37.0% New York $6,254,499 $0.32 1.0% $5,605,282 -9.5% North Carolina $5,047,383 $0.52 21.9% $4,523,465 9.2% North Dakota $392,142 $0.57 8.2% $351,438 -3.0% Ohio $3,093,519 $0.27 12.3% $2,772,412 0.6% Oklahoma $943,683 $0.25 -45.0% $845,729 -50.7% Oregon $1,660,625 $0.43 -27.7% $1,488,252 -35.2% Pennsylvania $4,932,813 $0.39 -23.0% $4,420,787 -31.0% Rhode Island $1,112,095 $1.06 14.7% $996,660 2.8% South Carolina $699,924 $0.15 -78.4% $627,272 -80.7% South Dakota $356,310 $0.43 224.4% $319,325 190.7% Tennessee $942,160 $0.15 -51.2% $844,364 -56.3% Texas $3,158,658 $0.12 -15.3% $2,830,789 -24.1% Utah $807,119 $0.29 -9.3% $723,340 -18.7% Vermont $76,550 $0.12 -62.8% $68,604 -66.7% Virginia $2,726,596 $0.34 -14.8% $2,443,575 -23.6% Washington $1,519,356 $0.22 -54.1% $1,361,647 -58.8% West Virginia $1,290,213 $0.70 13.8% $1,156,289 2.0% Wisconsin $2,498,116 $0.44 5.3% $2,238,812 -5.7% Wyoming $62,558 $0.11 -13.9% $56,064 -22.8% U.S. Total $88,648,854 $0.28 -15.3% $79,447,103 -24.1% 67 Endnotes 1 njury: The Leading Cause of Death Among Persons I 17 Bicycle Related Injuries. 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