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Perspectives in Disease Prevention and Health Promotion Seat Belt Use -- United States

In surveys conducted from 1981 to 1983, 76% of the U.S. adult population reported that they did not use seat belts (i.e., used seat belts sometimes, seldom, or never) (1). The percentages of men and women who did not use seat belts were similar, but the percentages were significantly higher for people who were younger, who were black, and who had completed fewer years of education. These differences persisted after adjusting for the other demographic characteristics (Table 1). The percentage of persons who did not use seat belts also varied widely by state, ranging from 68% in California to 89% in Arkansas (Figure 1). Persons who exhibited another particular risk behavior, i.e., smoking, binge drinking, chronic drinking, drunk driving, overweight, or inactivity, were significantly more likely to report not using seat belts than persons who did not exhibit that particular risk behavior. For example, 80% of smokers did not use seat belts, compared with 74% of nonsmokers (p 0.05).

These data were collected in the first phase of the Behavioral Risk Factor Surveillance System, a state-based surveillance system designed to monitor the prevalence of behavioral risk factors, such as smoking and failure to use seat belts. Twenty-eight states and the District of Columbia conducted population-based telephone surveys. A supplemental survey completed coverage of the remaining states. Reported by Behavioral Epidemiology and Evaluation Br, Div of Health Education, Div of Nutrition, Center for Health Promotion and Education, Div of Injury Epidemiology and Control, Center for Environmental Health, Office of Program Planning and Evaluation, Office of the Director, Div of Safety Research, National Institutes for Occupational Safety and Health, CDC.

Editorial Note

Editorial Note: Injuries from motor vehicle collisions (MVCs) are the fourth leading cause of death in the United States (2). In 1984, the most recent year for which complete data are available, 36,271 occupants of motor vehicles (including motorcycles) died on U.S. highways (3). Of these, 14,528 (28%) were under 25 years old, making MVC-associated injuries the leading cause of death among persons aged 5-24 years. In 1984, MVC-associated mortality among persons aged 15-24 years, 36.5 per 100,000, was nearly three times that associated with any other cause and accounted for more than one-third the total mortality in this age group (2). Because MVCs affect the young disproportionately, injuries from MVCs are the third leading cause of years of potential life lost (see Table V, p. 311). For 1984, MVC-associated injuries resulted in 1.3 million years of potential life lost before age 65. In addition, injuries from MVCs accounted for 27% of the occupational fatalities in 1984 (4). Of the estimated $33 billion in direct and indirect costs for occupational injuries in 1984 (5), $11 billion may be attributable to injuries from MVCs.

During 1982-1984, highway fatalities among occupants of passenger vehicles (excluding motorcycles, trucks, and buses) remained essentially unchanged in the United States (3,6,7). Throughout this period, occupant restraints were used by fewer than 6% of fatally injured persons. Nationwide data for 1985, the first year any state required seat belt use by adults, are not yet available.

Twenty-three states* and the District of Columbia have passed seat belt mandatory-use laws (MULs) for adults; 11 states** are already enforcing their laws with fines. Observational surveys in New York, Michigan, and Nebraska suggest that such laws increase seat belt usage initially (8-10). In New York, for example, observational surveys found that the prevalence of seat belt use increased from 16% before the law took effect to 57% 3 months after the law took effect, this prevalence declining to 46% 9 months after the law took effect. Additional surveys are needed to monitor the long-term impact of the laws.

The observational surveys used to assess the impact of the laws are complemented by self-report surveys, such as the Behavioral Risk Factor Surveys. Self-report surveys underestimate observed failure to use seat belts (11,12), but they can provide detailed demographic and behavioral data. Such data can be useful for planning intervention strategies. Currently, 25 states and the District of Columbia are participating in the Behavioral Risk Factor Surveillance System. In selected states, it will soon be possible to compare demographic characteristics of persons not using seat belts before and after MULs were enforced.

Regardless of how seat belt usage is measured, the goal of intervention is to reduce morbidity and mortality on U.S. highways. MULs appear to have lowered fatalities during the first few months of their enforcement. The New York State Department of Motor Vehicles reported that occupant fatalities decreased 17% for the first 9 months after New York's law was enforced, for the lowest highway fatality rate (per 100 million miles driven) in several decades. If all states enacted MULs, if all states experienced a decrease in highway fatalities comparable to that in New York, and if the decrease in highway fatalities persisted, approximately 4,000 lives could be saved nationwide each year.

Injury data are not currently available for states with MULs. However, the experience in Great Britain strongly suggests that the incidence of severe injuries is reduced by such laws. During 1983, the first year after the British law went into effect, 15% fewer patients were brought to the hospital following MVCs, and 25% fewer required admission than during the preceding year (13).

Nonetheless, MULs alone will not eliminate injuries and deaths on U.S. highways. Better enforcement of existing speeding and drunk-driving laws, augmentation of seat belts with passive restraints (e.g., air bags) and other vehicle-design changes to maximize occupant protection, improved engineering of highways to minimize crash occurrence, and effective public education about all aspects of highway safety are needed to reduce highway fatalities.


  1. Goldbaum GM, Remington PL, Powell KE, Hogelin GC, Gentry EM, The Behavioral Risk Factor Surveys Group. Failure to use seat belts in the United States. The 1981-1983 Behavioral Risk Factor Surveys. JAMA 1986;255:2459-62.

  2. National Center for Health Statistics. Annual summary of births, marriages, divorces, and deaths: United States, 1984. Monthly Vital Statistics Report 1985;33:20-1.

  3. National Center for Statistics and Analysis. Fatal Accident Reporting System, 1984. Washington, D.C.: National Highway Traffic Safety Administration, February 1986 (DOT publication no. HS-806-919).

  4. Bureau of Labor Statistics. Occupational injuries and illnesses in the United States, by industry, 1984. Washington, D.C.: U.S. Department of Labor, November 1985 (USDL publication no. 85-483).

  5. National Safety Council. Accident facts, 1985. Chicago, Illinois: National Safety Council, 1985.

  6. National Center for Statistics and Analysis. Fatal Accident Reporting System, 1982. Washington, D.C.: National Highway Traffic Safety Administration, May 1984 (DOT publication no. HS-806-566).

  7. National Center for Statistics and Analysis. Fatal Accident Reporting System, 1983. Washington, D.C.: National Highway Traffic Safety Administration, March 1984 (DOT publication no. HS-806-705).

  8. Rood DH, Kraichy PP, Carubia J. Evaluation of New York State's mandatory occupant restraint law: observational surveys of safety restraint use in New York State. Albany, New York: Institute for Traffic Safety Management and Research, December 1985.

  9. Wagenaar AC, Wiviott MBT. Direct observation of seat belt use in Michigan, July 1985. Ann Arbor, Michigan: University of Michigan Transportation Research Institute, August 1985.

  10. Williams JB. Safety restraint observation study of front seat passengers and small children. Lincoln, Nebraska: State of Nebraska Office of Highway Safety, December 1985.

  11. Waller PF, Barry PZ. Seat belts: a comparison of observed and reported use. Chapel Hill, North Carolina: University of North Carolina Highway Safety Research Center, 1969.

  12. Mayas JM, Boyd NK, Collins MA, et al. A study of demographic, situational, and motivational factors affecting restraint usage in automobiles. Washington, D.C.: National Highway Traffic Safety Administration, 1983 (DOT publication no. HS-806-402).

  13. Rutherford WH, Greenfield T, Hayes HRM, et al. The medical effects of seat belt legislation in the United Kingdom. London: Her Majesty's Stationery Office, 1985.

*California, Connecticut, Hawaii, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Tennessee, Texas, Utah, and Washington. **California, Connecticut, Hawaii, Illinois, Massachusetts, Michigan, Nebraska, New Jersey, New Mexico, New York, and Texas.

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