High-Visibility Enforcement for Seat Belts and Child Restraint and Booster Laws

[T]he most common high-visibility belt law enforcement method consists of short (typically lasting for two weeks), intense, highly publicized periods of increased belt law enforcement, frequently using checkpoints (in States where checkpoints are permitted), saturation patrols, or enforcement zones. These periods sometimes are called STEP waves (Selective Traffic Enforcement Programs) or blitzes but are now primarily conducted under NHTSA’s Click It or Ticket high-visibility enforcement program. NHTSA typically includes child restraint and booster seat use and enforcement as a part of their Click It or Ticket campaigns. (UNC Highway Safety Research Center, 2011, p. 2-36)

Effective, high-visibility communications and outreach are an essential part of successful seat belt law high-visibility enforcement programs ([Solomon, Chaudhary, and Cosgrove, 2004]) [and typically accompany CIOT enforcement efforts]. Paid advertising can be a critical part of the media strategy. Paid advertising brings with it the ability to control message content, timing, placement, and repetition ([Milano, McInturff, and Nichols, 2004]). (UNC Highway Safety Research Center, 2011, p. 2-25)


This method of highly publicized enforcement programs has been used in conjunction with mandatory restraint laws starting in Canada in the 1980s (Boase, Jonah, and Dawson, 2004; UNC Highway Safety Research Center, 2011, p. 2-19). After a conference sponsored by NHTSA in 1996, the National Safety Council (NSC) and the National Transportation Safety Board (NTSB) suggested using high-visibility enforcement of existing occupant-protection laws as a strategy to immediately increase seat belt and child restraint use (Milano, McInturff, and Nichols, 2004). North Carolina implemented a statewide program in 1993 using the CIOT slogan (Reinfurt, 2004; UNC Highway Safety Research Center, 2011, p. 2-19), which was “subsequently adopted in other States under different names and sponsors ([Solomon, Compton, and Preusser, 2004])” (UNC Highway Safety Research Center, 2011, p. 2-19). In 2000, South Carolina became the first state to use paid media to publicize a CIOT program, which increased seat belt use statewide (Milano, McInturff, and Nichols, 2004). NHTSA coordinated CIOT messaging in an eight-state region the following year, and the national program adopted the CIOT slogan by 2003 (Milano, McInturff, and Nichols, 2004). “NHTSA’s Click It or Ticket high-visibility enforcement model is described in detail in [Solomon, Chaudhary, and Cosgrove, 2004] and Solomon, Chaffe, and Cosgrove (2007)” (UNC Highway Safety Research Center, 2011, p. 2-19).


Most States currently conduct short-term, high-visibility belt law enforcement programs in May of each year as part of national seat belt mobilizations [supported by NHTSA] ([Solomon, Compton, and Preusser, 2004]; [Solomon, Chaffe, and Cosgrove, 2007]). In previous years, two mobilizations were conducted each year, in May and November [around the Memorial Day and Thanksgiving holiday weekends]. (UNC Highway Safety Research Center, 2011, p. 2-19)

These enforcement programs apply to both adult seat belt use and child restraint use, although proper child restraint use may be more difficult for enforcing officers to assess.

Approximately 10,000 law enforcement agencies took part in the national May 2007 campaign ([Solomon, Preusser, et al., 2009]) [the most recent year for which such data are available]. . . . All high-visibility enforcement programs include communications and outreach strategies that use some combination of earned media (news stories) and paid advertising. Communications and outreach can be conducted at local, State, regional, or national levels. . . . See [Milano, McInturff, and Nichols, 2004] for a detailed account of the history and evolution of the national campaigns. (UNC Highway Safety Research Center, 2011, p. 2-19, 2-25)


The majority of studies have assessed the effect that high-visibility enforcement programs have on seat belt use.

CDC’s systematic review of 15 high-quality studies (Dinh-Zarr et al., 2001; Shults et al., 2004) found that short-term, high-visibility enforcement programs increased belt use by about 16 percentage points, with greater gains when pre-program belt use was lower. CDC noted that many of the studies were conducted when belt use rates were considerably lower than at present, so that new programs likely will not have as large an effect. Belt use often dropped by about 6 percentage points after the enforcement program ended. Short-term, high-visibility enforcement programs thus typically have a ratchet effect: belt use increases during and immediately after the program and then decreases somewhat, but remains at a level higher than the pre-program belt use. (UNC Highway Safety Research Center, 2011, p. 2-19)

Between 2002 and 2005, NHTSA evaluated the effects Click It or Ticket campaigns [had] on belt use in the States. In 2002, belt use increased by 8.6 percentage points across 10 States that used paid advertising extensively in their campaigns. Belt use increased by 2.7 percentage points across 4 States that used limited paid advertising and increased by 0.5 percentage points across 4 States that used no paid advertising ([Solomon, Ulmer, and Preusser, 2002]). (UNC Highway Safety Research Center, 2011, p. 2-19)

Year-by-year results are summarized below.

As discussed in the discussion of the high-visibility seat belt enforcement intervention in the Countermeasures That Work report, NHTSA’s May 2002 CIOT campaign evaluation included observed seat belt use, motorist attitudes, and program knowledge and recall in 18 states at various stages of implementation of the CIOT program. In addition to a small amount of free and earned media, most states (14 of 18) bought advertisement placement—radio advertisement during rush-hour commutes and television ads during prime viewership times—that ran the week before and the first week of enforcement.

The 2003 campaign used extensive paid advertising: about $8 million nationally and $16 million in individual States ([Solomon, Chaudhary, and Cosgrove, 2004], Technical Summary). The advertising strongly supported the campaign with clear enforcement images and messages. Nationally, belt use following the 2003 campaign was 79 percent compared to 75 percent at the same time in 2002 (Glassbrenner, 2005). Twenty-eight States conducted small belt use surveys immediately before the May 2003 campaign. Across these States, belt use was 75.2 percent in 2002, 72.8 percent before the 2003 campaign and 78.5 percent immediately after the campaign. These results show the typical ratchet effect, with belt use dropping gradually after the 2002 campaign and then rising rapidly immediately after the 2003 campaign to a higher level than after the previous campaign ([Solomon, Chaudhary, and Cosgrove, 2004], Chapter IV). (UNC Highway Safety Research Center, 2011, pp. 2-20)

“[Milano, McInturff, and Nichols, 2004] summarize an extensive amount of information from national telephone surveys conducted in conjunction with each national campaign from 1997 through 2003” (UNC Highway Safety Research Center, 2011, p. 2-25). These findings included an increase of 21 percentage points in the number of people who saw, read, or heard about the enforcement efforts (from 43 percent to 64 percent) and a five-fold increase in recall of the CIOT message (from 3 percent to 15 percent).

The 2004 campaign increased paid advertising to about $12 million nationally and $20 million in the States ([Solomon, Chaffe, and Cosgrove, 2007]). As in 2003, the advertising strongly supported enforcement activities. Belt use nationally reached 80 percent following the campaign (Glassbrenner, 2005). Across the 50 States and the District of Columbia, belt use increased in 42 jurisdictions compared to the same time in 2003. When averaged across all 51 jurisdictions, belt use increased by 2.4 percentage points ([Solomon, Chaffe, and Cosgrove, 2007]). (UNC Highway Safety Research Center, 2011, p. 2-20)

For the 2005 campaign, paid media valued at $9.7 million nationally and $22 million in States delivered a strong enforcement related message. Overall, seat belt use rates improved in 2005 in a majority of States (35 of 47). The level of improvement was slightly higher among primary law States compared to secondary law States (+2.0 versus +1.2, median point change). Among 22 primary law States, 18 showed an increase while among 25 secondary enforcement States, 17 showed an increase (Solomon, Gilbert, et al., 2007). Nationally, the seat belt use increased to 82 percent in 2005. Activities were similar in 2006, with approximately $12 million in national paid advertising and $20 million in the States that year ([Tison, Solomon, et al., 2008]). National Click It or Ticket activities in 2007 were again similar and observed seat belt use remained at 82 percent through 2007. As of 2007, 12 States had achieved seat belt use rates of 90 percent or higher (Solomon, Preusser, et al., 2009). (UNC Highway Safety Research Center, 2011, p. 2-20)

Hedlund, Gilbert, et al., 2008, compared 16 states with high seat belt use rates and 15 states with low seat belt use rates. The single most important difference between the two groups was the level of enforcement, not demographic characteristics or the amount spent on media. Higher enforcement in high-use states resulted in those states issuing “twice as many citations per capita during their Click It or Ticket campaigns” as low-use states (UNC Highway Safety Research Center, 2011, p. 2-20). This was credited to more-vigorous law enforcement and the presence of primary enforcement of seat belt laws in the high-use states.

Few studies have examined the effectiveness of high-visibility enforcement programs on child passenger safety.

Pilot programs conducted in 1989 in eight communities demonstrated the potential effectiveness of child passenger safety law enforcement ([NHTSA, undated (b)]). The enforcement efforts increased the correct use of child restraints in the demonstration sites; the use of seat belts by older children also increased. In their systematic review of evidence of effectiveness for child restraint interventions, Zaza et al. (2001) determined that community-wide information plus enhanced enforcement campaigns were effective in increasing child restraint use. One study evaluated the effects of Tennessee’s “booster” provisions that added new requirements for 4- to 8-year-olds in 2005 ([Gunn, Phillippi, and Cooper, 2007]). Pre- and post-law observational survey data revealed a significant increase in booster seat use among 4- to 8-year-olds from 29 to 39 percent. [Decina, Lococo, et al., 2008] reported that an observational study conducted to evaluate a demonstration program found a 9-percentage-point increase in the use of child restraints, including booster seats [from 48.6 percent to 57.7 percent] for children age 4 to 8 following enactment of an enhanced child restraint law (booster seat law) in Wisconsin. (UNC Highway Safety Research Center, 2011, p. 2-36)

Recent Research on Effectiveness

Vasudevan et al., 2009, examined the effectiveness of three CIOT enforcement campaigns in Nevada, a secondary seat belt state, and found a significant increase of observed seat belt use for drivers and passengers in the period following each campaign. These increases ranged from 3 to 8 percentage points. Another CIOT intervention in Utah increased observed seat belt use by 8.3 percentage points, from 76.5 percent one week before enhanced enforcement to 84.8 percent one week after enhanced enforcement (Thomas, Cook, and Olson, 2011).

In Nevada, a media campaign around the state’s 2004 CIOT intervention resulted in 58 percent of respondents in a telephone survey being aware of the enhanced enforcement efforts. The majority (63 percent) indicated that they knew about the campaign because of a television message (Vasudevan et al., 2009).

Measuring Effectiveness

The effectiveness of short-term, high-visibility seat belt law enforcement is typically measured through changes in the percentage of people using proper restraints. Both observational and self-report measures can be used. Because evaluations of these campaigns are so time-sensitive and use typically drops following the campaign, effectiveness of this intervention cannot always be captured through annual surveys of seat belt use, such as NOPUS or BRFSS.

Other measures can be used to assess the effectiveness of high-visibility campaigns, although these typically focus on seat belt use and do not include measures for child restraints. Changes in seat belt use can also be measured by comparing the proportion of fatally injured front-seat occupants wearing seat belts before and after a campaign; however, such a measure is confounded because seat belts can prevent fatal injuries. Time-series analyses have been used to project the number of fatalities and injuries prevented with CIOT programs, although this is less common in the literature (Solomon, Preusser, et al., 2009; Tison and Willams, 2010).

In addition, the number of citations for seat belt and child restraint use during the campaign is easily calculated through police records. Media penetration or awareness of the campaign, captured through telephone surveys or street surveys, can also measure the effectiveness of the campaign.


High-visibility enforcement campaigns are expensive. They require extensive time from State highway safety office and media staff and often from consultants to develop, produce, and distribute publicity and time from law enforcement officers to conduct the enforcement. (UNC Highway Safety Research Center, 2011, p. 2-20)

In Nevada, overtime funding for enforcement costs approximately $213,000 to $321,000 for each statewide campaign during the years 2003–2005 (Vasudevan et al., 2009). Paid advertising, which increases a campaign’s effectiveness, costs for CIOT campaigns targeted at seat belt use for the general population “were about $125,000 per State for the 2002 campaign and over $400,000 in 2004 ([Solomon, Chaffe, and Cosgrove, 2007])” (UNC Highway Safety Research Center, 2011, p. 2-20).

Time to Implement

“A high-visibility enforcement program [and accompanying media campaign] require 4 to 6 months to plan and implement” (UNC Highway Safety Research Center, 2011, p. 2-20).

Other Issues

Effects in States with Primary and Secondary Enforcement of Seat Belt Laws

High-visibility enforcement campaigns are effective in both primary and secondary law States. NHTSA’s 2003 evaluation found that belt use increased by 4.6 percentage points across the primary law States and by 6.6 percentage points across the secondary law States; the primary law States had higher use rates before the campaigns ([Solomon, Chaudhary, and Cosgrove, 2004]; see also Nichols, 2002). The 2004 evaluation found that the campaign increased belt use in 25 secondary jurisdictions by an average of 3.7 percentage points. Belt use decreased in the remaining 5 jurisdictions by an average of 2.3 percentage points ([Solomon, Chaffe, and Cosgrove, 2007]). (UNC Highway Safety Research Center, 2011, pp. 2-20–2-21)

Effects on Low-Belt-Use Groups

CDC’s systematic review observed that short-term, high-visibility enforcement campaigns increased seat belt use more among traditionally lower-belt-use groups, including young drivers, rural drivers, males, African-Americans, and Hispanics, than among higher-belt-use drivers such as older drivers, suburban drivers, females, and Caucasians (Shults et al., 2004). NHTSA’s Region 5 implemented a Rural Demonstration Program (RDP) prior to the May 2005 Click It or Ticket (CIOT) mobilization. The goal of the RDP was to evaluate strategies for increasing seat belt usage in rural areas. Paid media was used to notify rural residents that seat belt laws were being enforced. Active enforcement was included during the initial phase in three of the six Region 5 States (Illinois, Indiana, Ohio), but only the paid media component was implemented in the remaining three States (Minnesota, Michigan, Wisconsin). During the RDP phase, States that had intensified enforcement had significant increases in usage in their rural targeted areas. All six Region 5 States intensified enforcement during the CIOT mobilization, but States that had intensified enforcement during RDP showed substantially greater overall statewide gains during the CIOT phase than did the States that had not intensified enforcement during the Rural Demonstration Program ([Nichols, Ledingham, and Preusser, 2007]). (UNC Highway Safety Research Center, 2011, p. 2-21)

Barriers to Enhanced Enforcement Programs for Child Restraints

[Decina, Lococo, et al., 2008] concluded that barriers to enhanced enforcement programs, especially as related to booster seats, include: parent/caregiver ignorance of child restraint laws; low perception of risk to child passengers; lack of knowledge about the safety benefits of booster seats among the public; lack of knowledge about the safety benefits of booster seats among law enforcement officers and members of the courts; low threat of being ticketed for violations; and lack of commitment to child passenger safety by law enforcement top management. (UNC Highway Safety Research Center, 2011, p. 2-36)

Strategies to Enhance Enforcement Programs for Child Restraints

[NHTSA (undated [b])] suggests that in order to maximize child restraint enforcement efforts, certain activities should be part of the overall program. These are: media coverage of enforcement and public information activities by the local press and radio and television stations; training of law enforcement officers in the benefits of child passenger protection and methods of effective law enforcement; information activities targeted to target audiences; information activities coinciding with community events; child restraint distribution programs; and public service announcements and other media coverage. [Decina, Hall, and Lococo, 2010] found that most effective approaches for enforcing booster seat laws depend on top management support to enforce these laws, having resources to support dedicated booster seat law enforcement programs, and enforcement methods that are dedicated to booster seat and other child restraint laws. (UNC Highway Safety Research Center, 2011, p. 2-37)

State Use

There is no definitive source of information regarding the use of CIOT on a state-by-state basis. According to NHTSA, all states have participated in the annual mobilization since 2004 (NHTSA, undated [a]). However, the number of states conducting additional mobilizations is unavailable without state-by-state research.

CDC Vital Signs: Motor Vehicle Crash Deaths. In 2013, the US crash death rate was more than twice the average of other high-income countries. www.cdc.gov/vitalsigns/motor-vehicle-safety