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Motor Vehicle Policy Brief

Passenger Vehicle Occupant (PVO) Deaths and Seat Belt Use among Rural Americans

CDC policy briefs provide a summary of evidence-based best practices or policy options for a public health issue. They also include information on the background and significance of the issue as well as current status and potential next steps. This policy brief is part of a series accompanying CDC’s Morbidity and Mortality Weekly Reports on rural health.


Motor vehicle crashes are a leading cause of death nationwide. Increasing seat belt use is an evidence-based strategy to prevent passenger vehicle occupant (PVO) deaths and has been shown to reduce the risk of serious injury or death by about 50%.[1] While less than 20% of the US population lives in rural areas, more than half of all passenger vehicle occupant deaths occur on rural roads.[2] This policy brief is a companion to CDC’s Morbidity and Mortality Weekly publication, Rural and Urban Differences in Passenger-VehicleOccupant Deaths and Seat Belt Use Among Adults United States, 2014 and will explore policy options that may increase seat belt use among vulnerable rural populations. The brief also includes three case studies that present examples from the field.

Issue Overview

Data from the MMWR demonstrate that people living in rural areas have higher rates of PVO deaths and a higher proportion of unrestrained deaths.[3] Rural residents consistently self-report significantly lower levels of seat belt use than their urban counterparts.[3]  These data highlight the need to improve motor vehicle safety and seat belt use among rural residents.

While there is evidence demonstrating the effectiveness of these polices in increasing seat belt use[4],[5], more information is needed to understand how to effectively target rural populations and reduce the seat belt use disparity.

There are several policy options that can be used to increase seat belt use by rural residents including:

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Primary enforcement state laws requiring seat belt use in the front and rear seats

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Enhanced/high visibility enforcement campaigns (such as Click It or Ticket)

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Policy Options

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Primary Enforcement Seat Belt Laws

Implementing and enforcing state seat belt laws is an effective strategy to increase seat belt use.[4],[5] There are two types of seat belt enforcement laws: primary (police officers can issue a ticket for failure to wear a seat belt even if that is the only violation) and secondary (police officers can issue a ticket only if another violation has occurred.)[6]

Primary enforcement, in comparison to secondary enforcement, has been associated with increased seat belt use and reduced crash deaths. Self-reported seat belt use in states with primary enforcement laws is 8 percentage points higher than in states with secondary enforcement.)[3] As of 2017, 34 states and the District of Columbia have primary enforcement laws and 15 states have secondary enforcement laws. One state, New Hampshire, has no laws regarding seat belt use for adults.[6]

Primary enforcement has been associated with higher seat belt use than secondary enforcement for all drivers and passengers covered by the law,5 and the MMWR findings indicate a similar effect among adults living in rural areas. Rural adults who live in states with primary enforcement laws have significantly higher seat belt use than rural adults who live in states with secondary enforcement laws.[3] Primary enforcement laws are one strategy that states can consider to begin to close the gap in seat belt use between rural and urban adults.

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Enhanced Enforcement

Enhanced enforcement programs are coordinated, highly publicized efforts to either increase the average number of citations each officer issues, increase the number of officers on patrol, use seat belt checkpoints, or some combination of those activities.[4],[5] Enhanced enforcement is accompanied by communications and outreach activities which are intended to raise awareness about enforcement of seat belt laws .[4],[5]

Targeted communications and outreach campaigns are often used in conjunction with other enforcement activities. They can increase awareness about upcoming enhanced enforcement campaigns and focus on reasons to wear a seat belt. The messages are often specifically designed to appeal to low-use populations.

Evidence has shown that enhanced enforcement is effective at increasing seat belt use and reducing injuries.[4] In addition, enhanced enforcement has been successfully executed in rural areas including a rural demonstration program initiated by three southeastern states.[7]

Case Studies

San Carlos Apache Tribe: Moving From Secondary to Primary Seat Belt Law[8]

In 2012, the San Carlos Apache Tribe passed a primary occupant restraint law that was more strict than the State’s existing secondary law. After the enactment of the law, the San Carlos Police Department was given a three month transition period to prepare itself and the public for enforcement of the new law. Activities during this grace period included: educating the public about the new law and the importance of wearing seat belts as well as training enforcement staff. Warning citations were issued for violations during this grace period with full enforcement beginning three months after enactment of the law. Observed seat belt use increased during the grace period and continued to increase with full enforcement of the new law.

Idaho Strategic Messaging and Enhanced Enforcement Campaign[9]

Idaho created messaging targeted at rural families and young males using a “family values” message that emphasized the importance of protecting family members by encouraging seat belt use. In addition, supporting law enforcement agencies to increase their buy-in and collaboration was a key component of the enhanced enforcement and awareness activities. Participating law enforcement agencies received supportive training as well as overtime pay or new speed detection equipment for increasing their seat belt-focused patrols.   The project included three strategies that were only carried out in Eastern Idaho including: providing a law enforcement liaison to help improve traffic stops, newspaper articles including local statistics on serious injuries.


[1] National Highway Traffic Safety Administration. Fourth report to Congress: effectiveness of occupant protection systems and their use. Washington, DC: US Department of Transportation; 1999.

[2] National Highway Traffic Safety Administration. Traffic safety facts 2015 data: passenger vehicles. Washington, DC: National Highway Traffic Safety Administration; 2017.,External

[3] Beck, L. F., Downs, J., Stevens, M. R., & Sauber-Schatz, E. K. Rural and Urban Differences in Passenger Vehicle Occupant Deaths and Seat Belt Use Among Adults, United States, 2014. MMWR Surveill Summ 2017.

[4] Dinh-Zarr TB, Sleet DA, Shults RA, Zaza S, Elder RW, Nichols JL, et al. Reviews of evidence regarding interventions to increase the use of safety belts. Am J Prev Med. 2001;21(4 Suppl):48–65.

[5] Goodwin, A., Thomas, L., Kirley, B., Hall, W., O’Brien, N., & Hill, K. (2015, November). Countermeasures that work: A highway safety countermeasure guide for State highway safety offices, Eighth edition. (Report No. DOT HS 812 202). Washington, DC: National Highway Traffic Safety Administration.

[6] Insurance Institute for Highway Safety. Safety Belts and Child Safety Seats. 2017. Available at

[7] Nichols, J. L., Chaffe, R., Solomon, M. G. & Tison, J. (2016, September). Evaluation of a Rural Seat Belt Demonstration Program in Florida, Georgia, and Tennessee. (Report No. DOT HS 812 328). Washington, DC: National Highway Traffic Safety Administration.

[8] Letouneau, R.J. & Crump, C.E. (2016) Tribal Motor Vehicle Injury Prevention (TMVIP) Best Practices Guide. Chapel Hill: Gillings School of Global Public Health.  (Developed for Centers for Disease Control and Prevention.)

[9] Blomberg, R. D., Thomas, F. D., & Cleven, A. M. (2008, August). Increasing Seat Belt Use Through State-Level Demonstration Projects: A Compendium of Initial Findings (Report No. DOT HS 811 014). Washington, DC: National Highway Traffic Safety Administration

Page last reviewed: September 20, 2017