Motor Vehicle Injury Safety Belts: Laws Mandating Use

The CPSTF finding is based on evidence from a systematic review of 33 studies (search period through June 2000).

The review was conducted on behalf of the CPSTF by scientists from CDC’s Division of Unintentional Injury Prevention with input from a team of specialists in systematic review methods and experts in research, practice and policy related to motor vehicle injury prevention.

As of June 2017, there are seat belt laws in 49 states, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands. New Hampshire, which does not have a seat belt law, does have a child passenger safety law that covers all drivers and passengers under 18 years of age. Current figures are available from the Governors Highway Safety Administration.

More details about study results are available in the published evidence review..

The systematic review included 33 studies.

• Fatal injuries decreased by a median of 9% (6 studies).
• Nonfatal injuries decreased by a median of 2% (6 studies).
• Fatal and nonfatal injuries combined decreased by a median of 8% (9 studies).
• Observed safety belt use increased by a median of 33 percentage points (10 studies).
• Police-reported safety belt use increased by 26 percentage points (2 studies).
• Self-reported safety belt use increased by a median of 16 percentage points (4 studies)

An economic review of this intervention did not find any relevant studies.

Results from this review should be applicable to adolescents and adults, as most of the included studies looked at motor vehicle occupants who were at least 16 years old.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• How do the level of enforcement and publicity influence the effectiveness of safety belt laws?
• Does the severity of fines have any bearing on the effectiveness of the laws?
• Do other penalties (e.g., license demerits) add to the effectiveness of the laws?
• Do exemptions for certain vehicles and occupants reduce the effectiveness of the laws?
• What are the cost-benefit, cost utility, and cost-effectiveness of interventions to increase safety belt use?

Included studies used self-reported and observational data.

Dinh-Zarr TB, Sleet DA, Shults RA, et al. Reviews of evidence regarding interventions to increase use of safety belts. American Journal of Preventive Medicine. 2001;21(4S):48-65.

Task Force on Community Services. Recommendations to reduce injuries to motor vehicle occupants: increasing child safety seat use, increasing safety belt use, and reducing alcohol-impaired driving. American Journal of Preventive Medicine. 2001;21(4S):16-22.

Zaza S, Carande-Kulis VG, Sleet DA, et al. Methods for conducting systematic reviews of the evidence of effectiveness and economic efficiency of interventions to reduce injuries to motor vehicle occupants. American Journal of Preventive Medicine. 2001;21(4S):23-30.

Centers for Disease Control and Prevention. Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving. MMWR. 2001;50(RR-7):1-13. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5007a1.htm.

Sleet DA, Branche CM. Road Safety is No Accident. Proceedings from a Symposium on High Visibility Enforcement – Building Sustained Safety Belt Use. Journal of Safety Research. 2004;35(2):173-4. Available at: http://www.sciencedirect.com/science/article/pii/S0022437504000295.

Zaza S, Sleet DA, Elder RW, Shults RA, Dellinger A, Thompson RS. Response to letter to the editor. American Journal of Preventive Medicine. 2002;22:330-1.

Sleet DA. Evidence based injury prevention: guidance for community action. In: Australian Third National Conference on Injury Prevention and Control. Australian Third National Conference on Injury Prevention and Control. Brisbane, Queensland, Australia; 1999.

Webb M. Research as an advocate’s toolkit to reduce motor vehicle occupant deaths and injuries. American Journal of Preventive Medicine. 2001;21(4S):7-8.

Waller PF. Public health’s contribution to motor vehicle injury prevention. American Journal of Preventive Medicine. 2001;21(4S):3-4.

Satcher D. Note from the Surgeon General. American Journal of Preventive Medicine. 2001;21(4S):1-2.

Novick LF, Kelter A. Guide to Community Preventive Services: a public health imperative. American Journal of Preventive Medicine. 2001;21(4S):13-15.

Moffat J. Motor vehicle occupant injury prevention: the states’ perspective. American Journal of Preventive Medicine. 2001;21(4S):5-6.

Miller TR. The effectiveness review trials of Hercules and some economic estimates for the stables. American Journal of Preventive Medicine. 2001;21(4S):9-12.

Task Force on Community Services, Zaza S, Briss PA, Harris KW. Motor vehicle occupant injury. In: The Guide to Community Preventive Services: What Works to Promote Health?. The Guide to Community Preventive Services: What Works to Promote Health? Atlanta (GA): Oxford University Press; 2005:329-84.

Effectiveness Review

Analytic Framework see Figure 1 on page 49

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Barancik JI, Kramer CF, Thode HC Jr, Harris D. Efficacy of the New York State seat belt law: preliminary assessment of occurrence and severity. Bull N Y Acad Med 1988;64:742 9.

Beaton SJ, Pearson GL, Arnegard RJ, Quinn KD. A field evaluation of the effectiveness of the Virginia safety belt law. Forensic Rep 1988;1:229 36.

Bernstein E, Pathak D, Rutledge L, Demarest G. New Mexico safety restraint law: changing patterns of motor vehicle injury, severity, and cost. Am J Emerg Med 1989;7:271 7.

Brillhart BA, Jay HM. The impact of Texas state legislation on the use of safety belts. Rehabil Nurs 1988;13:146 9.

Campbell BJ, Stewart JR, Reinfurt DW. Change in injuries associated with safety belt laws. Accid Anal Prev 1991;23:87 93.

Chorba TL, Reinfurt D, Hulka BS. Efficacy of mandatory seat-belt use legislation. The North Carolina experience from 1983 through 1987. JAMA 1988;260:3593 7.

Cope JG, Johnson AW, Grossnickle WF. Behavior engineering proposals: 3. Effects on drivers and passengers of a mandatory use law for safety belts. Percept Mot Skills 1990;71:291 8.

Desai A, You MB. Policy implications from an evaluation of seat belt use regulation. Eval Rev 1992;16:247 65.

Dodson TB, Kaban LB. California mandatory seat belt law: the effect of recent legislation on motor vehicle accident related maxillofacial injuries. J Oral Maxillofac Surg 1988;46:875 80.

Escobedo LG, Chorba TL, Remington PL, Anda RF, Sanderson L, Zaidi AA. The influence of safety belt laws on self-reported safety belt use in the United States. Accid Anal Prev 1992;24:643 53.

Fielding JE, Knight KK, Goetzel RZ. The impact of legislation on self-reported safety belt use in a working population. J Occup Med 1992;34:715 7.

Kalfus GR, Ferrari JR, Arean P, et al. An examination of the New York mandatory seat belt law on a university campus. Law Hum Behav 1987;11:63 7.

Legge JS Jr. Reforming highway safety in New York state: an evaluation of alternative policy interventions. Soc Sci Q 1990;71:373 82.

Lestina DC, Williams AF, Lund AK, Zador P, Kuhlmann TP. Motor vehicle crash injury patterns and the Virginia seat belt law. JAMA 1991;265:1409 13.

Loeb PD. Effectiveness of seat belt legislation in reducing various driver-involved injury rates in California. Accid Anal Prev 1993;25:189 97.

Loeb PD. The effectiveness of seat belt legislation in reducing injury rates in Texas. Am Econ Rev 1995;85:81 4.

Lund AK, Pollner J, Williams AF. Preliminary estimates of the effects of mandatory seat belt use laws. Accid Anal Prev 1987;19:219 23.

Margolis LH, Bracken J, Stewart JR. Effects of North Carolina’s mandatory safety belt law on children. Inj Prev 1996;2:32 5.

Pace BW, Thailer R, Kwiatkowski TG. New York State mandatory seatbelt use law: patterns of seatbelt use before and after legislation. J Trauma 1986;26:1031 3.

Preusser DF, Lund AK, Williams AF, Blomberg RD. Belt use by high-risk drivers before and after New York’s seat belt use law. Accid Anal Prev 1988;20:245 50.

Preusser DF, Williams AF, Lund AK. The effect of New York’s seat belt use law on teenage drivers. Accid Anal Prev 1987;19:73 80.

Reinfurt DW, Campbell BJ, Stewart JR, Stutts JC. Evaluating the North Carolina safety belt wearing law. Accid Anal Prev 1990;22:197 210.

Russell J, Kresnow M, Brackbill R. Effect of adult belt laws and other factors on restraint use for children under age 11. Accid Anal Prev 1994;26:287 95.

States JD, Annechiarico RP, Good RG, et al. A time comparison study of the New York State safety belt use law utilizing hospital admission and police accident report information. Accid Anal Prev 1990;22:509 21.

Streff F, Wagenaar AC, Schultz RH. Reductions in police-reported injuries associated with Michigan’s safety belt law. J Safety Res 1990;21:9 18.

Thyer BA, Robertson M. An initial evaluation of the Georgia safety belt use law: a nul MUL?Environment Behav 1993;25:506 13.

Tipton RM, Camp CC, Hsu K. Effects of mandatory seat belt legislation on self-reported seat belt use among male and female college students. Accid Anal Prev 1990;22:543 8.

Ulmer RG, Preusser CW, Preusser DF, Cosgrove LA. Evaluation of California’s safety belt law change from secondary to primary enforcement. J Safety Res 1995;26:213 20.

Wagenaar AC, Margolis LH. Effects of a mandatory safety belt law on hospital admissions. Accid Anal Prev 1990;22:253 61.

Wagenaar AC, Maybee RG, Sullivan KP. Mandatory seat belt laws in eight states: a time-series evaluation. J Safety Res 1988;19:51 70.

Wagenaar AC, Wiviott MB. Effects of mandating seatbelt use: a series of surveys on compliance in Michigan. Public Health Rep 1986;101:505 13.

Williams AF, Wells JK, Lund AK. Shoulder belt use in four states with belt use laws. Accid Anal Prev 1987;19:251 60.

Winnicki J. Safety belt use laws: evaluation of primary enforcement and other provisions. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 1995. DOT HS 808 324.

The following outlines the search strategy used for reviews of these interventions to increase use of safety belts: Laws Mandating Use; Primary (vs. Secondary) Enforcement Laws; Enhanced Enforcement Programs.

The reviews of interventions to reduce motor vehicle-related injury reflect systematic searches of multiple databases as well as reviews of reference lists and consultations with experts in the field. The team searched six computerized databases (MEDLINE, Embase, Psychlit, Sociological Abstracts, EI Compendex, and Transportation Research Information Services [TRIS]), which yielded 10,958 titles and abstracts for articles, book chapters, reports, and published papers from the Association for the Advancement of Automotive Medicine proceedings about safety belts, alcohol-impaired driving or child passenger safety. Studies were eligible for inclusion if:

• They were published from the originating date of the database through June 2000 (March 1998 for child safety seat interventions)
• They involved primary studies, not guidelines or reviews
• They were published in English
• They were relevant to the interventions selected for review
• The evaluation included a comparison to an unexposed or less-exposed population
• The evaluation measured outcomes defined by the analytic framework for the intervention

Search Strategy for Use of Safety Belts:

(MOTOR(W)VEHICLE?) OR AUTOMOBILE? OR CAR OR CARS OR TRUCK? OR (TRAFFIC(2N)(ACCIDENT? OR CRASH? OR DEATH? OR FATALIT? OR INJUR?))

AND

(SEAT(W)BELT?) OR SEATBELT? OR (SAFETY(W)RESTRAINT?) OR (SAFETY(W)BELT?) OR (OCCUPANT(W)RESTRAINT?) OR OCCUPANT(W)PROTECTION)

AND

INTERVENTION? OR OUTREACH? OR PREVENTION OR (COMMUNITY(3N)(RELATION? OR PROGRAM? OR ACTION)) OR DETERRENT? OR PROGRAM? OR LEGISLATION? OR LAW? OR EDUCATION OR DETERRENCE OR COUNSELING OR CLASS OR CLASSES OR TRAINING OR PROMOTION? OR BEHAVIOR?

NOT

PEDESTRIAN? OR MOTORCYCLE OR BICYCL? OR CYCLIST? OR (SCHOOL(W)BUS?) OR BUS OR BUSES OR AIRPLANE? OR AIR(W)TRANSPORTATION?) OR AVIATION? OR (AIR(W)TRAFFIC) OR (AIR(W)CRAFT) OR DIAGNOSIS OR THERAPY OR GUIDELINE OR COMMENT? OR HISTORY OR EDITORIAL

The CPSTF recommendation and evidence from this review may be used to inform decisions about maintaining safety belt laws. Following are considerations drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Engage partners throughout the process. Building support from the ground up can help secure policies that reinforce healthy behaviors in the community.
• Demonstrate why the policy is important. Use CPSTF findings and recent surveillance data to show partners how policies have been effective, and explain how strengthening them could further improve health outcomes in their community.
• Educate stakeholders. Keep the media, community influencers, and policymakers informed about safety belt laws to help communicate messages that are accurate and timely.
  • Keep messages brief and to the point. Use graphics, figures, or infographics to clearly demonstrate how the intervention can improve health outcomes.
  • Extend your communication reach by working through partners who have the most credibility with key audiences.
• Pay attention to sustainability. Continue to conduct surveillance related to safety belt use and disseminate findings.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce deaths from motor vehicle crashes — IVP-06
• Reduce the proportion of deaths of car passengers who weren’t buckled in — IVP-07