ALCOHOL, DRUGS AND RISK OF ACCIDENT,

SPEED, PERCEPTION OF RISK

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- 66 -

Odds that an Involved Driver was Drinking: Best Indicator

of an Alcohol-Related Crash?
Tippetts, A.S., Voas, R.B.
Pacific Institute for Research and Evaluation
11710 Beltsville Drive, Suite 300, Calverton, Maryland, 20705 USA

Keywords
Impaired driving, alcohol-related crashes, driver age, driver sex, fatal crashes
Abstract
The evaluation of the effectiveness of new alcohol safety laws and programs is critical to the
development of a successful national system for reducing alcohol-related crashes. Although
evaluations of U.S. laws, such as those reducing the legal blood alcohol concentration (BAC)
limit to .08 or establishing zero tolerance laws for youth 21 years old and younger, have been
conducted, it often has been difficult to compare the results because of the differing outcome
measures used. The measures reported include all crashes, single-vehicle crashes, nighttime
crashes, had-been-drinking crashes, and crashes involving drivers with positive or high BACs.
All of these measures fail to include a term reflecting the underlying rate of non-alcohol-related
crashes, which can be influenced by the quality of vehicles, roadways, urbanization, and the
economy, among other factors.
A standard method for reporting health statistics is to use population as the normalizing measure.
However, since access to a vehicle varies by socioeconomic class and urban rural location,
vehicle miles of driving (VMT) appears to be the method of choice for normalizing highway
injuries. However, VMT is of limited value for normalizing alcohol-related injuries because the
proportion of vehicle miles of travel that involve an impaired driver is more difficult to determine
and not available in the state estimates derived from state gas taxes. Conversely, non-alcoholrelated crashes occurring at the same times or locations or to the same groups of drivers can
provide a more specific method of normalizing alcohol-related events by controlling more
specifically for vehicle type, roadway conditions, or driver characteristics. Thus, for example, the
frequency of alcohol-related crash involvements to non-alcohol-related crash involvements can
be compared for specific at-risk groups such as African American males ages 21 to 35, a specific
group for which vehicle miles of travel are not available. This paper illustrates the use of that
type of normalization in comparison vehicle miles of travel in analyzing alcohol-related crash
involvements by age and gender.

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Introduction
A significant relationship between driver age and driver gender and involvement in impaired
driving crashes has been well established (1). The reversal of the two-decade downward trend in
alcohol-related fatalities in 2000 (1) places renewed importance on understanding such
differences for the development of new countermeasures. The best measure of alcohols role in
traffic crashes is the blood alcohol concentration (BAC) of crash-involved drivers. The Fatality
Analysis Reporting System (FARS)(2) provides a national census of fatal crashes in which BACs
are available for approximately 70% of killed drivers. BACs of the remaining 30% can be
accurately imputed by a method developed by Klein (3) and adopted by the National Highway
Traffic Safety Administration (NHTSA) for reporting FARS data. This ability to separate the
drinking from non-drinking drivers in fatal crashes provides the opportunity to contrast the two
for any specified group. Drinking drivers can be expressed as a percentage of all drivers for the
particular group in a fatal crash or can be expressed as the odds (drinking/non-drinking) that a
driver in a fatal crash will be drinking. This study compares that odds measure with the more
familiar VTM measure as a method of comparing the involvement of drivers in different age and
gender groups in fatal crashes.
Methods
From a 7-year FARS sample covering all drivers killed between January 1, 1990, and December
31, 1996, a total of 162,192 drivers117,632 (72.5%) of which had measured BACswas used
in this analysis. These were divided into two groups: 66,376 with measured or imputed BACs
greater than zero (drinkers) and 95,816 with zero BACs (nondrinkers). Because men and women
of different ages drive varying amounts, it is necessary to normalize the crash data based on
estimated miles of driving. The 1995 Nationwide Personal Transportation Survey (NPTS)
conducted by the Federal Highway Administration (4) provided annual mileage estimates
separately for men and women by age group. These data were used to calculate the number of
drinking and nondrinking drivers in a fatal crash per billion vehicle miles traveled (VMT). A
second method used the ratio of drinking drivers to nondrinking drivers within separate
age/gender groups as a basis for comparing driver crash involvement. This ratio provides the
odds that a driver killed in a crash had been drinking.
Results
The mileage death rates for male and female nondrinking drivers for different age groups are
contrasted in Figure 1a. The rates for males and females were generally similar, yielding Ushaped curves with greatly elevated rates for youths under 21 and elderly drivers over 70. The
greatest cross-gender difference occurred among 16- to 20-year-olds, where sober death rates
were about 20 for males and about 13 for females. Figure 1b provides the mileage rates for
drinking drivers. These curves contrast with those in Figure 1a in being J-curved, with the highest
involvement among young drivers and with males demonstrating significantly higher rates at all
age levels. The only two age/gender groups for which the mileage death rates were higher among
drinking versus nondrinking drivers were males aged 21-29 and 30-39.

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Sober deaths (per billion VMT)

Figure 1a: Nondrinking driver death rates by age and gender per annual miles driven
24
21
18
15
12
9
6
3
0
Males
16-20

Females

21-29

30-39

40-49

50-69

70+

Alcohol deaths (per billion VMT)

Figure 1b: Drinking driver death rates by age and gender per annual miles driven
14
12
10
8
6
4
2
0
Males
16-20

Females

21-29

30-39

40-49

50-69

70+

Figure 2 relates the drinking to nondrinking driver involvements by displaying the odds that a
killed driver had been drinking. As expected, the odds that a driver had been drinking were
greater for males than for females (odds ratios from 2.4 to 3.1, significant for all age groups with
all p-values <.0001) and were greatest for drivers between 21 and 39. Although differences
across age/gender groups can only be inspected visually with mileage death rates (because there
are no variance estimates for rates per VMT), groups can be statistically compared using odds
ratios. In pairwise contrasts across age groups within each gender, the only comparisons that
were not significantly different were those between the 21-29 versus 30-39 year old age groups
(p-values = .21 and .78, males and females respectively; all other p-values <.0001).

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Odds

Figure 2: Odds that a killed driver had been drinking by age and gender
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Males
16-20

Females

21-29

30-39

40-49

50-69

70+

Discussion
The U-shaped curves in Figure 1a are typical of those reported in previous studies (5). The
elevated rate for underage drivers is generally attributed to inexperience and risk taking (6), while
the elevated rate for the elderly is generally attributed to age-related decrements in cognitive and
motor functions and increased risk of fatal injury given that a crash occurs. The most significant
feature of the rate of nondrinking driver involvement is that, except for underage drivers, the rates
for males and females are similar. This suggests that relative to exposure measured by VMT,
females face the same risk factors as males and that traffic safety programs such as driver
licensing, safety belt laws, traffic enforcement, etc. are equally effective with both genders.
In contrast to Figure 1a, the drinking driver involvement rates in Figure 1b highlight the
significant role that both age and gender play in alcohol-related crashes. It is important to
recognize that the rates shown are based on all miles driven not just those driven at the time and
places where crashes occur, as in studies using roadside surveys to calculate the relative risk of
crash involvement at various BACs (7, 8). The rate shown is a function of both the sensitivity of
the particular group to impairment and the number of miles driven with a positive BAC by that
group, which cannot be separated from the total miles driven. Thus, the rates in Figure 1b
represent the overall risk of being a drinking driver in each group based on total VMT. It is clear
that the drinking driver rate is significantly lower for females and declines with age for both
genders, supporting the current policy of focusing alcohol countermeasures on young males aged
21-35.
Figure 2 relates the drinking to nondrinking driver rates by calculating the odds that a fatally
injured driver will have been drinking. With respect to age, this gives a substantially different
picture from Figure 1b. Although an underage fatally injured male driver is significantly more
likely to be alcohol-free than to have been drinking, the reverse is true of an adult male driver in
the 21 to 39 year age group. The relatively high rates of both sober and drinking driver deaths
among 16 to 20 year olds emphasizes the need to deal with their overall risk taking and
inexperience (as in the current emphasis on enacting graduated driving license laws), as well as

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increasing the enforcement of underage drinking laws. The fact that the odds a fatally injured
underage driver was drinking are lower than those for older drivers may, in part at least, reflect
the effectiveness of current minimum drinking age (9) and zero tolerance laws (10), which have
been enacted in all 50 states. Figure 2 clearly suggests that another important opportunity for
further reducing alcohol-related crashes lies with countermeasures aimed at the 21 to 39 year age
group, particularly among males.
References
1. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts 2000:
Alcohol. Washington, DC: National Center for Statistics & Analysis, National Highway
Traffic Safety Administration; 2000.
2. FARS. Fatal accident reporting system, 2000. Washington, DC: National Center for Statistics
and Analysis, Highway Traffic Safety Administration; 2001.
3. Klein T. A method for estimating posterior BAC distributions for persons involved in fatal
traffic accidents. Washington, DC: National Highway Traffic Safety Administration; 1986.
DOT HS 807 094.
4. Research Triangle Institute. User's guide for the public use data files: 1995 Nationwide
Personal Transportation Survey. Washington, DC: Federal Highway Administration
(FHWA); 1997, October. Publication No. FHWA-PL-98-002.
5. Cirelli EC. Crash data and rates for age, sex, groups of drivers, 1994: U.S. DOT, NHTSA,
National Center for Statistics and Analysis; 1995. Research Note.
6. Mayhew DR, Donelson AC, Beirness DJ, Simpson HM. Youth, alcohol and relative risk of
crash involvement. Accid Anal Prev. 1986; 18:273287.
7. Zador PL, Krawchuk SA, Voas RB. Relative risk of fatal crash involvement by BAC, age,
and gender. Washington, DC: U.S. Department of Transportation, National Highway Traffic
Safety Administration; 2000. Technical Report No. DOT HS 809-050.
8. Borkenstein RF, Crowther RF, Shumate RP, Ziel WB, et al. The role of the drinking driver in
traffic accidents. Blutalkohol. 1974; 11:1132.
9. Toomey TL, Rosenfeld C, Wagenaar AC. The minimum legal drinking age: History,
effectiveness, and ongoing debate. Alcohol Health & Research World. 1996; 20:213218.
10. Blackman K, Voas RB, Gullberg RG, Tippetts S. Enforcement of zero tolerance in the state
of Washington Evidence from breath-test records. Forensic Sci Rev. 2001, July; 13:7786.

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Alcohol, Travelling Speed and the Risk of Crash Involvement

McLean, J., Kloeden, C
Road Accident Research Unit, The University of Adelaide,
Adelaide, Australia 5005

Abstract
This paper compares the relationship between two factors that are known to affect the relative
risk of involvement in a casualty crash: a driver's blood alcohol level and his or her choice of free
travelling speed. It is concluded that measures which reduce travelling speeds are likely to be at
least as effective in reducing the frequency of casualty crashes in Adelaide as measures which
reduce drivers' blood alcohol levels.
Introduction
This paper reports on two case control studies: one, of the relationship between a driver's blood
alcohol concentration (BAC) and the risk of involvement in a crash, and the other of the
relationship between a driver's choice of free travelling speed and the risk of involvement in a
casualty crash. Both studies were conducted in Adelaide, South Australia, by the Road Accident
Research Unit (RARU) of the University of Adelaide.
The study of the relationship between a driver's blood alcohol concentration and the risk of crash
involvement yielded results which were similar to those obtained by Borkenstein et al in Grand
Rapids, Michigan in 1963 (1). There has been no other study of the relationship between free
travelling speed and the risk of involvement in a casualty crash in a metropolitan area. (One
currently in progress in Montreal is due to be completed in 2003.)
The results of the two case control studies reported here, which used similar methods and were
conducted in the same metropolitan area, make it possible to compare the relative risks of crash
involvement associated with a driver's BAC and choice of free travelling speed.
Methods
Alcohol and the Risk of Crash Involvement
In 1979 the Road Accident Research Unit conducted a case control study of the relationship
between a driver's blood alcohol concentration and risk of being involved in a crash relative to
that of a sober driver (2, 3). It was based on an in-depth study of a representative sample of
crashes to which an ambulance was called in metropolitan Adelaide (4).
The BAC of a crash involved driver was either measured at the scene of the crash by the research
team or the police or, for those who presented at a hospital for treatment of their injuries, by
means of analysis of a blood sample which is legally required to be taken at hospital from all

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persons over 13 years of age thought to have been injured in a road traffic accident in South
Australia. The post-crash interview with these drivers included questions relating to the route
which they had followed, or had intended to follow had they not been involved in the crash.
Control data was obtained at the same time of day and day of week as the crash at some point on
or near the case driver's route. Four drivers of about the same age and sex were breath tested
when they stopped at a red traffic signal using a procedure developed for this purpose (5). The
meter used at the crash scene for the cases and for all of the controls was the Lion Laboratories
Alcolmeter PST.
Travelling Speed and the Risk of Crash Involvement
In order to estimate the relationship between travelling speed and the relative risk of crash
involvement, a series of crashes was examined in detail in 1995 and 1996 to form the basis of a
case control study (6). The case vehicles were passenger cars involved in casualty crashes in 60
km/h speed zones in the Adelaide metropolitan area (the speed limit throughout most of the
metropolitan area is 60 km/h). The crashes were investigated at the scene by the Road Accident
Research Unit and reconstructed using the latest computer aided crash reconstruction techniques.
The case vehicles had a free travelling speed prior to the crash. A free travelling speed was
defined as the steady speed of a vehicle moving freely along a mid-block section of road or with
right of way through an intersection and not slowing to leave, or accelerating into, the road. The
drivers of case vehicles were also required to have a zero measured BAC to exclude the effects of
alcohol on the risk of being involved in a casualty crash.
The 604 control vehicles (four per case) were passenger cars matched to the cases by location,
direction of travel, time of day, and day of week. Their speeds were measured with a laser speed
meter which looked like a video camera. The operator of the meter was typically some hundreds
of meters beyond the location of the car when its speed was measured. In the early stages of the
study, information on the control driver's BAC was obtained by "random" breath testing by the
Police Breath Testing Section. As most of the crashes had been investigated during daylight
hours, very few control drivers were found to have a positive BAC and those who did were at
very low levels.
Results

Alcohol and the Risk of Crash Involvement

Fifty nine (19.7%) of the 299 crash involved drivers had a positive BAC; the median value was
0.12 and the highest was 0.35. Almost two thirds of these drivers who had been drinking had a
BAC above the legal limit for drivers which at that time was 0.08 g/100mL (it has been 0.05
since mid-1991).
One hundred (8.1%) of the 1,096 control drivers had been drinking. Their median BAC was 0.03,
the highest level was 0.18 and 18% of them were above the legal BAC limit. Subjective
assessment indicated that the drivers who refused (4.4%) to cooperate were more likely to have
been drinking than those who provided a breath sample. However, the refusals were also more
likely to be replaced as controls by other drivers who also had been drinking (5.5% of the
replacements were drinkers compared with 1.9% for all of the other controls).
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The relationship that was established between a driver's BAC and risk of involvement in a crash,
relative to that for a sober driver, is shown in Table 1. At a BAC of 0.05 g/100mL the risk of
crash involvement was found to be about 1.83 times greater than that for a sober driver. The 95%
confidence limits on this estimate were 0.87 and 3.85. At a BAC of 0.10, the relative risk was
approximately five times that of a sober driver.
Table 1: BAC of driver and the risk of involvement in a casualty1 crash: Metropolitan
Adelaide 1979
Nominal
BAC2
zero
0.02
0.05
0.08
0.12
0.15+
Total
1
2
3

BAC
range2
zero
0.01-0.03
0.04-0.06
0.07-0.09
0.10-0.14
0.15-0.35

No. of
cases
240
8
10
7
14
20
299

No. of
controls
1096
53
25
10
9
3
1196

Relative
risk
1.00
0.69
1.83
3.20
7.10
30.4

Lower
limit3
0.32
0.87
1.20
3.04
8.97

Upper
limit3
1.47
3.85
8.48
16.6
103.3

Crashes to which an ambulance was called.

g/100mL
95% confidence limits of the estimated relative risk

Travelling Speed and the Risk of Crash Involvement

The research team attended 952 crashes at the scene. The study was based on 148 of these
crashes. The reasons for excluding the other crashes are listed in Table 2.
Table 2: Crashes attended and reasons for exclusion from the study
Crashes attended
Total number of crashes attended
Crashes excluded
No ambulance transport required
Case vehicle was not a car or car derivative
Case vehicle did not have a free travelling speed
Case vehicle doing illegal manoeuvre
Crash due to medical condition of driver
Site not in a 60 km/h zone
Not a vehicle accident
Case driver had a positive blood alcohol concentration
Case vehicle rolled over
Insufficient information for crash reconstruction
Crashes included in the case control study

Number
of crashes
952
804
325
148
148
26
23
18
8
5
4
99
148

Note: 3 crashes yielded 2 case vehicles each giving a total of 151 total cases

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Cars involved in the casualty crashes (the cases) were generally travelling faster than cars that
were not involved in a crash (the controls): 68 percent of crash involved cars were exceeding the
60 km/h speed limit compared to 42 percent of those not involved in a crash. The difference was
even greater at higher speeds: 14 percent of crash involved cars were travelling faster than 80
km/h compared to less than 1 percent of those not involved in a crash. The crash-involved cars
were almost 10 times more likely to have been travelling faster than 70 km/h than were the noncrash-involved cars (29% vs 3%).
The relative risks of crash involvement for various speeds are shown in Table 3. It can be seen
that the risk of crash involvement approximately doubles for each increase in travelling speed of
5 km/h above the 60 km/h speed limit.
Table 3: Free travelling speed and the risk of involvement in a casualty1 crash relative to
travelling at 60 km/h in a 60 km/h speed limit zone: Metropolitan Adelaide
1995/6
Nominal
speed2
35
40
45
50
55
60
65
70
75
80
85
88+
Total
1
2
3

Speed
range2
33-37
38-42
43-47
48-52
53-57
58-62
63-67
68-72
73-77
78-82
83-87
88-147

No. of
cases
0
1
4
5
19
29
36
20
9
9
8
11
151

No. of
controls
4
5
30
57
133
205
127
34
6
2
1
0
604

Relative
risk
0
1.41
0.94
0.62
1.01
1.00
2.00
4.16
10.60
31.81
56.55
infinite

Lower
limit3
0.16
0.31
0.23
0.54
1.17
2.12
3.52
6.55
6.82
-

Upper
limit3
12.53
2.87
1.67
1.87
3.43
8.17
31.98
154.56
468.77
-

At least one person transported from the scene of the crash by ambulance.
km/h
95% confidence limits of the estimated relative risk.

Comparison of the Risks Associated with Alcohol and Speed

Figure 1 compares the relative risks of casualty crash involvement at various blood alcohol levels
and at various free travelling speeds in the Adelaide metropolitan area. It can be seen that a quite
small increase in travelling speed above the speed limit results in an increase in the relative risk
of casualty crash involvement that is comparable to that of an illegal blood alcohol level of 0.05.
Each 5 km/h increase in travelling speed above 60 km/h increases the risk of involvement in a
casualty crash by roughly the same amount as each increase in blood alcohol concentration of
0.05 g/100mL (Table 4).

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Table 4: Relative risks of involvement in a casualty crash for speed and alcohol
Speed
(km/h)
60
65
70
75
80
1
2

Speed
relative1 risk
1.0
2.0
4.2
10.6
31.8

BAC
(g/100mL)
zero
0.05
0.08
0.12
0.21

BAC
relative2 risk
1.0
1.8
3.2
7.1
30.4

Relative to a sober driver travelling at the speed limit of 60 km/h.

Relative to driving with a zero BAC.

Figure 1: Relative risks of involvement in a casualty crash for speed and alcohol
Relative Risk

40

30

20

10

0
60

65

70
75
Speed (km/h)

80

85

0.00

0.05

0.10
0.15
BAC (g/100mL)

0.20

0.25

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Discussion
Given that the crash risks associated with speeding and illegal drink driving are similar, and
speeding is more common, why isnt speed listed as a cause of accidents more often than drink
driving? The answer probably lies in the fact that it is a comparatively straightforward matter for
a drivers blood alcohol concentration to be measured after an accident whereas the estimation of
the travelling speed of a vehicle before the crash is rarely a straightforward matter.
One consequence of this underestimation of the role of speed in accident causation is the marked
disparity between the risks of involvement in a casualty crash and the penalties associated with
speeding and illegal drink driving. Drink driving is seen as a serious problem requiring strong
enforcement and severe penalties while speeding is generally seen as a comparatively minor road
safety issue. The results presented here indicate that speeding needs to be taken just as seriously
as drink-driving.
Thus far we have compared the risks associated with speeding and drink driving. However,
reducing travelling speeds can be expected to reduce the frequency of all crashes, including those
that are alcohol related. The reduction of travelling speeds, whether it be achieved by reducing
speed limits and/or by the control of speeding, has the effect of making the driving task easier. If
the driving task is made easier, drivers will make fewer mistakes, and that applies particularly to
impaired drivers. If travelling speeds are reduced, the mistakes that are still made will be less
likely to result in a crash, and those crashes that do occur will be less likely to result in injury or
death.
Acknowledgements
We thank the Federal Office of Road Safety of the Australian Department of Transport and
Regional Development for primary funding of both case control studies. Transport SA supplied
some personnel to work on the speed case control study and the Australian National Health and
Medical Research Council provided support through a Research Unit grant. We also thank the
South Australia Police and the South Australian Ambulance Service for providing assistance.
We also appreciate the support and contributions of the following people: Brian and Raymond
McHenry (McHenry Software, Inc., Cary, North Carolina), Giulio Ponte, Lisa Wundersitz,
Robert Baird and Matthew Baldock (RARU), Roland Earl and Roger Galbraith (Transport SA),
and Chris Brooks and John Goldsworthy (Federal Office of Road Safety).
References
1. Borkenstein RF, Crowther RF, Shumate RP, Zeil WB, Zylman R. The role of the drinking
driver in traffic accidents. Department of Police Administration, Indiana University,
Bloomington 1964.
2. McLean AJ, Holubowycz OT. Alcohol and the risk of accident involvement. In: Goldberg L,
editor, Alcohol, Drugs and Traffic Safety, Proceedings of the Eighth International Conference
on Alcohol, Drugs and Traffic Safety. Stockholm: Almqvist & Wiksell International,
Stockholm, 1981, 1:113-123.

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3. McLean AJ, Holubowycz OT, Sandow BL. Alcohol and crashes: identification of relevant
factors in this association. Office of Road Safety, Commonwealth Department of Transport,
Canberra 1980, CR 11.
4. McLean AJ, Aust HS, Brewer ND, Sandow BL. Adelaide in-depth accident study. Part 6: Car
accidents. Road Accident Research Unit, University of Adelaide, Adelaide 1981.
5. Holubowycz OT, McLean AJ, McCaul KA. A new method of breath testing the general
driving population. J Stud Alcohol 1991; 52:474-477.
6. Kloeden CN, McLean AJ, Moore VM, Ponte G. Travelling speed and the risk of crash
involvement. Federal Office of Road Safety, Commonwealth Department of Transport and
Regional Development, Canberra 1997, CR 172.

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- 80 -

Alcohol and the Perception of Speed

1

Leung, S. Y., 1Starmer, G. A., 2Godley, S.

Department of Pharmacology, The University of Sydney,

Department of Psychology, The University of Sydney, Sydney, New South Wales, Australia.

Keywords
Alcohol, ethanol, speed perception, risk-taking, gap-acceptance, time-to-collision, age.
Abstract
Alcohol-affected drivers, and specifically young alcohol-affected driver, are over represented in
road accidents in New South Wales. This single-blind study assessed the effects of a moderate
dose of alcohol on inexperienced and mature drivers reaction times, perception of vehicle speed,
awareness, and ability to perform complex driving manoeuvres such as overtaking. Participants
(20 males and 20 females) were required to consume an amount of alcohol sufficient to reach a
target blood alcohol concentration (BAC) of 0.080 g dL-1, and undertook two experimental
sessions on the STISIM Drive Driving Simulator at 30, 60 and 90 minutes. Comparisons were
made between performances at target BACs of 0.000 g dL-1 (placebo condition) and 0.080 g dL-1,
as well as between the performances of young and mature drivers.
Introduction
A large number of preventative measures have been adopted in order to curb the stagnantly high
incidence of road accidents in the state of New South Wales (NSW), Australia. These include a
lowered suburban speed limit (from 60 km/h to 50 km/h), restrictive ages and criteria for
potential licence holders, speed cameras, random breath test sites, and education campaigns on
the dangers of drink-driving. Nevertheless, speeding and alcohol currently remain the two
highest contributors to casualty road crashes in NSW, at 16% and 39% respectively (1).
Furthermore, while young drivers (aged 1720 years) comprised only 5% of the driving
population in NSW in 2000, they were involved in 14% of all crashes.
Driving a motor vehicle is a complex task. It is a learned skill that coordinates focus, perception,
decision-making, and motor control. After the consumption of alcohol, however, driving
performance has been shown to deteriorate via, among other factors, increases in speed
variability, lateral lane position variability, reaction time and steering responsiveness (2, 3).
Although extensive research has been conducted in the field of alcohol and general driving
performance, predominantly psychomotor performance, little attention has been focused on the
specific cognitive skills involved in driving a motor vehicle. To date, only one study has
investigated the effects of alcohol on a drivers perception of speed (4), and no significant effect
of alcohol was found. This finding, however, was attributed to the relative ease of the task,
because there is a consensus that the more demanding the task, the more likely will there be

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measurable impairment of performance after moderate doses of ethanol (5). Therefore, insight
into the relationship between moderate to high doses of alcohol, speed perception and crash risk,
is critically lacking.
Exploration of the influence of age on speed perception, both under the influence of alcohol and
in a sober state, has also been relatively neglected. It has been found, however, that young
drivers, in particular, are over-represented in overtaking accidents and have a higher rate of
accidents involving alcohol (6). This is often attributed to faulty choices of timing and speed
rather than a lack of vehicle control skills. It is unclear, however, whether such inappropriate gap
acceptance is due to risk-taking, a misperception of arrival time, or both. Another factor that
could also contribute to such misjudgements is a decrease in the drivers state of arousal. That is,
drivers that detect hazards slower than others could react impulsively and without due safety.
This study was designed to explore the ways in which gap-acceptance and perception are affected
by alcohol, and how this influence differs between young and mature drivers. Considering that
the perception of risk is reduced after alcohol (7) and is more prominent in young drivers (8), it
would appear that alcohol-affected drivers and, in particular, alcohol-affected young drivers,
would be more likely to misjudge safe gaps in traffic. These findings hold significant importance
in developing training strategies for the specific areas of deficit in performing complex driving
manoeuvres such as overtaking, as well as identifying and educating the public on the precise
limitations of alcohol consumption on the ability to safely drive.
Methods
Participants
Following ethics approval from The University of Sydney Human Ethics Committee, 40 healthy
volunteers (twenty male, twenty female; age ranges 18 to 21 years and 25 to 40 years), who were
not first-time drinkers of alcohol, were recruited for this study.
Participants were told to abstain from consuming alcohol for at least 24 hours prior to testing, and
to eat at least 2 hours before testing commenced. They were instructed not to drive on either of
the testing days.
Participants were offered out-of-pocket expenses, up to A$40, for their involvement in the study.
A$20 was guaranteed for the two 2 hour simulator sessions (one with alcohol and one with a
placebo), however, if the participant did not crash (collide with other vehicles, run off the road,
etc.) in either session, they received an additional A$20 as an incentive to drive as safely as
possible. For every crash in which they were involved, they lost A$5 from this additional A$20
payment.
Driving simulator
This project used a STISIM Drive driving simulator located at The University of Sydney. The
simulator includes a full car cabin fitted with a steering wheel, speedometer, accelerator and
brake pedals (Figure 2). Computer generated visual images project onto three screens resulting in
a 135 field of view (Figure 1). The STISIM Drive driving simulator provides a completely
flexible experimental environment where a variety of scenes can be constructed (e.g. straight and
curved roads, approaching vehicles and pedestrians) to interact with the participants vehicle.

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Figure 1: The STISIM Drive Driving

Simulator external body.

Figure 2: The STISIM Drive Driving

Simulator car cabin.

Experimental conditions
Using a mixed design, participants were given two sessions on the driving simulator, once after
alcohol (BAC = 0.08 g dL-1), and once after a placebo beverage (BAC = 0.00 g dL-1).
Alcohol administration
Before each session, participants drank an orange juice beverage. They were not informed which
alcohol treatment they had received. For the alcohol condition, alcohol (0.7 g kg-1) was
administered orally as a 1:3 solution of vodka (37% v/v) diluted with orange juice. The dose was
adjusted for bodyweight and gender. The placebo beverage comprised of an equivalent amount
of orange juice with 5ml of vodka floated on the surface to provide olfactory masking (9).
Participants were allowed 20 minutes to consume the beverage.
Experimental tasks
The experimental design aimed to explore how participants performed overtaking manoeuvres.
This was examined in terms of the tasks involved in performing these manoeuvres:
1. Detection time
Participants were required to press the horn button as soon as they detected an
approaching vehicle. These vehicles were programmed to enter the opposing lane by
either appearing from parked positions on the roadside, from behind buildings, or from a
distance but obstructed by trees. This was designed to measure the level of
awareness/alertness of the participants at the different experimental times and conditions.
2. Time-to-collision/contact estimations
Approaching vehicles disappeared at specific distances away from the participants
vehicles. Participant were required to estimate when the approaching vehicles would
have met their vehicle, bonnet to bonnet, if it had not disappeared. At this point,
participants were instructed to press the horn button. This task provided a measure of the
participants perception of speed, time and distance.

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3. Gap safety estimates.

Participants were presented with a scenario in which there was a vehicle ahead of theirs,
travelling in the same direction, with an approaching vehicle in the next lane. While the
participant was driving at a set speed, he/she was required to activate the horn when it was
considered that it was no longer safe to overtake the vehicle ahead. That is, before the
approaching vehicle became too close for a safe overtaking manoeuvre to be attempted.
This measured the participants perception of the adequate safety margins required in
potentially dangerous situations.
4. Gap acceptance measured through performing the manoeuvres.
Participants were required to perform overtaking manoeuvres, as soon as they deemed it
to be safe, across a succession of approaching vehicles. The gaps between the
approaching vehicles became progressively larger. This task provided a measure of the
participants perception of, and willingness to take, risks.
5. Self-rating of driving performance.
Participants were required to complete a questionnaire in which they were asked to
compare their driving performance in the simulator with their general driving
performance on road, as well as to compare their personal driving performance with that
of others in their age group. This was intended to provide some measure of the
participants self-assessment and decision-making ability, particularly while under the
influence of alcohol.
All four tasks were performed on the driving simulator at 30, 60 and 90 minutes after they
attained each of the two target BACs (0.000 and 0.080 g dL-1). The complexity of the driving
environment, in terms of the curvature of the road, intersections, other traffic, pedestrians, and
roadside buildings, was kept constant throughout the sessions.
Experimental procedure
Participants attended the laboratory on two occasions, on two separate days, separated by a twoweek period. The aims and procedures were carefully explained to the participants and their
informed consent was obtained. They were breath-analysed to ensure that they were alcohol-free,
and were then given a practice drive (approximately 5 min) on the simulator prior to their first
session. Participants then received either the alcohol or placebo treatment according to a
counterbalanced design, and consumed the beverage at a constant rate over a 20 min period,
under close supervision. After finishing their drinks, participants waited 10 min before being
instructed to wash their mouths with tepid water. Following this, the simulator session began in
which participants underwent two drives, each approximately 5 min in duration, at 30, 60 and 90
min. They were breath-analysed prior to each drive. The total session time, over both days, was
approximately 4 hours.
Collection and Analysis of Data
The Alco Sensor III (St Louis, Mo.) was used to measure breath alcohol at intervals throughout
the experiment, beginning 30 min after drinking had finished to avoid contamination of the breath
sample by residual mouth alcohol. The instrument employs a blood : breath factor of 2100 : 1,
and readings were corrected to the true mean blood : breath of 2285 : 1. Previous studies have

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shown a correlation in excess of 97% between BACs determined from breath and directly from
venous blood (10). Participants were not told which alcohol treatment they had received.
Results and Discussion
Experimentation will be complete by the end of June and the results presented at the conference
in August. Nevertheless, it is hypothesised that young drivers will display relatively poorer
driving skills than mature drivers and, across all participants unaffected by alcohol, there will be
a general underestimation of time-to-collision. This translates to relatively cautious margins of
safety and is consistent with preliminary research conducted at The University of Sydney. In
contrast, however, alcohol-affected drivers will underestimate time to a lesser degree, as will
young drivers both affected by alcohol and not. This corresponds to alcohol-induced increases in
aggression and risk-taking. A number of factors including driving experience, predisposition as
sensation seekers, gender and alcohol tolerance, are all expected to influence the results. For this
reason, it is impossible to predict exactly what trends will be observed, yet the results may
provide important information in gauging how such factors are weighted in driving performance.
References
1. Roads and Traffic Authority. Road Traffic Accidents in NSW 2000. Road Safety Strategy Branch,
New South Wales 2001.
2. Gawron, V.J., & Ranney, T.A. (1988). The effects of alcohol dosing on driving performance on a
closed course and in a driving simulator. Ergonomics, 31, 1219-44.
3. Stein, A.C. & Allen, R.W. (1987). The effects of alcohol on driver decision making and risk taking. In
Alcohol, Drugs and Traffic Safety. ed. Noordzji, P.C. & Roszbach, R. pp. 177-181. Amsterdam:
Exerpta Medica.
4. Kearney, S. A., & Guppy, A. (1988). The effects of alcohol on speed perception in a closed-course
driving situation. J Stud Alcohol, 49, 340-345.
5. Moskowitz, H., Burns, M. M., & Williams, A. F. (1985). Skills performance at low blood alcohol
levels. J Stud Alcohol, 46(6), 482-485.
6. Triggs, T. J. & Smith, K. B. (1996). Young Driver Research Program: Digest of Reports and Principle
Findings of the Research. (Report CR 164). Federal Office of Road Safety: Canberra.
7. Deery, H. A., & Love, A. W. (1996). The effect of a moderate dose of alcohol on the traffic hazard
perception profile of young drink-drivers. Addiction, 91, 815-827.
8. Deery, H. A. (1999). Hazard and risk perception among young novice drivers. J Safety Res, 30, 225236.
9. Starmer, G. A., & Bird, K. D. (1984). Investigating drug-ethanol interactions. Br J Clin Pharmacol,
18, 2S-35S.
10. Slemeyer, A. (1986). The Alcomat: A new mobile evidential breath tester. Alcohol, Drugs and Traffic
Safety, 1245-1255.

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- 86 -

They dont Test for it-so I do it:

Drug Driving from a Users Perspective
Davey, J., French, N.
Centre for Accident Research and Road Safety Queensland, Queensland University of
Technology, Carseldine, Queensland, Australia

Keywords
Drugs, driving, qualitative
Abstract
The developing but still limited amount of research into drug driving in Australia research has
generally been undertaken from a road safety orientation where drug driving is viewed within the
broader context of driver behaviour. As a result little knowledge from the field and research
discipline of substance use has been transposed into the drug driving area. Such a specific focus
precludes the broader behavioural, contextual and cultural issues associated with substance use
and in particular the major changes that have occurred over the last five to six years in the culture
and incidence of drug use in the Australian population. The relationship between substance use
and drug driving itself is an essential a key to understanding the behaviour and developing
appropriate policy and interventions. This paper outlines the findings from a series of focused
interviews with 211 illicit drug users to provide insights into the culture of drug driving from the
user perspective. The paper identifies drug driving as a subset behaviour of drug use where drug
driving was not necessarily viewed as deviant behaviour in itself but rather is an outcome of
illicit substance use. Drug driving was not of concern for the substance user. In some instances
interviewees saw their drug use as enhancing their driving skills and frequently the motor vehicle
was viewed as a safe place to use. More alarmingly there was almost universal agreement among
interviewees that the likelihood of being caught for drug driving by police was minimal and this
perception was reinforced by past experience. Key issues associated with developing
contextually appropriate interventions are discussed.
Introduction
The developing but still limited amount of research into drug driving in Australia has
traditionally been undertaken from a road safety orientation where drug driving is viewed within
the broader context of driver behaviour1. Such a specific focus may be slow to respond to the
changing trends and patterns in contemporary substance use and also precludes the broader
behavioural, contextual and cultural issues associated with substance use in Australia2. These
contextual issues add a sense of meaning and a greater understanding to drug driving behaviours.
To date, little knowledge from the field and research discipline of substance use has been
transposed into the drug driving area. Yet drug driving remains one of the most significant harms
associated with illicit substance use. The relationship between substance use and drug driving
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itself is a key to understanding the behaviour and developing appropriate interventions. From
one perspective drug driving can be seen as a subset of driving behaviours. However, drug use is
the precursor and situational framework within which drug driving occurs. Drug driving does not
happen in isolation to substance use and is a product of the context in which drug use takes place.
Drug driving is an outcome or a subset of drug use. The data presented in this paper explores the
relationship between drug use and driving behaviour and provides insight into the culture of drug
driving from the users perspective.
Methods
This paper reports on the findings of qualitative interviews investigating the relationship between
drug use and drug driving. 211 (137 males and 74 females) illicit drug users from rural and urban
areas of Queensland and northern News South Wales were recruited for the study. The
interviewees mean age was 24.6 years.
Interviews were approximately 45 minutes in length and included structured, semi-structured and
open-ended items to collect quantitative and qualitative information. In addition to demographic
data, driving history and drug use indicators the interviews collected detailed information about
drug driving behaviour and the characteristics of drug driving based on descriptions of actual
scenarios.
Participants were recruited via a snowballing technique which relied on the use of peer networks
and referrals. Initial contacts were made through informal networks, advertising in alternative
and regional press and key community agencies. Interviews were undertaken in both major urban
metro areas and provincial centres of Queensland and northern New South Wales. The primary
interview selection criteria was use of an illicit drug in the past twelve months and to have driven
within a six hours following ingestion of a drug.
Results
In the past 12 months more than three quarters (77%) of the sample had driven under the effects
of marijuana; 41% amphetamines, 42% heroin, 21% ecstasy, 5% cocaine, and 2% LSD or
another hallucinogen.
The interviewees identified two general type of users. Firstly, dependent users whose behaviours
approximate the general DSM IV criteria of drug dependent where drug use becomes the centre
priority in their life3. This group were generally daily users (injectors of heroin or
amphetamines) where maintenance of use dictated the routines of daily life, including driving.
All of these interviewees stated that their drug use was an everyday event and getting on was
the priority.
The second group, which were more characteristic of social recreational use, ranged from daily
exclusive marijuana users to occasional or binge party-drug users. Drug use and drug driving
behaviours ranged from a daily activity to a weekend activity. Their drug taking (mostly
marijuana, amphetamine or ecstasy) was tied in with personal relaxation or social events such as
dance parties and private social occasions.
On of the most identifiable themes to emerge from the interviews was that cars provided a
common space to use drugs away from public view. All of the interviewees had used drugs in the
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car. Everyone had used in a car both as a driver and as a passenger. The car is an essential part of
the drug use behaviour providing ready access to drugs and a place to use. Cars enable use at any
time. Among social and recreational type users cars and drug use are part of their broader
personal and social relationships. They are a means of private transport that offer a venue for
use. Interviewee comments were:

After work on the way home. Relaxing drive home and helps to unwind after the day..

Had drugs at home and then drove to the party..then top up later in the car

Regular thing (using in car) with friends going out and taking E.
For dependent type users, cars appear to be a major source of transport around using drugs and a
convenient place to use. Cars provide a relatively safe space for users to inject. The majority of
dependent type users mix up and use in the car shortly after scoring. For these types of users the
car become inextricable with drug usage and users drug driving was described as incidental.
The car was the accessory used to obtain and sell drugs and drug driving occurred within this
context of dependent use. Interviewee comments were:

(I) hit up in car. (Its) Safe place to hit up in car. You can lock the car. Get a parking spot
with a good view. Safe in a locked car. Like your own homeAlso its quick get away if you
need to.

I drop kids at school and ring my dealer. I usually have friend with me. Usually shoot up
in the carI feel safe in the car and its convenient and out of the public eye. (Were) two
girls. We dont look too scruffy and its a nice car. We dont look out of place.

Go. Get on. Have shot in the car. At a park. It feels safe.

I took drugs and driving just happened.. was already off my head so what did it matter.

Drug driving is a way of organising drugs. Its not to go shopping its purely to get on.
Interestingly, for almost all interviewees, the illegality of the driving behaviour seems to have
little significance as a deterrent across drug use types and categories. The illegality of drug
driving was often subsumed by the illegality of drug use. For the most part, deliberate changes in
ones driving behaviour were outcomes of avoiding detection of drug use rather than modifying
driving behaviour because of safety implications.
Where the interviews did identify compensatory behaviours it was almost exclusively among
social recreational type users who timed their driving after consuming drugs. This waiting period
was seen as protection strategy by which the individual could assess their level of impairment.
Some interviewees drove straight away hoping to get to where they were going before they
peaked. Others waited to drive until the effects of the drugs lessened. In these cases waiting
after consuming drugs rarely extended beyond 30 minutes. The assessment of impairment was
generally based around fear of detection as opposed to an evaluation of safe vehicle useage.
Interviewee comments were:

Take and drive straight away before it kicks in so I can be full on when I get there

If I am really hit I wait about 10 15 minutes just so I can get settled.

I smoke before I goI dont want to take it with me. I didnt want to get caught with it.
Dependent users were not concerned with waiting to drive after consuming drugs and generally
drove immediately after use. Fear of detection was generally the stated reason.
Among dependent type users an extremely risky behaviour of using drugs whilst driving was
identified. Over half of these interviewees stated that this was a regular behaviour in their drug- 89 -

driving repertoire. They frequently commented that driving and doing drugs at the same time
accentuated the high of the drug. Furthermore it reduced chances of detection as they felt a
stationary vehicle was a target for detection by police. Interviewee comments were:

Id drive whilst having it. Half the rush is doing it while driving.

Its fun to do it in the car. There's a thrill to driving and taking drugs. Did it in the car
whilst its moving until I was ready to sleep.

In the car while we are on the move. We are not hanging around looking sus.

Id have shots when I was driving. Id usually put my arm out and get a mate to do me up.
It was a regular thingnot obvious
Among social and recreational type users driving also enhanced the pleasurable effects associated
with drug use. They described it as relaxing or giving them a bit of a charge or boost to drive.
Interviewee comments were:

Its my favourite. I love driving after a smoke.

E makes you sensitive to the engine noises, the road.

I reckon its fantastic. I enjoy driving on Es. Im a big driver.

I enjoy driving stoned its easy to deal with the traffic then.
A common theme among all types of users was the belief that drug use improved their driving
skills. Interviewee comments were:

On amphetamines. I drive better. Im more alert. Never came close to an accident.

Actually feel more relaxed and can concentrate more while driving. Almost had an accident
when straight but never had any thing like that when stoned.
Very few dependent users felt that their driving skills were affected by drugs. Even when
interviewees did described themselves as unsafe drivers they acknowledge that this awareness did
not deter them from driving the car. Interviewee comments were:

I knew my driving was impaired but didnt matter.

Yeh, I did notice sometimes I was impaired. I would not be able to feel the pedals
sometimes but I wasnt going to pull up. I kept driving.
Almost all dependent type interviewees were not concerned with driving under the influence of
an illicit substance. Despite having recently used they felt they were safe and capable of driving
and in control of the vehicle. Interestingly, approximately half of the dependent type users stated
that they had never driven a car without being under the influence of drugs and were unaware of
what it was like to drive without drugs. Interviewee comments were:

I always felt under control when driving. Ive never driven straight so I have nothing to
compare it to.

Id drive no matter what. I didnt think it affected me. No risk.

I consider myself to be a safe driver. No accidents whilst I was smashed."

A common held belief was that amphetamines enhanced their driving skills. Interviewees felt
focused and more confident in their ability to drive the car. Interviewee comments were:

Speed doesnt effect driving, its actually goodalert. Dont run off the road or knock
pedestrians.

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Dependent and particularly heroin users did identify two high-risk times associated with drugs
and driving. These were when they were hanging out (withdrawals) and when they were "on
the nod (passing out). For example, typical scenarios for hanging out and 'nodding off
driving were:

Worst driving is when Im hanging out. Spewing in bucket driving down the highway.

Can fall asleep nod off at the wheel

My partner He may nod off. He nods off at lights. (I) Have to hit him to go.

On the highway on the inside lane. Nodding off

For recreational and social users almost all interviewees reported that at some stage they noted
physiological or psychological changes that may effect their driving. However, these drug effects
were not necessarily viewed as an impairment or barrier to driving. Interviewees generally
remained unconvinced that drug driving held any particular safety issue for them personally.
They made the distinction between the influence of the drug and their ability to drive. Emphasis
was placed on the individuals ability to control the situation rather than recognize their driving is
impaired through their drug use. Interviewee comments were:

I drive slowly when Im stoned. Im more observant.

Love it your wired. Feel hyperaware.

Fantastic. Feel safe, hugging the road.

Speed Im more alert. Read traffic a hell of a lot more focused.

Interviewees believed drug tolerance compensated for drug effects and that experience enabled
them to manage drug use and maintain their driving abilities. Drug driving was perceived as a
learned skill achieved over time with practice and increased drug tolerance. Recreational users
generally believed that they could compensate for any lack of concentration or impaired motor
skills co-ordination. They frequently used certain behavioural driving rituals such as fixating on
the white line or relying on their experience to assist in being competent at drug driving.
Interviewee comments were:

Im so used to it. Im a cautious defensive driver, keep thinking remember you are stoned..
so I dont get into a trance.

No I have a very high tolerance. Like on amphetamines. I drive better. Im more alert.
Never came close to an accident.

I am pretty alert. Because Im a motorcycle rider I use active skills shifting eyes on the
road. follow the pattern on the road.

I find singing helps me.

Almost all interviewees thought it was unlikely that they would be to be caught by police for
driving under the influence of an illegal drug. They believed that police dont test for illicit drugs
because they do not have the technology for an easy roadside test and they are poorly trained at
detecting someone under the influence of drugs. For example, interviewees said:

They dont test for it so (I) do it.

Because they dont have the instruments to test you with.

They just do drink driving. They don't know how to spot if your using.

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Furthermore, interviewees believed that there was little commitment on behalf of police to pursue
a drug driving conviction due to police reluctance to proceed with a blood test. As two
interviewees put it:

You never get caught unless you are obviously off your face and then they have to take you
to the hospital for the test and they couldnt be bothered there too lazy.

they dont have the time, it would take a whole shift to get one arrest for marijuana
driving theyve got to stuff around take you for a blood test, and you have to go to a
doctor or hospital for thattheyre not botheredthey dont know anywayas long as your
not drink driving.
Only one interviewee had been charged for a drug driving offence. However many interviewees
had been pulled over by police for a random breath test whilst under the influence of an illicit
drug. Through these experiences interviewees confirmed their belief that the likelihood of
apprehension was minimal and that if you were caught it was unlucky. For example:

Ive been pulled over and havent been caught put breathalyser on me. Fine. Drove off.
Worried about blood shot eyes. Thought they could smell it (marijuana) but they didnt. It
was 3 am. Just after getting my licence. Cant really get booked. Theyre not going to be
able to tell unless they test you for it. I just drove off.
Discussion
The above data highlights the importance of exploring the relationship between drug use and
drug driving behaviours. It outlines examples of the implicit link between the two behaviours
and provides an important framework for the development of intervention and education
programs targeting drug driving. Throughout the interviews drug-driving as a behaviour was
subsumed by the more overarching drug use behaviour. Drug driving was not necessarily seen as
deviant behaviour in itself, but rather as an outcome of illicit substance use. This relationship
represents a major structural barrier in developing specific programs to target drug driving.
Interviewees believed that with skill and experience they could compensate for any possible drug
effects on driving. In some instances interviewees saw their drug use as enhancing their driving
and frequently the motor vehicle was viewed as a safe place to use.
Among social and recreational type users, interventions should attempt to separate the behaviours
of drug use and driving. This separation would allow a focus on the driving behaviour without
being compromised by issues associated with drug use. Naturally changes in drug use behaviour
can influence driving behaviours. However using a harm reduction framework, changes in at risk
drug driving behaviours can be achieved with limited impact on drug use. This may be achieved
through both specific or broad based prevention and education programs. Education and
prevention strategies for dependent type users need to be conceptualised and delivered within the
context drug dependent behaviour. Trying to modify their driving behaviour in isolation to their
drug use would have limited success. The characteristic of these users is that obtaining and using
drugs becomes a priority in their life. Driving is integral to their drug use and interventions into
drug driving need to be framed within specific interventions into their dependent drug use
behaviour. Drug driving interventions could be incorporated into their treatment, custodial and
health care programs.

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Finally, and perhaps most importantly, the lack of any perceived likelihood of being caught for
drug driving is a major barrier to behaviour change. One of the cornerstones for Australian drink
driving public education programs has been a focusing of the individual's perception on the
likelihood of being caught. These programs combined with deterrence-based enforcement
strategies have been shown to be a highly successful countermeasure in reducing drink driving.
The data gathered in this research clearly shows that the perceived lack of detection is a strong
belief component for users engaging in drug driving. Both recreational and dependent type users
believe that they were not going to get caught. Furthermore it appears that this belief is reinforced
by actual experience This strongly suggests that work should continue on the development,
trialing and implementation of enforcement programs and roadside detection.
References
1. Austroads. Drugs and Driving in Australia. Sydney 2000, AP-R172.
2. Davey J. Changing Drug Patterns and Trends in Queensland and Australia: The Shift Into the
New Millennium. In Kozel N, editor, Epidemiological Trends in Drug Abuse: International
Epidemiology Work Group, June 1999; NIH-National Institute on Drug Abuse, Rockville
MD 2000, pp 47-59
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
(4th ed). American Psychiatric Association, Washington (DC), 1994.

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