Most Americans have a general sense that drunken driving isn’t as bad a problem as it was a generation ago. But few realize how much those numbers changed in a relatively short time. When the federal government started counting alcohol-impaired traffic deaths in 1982, there were more than 21,000 a year. By 2011, the death toll was down by 53 percent. States had raised the legal drinking age to 21 and adopted a common rule that a blood alcohol concentration (BAC) of .08 meant “too drunk to drive.” Many states also mandated the installation of interlock devices to prevent those with a history of drunken driving from turning on their ignition unless they were sober. Those laws, coupled with education and prevention campaigns, helped reduce drunk driving deaths to fewer than 10,000 in 2011.

But recently the trend has stalled. The total number of alcohol-impaired traffic fatalities actually rose in both 2015 and 2016. “Drunk driving has been around since the automobile was invented and it’s still the biggest killer on the highway,” says J.T. Griffin, the chief government affairs officer for Mothers Against Drunk Driving (MADD). Indeed, alcohol causes more traffic deaths per year than either speeding or driving without a seatbelt.

10,497: The number of fatal alcohol-impaired driving crashes in 2016, the highest since 2009

In January, the National Academies of Sciences, Engineering and Medicine issued a report about the causes of the problem and potential solutions. “Yes, we made progress. No, we didn’t get rid of it,” says David Jernigan, a Boston University public health researcher who helped write the report. “Ten thousand deaths are too many.”

The report provided a package of policy recommendations, one of which was for every state to lower the legal BAC limit from .08 to .05. In practical terms, that would mean most women couldn’t drive after two glasses of wine in an hour; most men couldn’t drive after three. The report is only the latest to call for a more stringent BAC limit: The National Transportation Safety Board has also called for a lower level.

Up to now, no state has imposed a limit of .05, but that’s about to change. Utah will go to .05 in December. In the past year, Delaware, Hawaii, New York and Washington state have also considered legislation to lower the limit. “It will change the conversation from, ‘If you have been drinking too much, you shouldn’t drive,’ to, ‘If you’ve been drinking, you shouldn’t drive,’” says Utah Rep. Norm Thurston, who sponsored the .05 legislation. The new message -- that driving shouldn’t occur after even moderate drinking -- “is probably what it should have been all along,” he says.

American alcohol policy is in a curious state of flux. On one hand, states and localities continue to tax alcoholic beverages not only to raise revenue but also to educate the public about the risks associated with drinking. On the other hand, states are passing laws that make alcohol easier to purchase by permitting sales on Sundays, in movie theaters and at grocery outlets. In December, Congress cut federal alcohol excise taxes to the tune of $4.2 billion over two years. The reduction is expected to bring down prices and increase consumption.

The national conversation around addiction has been dominated in recent years by opioids. Certainly, the rapid rise in opioid overdoses, which claimed 42,000 lives in 2016 alone, is a pressing issue for states across the country. The White House has declared a national public health emergency over the epidemic, and governments everywhere are marshalling efforts to combat the crisis.

But the fact is that alcohol kills roughly 88,000 Americans each year, more than double the number of opioid deaths. Almost half of alcohol fatalities come from chronic health problems attributed to excessive alcohol consumption, such as liver cirrhosis, breast cancer and heart disease. Those alcohol-induced deaths are on the rise. Excluding certain acute causes, such as homicides and traffic fatalities, the rate of alcohol-induced deaths increased by about 47 percent between 1999 and 2015.

Public health specialists say it’s time for a broader national dialogue about substance misuse, one that includes alcohol. “There continues to be a [reluctance to accept that] alcohol is an addictive substance because it’s legal, because it’s widely used, because people believe that unless it’s a drunk driving accident you don’t really die from it,” says Phyllis Randall, chair of the Loudoun County, Va., Board of Supervisors and a former mental health therapist who worked for 15 years treating offenders with substance abuse problems in an adult detention center.

The recent increase in alcohol-related deaths from chronic health problems is part of a new picture emerging about alcohol’s negative impacts on American life. While public officials are united in the fight against opioids, they are struggling to adjust their strategy toward a substance that is legal, widely available and increasingly popular among American consumers.



"There continues to be a [reluctance to accept that] alcohol is an addictive substance, says Phyllis Randall, chair of the Loudoun County Board of Supervisors. (David Kidd)

When it comes to alcohol abuse, one troubling development is that women are closing the gender gap. Over the last decade, the percentage of women who drink, the number of days they drink per month and the percentage who engage in binge drinking have all increased. Women are also visiting emergency rooms more often for alcohol-related reasons.

No empirical studies have identified why drinking among women is on the rise, though researchers have theories. Jernigan, the Boston University professor, points to the proliferation of sweet and fizzy alcohol drinks in the late 1990s that targeted young women. One study from the National Institute on Alcohol Abuse and Alcoholism cited changing cultural norms. The study speculated that it has simply become more socially acceptable for women to binge drink on a regular basis, the way some men do.

As more women drink, and the frequency and volume of the drinking increases, so does the risk of expectant mothers unintentionally exposing their fetus to alcohol and harming the child’s brain development. About 1 in 10 pregnant women in the U.S. report having had at least one alcoholic beverage in the past 30 days, according to the Centers for Disease Control and Prevention. Even light drinking during pregnancy can result in fetal alcohol spectrum disorders (FASD), an umbrella term for a group of conditions that can include abnormal growth and facial features, intellectual disabilities and behavioral problems.

Until recently, scientists have lacked accurate estimates on the prevalence of FASD because it is difficult to diagnose. But this year, a study of more than 6,000 first-graders in four communities in different regions of the U.S. found that up to 5 percent had FASD. The vast majority had not been diagnosed by a physician, though their parents and guardians knew the children had learning and behavioral difficulties. Children with FASD often are misdiagnosed as having attention deficit hyperactivity disorder, bipolar disorder or autism. Children with FASD don’t always have the visible facial abnormalities typically associated with prenatal alcohol exposure, but they can still have alcohol-induced intellectual disabilities and difficulties regulating their emotions. “This is a big player in early childhood development,” says Ira Chasnoff, a pediatrician at the University of Illinois College of Medicine in Chicago.

Chasnoff is working with a handful of states, including Arizona, Illinois and Iowa, to improve the way hospitals screen for prenatal alcohol exposure and provide treatment to families. Over the last decade, Congress has updated federal law to require that physicians ask expectant mothers about alcohol use. In the past, doctors were only supposed to ask about illicit drugs. But even today, most physicians still don’t ask about or report alcohol use by pregnant mothers. Some research suggests many of them don’t know Congress changed the requirement. The upshot is that hospitals identify only a small fraction of the more than 400,000 children born each year with prenatal exposure to alcohol or illicit drugs.

Historically, the federal government hasn’t prioritized alcohol in the way it has illicit drugs or, in today’s opioid crisis, prescription pain killers. “The federal government reacts to and bounces [from crisis to crisis],” says Chasnoff. “A few years ago, it was the methamphetamine crisis, and before that it was cocaine. The list goes on and on.”

88,000: The approximate number of people who die annually of alcohol-related causes, including traffic accidents and homicides

The problem with that approach is that policymakers are designing strategies that assume people use only one substance. “The reality is the great majority of women who are using drugs, especially during pregnancy, are polydrug users, and alcohol by far is the common thread,” Chasnoff says. In his own research, he has found that 81 percent of pregnant women who are using an illicit drug are also using alcohol.

Adult substance use in general is becoming a bigger problem for child welfare agencies. In 2000, 18.5 percent of children placed into foster care were removed from their homes at least in part because of their parents’ use of alcohol or other drugs. In 2015 the number was 34.4 percent. Child welfare experts believe substance abuse is one of the main reasons the overall number of children in foster care has increased each year since 2012 -- after a seven-year decline. The most frequently reported circumstance that leads to a child’s removal from home is neglect -- not physical abuse -- and neglect is often a byproduct of addiction.

Four years ago, the Iowa Children’s Justice Initiative, a division of the state judicial system, began working with Chasnoff to set up systems for early screening, substance use assessments and referrals for treatment both for expectant mothers and children under 5. Kathy Thompson, who directs the Iowa initiative, says the systems appear to be identifying more cases where prenatal alcohol exposure may be an issue, but it’s too early to know whether the initiative will ultimately prevent child removals. “I don’t know if we’ll ever capture the full impact,” she says, “because success would mean they never ended up in the child welfare system.”

In the next few years, more states may look to addiction treatment to control the growth in child welfare caseloads. Congress passed a law in February that allows states to direct money to substance use treatment for families whose children are at risk of being removed; in the past, these funds were reserved for helping children once they were in foster care. States are still waiting for more federal guidance on how to implement the new provision, but the change could mean that more children will be able to stay in their homes while their parents receive treatment.

While the medical community is still learning about the treatment options for prenatal alcohol exposure, it is more confident about drunken driving. “We have more than 10,000 deaths happening per year from something that is completely preventable,” says Jernigan, the Boston University professor. This year’s report from the National Academies of Sciences avoided prescribing a single solution to drunken driving. Instead, it recommended a group of policy responses, such as increasing alcohol taxes, limiting when and where alcohol is sold, adding treatment courts for DWIs (driving while intoxicated), mandating ignition interlock devices for first-time DWI offenders, expanding public transit and ride-sharing options, and lowering the BAC limit to .05.

Some of the recommendations are more practical than others. Even without a public health justification, states and localities are passing regulations that encourage the use of ride-sharing services such as Uber and Lyft. DWI courts are also on the rise. In fact, 46 states have at least one, and a growing number of drug courts include a division or track for DWI offenders.

62%: The increase in stand-alone DWI courts from 2009 to 2015

In some respects, however, alcohol policy is moving in the opposite direction from the National Academies’ recommendations. Federal alcohol taxes will be lower through 2019, thanks to the Tax Cuts and Jobs Act Congress passed in December. Rather than limiting alcohol sales, states are enacting more permissive policies. In the past year, Indiana, Minnesota, Oklahoma and Tennessee have joined 38 other states that have laws allowing alcohol sales on Sundays. Florida, Maryland and Pennsylvania have expanded the list of places where alcohol can be sold, including grocery stores and big-box retailers.

The recommendation that is most likely to be adopted by the majority of states is stronger laws around ignition interlock devices. As of May, at least 26 states required ignition interlock for all DWI offenders, according to the National Conference of State Legislatures. That’s a big leap from 2006, when only one state, New Mexico, had such a law. Expanding and strengthening ignition interlock laws is a top legislative priority for MADD. Tougher interlock laws also have the support of the American Beverage Institute, an industry group that has criticized many of the other recommendations in the National Academies’ report.

By comparison, a BAC limit of .05 is considered an impractical stretch in most states, even for advocacy groups like MADD. “MADD is still supporting the .08 limit, although we believe that the best choice is not to drink anything and drive, period,” says Griffin, MADD’s chief government affairs officer. “We know that impairment begins with a drink of alcohol. We just think that there’s more science and there’s more public support around .08.”

The American Beverage Institute flatly opposes a lower BAC limit. “The penalties for drunk driving are very steep, for good reason,” says Sarah Longwell, the institute’s managing director. “But if you recategorize .05 as a per se DWI violation, then you’re talking about putting people in jail, and mandating they install an ignition interlock, and hiking their insurance rates, and giving them $10,000 in fines for having one drink.” Instead of punishing drivers who engage in moderate drinking, Longwell argues that states should focus their limited resources on the binge drinkers and repeat DWI offenders who are responsible for most fatal alcohol crashes.

The National Transportation Safety Board rejects this argument and continues to advocate for a lower limit. The board notes that the U.S. has a higher rate of alcohol-impaired traffic fatalities than other industrialized nations, many of which use .05 as their legal BAC limit. Last year, researchers at the University of Chicago took traffic safety data from other countries that use the .05 limit and extrapolated what might happen if every state in the U.S. adopted the same standard. They concluded that fatal alcohol-related crashes would decline 11.1 percent, avoiding more than 1,000 deaths per year. (For its part, the American Beverage Institute said the researchers exaggerated the potential deterrence effect of a lower limit.)

Nonetheless, the public safety benefits caught the attention of Utah lawmakers. “It’s not about drinking,” says Rep. Thurston, the sponsor of the state’s new .05 BAC law. “It’s about not driving after you drink -- and it’s ultimately about saving lives.”