Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Friday, April 18, 2008

Click It Or Ticket: Failing America While Trying To Protect It – Pat Brooks

In 1993, North Carolina became the first state to enact a campaign in which neglecting seat belt use in a motor vehicle would be grounds for law enforcement pulling over drivers. Since then many other states have adopted this program. The National Highway Traffic Administration brags that the campaign “is the most successful seat belt enforcement campaign ever, helping create the highest national seat belt usage rate of 82 percent” (7). The campaign’s name and its message are simple: “Click it or Ticket.” Click it or Ticket is a failure to American citizens because the message of this campaign ignores the issue of social norms, rational empirical and normative re-educative approaches (skipping to coercion without educating the public), and the causes of accidents (wrongly assuming that wearing seat belts prevents accidents).
Social Norms
This campaign is a failure to Americans because it ignores the issue of social norms. Two studies were conducted in the United States and Sweden to examine relationships among several behaviors. The studies examined the interrelationships among a variety of self-reported perceptual and behavior measures predicting driving behavior. Part of the study focused on seat belt usage. Results show that emphasizing factors such “as comfort and social norms [is] an efficient way of increasing seat-belt usage” (8). The article goes on to articulate the need for creating the social norm, “giving the feeling that other drivers are using seat belts, and that it is alright to do so” (8). Because Click it or Ticket has previously increased seat belt use rates nationwide, it should be using the idea that it is socially acceptable and normal to buckle up in order to persuade the citizens who are not complying with the law to join the majority of Americans. By not appealing to this aspect of influence, it fails Americans.
The findings of another study show that using a social norms-based intervention can provide people with more accurate perceptions about health behaviors (5). This change in perceptions would in turn lead to a modification in their behavior (5). A study published in the Oxford University Press designed a model for health behaviors. Their model relied heavily upon social norms, showing that an intervention which does not account for social norms cannot be a success (6). Even advertisers have caught onto this idea and realized its potential for impact. In 2005, the American Academy of Advertisers looked at current public health interventions aimed at reducing college binge drinking. It concluded that “behavior is influenced by others' behavior - as well as our sometimes inaccurate perceptions of their behavior” (1).
The message of this campaign ignores rational empirical and normative re-educative approaches, skipping to coercion without attempting to educate the public. A study was done testing the hypothesis that giving children rewards for buckling up could increase their use of seat belts (10). During the reward phase at twenty five schools, children’s safety belt use increased from 4% to 66% and 5% to 70% in the United States and Sweden respectively. This study suggests that for children, a more effective approach than coercion is a system of positive reinforcement. The current Click it or Ticket campaign is a threat to drivers and does not attempt to offer any sort of reward system. Additionally, the menace of being ticketed by a law enforcement officer does not even reach children, since none of them can receive such tickets. If 100% of children under 5 years of age had used safety belts in the year 2000 alone, “an estimated 458 lives could have been saved” (4).
Another subgroup of individuals not being reached by the Click it or Ticket campaign and consequently with low probability of buckling up is the college age male (1). In 1985, researchers introduced a method, Flash for Life, that “increased belt use among 22% of unbuckled drivers” (3). In 2007, this intervention was revived and applied at a large university campus. In a study aimed at this particular age group, college students at a large university who were not buckled up were targeted by other students flashing signs that read “Please Buckle Up, I Care” (3). The university selected had already high seat belt use. The hypothesis of the study was that this positive reinforcement would be more effective than the current threat of Click it or Ticket for college aged drivers. The results of the study showed that “of 427 unbuckled drivers observed, 30% of these complied with the prompt” (3). Interestingly, the unbuckled male drivers were significantly more likely to buckle up when the student holding the sign was female. Another impact found in this study is an industrial one. It suggests that “a simple behavioral prompt could be used at most industrial complexes to increase safety belt use among vehicle occupants who are not buckled-up” (3). Programs such as Flash for Life are examples of better approaches to the issue of seat belt usage. By ignoring appeals that are targeted at specific subgroups of the population, Click it or Ticket is failing Americans.
Both of these studies showed alternatives to menacing intimidation, or coercion, which utilize positive reinforcement with compliance. The first steps to changing a behavior are rational empirical and normative re-educative approaches. These should be included in any intervention whose aim is to protect the public. The American Academy of Advertising has said that “fear-based appeals have been the dominant strategy over the years,” but that new evidence shows that marketing strategies from the normative and rational perspectives could be applied to some public health areas to make a greater impact than those fear-based approaches (1). “Behavior analysis has shown that [standard coercive practices] do not work” (11). Coercion lacks durability because it is “in the long run self-defeating” (11). It usually turns out that using punishment as a motivator will be counterproductive in the long run.
True Causes
The message of this campaign ignores the causes of traffic crashes, wrongly assuming that wearing seat belts prevents accidents. Seat belts may protect vehicle occupants when traffic crashes occur, but an effective intervention would target prevention of the crashes in the first place. Speeding, aggressive, drowsy, distracted or impaired drivers, and vehicle malfunctions all can be major contributors to traffic accidents.
In 1975 the National Highway Traffic Safety Association (NHTSA) created the Fatality Analysis Reporting System (FARS). FARS uses census data from all 50 states, Puerto Rico, and Washington D.C. Using FARS data, it is easy to see that there has been no significant decrease in the number of crashes since Click it or Ticket has been around. In 2005, twelve years after Click it or Ticket was enacted in the first state, “more than 6.1 million police-reported motor vehicle crashes occurred in the United States” (4). In 1994 there were 36,254 traffic fatalities compared with 38,588 in 2006. It is obvious and logical that a campaign solely trying to increase seat belt use has made no impact on the number of crashes in the United States.
Furthermore, alcohol is involved in 39% of fatal crashes and has a fatality rate of 75% in crashes between midnight and 3.m. (4) A successful campaign would target this major cause of traffic collisions. It would use prevention as its primary focus.
The total number of road deaths in the United States has either risen or stayed the same since Click it or Ticket. The table below outlines the trend of motor vehicle crashes in the United States over a 13 year period. (4)
Fatal Motor Vehicle Traffic Crashes


Click it or Ticket does not aim to reduce the number of traffic crashes or fatalities. It is like treating the symptoms without considering the disease. The campaign is a failure because the message ignores the causes of traffic crashes, wrongly assuming that wearing seat belts prevents accidents. A truly successful campaign would incorporate accident prevention as part of its message.
In conclusion, Click it or Ticket is a failure to Americans because the message of this campaign ignores the issue of social norms, rational empirical and normative re-educative approaches, skipping to coercion without educating the public, and the causes of accidents, wrongly assuming that wearing seat belts prevents accidents. If this campaign continues to be a failure, it could miss the opportunity to save countless lives. This failing campaign does not protect drivers or passengers from being involved in automobile crashes. Its focus on coercion and punishment will not provide the positive reinforcement that children and other subgroups of the population require. Its ignorance about the true causes of crashes will do nothing to prevent them. Continuing a failing program will continue to kill.
Cressey, Peter H. Alternatives to Fear Appeals: New Strategies for Social Behavior Campaigns. American Academy of Advertising 2005; 22(4): 10-28.
Colgrove, James. The Legacy of Jacobson v Massachusetts. American Journal of Public Health 2005; 95(4): 571-576.
Farrell, Leah V. Prompting safety-belt use in the context of a belt-use law. Journal of Safety Research 2007; 38(4):407-411.
Fatality Analysis Reporting System. Encyclopedia:
Hagman, Brett T. Social Norms Theory-Based Interventions: Testing the Feasibility of a Purported Mechanism of Action. Journal of American College Health 2007; 56(3): 293-298.
Jo, Heuisug. Structural Relationship of Factors Affecting Health Promotion Behaviors. Health Promotion International 2003; 18(3): 229-236.
National Highway Traffic Safety Association. Click It Or Ticket:
Ola, Svenson. Perceived driving safety and seatbelt usage. Accident Analysis and Prevention 1985; 17(2): 119-133.
Ouimet M.C. Perceived Risk and Other Predictors and Correlates of Teenagers’ Safety Belt Use During the First Year of Licensure. Traffic Injury Prevention 2008; 9(1): 1-10.
Roberts, Michael C. Rewarding Elementary Schoolchildren for their Use of Safety Belts. Health Psychology 1986; 5(3): 185-196.
Sidman, Murray. Coercion and its Fallout. Boston, MA: Authors Cooperative, 1989.

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  • At April 23, 2008 at 10:20 AM , Anonymous Jackie said...

    I'm not sure if this is nation-wide, but where I grew up, the "Click-it-or-ticket" signs were always on large billboards on the highways. When I drive, I'm much more likely to buckle my seatbelt at a traffic light, stop sign, or when stopped and waiting to turn -- NOT when I'm driving at 70mph trying not to be cut off.

    I wonder if the signs (which can serve as simple reminders as well as threats) are more effective where drivers have a better oppertunity to actually buckle the belt?

  • At April 23, 2008 at 10:17 PM , Blogger Matthew said...

    You mention that a Swedish study demonstrated the beneficial effects of positive re-inforcement for child safety belt wearing. First, I don't think this campaign was originally designed for children. Second, how might one institute a positive reward system on a large scale for seat belt use? Certainly, parents could positively reward their children for seat belt use on an individual level, but how, as a ph practicioner, could one develop a system for adults?

    Finally, in response to the table displaying fatal crashes - I would be interested to see the breakdown for each year - what percentage of each number of deaths were identified as fatalities that could likely have been prevented by wearing a seat belt? This data might clarify the argument.

  • At May 1, 2008 at 6:35 AM , Anonymous pat said...

    One time when I was pulled over with my brothers, they gave the driver a coupon for a free car wash because every passenger was buckled up. I have also heard of campaigns that give away coupons for free cups of Dunkin Donuts coffees. I believe there are creative ways to offer a positive rewards system for adults - if we are willing to think outside the box.


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