Children, Youth and Family Consortium

The designated driver concept is a new component of the nation's comprehensive strategy for reducing alcohol-related traffic fatalities through prevention, deterrence and treatment. This paper explains how the designated driver concept serves as a vehicle for changing social norms; describes the national designated driver campaign and the involvement of the public and private sectors; presents public opinion findings documenting the wide popularity and growing usage of the designated driver concept; responds to criticisms raised by advocates of other approaches; extracts seven generalizable lessons from the designated driver campaign; and applies those lessons to the issue of teenage alcohol abuse.

An important challenge lacing health professionals today is to learn to harness and channel the immense power of mass communication in the service of human health. To respond to this challenge, seven years ago the Harvard School of Public Health established a Center for Health Communication. The Center works closely with scholars in the behavioral sciences, side-by-side with practitioners in advertising, marketing, and public relations. Through this collaboration, the Center seeks to learn more about human behavior and how to influence it through mass communication. The Center's mission is to help develop, legitimize and institutionalize an emerging field of endeavor in academic public health, namely, mass communication and health

The Harvard Alcohol Project, a national media campaign conducted in collaboration with the television industry, illustrates the Center's strategy. Launched in Massachusetts in 1985, and nationally in 1988, we set out to demonstrate how a new social concept, the "designated driver," could be rapidly introduced and widely disseminated through mass communication, thereby promoting a new social norm that the driver doesn't drink. A shift in the behavior of a critical mass of social drinkers, through a change in social norms, is a prerequisite for mobilizing public opinion in support of stringent, costly efforts to target high-risk, recidivist drinking drivers.

I recall when the Commonwealth Fund sent me to Stockholm to study Sweden's approach to drunk driving prevention. I was amazed to discover how commonplace it is for a Swedish couple to discuss, "Who's driving tonight?" before going out for the evening. The implication of the query is clear: the designated driver doesn't drink any alcohol. Sweden has strict and consistent enforcement of tough laws against drunk driving, but I believe this is so because the Swedes have evolved a strong social consensus about the seriousness of the drunk driving offense.

Across from my hotel in Stockholm, on the waterfront, was a Mississippi riverboat called the Dixie Queen where young people socialize. I went over one Friday evening to collect some field data, and struck up a conversation at the bar with four young men. They had arrived together by taxi, and were going home by taxi; twenty U.S. dollars each way. The line of taxis dockside at the end of the evening stretched around the block. One of the men, a housepainter, said to me, "If I were to get drunk and then drive, my friends wouldn't speak to me, and my brother would beat me up." That's a social norm that goes far beyond the risk of arrest and conviction for drunk driving. Clearly, such a powerful, social norm does not evolve overnight.

Impressed by that experience, and aware of a local designated driver project organized by the Washington (DC) Regional Alcohol Program, Harvard set out to introduce the designated driver concept throughout the United States. This initiative, which we call the Harvard Alcohol Project, marks the first time that a health institution has joined forces with the nation's communications industry on an endeavor of this magnitude. All major Hollywood studios and the three leading television networks are participating. The Project has been supported by the Max Factor Family Foundation, the Pew Charitable Trusts, the Commonwealth Fund, the GTE Foundation, the ARCO Foundation, the Exxon Corporation and Nutri/System, Inc.

The Project broke new ground when television writers agreed to insert drunk driving prevention messages, including references to the use of designated drivers, right into the scripts of top- rated shows such as "The Cosby Show," "Cheers" and "L.A. Law."

The advantage of this approach is that short messages, embedded within dialogue, are casually presented by characters who serve as role models within a dramatic context, thereby facilitating social learning. The Harvard Alcohol Project represents the first successful effort to mobilize the creative community on such a scale, using dialogue in prime-time entertainment as a health promotion technology. In addition to entertainment programming, our communications strategy has included news coverage, advertising and a grass roots community-based effort to reinforce the impact of the national media.

Our advisors on this project have included John Chancellor, senior news commentator of NBC; Jack Valenti, president of the Motion Picture Association of America; Dr. Frank Stanton, former president of CBS; and Grant Tinker, former chairman of NBC and currently president of GTG Entertainment. It took Dr. Stanton two years to convince me to try the entertainment programming route. Finally, I told him that this former molecular biologist was ready to give it a try in Hollywood. Dr. Stanton then made a key intervention, arranging an introduction to Grant Tinker, and Tinker became the godfather of the Project, opening doors throughout Hollywood. In addition, John Chancellor introduced me to Jack Valenti, who in turn provided entree to the Writers Guild of America, West and the Screen Actors Guild; both guilds endorsed and widely publicized the project.

Over a four year period, I met with over 250 executive producers, senior producers, and chief writers from all the leading prime time shows. In addition to the designated driver message, I encouraged them to incorporate a broad array. of drunk driving prevention messages into scripts, encompassing prevention, deterrence and treatment. Since November, 1988, more than 140 prime-time programs have included sub-plots, scenes, dialogue or (in over 25 instances) an entire 30- or 60-minute episode supportive of the campaign, with audiences of up to 45 million. Many programs subsequently were rebroadcast, either as network re-runs or in syndication, greatly amplifying the campaign's exposure. In addition to frequent mentions of designated drivers, a majority of the programs have dealt with such other themes as server and peer intervention; underage drinking; the attitudes of police, judges and juries; and the social stigma and shame associated with an arrest for drunk driving.

In addition, at the request of the Harvard Alcohol Project, the ABC, CBS and NBC television networks have promoted the designated driver concept via network-produced and sponsored public service announcements (PSAs). Among the three networks, these messages were broadcast approximately 20 times per week during the December, 1988 holiday season. In December, 1989, at Harvard's request, President George Bush appeared in a network television PSA encouraging the use of designated drivers. During a 10-day period over the December 1989 holidays, the three networks aired the President's message 12 times, mostly in prime time. Based on the estimated audience of each program in which the PSAs were placed, the President's message received 215 million exposures. In December, 1990, President Bush appeared in a designated driver PSA stressing social host responsibility. The President said, "Each year, more than 20,000 lives are lost in alcohol-related traffic crashes. We can prevent this tragedy. This holiday season, if you host a party where alcohol is served, show your friends how much you care about their safety. Encourage them to choose a designated driver before any drinking begins. This holiday season, the designated driver is the life of the party." This message was broadcast on network television and distributed nationwide to local stations by the National Association of Broadcasters.

The networks have continued to air designated driver PSAs in concentrated bursts at particular times in the calendar year. For example, CBS runs four annual mini-campaigns, each consisting of a cluster of about seven prime-time PSAs, leading up to Memorial Day, Independence Day and Labor Day, and in early December. Many CBS messages stress the theme of social host responsibility. ABC and NBC continue to cluster their designated driver messages in December. In addition, at the local level, radio and television stations in many media markets have broadcast frequent designated driver PSAS.

This media "blitz" has included extensive news coverage of the designated driver campaign, including a front page story in The New York Times (Rothenberg, 1988); an editorial applauding the campaign in The New York Times (Editorial, 1989); a special 4- minute report on "ABC's World News Tonight with Peter Jennings" (September 26, 1989) ; major stories in the Washington Post (Hall, 1988) and the Los Angeles Times (Finke, 1988) ; and favorable editorial commentary and news coverage in many other newspapers, national newsweeklies and television newscasts. Also drawing extensive press attention were two special initiatives of the Harvard Alcohol Project: a community-based designated driver campaign on Martha's Vineyard (Walters, 1990) and a restaurant- based designated driver promotion at the Hard Rock Cafe (Associated Press, 1989).

The designated driver campaign soon became transformed into a national movement as a broad range of prominent individuals (e.g., former Surgeon General C. Everett Koop), government agencies (e.g., the National Highway Traffic Safety Administration) , national organizations (e. g., Mothers Against Drunk Driving), professional sports leagues (e.g., Major League Baseball), major corporations (e.g., State Farm Insurance), and leading police departments (e.g., the California Highway Patrol) endorsed and promoted the designated driver concept.

Fueled by this overall national effort, the designated driver concept became so deeply embedded in American life and language over a three year period that by 1991 the term was included in the Random House Webster's College Dictionary (Random House, 1991). The campaign's dramatic impact on awareness, acceptance and usage of the designated driver concept has been documented in national public opinion polls conducted by the Gallup Organization (Unpublished, National Gallup Poll, 1989), the Wirthlin Group (Unpublished, Wirthlin National Survey, 1990), and the Roper Organization (The Roper Organization, 1990, 1991a, 1991b; Unpublished, 1989; Unpublished, 1991).

In 1989, Gallup found that 67% of adults had noticed the designated driver messages on network television (Unpublished, Gallup National Poll, 1989). In 1990, Wirthlin found that 89% of respondents in the country were familiar with the designated driver program and gave it a favorability rating of 81 on a 100- point scale; the designated driver program rated higher than all other programs and industries measured. Among parents with children aged 13 - 18, Wirthlin found that 97% were familiar with the designated driver program, and gave it a favorability rating of 82. Among young adults aged 18 - 24, 97% were familiar with the designated driver program, and gave it a favorability rating of 88. For comparison, in a separate Wirthlin survey rating individuals, Mother Teresa scored highest with an 84. (Unpublished, Wirthlin National Survey, 1990)

The most detailed survey data have been collected by the Roper organization in studies of U.S. adults conducted in 1989 and 1991. Roper's 1991 findings, with selected comparisons to 1989, are highlighted below: 93% of Americans characterized the designated driver concept as an "excellent" or "good" idea (71%, excellent; 22%, good) . Among all drunk driving prevention strategies, U.S. adults gave their strongest endorsement to the use of designated drivers. Other anti-drunk driving ideas described as "excellent" or "good" by majorities included: more advertisements about drinking responsibly (81%); random police roadblocks to check for intoxicated drivers (69%); holding bar owners (60%) and private citizens (50%) legally responsible if they serve alcohol; and a ban on alcohol advertising (52%). (The Roper Organization, 19918)

37% of U.S. adults have themselves refrained from drinking in order to be a designated driver at least once in their lifetime, up sharply from 29% in 1989 (The Roper Organization, 199,a) . "In other words," Roper observed, "there have been a minimum of 68 million occasions when an adult--who might otherwise have driven home while under the influence of alcohol--was instead driven home by a designated driver, up from 52 million in 1989" (The Roper Organization, 199,b) . Because most of these people probably have been designated drivers more than once, and often have driven more than one person home, these numbers are likely to be underestimates.52% of U.S. adults under the age of 30 have been a designated driver, up from 43% in 1989 (The Roper Organization, 1991b) . This finding is especially important because this age group accounts for more than half of all drinking drivers who are fatally injured in crashes (Insurance Institute for Highway Safety, 1992).

46% of drinkers have been a designated driver, compared to 35% in 1989. 51% of frequent drinkers have been a designated driver, compared to 36% in 1989 (The Roper organization, 1990; Unpublished, 1991). Roper observed: "This indicates that it is not just the non-drinkers in a group who offer to be designated drivers, but that drinkers voluntarily refrain on occasions, and the concept is being implemented by this key group" (The Roper Organization, 1990).

35% of drinkers have been driven home by a designated driver, compared to 28% in 1989. 54% of frequent drinkers have been driven home by a designated driver, compared to 43% in 1989 (The Roper Organization, 1990; Unpublished, 1991).

61% of politically and socially active adults ("influentials") have been a designated driver, compared to 45% in 1989 (The Roper organization, Unpublished, 1989; Unpublished, 1991).

50% of executives and professionals have been a designated driver, compared to 36% in 1989 (The Roper Organization, unpublished, 1989; Unpublished, 1991).

46% of union members and 41% of blue collar workers have been a designated driver, compared to 33% and 34%, respectively, in 1989 (The Roper Organization, Unpublished, 1989; Unpublished, 1991).

Summing up, Roper observed, "Considering how relatively new the concept of the designated driver is, the sustained growth and support of the idea is impressive." And Roper concluded, "The designated driver concept is fast becoming ingrained in the nation's psyche ... The designated driver system has likely saved many young lives: Among those under 30, a majority have been won" (The Roper Organization, 1991c).

Some critics have conjectured, without evidence, that the availability of a designated driver might encourage excessive drinking by others in a group (DeJong and Wallach, Health Education Quarterly, in press). I have four responses to that.

First, young people certainly did not exercise restraint prior to the advent of designated drivers. Entire groups--including drivers--frequently became intoxicated, leading to many senseless deaths.

Second, the critic's line of argument is equally applicable to drunk driving prevention strategies that they strongly favor, such as sobriety checkpoints and administrative license revocation. Indeed, all strategies that focus exclusively on the drinking driver are subject to the same criticism; namely, that the availability of a driver with a blood alcohol concentration below the legal limit grants license to the driver's companions to drink to excess. In the case of the designated driver campaign, this concern is readily addressed through a careful framing of the message: If you drink, choose moderation and choose a designated driver who doesn't drink at all.

Third, national statistics confirm that abusive drinking among young people has not increased since the widespread acceptance of the designated driver concept in the late 1980's. Indeed, abusive drinking has actually fallen over this period by every available measure. Between 1980 and 1990, the proportion of high school seniors reporting alcohol use during the preceding month declined by 21%; reporting daily consumption of alcohol declined by 38%; and reporting consumption of 5 or more drinks in a row declined by 22% (Johnston, et. al., 19911a). Among college students during the same period, daily alcohol use declined by 42%; binge drinking declined by 7%; and thirty day use declined by 9% (Johnston, et. al., 1991'5). This is not to say that we do not have a continuing, severe problem of alcohol abuse, including binge drinking, among America's youth; we do. It is simply to say that there is no evidence that the popularity of the designated driver concept has exacerbated the problem of abusive drinking.

Fourth, the critics, point of view is reminiscent of attacks on condom distribution in schools and clean needle exchange programs. Each of these public health strategies has been attacked for allegedly condoning undesirable behavior. While continued efforts are needed to curb alcohol consumption by minors and reduce abusive drinking by adults, there also is a compelling, immediate need to save lives on the nation's highways.

I would like now to draw seven lessons from our experience with the designated driver campaign. The first lesson relates to timing. Important issues that arise on the public agenda, such as drug abuse, AIDS, and drunk driving, have a natural life history with fairly discrete stages that may extend over years and even decades. There is often a long incubation period with intensive activity behind the scenes on the part of activists and interest groups, but little public visibility. Next may come an initial growth phase, as the issue begins to surface publicly, including in the media. This may be followed by an exponential growth phase, in which the issue seemingly explodes out of nowhere, sometimes triggered by a specific event such as the death of Len Bias from a cocaine overdose, or the news that Rock Hudson contracted AIDS, or the Clarence Thomas sexual harassment hearings. Next may come a high plateau phase; and then a refractory period in which public interest begins to wane, or a backlash may even emerge, as is currently the case with the problem of homelessness.

Each of these phases demands different kinds of strategies to move the issue forward. The amount of media that you can attract to an issue will vary enormously depending upon which stage you are at in the issue's life cycle. For example, Ted Turner was recently interviewed by David Frost and Turner commented that he had devoted a special week of programming on CNN to the problem of world famine. He added that CNN experienced its lowest ratings in the network's history that week. The point of that anecdote is that, even when you own the media and you can dictate what it covers, if the timing isn't right and if the public isn't ready, they'll simply shut it off. Nonetheless, a lot of important work must be done during the largely invisible incubation period--that's how we get beyond it--and funding agencies need to be very forgiving as to measurable outcomes during this period.

So '

Lesson #1 from the designated driver campaign is TIMING. The public and the television producers with whom we worked were primed and ready to respond to our project, thanks to all the previous work performed by public health professionals, by government agencies, and by grass roots groups such as Mothers Against Drunk Driving. We were building on their foundation. we were seeking to add momentum to changes already underway. We were not trying to push a boulder uphill--rather, we were seeking to direct it downhill. The question is sometimes asked, "Who are you to choose which issue society should take on?" My response to that is that we didn't choose it, the times chose it. The times were ready for it.

Lesson # 2: FOCUS. We did not attempt to take on the entirety of alcohol use and abuse in American society. Instead, we selected a small, manageable piece of the overall problem, namely drunk driving, where we thought we could achieve something meaningful. Moreover, we didn't adopt a comprehensive approach to drunk driving prevention. We decided to focus all of our attention and limited resources on a single approach, the designated driver. That became our product, the designated driver, and we sought to sell our product in the marketplace. We felt that if we could capture the public imagination with this one fresh approach, we could energize and invigorate the entire anti-drunk driving movement. That is, we could use the designated driver concept as a wedge to achieve new movement on a variety of fronts in drunk driving prevention.

Lesson #3: SIMPLICITY. From our discussions with leading practitioners on Madison Avenue, we understood that if you want to work effectively with the media you need a very simple message: billboard language, a slogan. Now, there needs to be considerable complexity and subtlety beneath the surface. The slogan should be the tip of an iceberg; there needs to be an iceberg beneath the tip. For example, the designated driver message embodies several key strengths: it gets beyond the negative dictum "don't drink and drivel' and offers a positive step that people can take. It is addressed to a social group and not simply to an individual; it promotes interpersonal communication within that group. It encourages people to plan ahead if they intend to drink. It lends social legitimacy to the non-drinking role. It asks for a very modest shift in behavior, a shift that can help prevent 500,000 serious injuries and almost 20,000 fatalities each year. And, most importantly, it fosters a fundamental change in the social environment by promoting a new social norm, a social expectation, that the driver does not drink any alcohol.

Lesson #4: POSITIONING. We conducted extensive consumer research to gauge how best to position our product in the consumer's mind. For example, our studies taught us that we needed to position the designated driver as an attractive, popular, valued member of the social group, avoiding any hint that the designated driver is the designated babysitter, outside the group, outside the fun.

Lesson #5: CREATIVITY. We recruited as partners some of the most creative minds on Madison Avenue. Using our consumer research as a point of departure, they designed a poster and a table card carrying the line, "The Designated Driver is the Life of the Party," and they created artwork to support the line, positioning our product in an environment that is up, that is fun, that is filled with 6-color day-glo party streamers. The table card version has been well received by restaurant owners around the country. It places our message right on the table in front of a group of friends that is about to order the first round of drinks. We've used the posters and table cards in a community- based public awareness campaign that we field tested on Martha's Vineyard; we blanketed the Island with our message, transforming the Vineyard into "the nation's first designated driver island." The National Restaurant Association- has distributed our designated driver poster to restaurants and taverns around the country.

Lesson #6: CONSENSUS. We chose a non-controversial issue, drunk driving prevention, about which there is broad social consensus. There is no other side arguing in favor of drunk driving. The alcoholic beverage industry gets a black eye from drunk driving, so they support our objective. Some people have expressed concern about the alcoholic beverage industry's having embraced the designated driver concept. My response to that is the famous saying, "My enemy's enemy is my friend." The enemy in this case is drunk driving. Hence, there were no important political or economic barriers to our achieving adequate exposure for our message.

Lesson #7: EXPOSURE. Thanks to our partners at the networks and the studios, and the success of public relations activities which generated extensive news coverage, our designated driver message received exposure sufficient to catch on. Indeed, it's become self-sustaining. Across the country, many local and state government agencies have instituted designated driver programs in collaboration with the private sector. In California, for example, the California Highway Patrol runs a state-wide designated driver program involving restaurants and taverns. The California Department of Motor Vehicles includes information about the state-wide designated driver program in its Driver's Handbook. The Los Angeles County Designated Driver Coalition sponsors major events to promote the designated driver concept, and issues English and Spanish language versions of a pamphlet entitled, "Be A Designated Driver, A Choice You Can Live With!"

Coalition members include the Los Angeles Chapter of Mothers Against Drunk Driving, the City of Los Angeles Police Department, the Los Angeles County Sheriff's Department, The California Restaurant Association, and the California Department of Alcoholic Beverage Control.

When I arrived in Los Angeles on a recent trip, I realized that I had left my sunglasses at home in Boston. I bought a new pair in the hotel, and noticed that, in the corner of one lens, there were two overlapping capital D's. Instead of saying "Pierre Cardin," it said "DD." I noticed that the carrying case had the same insignia. Then I turned over the carrying case, and lo and behold it's a new line of sunglasses called "Designated Driver." Imported. $35. It's catching on.

I would like now to apply the lessons outlined above to the problem of alcohol use by adolescents.

Alcohol presents a tough communications problem. Our lives are filled with mixed messages about alcohol. Is it a popular social beverage for adults, or a drug? Well, both. Is it an illegal substance for adolescents, or a gateway to sex, male bonding and all-around fun? Well, all-of-the-above.

In this mixed communications environment, it is difficult to frame a health message on teen alcohol use that will be heard by teens, that will be credible to teens, that will make a difference in a teen culture in which Bud Light and Coors are deeply entrenched in ritualized rites of passage.

Perhaps the most pragmatic approach, given these realities, is to focus our limited resources on abusive teen drinking. That is, focus on the dangers of serious alcohol abuse. This eliminates ambivalence and ambiguity, providing us with a message that is honest, clear and applicable to all age groups--adult and adolescent. It eliminates any economic opposition to our message. It gives high visibility to a hard-hitting, accurate, negative message about alcohol abuse.

Success in this area depends on identifying narrowly defined "windows of opportunity" within the broad, complex area of alcohol abuse. A review of national public opinion research findings has revealed one highly promising opportunity: a Gallup Youth Survey found that 41% of teenagers aged 13-1l believe that at least one of their friends may have a very serious problem with alcohol abuse (Gallup, 1990). This suggests that large numbers of teenagers would likely be receptive to a message about how to help a friend in this situation. Their pre-existing concern provides a narrowly defined window of opportunity for communicating a high-profile message about alcohol abuse to an attentive, primed audience.

We are exploiting this opportunity through the Center's new project, "Operation Breakthrough." The project is supported by grants from the JM Foundation, the Scaife Family Foundation, the Metropolitan Life Foundation, the Pew Charitable Trusts and the Exxon Corporation. Our thesis is that an invisible barrier often prevents adolescents from reaching out to help a friend who's known to be in serious trouble with alcohol abuse. our goal is to break through that barrier by teaching skills for intervening, and by creating a social climate that sees interpersonal interventions among teenage friends as highly valued social acts. In the project's first few months, we were able to convince the producers of "Blossom," a prime-time series on NBC especially popular among teens, to create a 30-minute episode depicting how one teen can intervene to help a troubled friend. More recently, we worked with the producers of "Beverly Fills, 90210, 11 currently the most popular series among teenagers, on a 60-minute episode depicting interpersonal interventions. Currently, we are developing a brochure for teenagers, entitled "Does Your Friend Have A Drinking Problem?", stressing the value of interpersonal interventions.

This same strategy of promoting interpersonal interventions is likely to feature prominently in future efforts to reduce the toll from alcohol-related traffic fatalities. Reaching the high- risk drinking driver will require a combination of strict and highly visible police enforcement, severe financial penalties accompanying drunk driving convictions, and the creation of a social environment in which interpersonal interventions to deter drunk driving are highly valued. When a recidivist drunk driver, with several previous criminal convictions, makes headlines by finally causing a fatal crash, the ensuing public outrage typically is directed at law enforcement and the judiciary. But what about the responsibilities of the spouse, friends, bartenders, waitpersons and others who idly stood by, embarrassed at the prospect of "making a scene," and watched the inebriated individual get behind the wheel of a car? I believe that a major effort is needed to create a social climate that views interpersonal interventions as socially expected in situations such as this, and views a failure to intervene as shameful. Such interventions frequently will be difficult, often will fail, and sometimes will save lives.

LESSONS FROM THE DESIGNATED DRIVER CAMPAIGN

Abstract

Introduction

The Public's Response

A Response to Critics

Lessons from the Designated Driver Campaign

"Operation Breakthrough" and Interpersonal Interventions

References