Legislative and Regulatory Strategies to Reduce Childhood Unintentional Injuries

111

Legislative andRegulatory Strategies to Reduce ChildhoodUnintentional InjuriesRichard A. SchieberJulie GilchristDavid A. Sleet

AbstractLaws and regulations are among the most effective mechanisms for getting large seg-ments of the population to adopt safety behaviors. These have been applied at boththe state and federal levels for diverse injury issues. Certain legal actions are taken toprevent the occurrence of an otherwise injury-producing event, while other legalactions are designed to prevent injury once an event has occurred. At the federal level,effective laws and regulations have been directed at dangers posed by unsafe manu-factured products or motor vehicle design. At the state level, effective safety laws andregulations have been directed at encouraging safety behaviors and regulating the useof motor vehicles or other forms of transportation.

In this article, six legislative efforts are described to point out pros and cons of the leg-islative approach to promoting safety. Three such efforts are aimed at preventinginjury-producing events from occurring: mandating child-resistant packaging for pre-scription drugs and other hazardous substances, regulating tap water temperature bypresetting a safe hot-water heater temperature at the factory, and graduated licensing.Three other examples illustrate the value and complexities of laws designed to preventinjuries once an injury-producing event does occur: mandatory bicycle helmet use,sleepwear standards, and child safety seat use. This article concludes with specific rec-ommendations, which include assessing the value of laws and regulations, preventingthe rescission of laws and regulations known to work, refining existing laws to elimi-nate gaps in coverage, developing regulations to adapt to changing technology, explor-ing new legal means to encourage safe behavior, and increasing funding for basic andapplied research and community programs.

Further reductions in childhood injury rates will require that leaders working in thefield of injury prevention together provide the creativity to devise new safety devicesand programs, incentives to persuade the public to adopt a “culture of safety” as asocial norm, training and education to develop new leaders and workers, and the polit-ical will to challenge the status quo and engage the public interest.

The Future of Children UNINTENTIONAL INJURIES IN CHILDHOOD Vol. 10 • No. 1 – Spring/Summer 2000

Richard A. Schieber,M.D., M.P.H., is a child-hood injury epidemiologistat the National Centerfor Injury Preventionand Control, Centers forDisease Control and Pre-vention; and associateprofessor of surgery atEmory University School ofMedicine in Atlanta, GA.

Julie Gilchrist, M.D., is achildhood injury epi-demiologist at theNational Center forInjury Prevention andControl, Centers forDisease Control and Pre-vention, in Atlanta, GA.

David A. Sleet, Ph.D.,is the Associate Directorfor Science in the Divi-sion of UnintentionalInjury Prevention,Centers for DiseaseControl and Prevention;and adjunct professorat Emory UniversitySchool of Public Healthin Atlanta, GA.

http://www.futureofchildren.org


112 THE FUTURE OF CHILDREN – SPRING/SUMMER 2000

State and NationalLegislation and RegulationSafety legislation and regulation typicallyoperate by mandating the manufacture ofsafe products or by encouraging safe behav-iors. The distinction between laws and regu-lations is sometimes confusing. A law islegislative in nature, voted upon by mem-bers of the U.S. Congress and approved bythe president, or voted upon by members ofstate legislatures and approved by theirgovernors. Regulations are administrativeactions based on laws, and a regulation car-ries the force of the law that supports it.

Jurisdiction over an issue is primarilylocated at either the state or federal level. TheU.S. Constitution, especially Articles 1 and 8,and the 10th Amendment, determineswhether responsibility for enacting a particu-lar law lies within the powers of the federalgovernment or whether it is the responsibilityof each state. Modern manifestations of juris-dictional authority are evident in traffic laws,among others. For example, the federal gov-ernment cannot pass legislation concerningmotor vehicle traffic within each state, unless

the sole purpose of such traffic is to carrygoods or people in interstate commerce. TheU.S. Congress does not have the constitu-tional authority to amend or repeal a statemotor vehicle law. However, it can persuadestate legislators to pass traffic safety legislationby diverting a portion of a state’s HighwayTrust Fund apportionment normally used tobuild roads if the state does not enact a lawtaking a recommended position on a specificissue. Past examples that have successfullyused this fiscal inducement include the estab-lishment of a national minimum drinkingage, a national maximum speed limit, anational maximum blood alcohol concentra-tion law, and state motorcycle helmet laws.

During the past 25 years, legislation andregulations have been used successfully in theUnited States to prevent childhood injuriesand improve the health and safety of childrenand teenagers (see Table 1). These strategieshave been used to change individual behavior(for example, state bicycle helmet use laws), tochange a legal process (for example, state-based eligibility to obtain full driver’s licenseprivileges under graduated licensing laws),and change the way a product is manufactured

State and national government agencies conduct many large-scale, vitalchildhood unintentional injury prevention programs. National non-governmental organizations (NGOs) enhance these activities through

collaboration and by encouraging the passage of laws and regulations. Byconducting activities at a geopolitical unit above the local community orcounty level, economy of scale is achieved, enhancing the efficiency ofscarce resources. Centrally directed activities also can improve communica-tion, making it more likely that a local unit will share, rather than unwit-tingly duplicate, educational materials and other resources with othercommunities in the state. Some activities, particularly injury surveillance,require substantial maintenance funds that only state or large city govern-ments can afford.

State and federal legislation and regulations have substantiallyenhanced children’s safety. The activities resulting from such laws includeissuing regulations, imposing taxes and allowing tax exemptions and otherincentives and disincentives, appropriating funds to educate and trainhealth professionals and the public, and funding research studies.1 Thisarticle focuses on the enactment of laws and the issuance of regulations asimportant vehicles to reduce childhood injuries. Using examples, theadvantages, disadvantages, and barriers of various legal strategies aredescribed, and important future challenges are noted. Examples of suc-cessful collaborations between government agencies and NGOs aimed atreducing injuries among children also are discussed.


113Legislative and Regulatory Strategies to Reduce Childhood Unintentional Injuries

Law Level Number of States Description

Bicycle helmetsa State/ 16 states/62 local or Coverage varies from underlocal county laws 12 to under 18 years of age

Child safety seatsb State 50 states andWashington,DC Coverage varies widely by age and position in car

Drinking age State 50 states andWashington,DC Legal drinking age is 21years old

Firearm storage State 16 states with laws Requirements to keep regarding safe storage firearms from children vary

widely from under 14 toOne state with law under 18 years of age; regarding trigger locks charges vary from

misdemeanor to felony

Flammable Fabrics Act Federal — Established flammability standards for fabric garments with strict standards for children’s sleepwear

Graduated licensingb State 11 states with 3-tiered system Steps in licensing vary meeting minimum NCUTLOc widely, with minimum criteria, including at least length of permit from 0 to6 months with learner’s permit 12 months; most with someand at least 6 months with nighttime driving restriction; intermediate license some with zero alcohol restricting nighttime driving; tolerance or restrictions 6 states with less strict criteria on age or number of within a 3-tiered system passengers

Motorcycle helmetsb State 47 states have some form of Coverage varies widely by helmet law; 22 states and age and experience from Washington, DC, have laws all riders to under one year covering all riders; remaining and from all licenses to only25 vary by age first year of licensure

Poison Prevention Packaging Federal — Child-resistant closures onAct of 1970 medicines and household

substances

Safety beltsb State 14 states and Washington, Coverage varies widely by DC, have primary safety age and position in carbelt laws; 35 states have secondary laws; New Hampshire has no mandatory safety belt use law

Table 1

Summary of Common State and Federal Laws Targeting Child Safety

a Information from the Bicycle Helmet Safety Institute Web site at http://www.bhsi.org/webdocs/mandator.htm.b Information from the Insurance Institute for Highway Safety.c National Committee on Uniform Traffic Laws and Ordinances.

or packaged (for example, federal regulationsconcerning child-resistant packaging of haz-ardous materials). Although legislation thatmandates personal behavior is often contro-versial, laws that address children’s safety aremore acceptable to the public because histori-cally our society has recognized the value ofgovernment regulation in protecting childrenwho could not otherwise protect themselves.2Even so, proposed safety legislation is oftenaccompanied by controversy, and whenenacted, it has certain limitations and hasexperienced some setbacks.

Six examples of safety legislation and reg-ulations are discussed below. They demon-strate how legislators and administratorsrespond to citizens and industry advocatingvarious positions of an issue; the incrementalnature of the legal process; the long-termeffectiveness of legal strategies; the limitationsof the federal government in intervening at alocal level; and the occurrence of unex-pected, and sometimes undesirable, effects ofa law. Three of these legislative efforts preventinjury-producing events from occurring(child-resistant packaging, safe hot tap watertemperature, and graduated licensure), whilethe other three are designed to prevent aninjury once an injury-producing event doesoccur (bicycle helmets, sleepwear standards,and child safety seats).

Legislative Efforts to PreventInjury-Producing Events

Child-Resistant Packaging LegislationOne of the earliest, most successful applica-tions of safety legislation to prevent specific,serious, and frequent injuries was the PoisonPrevention Packaging Act (PPPA), enacted in1970. This case exemplifies the incrementalnature of the legal process and the interactionbetween laws and their associated regulations.

Although the mortality rate from allchildhood poisonings had graduallydecreased since the late 1950s, an estimated500,000 to 2 million unintentional poisoningingestions were sustained annually by youngchildren prior to the enactment of the PPPAin 1970.3 These poisonings occurred eventhough two new strategies, the establishmentof local poison control centers and the refor-mulation and repackaging of children’saspirin, were undertaken. In 1968, thenumber of children’s aspirin tablets wasreduced to 36 per package (a sublethal dosefor most two-year-olds) and the strength ofeach tablet was decreased to 1.25 grains(81.25 mg). In 1969, two major manufactur-ers of baby aspirin voluntarily improvedtheir packaging by providing bottles withsafety closures. The use of safety closureswas deemed particularly important in the



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subsequent decline in the number of chil-dren poisoned by ingesting baby aspirin.3Based on this early success, the PPPA estab-lished special packaging requirements for 21categories of toxic household substancesand medications. Using regulations and test-ing protocols, child-resistant closures thatcould not be opened by 80% of childrenwere developed, manufactured, andrequired as lids on specific categories of sub-stances and medications during the eight-year phase-in period beginning in 1972.

The benefits of this law and its regula-tions were quickly realized. Aspirin (bothadult and baby strength) was the first prod-uct to require special packaging. Data frompoison control centers indicated that, begin-ning with the period preceding the 1972safety requirement until two to three yearsafterwards, unintentional ingestions of chil-dren’s aspirin declined by about one-half.3An effect of similar magnitude was notedafter other drugs came under this packagingregulation. Between 1973 and 1978, unin-tentional ingestions of all drugs by childrenyounger than five years of age declinedby 44%, preventing nearly 200,000 suchingestions, with more than one-half of thisdecline occurring during 1973 to 1974.Concomitant with these new packagingrequirements, mortality of children youngerthan five years of age from unintentionalpoisoning by oral prescription drugsdecreased abruptly when the law firstbecame effective, then decreased 45% morebetween 1974 and 1992 (see Figure 1).4 Thistranslates into an estimated 460 fewer deathsamong children between 1974 and 1992than projected without the law.

This example shows that the legislativeprocess can be slow. The first congressionalhearings took place 4 years before the lawwas enacted, 6 years before the first drug wasregulated to be stored in child-resistant con-tainers, 8 years before all prescription drugswere so regulated, and 14 years before thelast nonprescription drug (acetaminophen)was so regulated.

The law has two notable drawbacks. First,there was no realistic way to enforce it univer-sally, given the number of pharmacies in theUnited States. One study suggested that phar-macists were noncompliant when filling aboutone-fourth of prescription drugs.5 Second,

child-resistant closures posed problems formany elderly and disabled persons who lackedthe manual dexterity required to open suchcontainers. Accordingly, the original law pro-vided that these persons could have theirprescription medications dispensed in non-child-resistant packaging, if so directed bythe prescriber or if requested by the pur-chaser. To accommodate elderly and dis-abled adults without compromising thesafety of young children, the U.S. ConsumerProduct Safety Commission (CPSC) revisedits testing protocol in 1995 (effective forproducts packaged after January 1998) toaccommodate older adults. The current testprotocol requires that 90% of older adults

can open the package twice within the allot-ted test period, while 80% of young childrenmust not be able to open it.6 This is an exam-ple of how the regulatory process can beused to modify those aspects of a law or ear-lier regulations in response to the valid con-cerns of a special group.

Regulating Hot Tap Water TemperatureChildren sustained an estimated 12,400scald burns in 1997, of which nearly one-fourth were caused by tap water that wastoo hot.7 Most tap water scalds occur in thebathroom and can be severe and disfigur-ing. Although adult (rather than sibling)supervision and testing the bathwater tem-perature by hand before each bath arenecessary measures, a more reliable way ofpreventing bathtub scalds is to lower thetemperature setting of the hot-waterheater (see the article by DiGuiseppi andRoberts in this journal issue). The likeli-hood of a scald injury increases whenwater temperature exceeds 125°F to 130°F.The thermostat dial setting of hot-waterheaters in the past was preset at the factory


Concomitant with these new packagingrequirements, mortality of children youngerthan five years of age from unintentional poisoning by oral prescription drugsdecreased abruptly when the law firstbecame effective, then decreased 45% more between 1974 and 1992.

to 140°F or 150°F. These temperatures willcause a full-thickness burn in the skin ofadults within two to five seconds, and evenfaster in children.8

One workable solution to lower residen-tial hot-water heater temperature dial set-tings is to have manufacturers adjust thesetting to 120°F at the factory, since home-owners rarely adjust the standard settingafter the unit has been installed. This strat-egy was recommended in a 1978 study ofupper-middle-class and indigent families inSeattle, in which the 57 homes tested hadbathtub water that reached a mean of 142 ±26°F, yet only 45% of home owners had everattempted to reduce the hot-water heatersetting.9 Presetting a lower temperature atthe factory was suggested as a strategy thatwould reduce the likelihood of tap waterscald burns associated with child abuse aswell as unintentional scald burns.

The CPSC was petitioned in 1980 tomandate maximum water heater tempera-tures of 130°F, but the petition was denied.10

Subsequently, however, the gas heaterindustry did change the preset temperatureto 130°F, the minimum setting available onmost units. The electric heater industry,though, allowed a preset temperature of upto 160°F. Lower maximum temperatureswere still needed by both industry groups.In 1980, Florida passed a 125°F preset tem-perature law, followed by a 120°F standardin Washington State. Other states began toform coalitions to foster the development ofstate laws requiring a safer factory-presettemperature. The American Academy ofPediatrics (AAP) helped through the effortsof its state chapters and by developingmodel state legislation. In response to theseefforts, concern about a myriad of state-based regulations, and the threat of liti-gation, the Gas Appliance Manufacturers



Source: Rodgers, G.B. The safety effects of child-resistant packaging for oral prescription drugs: Two decades of experience.Journal of the American Medical Association (1996) 275:1661–65.

Figure 1

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Association, developed voluntary standards.The gas hot-water heater standard directedthat all units should be preset at the factoryto their lowest setting, and have a dial mark-ing or detent to indicate 120°F. The electrichot-water heater voluntary standarddirected that the factory preset temperaturenot exceed 125°F.11

These regulatory measures, in conjunc-tion with public education, worked. In a 1983Seattle study, the proportion of homes with amaximum hot-water temperature setting lessthan 130°F increased from 20% before thelaw to 77% five years after the law took effect.Only 8% of households adjusted their hot-water temperature setting upward anytimeafter installation. Concomitantly, the hospitaladmission rate for children with scald burnsdecreased by more than 50%.12 This exampleshows how cooperation between professionalgroups, advocates, state legislators, and indus-try representatives can establish an effectivenational voluntary standard.

Graduated Licensing Systems Young people between 15 and 20 years of agerepresent about 7% of all drivers, yet they areinvolved in 14% of all fatal crashes and 17%of all nonfatal crashes reported to thepolice.13 Key risk factors for deaths amongthese drivers include driver inexperience,male gender, speeding, low rates of safety beltuse, driving at night, and alcohol or drug use.Nearly one-third of all teenage drivers killedwere drinking.14 Experience level is also

important; the fatality rate decreases sharplyafter the second year of driving.

State rather than federal laws and regula-tions govern motor vehicle licensure andcan have a positive impact on reducingcrashes and injuries among teenage drivers.The ideal licensure system would provideteenagers with sufficient opportunity toacquire the necessary experience anddevelop good driving skills while protectingthem from high-risk situations. A graduatedlicense system can provide such protectionby adding incentives that promote safety beltuse and sober driving and that discouragespeeding, nighttime driving, and recklessdriving. A full graduated licensing systemconsists of three tiers: a learner’s permit; aprovisional license, usually awarded after sixmonths of infraction-free driving; and a fulllicense, usually awarded after two years ofinfraction-free driving (see Table 2). Duringthe learner’s permit phase, teenagers maydrive only when accompanied by an adult,and not at night. During the provisionalphase, driving with a parent or adult is notrequired, but the number and/or ages ofother passengers is often restricted to avoiddistractions. Each phase embraces zero alco-hol tolerance and mandatory safety belt use.

The effectiveness of graduated licensingsystems has been reviewed.15 The first gradu-ated licensing law, adopted in New Zealand in1987, is the only one that encompasses all therecommended components of a three-tiered


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system. An evaluation of this law found thatserious motor vehicle–related injuriesdecreased by 23% among 15- to 19-year-olddrivers. In part, this decline in injuries was theresult of teenagers driving less after the lawtook effect. Even adjusting for the reducednumber of miles driven, however, investiga-tors found an 8% reduction in the occur-rence of serious traffic injuries.16,17

As of 1999, some 17 states have a three-tiered graduated licensing system with atleast one of the core elements specified bythe National Committee on Uniform TrafficLaws and Ordinances: a minimum of six

months each in the learner and intermediatestages with nighttime driving restriction.18

Early indicators suggest that even programswith limited restrictions reduce crashes. Forexample, the crash rate for 15- to 17-year-olddrivers in California and Maryland wasreduced by about 5%, while in Oregon, thecrash rate for adolescent male driversdecreased 16% following the implementa-tion of graduated licensure.19

The next step is to evaluate the benefitsand problems of existing graduated licens-ing programs. Evaluations are needed todetermine which components, singly or in


Level Eligibility Possible Components

Learner’s permit • Knowledge test (Part 1) • Visually distinct license• Hearing/vision screen • All driving supervised by a licensed adult

• Safety belt requirement for all occupants• Zero alcohol tolerance• Permit cancelled if convicted of any

alcohol-related offense• Driver education• Crash- and conviction-free period for

advancement• Speed or road use restrictions• Passenger restrictions

Intermediate license • Successfully complete • Nighttime driving restriction unless learner stage accompanied by a licensed adult

• Basic driver education • Safety belt requirement for all occupants• Knowledge test (Part 2) • Zero alcohol tolerance• Pass on-road driving test • License revocation for any alcohol-related

offense• Visually distinct license• Crash- and conviction-free period for

advancement• Minimum number of hours driving

supervised by a licensed adult• Advanced driver education• Speed or road use restrictions• Passenger restrictions

Full license • Successfully complete • Zero alcohol tolerance for drivers underintermediate stage age 21

• Return to intermediate licensure for driverswith suspended or revoked licenses, witha crash- and conviction-free period required prior to reobtaining license

Note: Eleven states meet the minimum requirements for the graduated licensing systems of the National Committeeon Uniform Traffic Laws and Ordinances (a minimum of six months in the learner stage and a minimum of six monthsin the intermediate stage with a nighttime driving restriction): California, Delaware, Florida, Georgia, Iowa,Massachusetts, Michigan, New Jersey, North Carolina, Ohio, and Rhode Island.

Table 2

Possible Components of a Graduated Licensing System

combination, are most effective, and the ageat which restrictions are most appropriate.Potential disadvantages of graduated licen-sure systems should be explored. Parents ofteenage drivers often depend on them totransport younger siblings, run errands, takecar pool shifts, or drive to a job or an athleticevent at night. Evaluation results will helpshape a sensible and longer-lasting safetyapproach to teenage driving.

Legislative Efforts to Prevent Injuries in anInjury-Producing Event

Bicycle Helmet Use Legislation Unlike the previous examples aimed at pre-venting injury-producing events fromoccurring, bicycle helmets are designed toprevent an injury when a crash event occurs.Early studies indicated that as many as 88%of serious brain injuries could be preventedby bicycle helmet use20 and that helmet useis inversely correlated with hospital admis-sions and deaths from bicycle-related headinjuries.21–23 Despite these findings, a 1994nationally representative survey indicatedthat only 50% of child bicyclists ages 5 to 14owned a helmet, and only 25% of themalways wore it in the past month whenriding, as reported by their parents andother adults.24

The first mandatory bicycle helmet uselaw was passed in 1990 in Victoria, Australia.During the previous decade, safety expertshad conducted a comprehensive, multifac-eted, school- and community-based educa-tion program, yet helmet use remained only31% among bicycle riders.21 One year afterthe legislation was enacted, helmet use(measured by observational surveys)increased to 75%, and the number of bicy-clists killed or hospitalized with a head injurydecreased by 51%. However, this legislationproduced some unintended effects. Mostimportantly, a 36% decline in observed bicy-cle riding among Melbourne children ages 5to 17 was noted one year after the law tookeffect, and reduced bicycling can be coun-terproductive to physical fitness. The largestdecrease in riding (44%) was observedamong 12- to 17-year-olds. This decline inriding was substantiated by a 24% decline inthe number of bicyclists admitted to hospi-tals for treatment of primary injuries to areasother than the head that would not be pro-tected by a helmet. Some observers sug-gested that the measured reduction in headinjuries may have been attributable to thedecrease in bicycling rather than toincreased helmet use.

The Australian experience taught severallessons that became tenets of successful local



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injury prevention programs. First, enact-ment of a law should be accompanied bypublic education and active enforcement toachieve better public compliance. InVictoria, the state helmet use law wasaccompanied by enforcement at someschools—children were prohibited fromriding to and from school without a helmet.Second, addressing a multifaceted problemsuch as bicycle-related traffic crashes mayrequire that several aspects of the problembe attacked simultaneously. When bicyclehelmet legislation passed in Victoria, a large-scale campaign was being conducted toreduce motorist speeding and intoxication,two well-known contributors to bicycle–motor vehicle crashes. Attending to theproblem of risky driver behavior wasdesigned to reduce the likelihood of a crash,

while the helmet law was intended to pro-vide additional physical protection in theevent of a crash.

The Australian success encouraged law-makers in the United States to consider simi-lar legislation. The first mandatory helmetuse ordinance was passed in Howard County,Maryland, in 1990, after two youths from thesame middle school died within nine monthsof one another while bicycling without hel-mets (see the article by Klassen and col-leagues in this journal issue).25 Subsequently,New Jersey enacted a similar law for childrenin 1992, and over the next seven years, 15other states passed laws requiring child bicy-clists to wear helmets. These laws vary in theages covered, ranging from under 12 years ofage in Pennsylvania and Tennessee to under18 years of age in California.26 Forty-threepercent of children less than 15 years of agein the United States are now covered by abicycle helmet law.26,27 Legislation in sevenstates also mandates that educational and dis-count helmet programs be conducted.

Compared with the Australian experi-ence, how effective could we expect manda-tory helmet use laws to be in the UnitedStates? This was an important question,because, unlike in Australia, the argumentof personal choice frequently arises in theUnited States. The first study evaluating theeffectiveness of a bicycle helmet law in theUnited States was conducted in HowardCounty, Maryland, where observed helmetuse increased from 4% before the law to47% afterwards and did not increase signifi-cantly in two adjacent counties that lacked alaw (see the article by Klassen and colleaguesin this journal issue).28 The first evaluationof a state law took place in Georgia. In ahousehold telephone survey there, the pro-portion of children reported to use a helmetthe last time they rode a bicycle increasedfrom 33% immediately before the law wasenacted to 52% during the five months after-ward.29 These results should be interpretedwith caution, however, since self- or proxyreports of safety behavior may overestimatethe true prevalence of a behavior.30 To verifythe Georgia findings and test the validity ofproxy reports for bicycle helmet use, a sub-sequent study was conducted in Oregonimmediately following passage of that state’smandatory helmet use law.31 Again, reporteduse increased substantially, from 37% to66%, in the population affected by the law.Compared with observational surveys con-ducted at the same time, proxy reports over-estimated true use, but the degree of changewas similar (25% before to 49% after thelaw). Thus, self-reported use appears to be avalid proxy measure to quantify the direc-tion and degree of change, even if it doesnot indicate the level of helmet use withgreat accuracy.

What is the effect of strict enforcement ofbicycle helmet laws or regulations? In the onlyknown evaluation of enhanced enforcementof bicycle helmet use, the city council of a smallrural town in Georgia strengthened the exist-ing state mandatory helmet use law by autho-rizing police to confiscate the bicycle of anychild not wearing a helmet.32 Results indicatethat helmet use among children increasedfrom 0% to 71% (mean 45%) during the nextfive months, while helmet use among adults(not covered by the law) remained 0%.Although this is a drastic measure that may notbe feasible in larger communities, some statesare exploring alternative options to enforce



Forty-three percent of children less than 15 years of age in the United States are now covered by a bicycle helmet law.Legislation in seven states also mandatesthat educational and discount helmet programs be conducted.

their laws. In Florida, for example, an elemen-tary school–based policy was establishedrequiring children to wear a helmet whenriding to or from school. Preliminary unpub-lished results indicate that more than 75% ofstudents at schools with a school policy sup-ported by a state law wear a helmet, yet onlyabout 45% of such students use one whileriding in their neighborhoods.

Flammable Sleepwear RegulationsSleepwear flammability regulations exem-plify four issues: (1) the safety benefits of reg-ulating the manufacturing of a commonlyused product; (2) how difficult it is for regu-lations and standards to keep pace withchanges in family customs, children’s fash-ions, and changes in the industry; (3) theinterplay between various government agen-cies, technical experts, the garment manu-facturing industry, and safety advocacygroups, all trying to be responsive to the per-ceived needs of the public and their particu-lar constituents; and (4) the publicconfusion sometimes associated with ahighly technical matter.

To reduce the flammability of nighttimegarments that cause injury or death by ignit-ing and continuing to burn, in 1971 a flam-mability standard was established forsleepwear worn by children approximately 12years and younger.33 The performance testfor this standard requires that fabric, seams,and trim of garments designated as sleepwear(for example, nightgowns, pajamas, androbes) stop burning after removal from athree-second exposure to a small open igni-tion source that resembles a match or ciga-rette lighter flame. The public often doesnot recognize that this flame is much lessthan that which would occur in a bedding orhouse fire, and that during the test, thefabric may ignite, as long as it self-extinguishes.Accordingly, any type of fabric may be used tomake sleepwear garments, provided that itpasses this test. For example, many 100% poly-ester fabrics pass the test, while untreatedcotton fabrics generally do not.

CPSC has noted that a second factor,tightness of fit, is an important determinantof the likelihood of a burn occurring oncesleepwear ignites. Tight-fitting clothing thatconforms closely to the body is less likely tocatch fire in the first place and less likely toallow heat to develop between the fabric and

the body, decreasing the likelihood of ther-mal injury, even when the fabric used doesnot pass the flammability test described. Thishas become an important and contentiousissue during the past few years, as garmentmanufacturers have wanted to manufactureand market sleepwear made of more com-fortable material that might not pass theflammability test described.

For example, wearing oversized cottonT-shirts or other loose-fitting garments tobed became popular among children, butincreased the risk of burn injuries. Wearingloose-fitting clothing creates a gap betweenthe child and garment, which supplies fuel(oxygen) and prevents the skin from absorb-ing the heat produced. The resulting chim-ney effect allows the flame to spread quicklyalong an unrestricted path. CPSC estimates

that approximately 200 to 300 burn inci-dents each year occur with loose-fitting day-wear worn as sleepwear, mostly cotton orcotton-blend T-shirts.

Another fashionable garment to wear tobed was long underwear, which, althoughsnug-fitting, is not sufficiently tight fitting toqualify as a safe nightwear alternative. Also,like T-shirts, long underwear was marketedas daywear and not subject to the sleepwearflammability test nor the tightness-of-fit reg-ulation described below. The distinctionbetween such daywear and true tight-fitting(regulated) sleepwear became blurred, con-fusing parents and retailers. In fact, retailstores commonly stocked regulated andunregulated products on the same shelf. Toproperly regulate this garment, theCommission needed to frequently revise itsenforcement guidelines for manufacturersto keep pace with changes in the fashionindustry, a matter quite difficult to accom-plish in practice.

The Commission sought other mecha-nisms to ensure sleepwear safety. Returning



CPSC estimates that approximately 200 to300 burn incidents each year occur withloose-fitting daywear worn as sleepwear,mostly cotton or cotton-blend T-shirts.

to the tightness of fit issue, the Commissionspecified the maximum measurements thatcould exist at various body sites for eachsize.33,34 In general, the dimensions of suchtight-fitting sleepwear required a tighter fitthan long underwear provided. A strugglebetween fire/burn prevention advocatesand the Commission began when the latterpublished an advance notice of proposedrulemaking in 1993 (made final effectiveJanuary 1997) that would, among otherthings, amend the original sleepwear flam-mability standard to exempt tight-fittingsleepwear defined according to the revisedspecifications.35 Because this coincided withthe wish by industry to satisfy consumerdemands for a wider array of sleepwear andthe use of more comfortable fabric such ascotton, safety advocates claimed that the

Commission was bowing to industry pres-sure. This opinion was given more credencewhen the industry subsequently notified theCommission of problems related to the spec-ified measurement sites that made proto-types of tight-fitting sleepwear difficult tomake or uncomfortable. The manufacturersproposed the CPSC adopt a new, generallylarger, set of dimensions in its standard, inaddition to permitting the use of cotton-based fabrics. In January 1999 theCommission amended the 1997 exemption,adjusting the points of measurement,although not technically enlarging the allow-able measurements themselves.36,37 Thisposition was upheld in June 1999, even aftera review by the General Accounting Office.

To advocates, the process suggests thatCPSC relaxed the flammability standard overtime by allowing cotton fabrics to be used,provided the garment was tight-fitting, thenlater allowing the fit to be relaxed, in effectcircumventing the intent of the original stan-dard. The debate is fueled by confusion

about an admittedly complex subject withcomplex regulations, incomplete publicinformation, and the appearance (to some)that the Commission is bowing to industrypressure. The Commission would like toaddress the hazard created when families useloose garments not intended as sleepwear,which are not flame-resistant (long under-wear and loose T-shirts). To address this,CPSC is trying to offer a safe alternative tolong underwear—tight-fitting sleepwear—which could then be made of cotton or othermore comfortable fabric. The industry wantsto be responsive to perceived customerdemand and new fashion trends. Safety advo-cates, including the Safe Children'sSleepwear Coalition, prefer to abolish the1997 and 1999 exemptions and return to theoriginal standard.38 This group believes thata tight fit will not be achieved in practiceunder the revised standards, since the gar-ment manufacturing industry will adopt theuse of cotton materials, while parents arelikely to purchase larger sizes than intendedby the regulations to obtain a loose, morecomfortable fit for their children. This issueillustrates how well-intended and effectivesafety regulations can have difficulty keepingup with changes in fashion and industry, andhow changes in regulations can confuse thepublic and create conflict.

Child Safety Seat Lawsand RegulationsMotor vehicle crashes cause many pre-ventable deaths and injuries to child occu-pants. One of the most important aspects ofprotection afforded to small children ridingin vehicles is the proper use of a child safetyseat. In many communities, using a childsafety seat for every ride has become a socialnorm. The National Highway Traffic SafetyAdministration (NHTSA) of the U.S. Depart-ment of Transportation estimates that childrestraints—including child safety seats, belt-positioning boosters for preschoolers andearly-elementary-age children, and safetybelts—saved the lives of 3,894 childrenbetween 1975 and 1997.13 This number isparticularly impressive considering the rela-tively mild public response to the problem,both in terms of federal and state resourcesas well as the degree of public attention paidto injury prevention.

Three important prerequisites wereneeded before state governments could



Motor vehicle crashes cause many preventable deaths and injuries to childoccupants. One of the most important aspects of protection afforded to small children riding in vehicles is the proper use of a child safety seat.



consider child occupant protection laws.First, regulations were needed for the man-ufacture of child safety seats according to aprescribed set of safety and performancestandards. Accordingly, the NHTSA revisedFederal Motor Vehicle Safety Standard No.213, and in doing so, incorporated dynamiccrash test standards for the first time.39 A setof biomechanical dummies, one weighing17 pounds to simulate a 9-month-old infantand another weighing 33 pounds to simulatea 3-year-old, then needed to be designed sothat crash tests could be conducted with pro-totype child safety seats. These tests mea-sured the forces acting on many parts of thebody and the degree of protection affordedby the child safety seat. Based on these testresults, a set of design and test standards wascodified and required for the manufactureof all child safety seats. Second, the publicneeded to be convinced that safety seat usewas an important, effective measure that out-weighed its inconvenience. This was accom-plished through ongoing educational andpromotional programs such as child safetyseat giveaways and rentals provided throughmany government and nongovernmentagencies, in particular the AAP, the NationalSAFE KIDS Campaign (NSKC), vehiclemanufacturers, insurance companies, andthe International Association of Chiefs ofPolice. Third, child safety seats needed tobecome widely available and affordable.This was eventually achieved by increasedpublic demand, which increased manufac-turers’ supply and reduced the per-unit cost.

The first state law mandating the use ofchild safety seats in motor vehicles tookeffect in Tennessee in 1978, due largely tothe work of Robert Sanders, M.D., aTennessee pediatrician working in publichealth.40 Subsequently, observed safety seatuse among children younger than four yearsof age in Knoxville and Nashville increasedfrom 8% to 29% within 2½ years. By com-parison, observed child safety seat use inLexington and Louisville, Kentucky (whereno safety seat law existed), only increasedfrom 11% to 14%.41 This legislative success,coupled with the availability of affordable,effective child safety seats, led to the passageof mandatory child safety seat laws in all 50states by 1985.

As legislation became successful atincreasing child safety seat use, another

problem became evident—improper safetyseat use.42 The NHTSA estimates that childrestraints are 71% effective in reducing thelikelihood of death in motor vehicle crasheswhen installed correctly in a vehicle in whichthe safety belts, seats, and child safety seatsare compatible.43 However, because manychild restraints are either not being usedcorrectly or installed in vehicles with seats orsafety belts that are not fully compatible, thepractical effectiveness is reduced to 50% to59%.44 Incorrect safety seat use is quitecommon. Although nearly 80% of childrenwere restrained in a recent study inKentucky (after a law took effect), only 20%were restrained properly.45 In four otherstates, although 85% of infants and 60% ofchildren under age four were restrained,only 20% were restrained properly.46 The

two main problems are the poor fit or frankincompatibility between certain child safetyseat models and certain vehicles when usedin certain seating locations, and misunder-standing by the user.

One technological solution is the use of auniversal child restraint attachment system.The European ISOFIX standard and theCanadian CANFIX standard precededAmerican efforts in this regard. These sys-tems have fixed struts that emerge from thebench and lock into all child safety seatsequipped with the corresponding compo-nent. Since the problem of car seat incom-patibility was recognized in 1991, federalagencies and vehicle manufacturers in theUnited States have pursued universal fittings,but the need for global harmonization andthe large number of types of vehicle modelsand manufacturers slowed development.However, the NHTSA recently adopted vehi-cle manufacturing regulations that requireall 1999 and newer model cars to include arear-mounted tether that secures the top of asafety seat, as well as a pair of six-inch fixed

Incorrect safety seat use is quite common.Although nearly 80% of children wererestrained in a recent study in Kentucky(after a law took effect), only 20% wererestrained properly.



struts that secure its bottom. The regulationextends to all new light trucks and multipur-pose vehicles beginning in 2000.47 This regu-lation should make child safety seatsuniversally compatible with all new vehiclesso that families can correctly and easily movesafety seats to other seating positions or othervehicles as needed.

Car safety seat checkups have indicatedthat, despite good intentions and a higheducational level about the subject, parentsmay not know or understand how a childshould be placed in a child safety seat, or

how the seat should be installed in an older-model vehicle. This confusion is beingaddressed by ongoing national educationalefforts, such as the collaborative effortsbetween federal agencies and NGOsdescribed below.

Relationship BetweenNongovernmentalOrganizations andLegislative and RegulatoryAgenciesNGOs exert a strong influence on govern-ment, either by collaborating with state orfederal agencies in conducting local projectsor by independently encouraging the adop-tion of laws and regulations. NGOs includeprofessional organizations, nonprofit groups,philanthropists, industry, and special interestgroups. This section describes two NGOs thathelped increase the correct use of child safetyseats by collaborating with federal agenciesand the business community. Additional keyNGOs engaged in injury prevention activitiesare included in the Appendix at the end ofthis article.

Both government and NGOs have beenconcerned about the low rate of child safetyseat use, as well as the high rate of incorrectuse, particularly among disadvantaged fami-lies. Concerned experts from industry, gov-ernment regulatory and research agencies,universities, community groups, and thepublic gradually developed partnershipsand working coalitions to address incorrectsafety seat use. At the federal level, thesepartnerships were developed among two orthree agencies, while at the communitylevel, coalitions often involved a dozen ormore groups working together.

In the early 1990s, the NHTSA assembleda child safety seat misuse team of experts fromresearch, rulemaking, policy, and othergroups. The team established a four-yearnational child safety seat distribution pro-gram developed through collaboration withthe NSKC, a grassroots program with safetycoalitions in all states. The NSKC was begunin 1988 with critical support from Johnson &Johnson. Through more than 250 local coali-tions, the NSKC strives to implement com-prehensive, multifaceted, community-basedinjury prevention programs that address themajor causes of serious childhood injuries.With NHTSA support, the NSKC has raisedpublic awareness concerning the lack of childsafety seats, and it has distributed safety seatsto many families. Senior NSKC staff also havemet with members of Congress and theirstaffs to help them better understand theproblem of safety seat misuse and find viablesolutions. The NSKC developed a compre-hensive state legislative program thatincluded model state legislation for passengersafety. The NSKC then monitored the devel-opment of state legislation, identified gaps inage groups or seating location, and held lead-ership workshops to train local advocates towork with their legislators.

The national child safety seat effort, facil-itated by the NHTSA, was substantiallyboosted by funds provided by GeneralMotors Corporation (GM) to NGOs. As partof a 1995 legal settlement between the DOTand GM related to an alleged defect affectingthe safety of certain pickup trucks, GM pro-vided $8 million over two years for a nation-wide child safety seat distribution programthat targeted low-income families and thosewith special needs children. The four princi-pal organizations chosen to administer this

Car safety seat checkups have indicated that, despite good intentions and a high educational level about the subject, parentsmay not know or understand how a childshould be placed in a child safety seat, orhow the seat should be installed in an older-model vehicle.

program and distribute child safety seatswere the NSKC, the National Easter SealSociety, the Safe America Foundation, andthe National Association of Children’sHospitals and Related Institutions. Throughlocal chapters and constituent members ofthese organizations, about 200,000 childsafety seats were distributed nationwide. Thenext year, GM donated $10.6 million to theNSKC to promote correct car seat and safetybelt use. The NSKC developed and distrib-uted information in English and Spanish toteach parents and caregivers about correctchild safety seat and safety belt use. Morethan 400 local GM dealers participated intwo-hour child passenger safety workshops.Dealerships began conducting car seatcheckup events where local experts, largelytrained by NHTSA staff, reviewed child safetyseat hardware for correct size, fit, and instal-lation, and taught its correct use. Based onthe success of this program, GM recentlycommitted another $5 million to the NSKCto provide thousands of child safety seats toneedy, minority, at-risk families. The NSKChas partnered with the National Council ofLa Raza and the National Association for theAdvancement of Colored People (NAACP)to ensure that the program reaches Hispanicand African-American families and that cor-rect safety seat use is reinforced in culturallyappropriate ways. This is an example of part-nership among several nonprofit grassrootsorganizations, a federal agency, and industry.

Professional organizations have also par-ticipated in the child safety seat effort. TheAAP initiated the “First Ride Safe Ride” pro-gram in 1980 to encourage parents to use achild safety seat when taking their newborninfant home from the hospital. The AAP alsotook direct action concerning the child safetyseat incompatibility problem by asking thefederal government to consider modifyingthe manner in which child safety seats aresecured to vehicles. The AAP formally peti-tioned the NHTSA, requesting it to considerrequiring a tether anchor for child safetyseats, and provided the NHTSA with formalcomments on its proposed rule making foruniversal child safety seat attachments. (Box1 explains the rule-making process used bythe NHTSA and provides an example of pro-cedures followed by other regulatory agen-cies.) The AAP also keeps its members (andindirectly, the public) informed of currentbest practices by issuing policy statements

that address specific injury risks and methodsof prevention.48 Five recent policy statementshave provided recommendations for the useof child safety seats with normal newborns,infants, and children, as well as those withspecial needs.49–53 In addition, the AAP pro-vides technical assistance to pediatriciansworking with legislators who want to proposenew state legislation or strengthen existinglaws. Such technical assistance includesdeveloping model state legislation, trackingproposed and existing legislation to providestate-by-state comparisons, and providingbackground educational materials. Suchcollaboration between government agencies,

legislators, and pediatricians demonstratesthe power of groups working together toaddress a large problem that no one groupcan sufficiently manage alone.

Future ChallengesFuture challenges for using legal strategiesto reduce the occurrence of childhoodinjuries may be grouped into five categories:(1) assessing the relative success of existinglaws and regulations, compared with theirhuman, societal, and dollar costs; (2) main-taining existing legal actions of demon-strated value by withstanding efforts ofbudget managers to reduce their scope andof special interest groups to rescind laws; (3)refining existing laws to make them moreeffective and, where possible, to fill gaps incoverage with regards to age groups or situ-ations; (4) keeping pace with technology byusing new techniques and methods toenhance safety and regulate the unsafeeffects of new devices; and (5) exploringnew legal means of encouraging safe behav-ior while maintaining individual freedomof choice.

Assessing the Valueof Laws and RegulationsBefore adopting additional legal actions,an assessment should first be made of the



General Motors recently committed another$5 million to the National SAFE KIDSCampaign to provide thousands of child safetyseats to needy, minority, at-risk families.



relative success or failure of those federal lawsand regulations, state laws, local ordinances,and administrative actions that have not yetundergone formal evaluation. The personalcost of these strategies should be measured interms of both dollars and the effect on indi-vidual freedom lost for a greater good. For thelatter, however, no standardized or universallyaccepted measure yet exists. Success in injuryprevention is generally measured in terms oflives saved, crashes or injuries avoided, orreduced injury severity. A scale that indicates asense of value to the consumer (parent

and/or child) would be useful to measure thesuccess of legal efforts. It is important to eval-uate the benefit of a particular law comparedwith broadscale public education or positiveindustry- or school-based incentives such asreduced insurance premiums for well-performing students. The relative effect of leg-islation, alone or combined with varyingdegrees of enforcement and public educa-tion, also should be examined.

As discussed previously, graduated licen-sure is one example of a legislative strategy

How a Safety Issue Becomes a Regulationfor Motor Vehicle Equipment

1. The rulemaking process begins with a petition, usually by a citizen or organiza-tion, to introduce or amend an existing standard to regulate motor vehicleequipment. Less commonly, the National Highway Traffic and SafetyAdministration (NHTSA) recognizes a problem first and initiates this process.The petition must be in writing, identify the problem in terms of safety, and pro-pose a practical way to regulate it that is enforceable. Its expected benefit mustoutweigh the cost of making the equipment change. Once NHTSA staff analyzeits merit according to these criteria, the petition is either granted or denied.The petitioner is informed of these results and the reasons for the decision.

2. Ordinarily, NHTSA staff conduct research on the issue using available data. Theirpreliminary findings are published in the Federal Register as an Advance Notice ofProposed Rulemaking or Notice to Request Comments, with a time period allowed forwritten comments to be made by the public, industry, and other groups.

3. NHTSA then conducts additional, in-depth research, if needed, which mayinclude new studies. When these findings are known, NHTSA posts a Notice ofProposed Rulemaking (NPRM) in the Federal Register. The public is then given asecond period to write comments.

4. After all comments have been considered, the NHTSA issues either aSupplemental NPRM or a Final Rule. The latter includes an effective date withinwhich manufacturers must comply. Since many safety issues are specific to amodel year of vehicle, the effective date is often stated in such terms. Also, theeffective date may spread out over several years, with an increasing proportionof vehicle models coming into compliance each year over a three- to four-yearperiod.

5. If warranted, the public or a vehicle manufacturer may propose a brief Petitionfor Reconsideration, requesting, for example, an extension of the deadline forcompliance.

6. The NHTSA issues an Amended Final Rule.

The total time between initial petition and final rule is typically three to four years.For car seat incompatibility (a particularly difficult technical issue), an internaldecision was made to change vehicles in 1991, with a petition following in 1995.The final rule was in spring 1999.

Box 1

that appears promising, but it requires fur-ther evaluation to identify which aspects aremost effective. Specifically, how much incre-mental benefit would be derived fromextending the hours of curfew versus post-poning the entry age of driving via alearner’s permit versus extending the dura-tion of the provisional phase?

The relative effectiveness of new safetymethods, compared with traditional meth-ods, also must be evaluated. For example,Congress has appropriated funds to establisha toll-free telephone number for a nationalpoison control center to augment the dwin-dling number of local poison controlcenters. These centers have experienced sub-stantial financial pressures in recent years ashospital and state budgets have reduced oreliminated their funding. However, the effec-tiveness of a nationally coordinated tele-phone line, compared with the previouswidespread availability of local poison con-trol centers, deserves further study.

Maintaining Existing Lawsand Regulations That WorkPublic will is expressed through laws.However, once established, a law is vulnera-ble to attack from special or single interestgroups that seek to overturn the law in sub-sequent legislative sessions, particularly if itssafety benefits have not been well docu-mented or publicized. The interest withinthe garment manufacturing industry tomodify long-standing and successful regula-tions concerning children’s sleepwear illus-trates this point. Two other examples—anational speed limit law and state and locallegislation mandating bicycle helmet use—also demonstrate the need for injury pre-vention specialists and health professionalsto be constantly vigilant, protecting the exis-tence of successful strategies.

The national speed limit law, establishedin 1973 to conserve gasoline during a short-age created by the Arab oil embargo, wascredited with saving many lives. Congressvoted to rescind the law in 1995 in responseto pressure by the National MotoristsAssociation (a membership organizationdevoted to protecting the interests of NorthAmerican motorists), governors and legisla-tors from some western states, and others.These groups voiced the public’s apathyabout the risks associated with speeding,

which emerged once the threat of a gasolineshortage no longer existed. Warnings thatthe number of highway traffic fatalitieswould increase if the law was overturned—asit had in 1987, when some states adopted a65 mph limit on rural highways—werelargely ignored. These warnings had beencorrect, however, and in the 12 states thatsubsequently adopted higher speed limits,fatalities increased by 12% on interstates andfreeways and by 6% on all roads combined.54

Mandatory bicycle helmet use laws forchildren have similarly come under attack.Residents of some states argue that these lawsinfringe on the individual’s right to choosehis or her own behavior, and some peoplequestion the added benefit of helmet use.Although no state law has been rescinded,

a local helmet use law in Seymour,Connecticut, that covered both adults andchildren was overturned in 1999, a year afterit was passed. Other local helmet use lawsalso have been attacked.

Refining Existing LawsThe adoption of new state laws, particularlythose that mandate personal behavior, is typ-ically an incremental process. The languageadopted is most often the result of compro-mise, in which certain aspects desired bysafety experts and advocates are deleted orrestricted in scope. Without compromises,such as restricting the age limits affected bya bicycle helmet bill, the legislation wouldnot likely pass. However, these compromisesmay leave unintended gaps in coverage.Consequently, safety experts and advocatesneed to identify and prioritize the impor-tance of such gaps and judge the ease withwhich a law could be amended during sub-sequent legislative sessions.

Child motor vehicle occupant protectionlaws are an important example of where crit-ical gaps in legislation exist. Typically, certainages, seating locations, or vehicles registered



In the 12 states that subsequently adoptedhigher speed limits, fatalities increased by12% on interstates and freeways and by 6% on all roads combined.

out of state are excluded from the laws. Moststate laws do not address the key transitionstage between preschool and early elemen-tary school. By about four years of age, mostchildren have outgrown their child safetyseat but are too short to fit properly into anadult three-point shoulder-lap safety beltuntil they reach seven to nine years of age. Toprevent the upper portion of the shoulderbelt from lying across the child’s neck (ratherthan the chest, as designed), a belt-positioningbooster seat should be used to elevate thechild to the proper height.42 Presently, fewstates require booster seats to be used, how-ever, and the public is largely unaware of thebenefit or even the existence of thesedevices. A national program is needed toeducate families to increase the use ofbooster seats, and state legislatures need to

consider bills that would cover childrenduring this transition period. Since childrenvary so much in size at any given age, legisla-tors should base transition requirements onbody weight rather than age.

Legislation also should be refinedaround the ability of police to enforce safetybelt and child safety seat laws. Presently, twotypes of state laws exist concerning safetybelt use. Primary enforcement laws in 17states and the District of Columbia permitpolice to stop and cite a driver solelybecause an occupant covered under the lawis unrestrained. Secondary enforcementlaws (in 33 other states) allow police to citea driver only if he is stopped for anotheroffense. New Hampshire still has no manda-tory safety belt law. On the other hand, all50 states plus the District of Columbia havesome type of law requiring the use of childsafety seats. Currently, federal agencies aredirecting efforts toward converting sec-ondary laws into primary laws at the statelevel. A systematic review of occupant

restraint laws for adults found that, com-pared with no law, a primary law was associ-ated with a 1.5- to 4.1-fold increase inobserved safety belt use and a 3% to 31%decrease in traffic fatalities.55 A secondarylaw was associated with a 2.1- to 2.6-foldincrease in safety belt use and a moremodest decrease in traffic fatalities. Eventhough the transition from secondary to pri-mary enforcement laws probably has merit,more certainty on this issue would be wel-come. Accordingly, more rigorous evalua-tions should be done in those states wheresuch laws are being changed.

Developing Regulations toAdapt to Changing TechnologyTechnological progress poses challenges forinjury prevention. One challenge is to adoptnew methods and devices that could reducethe incidence or severity of childhoodinjuries. For example, radar and laser tech-nologies are used to measure vehicle speed,although these technologies were originallydeveloped for other applications.

Another challenge is to monitor newsafety devices for unexpected consequencesand to manage such consequences. Perhapsthe best publicized example of this is theuntoward interaction between children andair bags. Air bags have reduced front-seatfatalities by about 27% in frontal crashes and11% overall,56–58 but approximately 70 chil-dren have sustained a lethal injury from an airbag as it deployed during a low-impact crashthat in itself would not have been fatal. Theimpact on the head or neck by the air bag asit deployed at more than 200 miles per hourclose to the child was the mechanism ofinjury. The NHTSA mandated the placementof front–passenger seat air bags in all carsbeginning in model year 1998, and in all lighttrucks the following year. Solutions to reducethe risk of air bag–related injuries also wereproposed. These included participating in alarge-scale national educational campaign towarn parents of these dangers and that allchildren 12 years of age and under should sitin the back seat where a front-passenger airbag cannot reach. However, this was not pop-ular because many parents insist that theirinfant ride in the front seat where they canbetter attend to their needs. Sometimes achild cannot be seated in the back, as when aparent is transporting more than three youngchildren in a sedan or when the vehicle lacks



Air bags have reduced front-seat fatalities by about 27% in frontal crashes and 11%overall, but approximately 70 children havesustained a lethal injury from an air bag as it deployed during a low-impact crashthat in itself would not have been fatal.



a back seat entirely. Accordingly, the NHTSAis encouraging the development of long-range solutions, including air bags thatdeploy with less force and air bag systems thatdo not deploy if the passenger weight or seat-ing position indicate that the air bag mightcause injury. Meanwhile, the NHTSAapproved regulations that, effective January1998, permit the installation of an on-offswitch in certain situations, such as for a med-ical need or critically short adult drivers.59

Exploring New Legal Means to Encourage Safe Behavior Many barriers discourage the adoption ofnew legislation or regulation concerningpersonal behavior. First, the public is oftenunaware, or even denies, that a particularbehavior or product poses a real threat.Therefore, it seldom spontaneously encour-ages elected officials to seek legal means toreduce injury risk. Second, a delicate bal-ance exists between passing legislationaimed at altering personal behavior and thefreedom to choose one’s behavior. Many leg-islators are wary of legislation that mayinfringe on this freedom, on the groundsthat, in a democracy, free but informed willshould determine such decisions. Legis-lators do consider such bills, however,because the consequences, especially thecost of medical care and disabilities, arelikely to be borne by the public rather thanby individuals. Legislators also take childreninto special consideration because they arenot considered legally competent to makeinformed choices. Accordingly, ample prece-dent exists to use legal means to encouragesafe behaviors, and such laws and regula-tions often are effective. Third, legislatorsare wary of passing legislation that is difficultor futile to enforce or that carries no penalty.Police are reluctant to enforce such laws,particularly if they sense that local judges willnot support them by convicting violators.Finally, concern exists among some minoritygroups that additional laws established tomandate behavior will be used by the policeand courts to indiscriminately harass or pref-erentially punish them, particularly whenpolice are granted additional powers toenforce laws.

Against this negative background, sub-stantial room exists for using the legal systemto help reduce childhood injuries. In recentyears, product liability suits and federal

regulations have become more widespreadin an effort to hold manufacturers account-able for injuries that occurred as a result ofunsafe products. For example, the GM settle-ment previously described was a landmarkcase in which an alleged unsafe product wasre-engineered and a major occupant protec-tion safety program was put into place aspart of the penalty assessed. In anotherexample, concerns of legal liability arisingfrom failure to meet the recommendedguidelines of the CPSC have led to a wide-spread upgrading of playgrounds in schools,public parks, and day-care centers. Finally,many commonly used products, includingcar safety seats, air bags, and sports equip-ment, contain lengthy instructions and evenwarning stickers to educate consumers ontheir proper use. However, these are at least

in part created to reduce the manufacturer’sliability that could result from inadequatepublic notification of a known hazard. In alitigious society, manufacturers’ concernover the threat of lawsuits is a powerfulmechanism to improve product safetythrough standard setting or better design,when possible, and occasionally even by vol-untary removal from the market when noother option will suffice.

Another alternative used by the legalsystem to promote certain behavior changesis to create positive incentives, such asthrough the tax system. Tax incentives havealready been used widely to encouragebehavior change in other areas. One exam-ple is the creation of tax credits and exemp-tions designed to modify behaviors thataffect the environment, such as the use ofsolar power in homes during past oil short-ages. These approaches could be successfulif applied to safety issues as well.

In a litigious society, manufacturers’ concern over the threat of lawsuits is apowerful mechanism to improve productsafety through standard setting or betterdesign, when possible, and occasionallyeven by voluntary removal from themarket when no other option will suffice.

Key National Resource Organizations for Children’s Safety

Nongovernmental OrganizationsAdvocates for Highway and Auto Safety

An alliance of consumer, health, and safety groups and insurance companies and agents workingtogether to make America’s roads safer. Advocates encourage the adoption of federal and state laws,policies, and programs that save lives and reduce injuries.

www.saferoads.org (202) 408-1711

Appendix

ConclusionEnacting safety-related legislation at thestate and federal levels is a powerful way toencourage change in individuals and pop-ulations. In the past 25 years, the inci-dence rates of many unintentionalchildhood injuries have decreased dramat-ically, in part due to the effective use oflegislation and regulation. For maximumeffectiveness, laws, regulations, and poli-cies must be supported by the public andadequately enforced at the communitylevel. There, a principal challenge is tocoordinate the many public and privategroups involved in childhood uninten-tional injury prevention to produce a criti-cal mass for action. In the near term,national agencies and organizations shouldimplement strategies known to work, andevaluate others that show promise.

Substantially greater funding for injuryprevention activities is needed from thepublic and private sectors, industry, andmajor philanthropic organizations. TheInstitute of Medicine has reviewed theUnited States’ need for better injury preven-tion three times. In its latest report, issued in1999, this body recognized that “support forinjury research has been seriously inade-quate when measured against the magni-tude of the injury problem. . . . By anymeasure of social burden (deaths, years ofpotential life lost, disability or disability-adjusted life years, and economic costs),injuries exact a major toll.”60 The report alsonoted that, at the National Institutes ofHealth, for every $1 spent to support injuryresearch in 1996, $13 was spent on cancerresearch, $7 was spent for HIV/AIDS, and$4 was spent for heart disease. Further,resources were considered insufficient to

provide state public health departments withadequate infrastructure to undertake effec-tive initiatives.

Interest and financial investment ininjury prevention are necessary to develop a“culture of safety,” in which safety becomes asocial norm. The field of injury preventionneeds creative talent and ideas fromresearchers, practitioners, and industry. Itneeds incentives to encourage individuals,families, and communities to become safetyconscious and practice good safety tech-niques. It needs to train, develop, andencourage health professionals to deal witha quickly changing environment. Finally, itneeds its political leaders to have thecourage and tenacity to challenge the statusquo, to engage the public interest in thisarena, and to manifest hope in their chil-dren by investing in their future throughinjury prevention.

The authors sincerely appreciate the assis-tance of Leslie Teach, James Belloni, SandraBonzo, Mary Ann Fenley, Daphna Gregg,Krista Hopkins, Jacquelline Parrish, CaryllRinehart, Daniel Sosin, and Joanna Taliano ofthe National Center for Injury Preventionand Control. Cheryl Neverman and GeorgeMouchahour of the National Highway TrafficSafety Administration helped review commentsconcerning child safety seat problems and rule-making. Jacquie Elder and Margaret Neily of theU.S. Consumer Product Safety Commission, andJohn Hall of the National Fire ProtectionAssociation, provided critical review of the issuesconcerning flammable sleepwear. Allison Randat the American Academy of Pediatrics andAngela Mickalide at the National SAFE KIDSCampaign helped us better understand the work-ings of their organizations.





American Academy of Pediatrics

A professional organization committed to the attainment of optimal physical, mental, and social healthof all infants, children, adolescents, and young adults. The Web site provides information and materialsnot only for pediatricians, but also for parents, advocates, and policymakers.

www.aap.org (800) 433-9016

American National Standards Institute

A membership organization involved in product safety. ANSI promotes and facilitates the establishmentof voluntary consensus standards, systems to assess conformity, and accreditation of third-party productcertification.

www.ansi.org (212) 642-4900

American Society for Testing and Materials

Provides a forum for producers, consumers, and representatives of government and academia todevelop standards by consensus. Activities encompass areas including metals, paints, plastics, textiles,petroleum, construction, energy, the environment, consumer products, medical services and devices,computerized systems, and electronics.

www.astm.org (610) 832-9585

Children’s Safety Network

Fosters the development and inclusion of injury and violence prevention strategies into maternal andchild health services. Four CSN Resource Centers are funded by the Maternal and Child Health Bureauat the Department of Health and Human Services.

www.edc.org/HHD/csn (617) 969-7101

The Foundation Center

A guide to foundations that provides detailed information on the interests and restrictions of individualfoundationsandonthemoney theyhavegranted.Thecenterhasofficesandlibraries thatcoverall50states.

www.fdncenter.org (800) 424-9836

Injury Control Resource Information Network

Provides comprehensive listings of injury control resources through the Internet.

www.injurycontrol.com/icrin

Insurance Institute for Highway Safety

An independent research and communications organization wholly supported by automobile insurers.IIHS is dedicated to reducing highway crash deaths and injuries, and property damage losses. Instituteresearch and communications products are used worldwide by policymakers, automakers, and consumers.

www.hwysafety.org (703) 247-1500

Juvenile Products Manufacturers Association

A national trade association of companies that manufacture and/or import infant products such as cribs,car seats, strollers, bedding, accessories, and decorative items. JPMA developed a certification programfor juvenile products, publishes materials outlining safe product use and safety measures for home andcar, and sponsors Baby Safe Month each September to raise awareness of important safety issues.

www.jpma.org

Appendix (continued)



Mothers Against Drunk Driving

Seeks effective solutions to the problems of drunk driving and underage drinking. MADD supportspeople who have experienced an alcohol-related event in their family or among their friends. Specificattention is paid to programs that encourage designated drivers, responsible partying, and awareness ofdrinking and driving during the holiday season, as well as programs that help youth defend their choicenot to drink or not to drive while impaired. The work of the organization is conducted through themedia, legislators, educational workshops, federal highway funding sanctions, public awareness educa-tion, and networking with other concerned citizens and safety groups.

www.madd.org (800) get-MADD

National Fire Protection Association

A membership organization that advocates scientifically based consensus codes and standards, research,and education for fire and related safety issues.

www.nfpa.org (800) 344-3555

National Program for Playground Safety

Serves as a public resource for the latest information on playground safety and injury prevention.Available information includes playground safety data, inspection, training, and materials distribution.

www.uni.edu/playground (800) 554-PLAY

National SAFE KIDS Campaign

Coalitions work as a nationwide movement to prevent childhood unintentional injury through educa-tion. Web site includes Spanish- and English-language information, family safety checklist, and a vari-ety of injury topics affecting children, including bicycle safety, firearm safety, fall prevention, andwater safety.

www.safekids.org (202) 662-0600

National Safety Council

An international public service organization with a mission “to educate and influence society to adoptsafety, health, and environmental policies, practices, and procedures that prevent and mitigate humansuffering and economic losses arising from preventable causes.”

www.nsc.org (800) 621-7619

Snell Memorial Foundation

A nonprofit organization that conducts research, education, testing, development, and certification ofhelmet safety standards.

www.smf.org (916) 331-5073

Government OrganizationsCenters for Disease Control and Prevention/National Center for Injury Prevention and Control

A federal research agency within the Department of Health and Human Services. Web site provides linksto fact sheets, publications and resources, research grants, funding opportunities, a “what’s new” section,scientific and surveillance data, links to other CDC centers and injury-related Web sites, and informationabout the center. NCIPC administers an extramural grant program of over $20 million, with grants awardedannually to researchers, universities, and other organizations. NCIPC also supports 55 state and communityinjury prevention programs and comprehensive injury control research centers throughout the UnitedStates. In addition to conducting research, surveillance, intervention, and evaluation studies, these centersserve as training centers and resources to the public, media, and allied health professionals.

www.cdc.gov/ncipc (770) 488-1506




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Maternal and Child Health Bureau

MCHB, within the Department of Health and Human Services, works to promote and improve thehealth of the nation’s mothers and children through providing funds and resources for state and localprograms, and through the Healthy Start Initiative and the Emergency Medical Services for Childrenprogram.

www.mchb.hrsa.gov (301) 443-0205

National Highway Traffic Safety Administration

A federal regulatory agency within the U.S. Department of Transportation responsible for reducingdeaths, injuries, and economic losses resulting from motor vehicle crashes through setting and enforc-ing safety performance standards for motor vehicles, and through grants to state and local governments.Web site includes information on recalls of automobiles and associated equipment.

www.nhtsa.dot.gov (800) 424-9393

State Health Departments

Provide resources, injury surveillance data, programmatic information, and funding information. TheState and Territorial Injury Prevention Directors Association (STIPDA) can provide contact informationto locate injury professionals in a particular state health department.

www.stipda.org (770) 690-9000

U.S. Consumer Product Safety Commission

An independent federal regulatory agency that helps keep American families safe in their homes byreducing the risk of injury or death from consumer products. Web site provides information on unsafeand recalled products and can be used to report injuries from consumer products.

www.cpsc.gov (800) 638-2772

Network of Government and Nongovernmental OrganizationsNational Bicycle Safety Network

NBSN is a coalition of public and private organizations and agencies working together to prevent alltypes of bicycle-related injuries and to promote safe bicycling as a viable transportation alternative byexchanging information on programs, legislation, and research, and by sharing resources.

www.cdc.gov/ncipc/bike



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Documents

Legislative and Regulatory Strategies to Reduce Childhood Unintentional Injuries