Drinking and Recreational Boating Fatalities: A

Population-Based Case-Control Study

Gordon S. Smith; Penelope M. Keyl; Jeffrey A. Hadley; et al.
Online article and related content
current as of December 12, 2009.

JAMA. 2001;286(23):2974-2980 (doi:10.1001/jama.286.23.2974)

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ORIGINAL CONTRIBUTION

Drinking and Recreational Boating Fatalities

A Population-Based Case-Control Study
Gordon S. Smith, MB, ChB, MPH
Penelope M. Keyl, MSc, PhD
Jeffrey A. Hadley, PhD
Christopher L. Bartley, MA
Robert D. Foss, PhD
William G. Tolbert, MA
James McKnight, PhD

43 MILLION
people reported using a
motorboat in the United
States in 1994, 1 and
about 800 people died in 1998 from recreational boating.2 Alcohol is commonly involved in drownings and other
unintentional injury fatalities3-7 and is
increasingly recognized as an important factor in many boating fatalities.8,9 Data from 4 states with high testing rates for 1980 to 1985 suggest that
51% of people involved in boating fatalities had a blood alcohol concentration (BAC) of at least 40 mg/dL, and
30% had a BAC higher than 100 mg/
dL.4,10 Other countries such as Canada11
and Finland12 have an even higher proportion of boating fatalities linked to alcohol use.
Alcohol use while boating affects the
probability not only of ending up in the
water but also of survival once that happens. Because of this apparent double
jeopardy, alcohol use may actually be
more hazardous on a boat than in other
settings, with even low BACs greatly increasing relative risk (RR).8,13,14 Although these and other studies4,8,15,16
suggest that alcohol increases the RR
of dying while boating, this relationship has not been well quantified.
This study sought to better define the
relationship between alcohol use and the
ORE THAN

Context Alcohol is increasingly recognized as a factor in many boating fatalities, but

the association between alcohol consumption and mortality among boaters has not
been well quantified.
Objectives To determine the association of alcohol use with passengers and operators estimated relative risk (RR) of dying while boating.
Design, Setting, and Participants Case-control study of recreational boating deaths
among persons aged 18 years or older from 1990-1998 in Maryland and North Carolina (n = 221), compared with control interviews obtained from a multistage probability sample of boaters in each state from 1997-1999 (n=3943).
Main Outcome Measure Estimated RR of fatality associated with different levels
of blood alcohol concentration (BAC) among boaters.
Results Compared with the referent of a BAC of 0, the estimated RR of death increased even with a BAC of 10 mg/dL (odds ratio [OR], 1.3; 95% confidence interval
[CI], 1.2-1.4). The OR was 52.4 (95% CI, 25.9-106.1) at a BAC of 250 mg/dL. The
estimated RR associated with alcohol use was similar for passengers and operators and
did not vary by boat type or whether the boat was moving or stationary.
Conclusions Drinking increases the RR of dying while boating, which becomes apparent at low levels of BAC and increases as BAC increases. Prevention efforts targeted only at those operating a boat are ignoring many boaters at high risk. Countermeasures that reduce drinking by all boat occupants are therefore more likely to
effectively reduce boating fatalities.
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JAMA. 2001;286:2974-2980

RR of death while boating. We conducted a large population-based casecontrol study of alcohol use and recreational boating fatality risk in 2 states,
Maryland and North Carolina. These
states include a diversity of waterways
on which recreational boating takes
place. We sought to determine the magnitude of the estimated RR of dying associated with alcohol use, adjusting for
known or potential risk factors for
drowning and other boating deaths. We
also examined whether RRs were different for passengers and operators and
whether low BACs pose a significant RR.
METHODS
Identifying and Selecting
Boating Fatalities

We searched official state boating fatality records and medical examiner files

2974 JAMA, December 19, 2001Vol 286, No. 23 (Reprinted)

in each state to identify all recreational

boating deaths classified as accidental that occurred from 1990 to 1998 in
Maryland and North Carolina. Only
boating deaths that occurred from April
through October (n=403 of 502 deaths)
were included in the study. Boating activity declined markedly outside these
months, making control interviews proAuthor Affiliations: Johns Hopkins Center for Injury Research and Policy, Baltimore, Md (Drs Smith, Keyl, and
Hadley); Department of Emergency Medicine, Johns
Hopkins School of Medicine, Baltimore (Drs Smith and
Keyl); Highway Safety Research Center, University of
North Carolina at Chapel Hill (Dr Foss and Messrs Bartley and Tolbert); Pacific Institute for Research and Evaluation, Rockville, Md (Dr McKnight). Mr Tolbert is now
at Rho Inc, Chapel Hill, NC. Dr Smith is now also at the
Center for Safety Research, Liberty Mutual Research
Center for Safety and Health, Hopkinton, Mass.
Corresponding Author and Reprints: Gordon S. Smith,
MB, ChB, MPH, Center for Safety Research, Liberty
Mutual Research Center for Safety and Health, 71 Franklin Rd, Hopkinton, MA 01746 (e-mail: Gordon.Smith
@LibertyMutual.com).

2001 American Medical Association. All rights reserved.

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DRINKING AND RECREATIONAL BOATING FATALITIES

hibitively expensive and difficult. Because of difficulty finding control subjects at night, especially in North
Carolina, boating deaths that occurred
between midnight and 7:00 AM in Maryland and between 9:00 PM and 7:00 AM
in North Carolina were excluded from
the study (13.9% of eligible cases).
Deaths associated with the use of sailboats, personal watercraft (ie, jet skis),
and rafts were excluded (16.1% of eligible cases). Deaths on sailboats are rare,
and personal watercraft and rafts are different from other boat types.2,17,18 Fatality and control subjects younger than 18
years (9.7% of eligible cases) were excluded because the parents of potential
underage control subjects were often not
available to give consent. Small inland
bodies of water were excluded in Maryland, since only 3% of eligible deaths
occurred in them and they were widely
dispersed. Despite the Coast Guard definition of a boating death,2 individuals
who drowned while swimming from a
boat were included in our study, although some of our analyses excluded
them.
Control Subject Selection

Control subjects were from a stratified random sample of boats from waterways in each state during the boating season (April through October)
from 1997 through 1999. A complex
sampling design was used to ensure that
control subjects were drawn from the
same locations as fatality subjects in
each state. First, the states navigable
waterways were divided according to
geographic area and type of waterway
into strata that reflected cultural and demographic differences (T ABLE 1).
Within each stratum, areas were selected to represent locations of boating activity. Given the large differences in the types of waterways and
their distribution in Maryland and
North Carolina, sampling procedures
were tailored for each state.
Selection of Waterways
for Control Survey

North Carolina. The state was first divided into 3 geographically and cultur-

Table 1. Sampling Features Taken Into Consideration in Study Design or Analysis:

Boating Case-Control Study, Maryland and North Carolina
Sampling Feature
Strata

Description
Navigable waterways in each state were stratified according to
geographic area and type of waterway, resulting in 5 strata in
North Carolina and 9 in Maryland.

Area

Within each stratum, waterways were selected to represent boating

activity in the stratum. In the analysis, observations within each
area were treated as clusters to account for the lack of
independence of the observations.
We sampled all operators and up to 2 passengers per boat. Weights
were calculated and used in the analysis to adjust for this
differential sampling between operators and passengers.

Weights

Time of day

Within each stratum, interviews were conducted to cover all times of

day rather than attempting to match the time-of-day distribution of
cases. Analyses were adjusted for the confounding effects of time
of day on the relationship of BAC levels with death.

ally distinct regions (coastal, midstate,

and western) with historically different patterns of alcohol use.
Bodies of water were categorized into
ocean/bay/sound waterways, large and
medium-sized lakes, and small lakes and
rivers. The ocean/bay/sound waterways were treated as 1 stratum, large and
medium-sized lakes in each region composed 3 additional strata, and all smaller
lakes and rivers composed the final stratum (a total of 5 strata). Within the
ocean/bay/sound stratum,19 geographically distinct areas were identified, and
6 of these were randomly selected. Each
of the 12 largest lakes and 6 of the 10
medium-sized lakes were randomly selected as sampling areas, with the number of medium-sized lakes selected proportionate to the population within each
region. For the small lake and river stratum, the state was subdivided by latitude and longitude. Of the 210 resulting subdivisions, 42 (20%) were selected,
with a probability proportionate to the
population within the region. Within
each selected subdivision, 2 areas, 1
small lake and 1 river, were then randomly chosen from navigable waterways, which resulted in the selection of
30 small lakes and rivers across the state,
for a total of 54 selected areas in North
Carolina.
Maryland. Recreational boating in
Maryland occurs primarily in 4 bodies
of water, with the majority occurring
on the Chesapeake Bay and its many
river estuaries and also on the Potomac River.

2001 American Medical Association. All rights reserved.

Deep Creek Lake and the Atlantic

Ocean are 2 other areas where boating
is popular, but neither had any boating fatalities during the study period.
Chesapeake Bay was divided into 6
strata corresponding to the upper,
middle, and lower sections on both the
western and eastern sides of the bay.
The Potomac River was divided into 3
strata, 2 below Washington, DC, and
1 nontidal part above it. Each stratum
was divided into areas that could be surveyed in 1 day.
On-Water Procedures

Teams of 2 interviewers visited designated areas (eg, a lake, river, or region

of a bay) multiple times by boat on a
predetermined schedule that included
both weekdays and weekends. On each
visit, interviewers moved systematically around the water to ensure that
the entire area was covered. Upon arriving at a designated location, interviewers identified up to 6 boats nearest to them and then used a die to
randomly select 1 to interview. Only
stationary or slowly moving boats were
sampled. These fell into 2 categories:
those that were anchored, moored,
drifting, or berthed, and those that were
arriving at destinations in a sampling
area such as a fishing area, beach, marina, or boat ramp after being under
way. In Maryland only, because of the
large size of the Chesapeake Bay, we
also used shore teams to interview boaters who were returning to a boat ramp
or marina. Boats were approached in the

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2975

DRINKING AND RECREATIONAL BOATING FATALITIES

order in which they arrived at the shorebased sampling site.

The selected boat was approached and
the operator was asked to participate in
the study. The operator was interviewed and asked to provide details on
the boat and the boats activities in the

past hour. Next, the operator and up to

2 randomly selected passengers (18
years) were asked to complete a short
self-administered questionnaire that included questions on general health and
demographic characteristics. Last, the operator and the selected passengers were

Table 2. Comparison of Boat and Demographic Characteristics for Fatality and Control
Subjects, Maryland and North Carolina
No. (%)

Boat type
Cabin motorboat
Open motorboat (3 m)
Small boats*
Time of day
7:00-10:00 AM
10:01 AM-noon
12:01-2:00 PM
2:01-4:00 PM
4:01-6:00 PM
6:01-8:00 PM
8:01-10:00 PM
10:01 PM-midnight
Day of the week
Weekend
Weekday
Sex
Male
Female
Race
Black
Nonblack
Occupant status
Operator
Passenger
Age, y
18-20
21-30
31-40
41-50
51-60
61-70
70
Activity
Cruising
Fishing
Drifting
Anchored
Waterskiing
Racing
Towing

Fatality Subjects
(n = 221)

Control Subjects
(n = 3943)

18 (8.1)
154 (69.7)

597 (15.1)
3118 (79.1)

49 (22.2)

228 (5.8)

26 (11.8)
21 (9.5)
31 (14.0)
43 (19.5)
27 (12.2)
46 (20.8)

79 (2.0)
336 (8.5)
649 (16.5)
971 (24.6)
853 (21.6)
724 (18.4)

20 (9.0)
7 (3.2)

296 (7.5)
35 (0.9)

124 (56.1)
97 (43.9)

2685 (68.1)
1258 (31.9)

204 (92.3)
17 (7.7)

2860 (73.4)
1034 (26.6)

52 (24.3)
162 (75.7)

132 (3.8)
3324 (96.2)

97 (43.9)
124 (56.1)

2108 (53.5)
1835 (46.5)

14 (6.3)
45 (20.4)

89 (2.6)
634 (18.4)

45 (20.4)
42 (19.0)
36 (16.3)
25 (11.3)
14 (6.3)

1008 (29.3)
858 (24.9)
557 (16.2)
205 (6.0)
88 (2.6)

90 (40.7)
85 (38.5)
36 (16.3)
16 (7.2)
6 (2.7)
6 (2.7)
2 (0.9)

1858 (47.1)
1926 (48.8)
1763 (44.7)
785 (19.9)
315 (8.0)
11 (0.3)
12 (0.3)

*Includes all boats less than 3 m long and all canoes, kayaks, and rowboats.
Numbers do not equal n because of missing values.
Nonblack consists of 97% white fatality subjects and 98% white control subjects, with the remainder other nonblack
races or unknown.
There may be more than 1 activity per fatality subject and control subject; thus, the percentage will not add up to 100.

2976 JAMA, December 19, 2001Vol 286, No. 23 (Reprinted)

asked to provide a breath sample for alcohol testing by a handheld breathalyzer (CMI Intoxilyzer D-400R; CMI Inc,
Owensboro, Ky). The interviewer also recorded information about the boat, number of passengers, evidence of alcohol
use, apparent sobriety of the operator,
and refusals. Institutional review boards
for the protection of human subjects at
the Johns Hopkins School of Public
Health and the University of North Carolina School of Public Health approved the
study procedures.
Adjustments in BAC for
Endogenous Alcohol in Fatalities

When recovery of a body is delayed,

decomposition can result in postmortem alcohol production. Rather than
excluding the subjects that were not
recovered within 1 or 2 days after
death,19 we used a conservative procedure based on new evidence about the
time course of decomposition to adjust
those subjects BAC levels (J.A.H. and
G.S.S., unpublished data, 2001). The
amount subtracted from the observed
BAC started as 0 mg/dL for cases with
a submersion time of 12 hours and
increased linearly to a maximum of 40
mg/dL for bodies recovered after 96
hours in the water. Few drowning victims produce endogenous alcohol levels as high as 40 mg/dL, even at the longest recovery times.20,21 Cases in which
the body was recovered more than 1
week after the incident were excluded.
Statistical Analysis

The increased RR of fatality associated

with BAC, after adjustment for other factors, was estimated by calculating odds
ratios (ORs) using logistic regression
in Stata (StataCorp, Version 6, 2000;
College Station, Tex). Effects of the sampling design (stratification, clustering,
and weighting) were accounted for in
the analysis by using the svy Stata commands. Each area within a stratum
where control boaters were sampled (eg,
a lake, a section of river, or an area of
bay) was treated as a primary sampling unit or cluster (Table 1). Because
the number of passengers in control
boats ranged from 0 to 14 but a maxi-

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DRINKING AND RECREATIONAL BOATING FATALITIES

RESULTS
Fatality Subjects

Of the 253 boating victims meeting inclusion criteria, 15 (6%) were excluded from the analysis because their
bodies were recovered more than 1
week after death or were recovered after an unknown length of time. Among
the 238 eligible fatality subjects, 76%
were recovered within 24 hours of
death; 11%, within 25 to 48 hours; 9%,

within 49 to 96 hours; and 4%, within

97 to 168 hours. Seventeen of these subjects (7.1%) were not tested for BAC.
Of the 221 subjects included in the
study, 55% had a positive BAC (adjusted for recovery time); 36% had a
BAC of at least 50 mg/dL; 27%, at least
100 mg/dL; 18%, at least 150 mg/dL;
11%, at least 200 mg/dL; and 7%, at least
250 mg/dL. Most subjects had been in
open motorboats at least 3 m long
(69.7%), and the largest number of
them died between 6:00 and 8:00 PM
(20.8%; Table 2). Subjects were predominantly male and nonblack, less
than half were operators, and most were
21 to 40 years of age. Eligible subjects
excluded because of missing BAC data
did not have different demographic factors. Eleven subjects (3.2%) died in
rough water, which precluded safely interviewing control subjects in similar
conditions, but because they had BACs
similar to those of other subjects, they
were kept in the study. Passengers were
more likely than operators to have a
positive BAC (68% vs 48%; P.001)
that was at least 100 mg/dL (37% vs
27%; P =.04).

boats sampled for the control survey

agreed to participate; 87% completed
the self-administered questionnaire, and
86% provided a valid breath sample. Of
those who gave a breath sample, 7.6%
refused the self-administered questionnaire. The interviews yielded a total of
4801 potential controls (2468 operators and 2333 passengers), of whom
3943 provided a valid breath sample
and were included in the analysis (Table
2). Boating and demographic characteristics of persons who provided a
breath sample differed little from that
of those who refused, although those
on open motorboats, those who were
approached earlier in the day, female
subjects, and younger persons were
somewhat more likely to participate.
Only 17% of participants had a positive BAC. Of those, 7.4% had a BAC of
at least 50 mg/dL; 3.4%, at least 100 mg/
dL; 1.4%, at least 150 mg/dL; 0.6%, at
least 200 mg/dL; and 0.3%, at least 250
mg/dL. These figures represent crude
unweighted distributions from a stratified sample and thus are not representative of boaters in these areas.
Relative Risk

Control Subjects

The number of boats sampled from each

of the 14 strata ranged from 75 to 504.
Almost all (93%) of the operators of

A greater proportion of control subjects were in motorboats at least 3 m

long and were female, nonblack, and 21
to 50 years of age (Table 2). The RR of

Figure. Relative Fatality Risk While Boating by BAC, Maryland and North Carolina
100

50

Adjusted Odds Ratio,

95% Confidence Intervals

mum of only 2 passengers was sampled,

appropriate weights were applied to provide a valid comparison of operators and
passengers. All analyses were adjusted
for the confounding effects of time of
day (resulting from the sampling schedule) by including variables for time of
day in 2-hour increments. For the main
analysis, both BAC and age were treated
as continuous variables. Higher-order
terms were considered for both variables. Categories of BAC were created
only to compare the results with findings from other studies.
Multiple imputations were carried
out to replace missing values for sex,
race, and age (1%, 12%, and 12%, respectively, for controls and 15% for race
for subjects; TABLE 2). A hot-deck procedure using the approximate Bayesian
bootstrap method of Rubin and Schenker22,23 was used. Ten imputations were
performed for each analysis. This approach assumes that within each state
(Maryland or North Carolina) and boat
type, missing values for subgroups of
subjects had the same distribution as
known values.
Crude analyses suggested that control operators who refused to participate might have had higher BACs than
participating operators; 5% and 2%, respectively, were judged to be at least
moderately impaired. For operators
only we evaluated the extent to which
refusals to give a breath sample might
have influenced BAC RR estimates. The
hot-deck method described above was
used to impute the missing BACs, assuming missing values for BACs had the
same distribution as those with known
BAC within each level of the interviewers assessment of impairment.

10

1
0

50

100

150

200

250

BAC, mg/dL

Logarithmic scale indicating odds ratio of dying relative to having a blood alcohol concentration (BAC) of
0 mg/dL. Dashed lines indicate 95% confidence intervals.

2001 American Medical Association. All rights reserved.

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DRINKING AND RECREATIONAL BOATING FATALITIES

Table 3. Comparison of Adjusted Odds Ratios of Dying While Boating by Blood Alcohol
Concentration (BAC) Point Estimates for All Study Participants vs Only Those Who
Were Not Swimming*
Adjusted Odds Ratio (95% Confidence Interval)
BAC, mg/dL
0

All Study Participants

(n = 4164)
1.0

Excluding Swimmers
(n = 3251)
1.0

10
20
30

1.3 (1.2-1.4)
1.7 (1.6-1.9)
2.2 (1.9-2.6)

1.4 (1.3-1.5)
1.8 (1.6-2.1)
2.5 (2.1-2.9)

40
50

2.9 (2.3-3.6)
3.7 (2.8-4.7)

3.2 (2.6-4.0)
4.2 (3.3-5.5)

80
100
150

7.1 (5.0-10.1)
10.4 (6.9-15.7)
23.0 (14.0-37.9)

8.5 (5.9-12.3)
12.8 (8.4-19.6)
27.9 (16.6-47.0)

200
250

39.4 (22.4-69.6)
52.4 (25.9-106.1)

43.9 (24.6-78.4)
49.6 (25.2-97.5)

*Adjusted for age, race, sex, occupant status, boat type, location, time of day, and weekend/weekday. The adjustment included weights for differential passenger selection probabilities.
Includes all boating fatality and control subjects.
Excludes subjects who died after swimming off a boat and control subjects from boats where occupants swam in the
past hour.

Table 4. Adjusted Odds Ratios of Dying

While Boating by Blood Alcohol
Concentration (BAC) Ranges
Adjusted Odds
Ratio (95%
Confidence Interval)
BAC ranges, mg/dL
0
1-49
50-99
100-149
150
BAC dichotomized,
mg/dL
50
80
100

1.0
2.8 (1.6-4.8)
5.7 (2.9-10.8)
12.0 (5.8-24.9)
37.4 (16.8-83.0)
10.5 (6.7-16.5)
13.9 (8.3-23.4)
15.7 (9.0-27.5)

*Adjusted for age, race, sex, occupant status, boat type,

location, time of day, and weekend/weekday. The adjustment included weights for differential passenger selection probabilities.

death by BAC level, compared with that

of subjects with a BAC of 0 mg/dL, was
determined in analyses to be a secondorder quadratic relationship when adjusted for age, race, sex, occupant status, boat type, location, time of day, and
weekend/weekday. Age was modeled as
a third-order quadratic relationship.
The ORs for dying by BAC increased
most rapidly at lower BACs, with the
rate of increase leveling off at higher
BACs (FIGURE). The RR of death was
increased even at a BAC of 10 mg/dL
(OR=1.3; 95% confidence interval [CI],
1.2-1.4), increasing to an OR of 52.4 at
a BAC of 250 mg/dL (95% CI, 25.9-

106.1; TABLE 3). When only those persons meeting the official Coast Guard
definition of boating accidents were
considered (ie, when the 22 subjects
[10%] who died while voluntarily
swimming from a boat and when control subjects from boats where people
were swimming were excluded), there
was no significant change in the RRs of
fatality (Table 3).
Additional analyses were conducted
by using categories of BAC and dichotomizing BAC at different cut points to permit comparisons with other studies
(TABLE 4). These values have wider CIs
than estimates of RR when BAC is used
as a continuous variable.
Interactions and
Sensitivity Analyses

The RR associated with BAC was not

significantly different between operators and passengers, male and female
subjects, black and nonblack persons,
persons of different ages, or different
types of boats.
Adjusting for the potential bias resulting from control subjects who declined to give breath samples decreased the ORs, but the differences
were not significant. Because subjective impressions of intoxication are unreliable, we elected to present findings based on actual measurements, as

2978 JAMA, December 19, 2001Vol 286, No. 23 (Reprinted)

has been the practice in the few studies that have evaluated refusal bias.24-26
COMMENT
The most important finding in this
study is the strong positive association of BAC with the RR of death among
recreational boaters aged 18 years and
older, even at BACs less than 50 mg/
dL. In addition, passenger and operator drinking is associated with the same
increased RR of death, regardless of
whether the boat is under way.
Dose-Response Effects of Alcohol

The RRs associated with alcohol use and

boating fatality increase markedly as the
BAC increases, from an OR of 1.3 at a
BAC of 10 mg/dL to 52 at 250 mg/dL.
Our finding of increased RR at low
BACs is consistent with experimental
studies that find significant impairment in many safety-related tasks at
BACs below 50 mg/dL.27-30
Alcohol can affect boater safety in
multiple ways, influencing both the risk
of ending up in the water (or crashing) and chances for survival in the
water.8,13,14,29-31 Alcohol impairs balance and coordination, which can increase the risk of falling overboard
whether a boat is under way or not. Impaired judgment resulting from an elevated BAC can also increase the likelihood of being in high-risk situations,
and unlike on the roadway, having a sober operator will not necessarily protect impaired occupants. The effects of
alcohol on the probability of survival
are greater than for other injury causes31
and, once a person enters the water, include an increased risk of hypothermia and a reduced ability to keep the
head above water.8,13,14,29 Thus, a simple
fall overboard can prove fatal.
Although there is substantial evidence for the risk of drinking and driving,27,30,32-34 there is surprisingly little information about the risk of drinking and
other injuries, including those associated with boating. Besides that reported here, the only study designed to
estimate the risk of drinking for boaters was conducted at boat ramps in
California. That study had a small

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DRINKING AND RECREATIONAL BOATING FATALITIES

sample size and did not control for several relevant factors such as region, time
of day, age, sex, or boat type.4 It found
a crude 10.7-fold increased risk of boating fatality among operators with BACs
higher than 100 mg/dL, and CIs were
wide (95% CI, 4.7-68.8). In this study,
we found a clear dose-response relationship and controlled for many potential confounding variables. In addition to elevated RR at very low BACs,
we also found a much greater RR of
death at higher BACs than the California study reported. Our main analyses
included subjects swimming or diving
off a boat, since swimming is a common part of boating activities, although excluding them in accordance
with Coast Guard practice2 did not
change the RR.
Operators vs Passengers

Alcohol use has long been a part of recreational boating; 30% to 40% of boaters surveyed report drinking while boating.1,6,35-38 Many of these boaters believe
that they can safely drink more when at
anchor or tied up and when they are passengers rather than operators.36 Current legislation concentrates entirely on
alcohol use by the boat operator while
the boat is under way, prohibiting operation of a boat while intoxicated, as
have many safety campaigns.8,9,15 Some
have even promoted the use of a designated driver when boating, with the implication that passengers can drink as
much as they like as long as the operator remains sober. Although these approaches initially appear attractive, they
ignore the reality that passengers can put
themselves at risk regardless of the operators actions or alcohol use. Only
about half the recreational boating fatalities could be attributed to operator
error.8 Most boating fatalities involve
drowning; only 18% involve collisions
with other boats or objects. The majority of fatalities involve falling overboard, and almost half (46%) of these
occur when the vessel is not under way.
Indeed, our findings clearly indicate that
the RR of death is similar for operators
and passengers and increases for both
groups as BAC increases.

Many fatalities occur in unpowered

or low-powered boats,2,8,15 and many
others occur while boats are not in operation, which undermines the assumption that boat handling by drunken operators is a primary cause of boating
fatalities. Unfortunately, since boating police rarely test surviving operators for alcohol use, it is impossible with
current data to assess the role of impaired operators in increasing the risk
of death for other boaters.
Policy Implications

The implicit assumption of designated

driver programsthat a passenger can
drink as long as the operator remains soberis dangerous for boaters. All persons on a boat have an increased RR of
mortality if they have been drinking,
even at low BACs. These findings suggest that countermeasures directed only
at operators of moving boats are likely
to have less impact on alcohol-related
boating fatalities than broader efforts to
address drinking by anyone engaged in
recreational boating.
Study Limitations

Temporal changes in drinking practice among boaters could affect alcohol risk estimates, since fatality- and
control-subject data were collected for
different years. However, throughout
the study period BACs among subjects did not change significantly over
time, nor did RRs of death estimated
across cases from 1990 to 1994 and
from 1995 to 1998.
Although many potentially confounding variables were taken into account, we were unable to adjust for
other variables that might affect risk,
such as the boaters swimming ability,
the operators boating skills and experience, use of personal floatation devices, water and weather conditions,
and the condition and seaworthiness of
the boat. Use of personal floatation devices was low among control subjects
(about 6.7% of adults in control boats),
but because such use was assessed only
at the boat level and not for individuals, it was impossible to include it in our
analyses. However, this study was de-

2001 American Medical Association. All rights reserved.

signed to look at the total RR of death

when subjects had been drinking, not
to separately examine the influence of
BAC on the risk of falling in the water
(or crashing) and surviving once in the
water. Personal floatation device use
and swimming ability would have a direct effect only on the latter. Finally, although we controlled for boating exposure with the random selection of
control subjects, some groups, such as
persons in boats that spent most of their
time under way, may have been underrepresented.
Author Contributions: Study concept and design:
Smith, Keyl, Hadley, Bartley, Foss, Tolbert, McKnight.
Acquisition of data: Smith, Hadley, Bartley, Foss,
Tolbert, McKnight.
Analysis and interpretation of data: Smith, Keyl,
Hadley, Bartley, Foss, McKnight.
Drafting of the manuscript: Smith, Keyl, Hadley,
Bartley, Foss.
Critical revision of the manuscript for important intellectual content: Smith, Keyl, Hadley, Bartley, Foss,
Tolbert, McKnight.
Statistical expertise: Smith, Keyl, Hadley, Bartley, Foss.
Obtained funding: Smith, Keyl, McKnight.
Administrative, technical, or material support: Smith,
Hadley, Foss, Tolbert.
Study supervision: Smith, Keyl, Foss, Tolbert, McKnight.
Funding/Support: This study was supported by grant
R29AA07700 from the National Institute of Alcohol
Abuse and Alcoholism.
Acknowledgment: We wish to acknowledge the assistance of the staff, interviewers, boat operators, and
assistants at the Pacific Institute for Research and Evaluation (PIRE), Calverton, Md, and the University of North
Carolina at Chapel Hill, who coordinated field data collection. We would also like to acknowledge the assistance of the Maryland Department of Natural Resources, the North Carolina Wildlife Resource
Commission, and the medical examiners offices in
Maryland and North Carolina, without whose help this
study would not have been possible. We also wish to
acknowledge the assistance of the University of Auckland Injury Prevention Research Centre.
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Experience, the universal mother of Sciences.

Miguel de Cervantes Saavedra (1547-1616)

2980 JAMA, December 19, 2001Vol 286, No. 23 (Reprinted)

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