Abstract
Purpose:
Based on a nationally representative adult sample, the present study examined the prevalence and trends of driving under the influence (DUI) of alcohol in the United States from 2002 to 2017.
Methods:
Using data from the 2002–2017 National Survey on Drug Use and Health, the prevalence of DUI of alcohol in 2012–2017 were estimated to test for changes in trend and to identify populations at elevated risks of alcohol-involved driving.
Results:
Since 2002, the prevalence of DUI of alcohol has gradually decreased from a high of 15.1% in 2002–2004 to 11.8% in 2012–2014 and 8.5% in 2016–2017, indicating percent decreases by 21.6% and 43.7%, respectively. While decreasing trends were observed across all major sociodemographic and criminal justice subgroups (except older adults), men, young adults, Whites, and those with higher household income continued to be associated with greater risks of alcohol-involved driving. Nevertheless, DUI arrests continued to increase among women, narrowing the gender gap.
Discussion:
Despite the decreased alcohol-involved driving over the past decade, there remains worrisome levels among young adult males. This underscores the need for alcohol policies and public awareness campaigns targeting young adult males. Moreover, further research is needed to elucidate the potential differences in the populations who reported driving under any influence of alcohol and who were involved in fatal crashes.
Keywords: driving under the influence, alcohol, trend, DUI arrests
1. Introduction
Driving under the influence (DUI) of alcohol is a significant public health problem. Over 30% of motor vehicle traffic fatalities were caused by alcohol-impaired driving, resulting in 10,874 lives lost and $44 billion costs incurred in 2017 alone (Naimi et al., 2018; National Highway Traffic Safety Administration, 2018). Additionally, nearly 1 million arrests were made for DUI during the same year (The Federal Bureau of Investigation, n.d.). Several key policies have been implemented to reduce DUI of Alcohol. For instance, by 2004, all states enacted new legal limits of alcohol-impaired driving at a blood alcohol concentration [BAC] of 0.08g/dL. By 2011, 42 states adopted so-called the “Administrative License Revocation” law, which enables states to suspend or revoke driver licenses when a driver was found driving with a BAC of 0.08% or above (Ying et al., 2013).
Despite recent policy changes at the federal and state levels, evidence is limited about how many Americans are involved in drinking and driving and how these rates have changed. NHTSA releases data on drivers’ alcohol involvement, but this data only captures those involved in fatal traffic crashes. Some studies (Quinlan et al., 2005; Schwartz & Beltz, 2018) report population-based estimates based on national surveys such as the Behavioral Risk Factor Surveillance System (BRFSS), but these studies also have limitations. For instance, the BRFSS asks whether respondents drove when they have had “perhaps too much” drink during the past month (Centers for Disease Control and Prevention [CDC], 2018a). Due to the possibility of subjective interpretation of the question, consistent estimation and comparison of the DUI of alcohol prevalence may not be warranted across respondents and years.
To inform prevention efforts while triangulating existing evidence, further evaluation of trends in the prevalence of DUI of alcohol and identification of populations at heightened risk is critical. Especially, evidence on the scope of the population who drive under any degree of alcohol influence is important to provide insights on more general alcohol-involved driving behaviors and to enable early detection and intervention of problematic driving activities. Moreover, large variations in DUI of alcohol patterns and risks across population subgroups (e.g., age, sex, race/ethnicity, socioeconomic status [SES], criminal justice history) require investigations into identifying those at greatest risk (Calling et al., 2019; Casswell et al., 2003; Dickson et al., 2013; Impinen et al., 2011; Schwartz & Beltz, 2018). For instance, Schwartz and Beltz (2018) showed that men’s alcohol-impaired driving rates continue to remain higher than women’ despite an overall decreasing trend. Yet, DUI arrests have increased among women since 1985, narrowing the gender gap (Schwartz & Beltz, 2018; Schwartz & Rookey, 2008). In a study examining major racial/ethnic groups, Whites were more likely to be involved in alcohol-impaired driving than African-Americans and Hispanics–though people of color were overrepresented in arrests and crashes (Romano et al., 2010). Studies also point to the different drinking and driving behaviors by prior DUI and other criminal arrests. Labrie and colleagues (2007) found that a history of anti-social behavior and criminal justice system encounters were as important as prior alcohol-related problems in predicting a higher recidivism rate.
The present study addresses prior gaps by examining the prevalence and trends of DUI of alcohol in the United States since 2002 using data from National Survey of Drug Use and Health (NSDUH). We present population-based prevalence estimates for past-year DUI of alcohol among all respondents aged 18 or older and various subgroups by sociodemographic characteristics and criminal justice involvement. Then we tested for changes in trend in DUI of alcohol by comparing with the rates from 2002 to 2017.
2. Material and Methods
2.1. Data and Sample
The NSDUH provides nationally representative cross-sectional estimates of substance use and behavioral health outcomes among non-institutionalized civilians aged 12 and older in the United States. In each year, multistage area probability sampling strategy was used to recruit participants, who were interviewed privately at their residence. To reduce socially desirable responding of sensitive behaviors, the interview was carried out using computer-assisted interviewing methodology as a confidential means of reporting. From the 2002–2017 NSDUH data, the present study included an analytic sample of 615,882 adults aged 18 or above (286,562 men and 329,320 women). More detailed descriptions of the NSDUH are available elsewhere (Center for Behavioral Health Statistics and Quality, 2018).
2.2. Measures
2.2.1. DUI of alcohol.
All participants were asked: “During the past 12 months, have you driven a vehicle while you were under the influence of alcohol?” Those who reported yes were classified as having involved in DUI of alcohol and were coded as 1, and coded 0 otherwise. While this measure is fully comparable across years from 2002 to 2014, changes in the respondents eligible for DUI questions in 2015 and changes to the drug-related questions in 2016 require caution in comparing estimates between pre-2014 and post-2014 (Center for Behavioral Health Statistics and Quality, 2016, 2017).
2.2.2. Sociodemographic factors and criminal justice involvement.
In addition to key sociodemographic characteristics including age, sex, race/ethnicity, household income, and urbanicity of residence, three indicators (0=no, 1=yes) of criminal justice system involvement in the past 12 months were also examined. These included: any arrests and booking, not counting minor traffic violations, arrests/booking for DUI, and probation/parole status.
2.3. Statistical Analysis
Using the fully comparable data, we first assessed the prevalence of DUI of alcohol in the early 2000s (2002–2004) and 2010s (2012–2014) for the total sample and sociodemographic and criminal justice involvement subgroups. Samples of three adjacent years were combined to obtain a more stable and consistent estimation. Additionally, the prevalence in years 2016–2017 was examined to provide the most recent rates of DUI of alcohol. Second, annual trends of DUI of alcohol among the whole sample and the trends of DUI arrests and booking among those reporting past-year DUI of alcohol were examined while stratifying by key demographic factors. Third, we tested the significance of the DUI of alcohol trends by including year as a continuous independent variable in multiple logistic regression models (while controlling for the sociodemographic factors) as the CDC (2016) suggests. All estimates were weighted to account for the NSDUH’s stratified cluster sampling design (Substance Abuse and Mental Health Data Archive, 2014). While supplementary analyses including the 2015–2017 data follow similar steps above, adjusted weights were created to account for three additional years of data in consistent with the CDC (2018b)’s technical guideline.
3. Results
3.1. Trends in DUI of Alcohol among U.S. Adults
Table 1 displays the prevalence and trends of DUI of alcohol from the early 2000s to 2010s among the full sample and subgroups by demographic characteristics and criminal justice involvement. The prevalence in DUI of alcohol decreased from 15.1% in 2002–2004 to 11.8% in 2012–2014, indicating a 21.6% reduction. This decreasing trends were supported by test of trends for 2002–2014 (AOR = 0.967, 95% CI = 0.963–0.971) and 2002–2017 (AOR = 0.956, 95% CI = 0.953–0.958) as shown in Table A.1.
Table 1.
Past Year Prevalence of Self-Reported Driving Under the Influence of Alcohol among Adults in the United States, NSDUH 2002–2017
| Primary Analysis w/ Fully Comparable Data | Supplemental Estimates | |||||||
|---|---|---|---|---|---|---|---|---|
| 2002–2004 | 2012–2014 | Contrasting: 2002–2004 v. 2012–2014 | 2016–2017 | |||||
| % | 95% CI | % | 95% CI | Δ pp | % change | % | 95% CI | |
| Full Sample | 15.1 | 14.8–15.5 | 11.8 | 11.6–12.1 | −3.3 | −21.6 | 8.5 | 8.2–8.8 |
| Demographic Subgroups | ||||||||
| Age | ||||||||
| 18–25 | 26.1 | 25.6–26.5 | 17.1 | 16.6–17.5 | −9.0 | −34.5 | 10.7 | 10.2–11.2 |
| 26–34 | 21.7 | 20.8–22.6 | 17.8 | 17.0–18.6 | −3.9 | −18.1 | 12.1 | 11.4–12.9 |
| 35–64 | 13.7 | 13.2–14.1 | 11.3 | 10.9–11.8 | −2.3 | −17.0 | 8.8 | 8.4–9.2 |
| 65+ | 3.0 | 2.5–3.8 | 4.0 | 3.5–4.6 | +1.0 | +32.6 | 3.4 | 3.0–3.8 |
| Sex | ||||||||
| Female | 10.4 | 10.0–10.7 | 8.4 | 8.1–8.7 | −2.0 | −18.9 | 6.1 | 5.8–6.4 |
| Male | 20.3 | 19.7–20.9 | 15.6 | 15.1–16.1 | −4.7 | −23.2 | 11.1 | 10.7–11.5 |
| Race/Ethnicity | ||||||||
| White | 16.9 | 16.5–17.3 | 13.5 | 13.1–13.9 | −3.5 | −20.5 | 10.1 | 9.8–10.5 |
| Black | 10.7 | 9.8–11.6 | 8.7 | 8.0–9.4 | −2.0 | −18.7 | 5.5 | 4.9–6.1 |
| Hispanic | 11.2 | 10.4–12.1 | 9.3 | 8.5–10.0 | −2.0 | −17.6 | 6.0 | 5.4–6.6 |
| Other | 9.5 | 8.4–10.6 | 7.7 | 6.9–8.6 | −1.8 | −18.5 | 5.0 | 4.4–5.8 |
| Education | ||||||||
| Less than high school | 8.7 | 8.1–9.4 | 5.4 | 4.9–5.9 | −3.3 | −37.9 | 2.9 | 2.5–3.5 |
| High school | 13.7 | 13.2–14.2 | 9.5 | 9.0–10.0 | −4.2 | −30.7 | 5.7 | 5.2–6.2 |
| Some college | 18.0 | 17.4–18.6 | 13.3 | 12.7–13.8 | −4.7 | −26.1 | 9.1 | 8.7–9.5 |
| College or higher | 18.4 | 17.7–19.2 | 15.9 | 15.3–16.5 | −2.5 | −13.6 | 12.4 | 11.8–13.0 |
| Marital Status | ||||||||
| Married | 11.8 | 11.4–12.1 | 10.1 | 9.6–10.5 | −1.7 | −14.4 | 7.6 | 7.3–7.9 |
| Divorced/Separated/Widowed | 12.8 | 12.0–13.6 | 9.3 | 8.6–10.0 | −3.5 | −27.3 | 6.9 | 6.4–7.4 |
| Never married | 24.9 | 24.3–25.6 | 17.2 | 16.6–17.7 | −7.7 | −30.9 | 11.2 | 10.8–11.7 |
| Income | ||||||||
| <$20,000 | 11.5 | 11.0–12.1 | 8.1 | 7.6–8.7 | −3.4 | −29.8 | 4.8 | 4.4–5.3 |
| $20,000–$39,999 | 12.6 | 12.2–13.1 | 9.2 | 8.8–9.7 | −3.4 | −26.9 | 5.8 | 5.4–6.3 |
| $40,000–$74,999 | 16.2 | 15.6–16.8 | 11.9 | 11.3–12.6 | −4.3 | −26.3 | 8.1 | 7.5–8.7 |
| ≥$75,000 | 19.2 | 18.4–20.0 | 15.6 | 14.9–16.2 | −3.6 | −19.0 | 11.8 | 11.3–12.2 |
| Urbanicity | ||||||||
| Non-metro | 12.5 | 11.4–13.6 | 8.4 | 7.5–9.3 | −4.9 | −32.8 | 6.6 | 5.9–7.5 |
| Metropolitan | 15.3 | 14.9–15.7 | 12.1 | 11.8–12.4 | −3.2 | −21.1 | 8.6 | 8.3–8.9 |
| Any Arrests/Booking | ||||||||
| No | 14.5 | 14.1–14.8 | 11.5 | 11.1–11.8 | −3.0 | −20.7 | 8.3 | 8.0–8.6 |
| Yes | 38.7 | 36.5–40.9 | 30.0 | 27.9–32.2 | −8.6 | −22.3 | 20.7 | 18.4–23.1 |
| Arrest/Booking for DUI | ||||||||
| No | 14.7 | 14.5–15.0 | 11.6 | 11.3–11.9 | −3.1 | −21.3 | 8.3 | 8.0–8.6 |
| Yes | 72.3 | 67.0–77.0 | 68.6 | 63.9–73.0 | −3.7 | −5.1 | 56.7 | 50.1–63.0 |
| Probation/Parole | ||||||||
| No | 14.7 | 14.4–15.1 | 11.6 | 11.3–11.9 | −3.2 | −21.4 | 8.5 | 8.2–8.7 |
| Yes | 30.4 | 28.41–32.55 | 24.2 | 21.9–26.54 | −6.3 | −20.7 | 12.0 | 10.1–14.3 |
Note: Estimates adjusted for survey design effects. According to SAMHDA, data from 2015–2017 are not fully comparable due to changes in survey design; therefore, we conduct separate supplemental tests. Δ pp = percentage point change from 2002–2004. % change determined by dividing the pp change by the 2002–2004 value.
All major sociodemographic and criminal justice subgroups except older adults aged 65+ showed decline in 2012–2014 and then again in 2016–2017 (see Table 1). In 2012–2014, 15.6% (11.1% in 2016–2017) of men and 8.4% (6.1% in 2016–2017) of women reported DUI of alcohol, indicating reductions by 23.2% and 18.9% from 2002–2004, respectively. Declines were gradual and consistent over the study period as shown in the upper chart of Figure 1. Test of trends supported significant decreases over the past decade for both men (AOR = 0.966, 95% CI = 0.961–0.971) and women (AOR = 0.968, 95% CI = 0.963–0.974).
Figure 1.
Prevalence of Driving Under the Influence (DUI) of Alcohol and DUI Arrests among Respondents Who Reported Past-year DUI of Alcohol by Sex in the United States, NSDUH 2002–2017.
Notes. Y-axis displays the survey adjusted prevalence for the corresponding outcome. According to Substance Abuse and Mental Health Services’ Center for Behavioral Health Statistics and Quality (2018), data for self-reported DUI of alcohol from 2015–2017 are not fully comparable to data prior to 2015 due to changes in survey design.
Additionally, several findings from subgroup analyses are worth noting. First, respondents aged 26–35, due to their slower declining rate than those aged 18–25 (during 2002–2014, AOR = 0.967 for ages 26–34 and AOR = 0.941 for ages 18–25), matched the rates of DUI of alcohol of the youngest age group in 2012–2014. In 2016–2017, 12.1% of respondents aged 26–34 drove under the influence of alcohol, significantly higher than the rates among those aged 18–25 (10.7%). Second, Whites continued to be the racial/ethnic group with the highest prevalence of DUI of alcohol with more than one in every ten adults involved in drunk driving. Third, those with higher SES (i.e., household income of $75,000+ and college education or above) reported the highest prevalence in drunk driving and showed the smallest percent decline over the last decade compared to lower SES groups. Lastly, respondents who encountered the criminal justice system in the past year had greater likelihoods of DUI of alcohol. However, the magnitudes of the decrease in DUI of alcohol prevalence over time were similar to those who were not arrested or booked.
3.2. Trends of DUI Arrests/Booking among Those Engaged in DUI of Alcohol
The lower chart in Figure 1 displays the prevalence of DUI arrests and booking among those reporting DUI of alcohol in the past year. Overall, higher percentages of men reporting DUI of alcohol were more likely to be arrested and booked, ranging between 2.6% and 4.9%, with no significant time trends since 2002 (AOR = 0.999; 95% CI = 0.980–1.018 for 2002–2014). Additionally, significant and gradual increases in women’s DUI arrests and booking were observed from 1.2% in 2002 to 2.3% in 2014 (AOR = 1.055; 95% CI = 1.070–1.082) and 2.5% in 2017 (AOR = 1.040, 95% CI = 1.021–1.059).
4. Discussion
Although we identified decreasing trends in DUI of alcohol (except among older adults), we also found that nearly one in every ten adults in the United States drove under the influence of alcohol. Respondents who were aged 26–34, male, and White, and who reported higher SES as well as those with past-year criminal justice system encounters were more likely to engage in alcohol-involved driving in consistent with prior literature such as Caetano and McGrath (2005) and Labrie et al. (2007). While greater reductions in the prevalence of DUI of alcohol among those under 26 years old is encouraging, preventive efforts targeting those in their late 20s and early 30s as well as other at-risk sociodemographic subgroups are needed. Moreover, special attention is needed with respect to observed gains in the number of women arrested. Increased alcohol use among women in adolescence and young adulthood as well as a lower legal limit of alcohol-impaired driving are considered important factors underlying the gendered DUI arrest trends (Robertson et al., 2011; Schwartz, 2008). Thus, further investigation elucidating who were more affected by the recent alcohol use trends and driving behaviors among women involved in DUI of alcohol is warranted.
Importantly, national reports reveal that the number of alcohol-impaired drivers involved in fatal crashes have started to rise since 2011 in contrast to overall decreases in DUI of alcohol throughout the past decade (see Figure A.1). This implies that though fewer Americans drive under any influence of alcohol, the number of alcohol-impaired drivers who are involved in fatal crashes has not subsided since the early 2010s. Thus, it is important to implement measures focused on recalcitrant heavy drinkers who drive that may also have co-existent substance use problems (Hingson et al., 2008). Unfortunately, this may be especially common among young adults who constitutes the largest age group involved in fatal drunk-driving crashes (National Highway Traffic Safety Administration, 2018).
The present study has several limitations. First, data on DUI of alcohol and criminal justice involvement were derived from respondents’ self-reports. Social desirability bias and subjective assessment of intoxication may have affected responses’ accuracy. However, NSDUH’s adoption of the computer-assisted self-interviewing method is considered effective in encouraging honest disclosures. Second, DUI of drugs, an increasingly important part of the DUI problem (Nochajski & Stasiewicz, 2006), was not examined in the study due to multiple changes in the NSDUH’s study designs specific to these questions. Third, DUI trends by different degrees of alcohol influence could not be examined due to lack of BAC information. Data on BAC are needed to better understand the slower reductions in traffic fatalities involving alcohol-impaired drivers than the rates of reductions in DUI of alcohol. Lastly, lack of contextual information limited further investigations into the underlying mechanisms of a higher DUI risk such as higher SES and neighborhood characteristics (e.g., ethnic densities, policing practices). Future research is needed to elucidate the role of salient individual (e.g., affordability, drinking behaviors) and neighborhood factors.
Despite the aforementioned limitations, the present study provides an important triangulation source for existing evidence which largely focuses on driving with BACs of 0.08g/dL or above. While we observed decreasing trends in DUI of alcohol influence among a nationally-representative U.S. adult sample, we also identified target groups for prevention efforts. Specifically, the present investigation points to further division between Americans who drive following heavy drinking episodes and the aggregates who refrain from drinking and driving at all. Alcohol policies and public awareness campaigns need to target young adult males (mostly White) concomitantly with additional research that sheds light on the potential differences in the populations who were involved in fatal crashes and who reported driving under any influence of alcohol.
Highlights.
About one in ten Americans are driving under the influence of alcohol(DUI-Alcohol).
Contrary to overall decreases, DUI-Alcohol remained unchanged among older adults.
The prevalence among those aged 26–34 exceeded the rates among those 25 or under.
Male, White, and higher income continue to be associated with a greater prevalence.
DUI arrests increased among Women, narrowing the gender gap.
Acknowledgments
This work was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health [Award Number K01AA026645]. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIAAA or the NIH.
Table A.1.
Test of Significance for Trends in Past Year Driving Under the Influence of Alcohol among Adults (Aged 18+) in the United States, NSDUH 2002–2017
| Primary Analysis w/ Fully Comparable Data 2002–2014 | Supplemental Test 2002–2017 | |||
|---|---|---|---|---|
| AOR | 95% CI | AOR | 95% CI | |
| Full Sample | 0.967 | 0.963–0.971 | 0.956 | 0.953–0.958 |
| Demographic Subgroups | ||||
| Sex | ||||
| Male | 0.966 | 0.961–0.971 | 0.953 | 0.950–0.957 |
| Female | 0.968 | 0.963–0.974 | 0.955 | 0.951–0.959 |
| Age | ||||
| 18–25 | 0.941 | 0.937–0.944 | 0.925 | 0.922–0.927 |
| 26–34 | 0.967 | 0.960–0.974 | 0.951 | 0.946–0.956 |
| 35–64 | 0.979 | 0.973–0.984 | 0.970 | 0.966–0.974 |
| 65+ | 1.016 | 0.989–1.044 | 1.005 | 0.988–1.022 |
| Race/Ethnicity | ||||
| White | 0.967 | 0.963–0.971 | 0.957 | 0.954–0.959 |
| Black | 0.975 | 0.962–0.987 | 0.957 | 0.949–0.965 |
| Hispanic | 0.963 | 0.953–0.974 | 0.946 | 0.939–0.954 |
| Other | 0.975 | 0.959–0.991 | 0.959 | 0.948–0.970 |
| Education | ||||
| Less than high school | 0.951 | 0.940–0.962 | 0.937 | 0.928–0.946 |
| High school | 0.955 | 0.949–0.961 | 0.942 | 0.937–0.947 |
| Some college | 0.962 | 0.956–0.968 | 0.949 | 0.945–0.953 |
| College or higher | 0.985 | 0.979–0.992 | 0.975 | 0.971–0.979 |
| Marital Status | ||||
| Married | 0.980 | 0.974–0.986 | 0.970 | 0.966–0.974 |
| Divorced/Separated/Widowed | 0.965 | 0.956–0.975 | 0.959 | 0.953–0.966 |
| Never married | 0.952 | 0.948–0.957 | 0.937 | 0.933–0.940 |
| Household income | ||||
| <$20,000 | 0.951 | 0.943–0.958 | 0.934 | 0.929–0.940 |
| $20,000–$39,999 | 0.961 | 0.954–0.967 | 0.949 | 0.944–0.953 |
| $40,000–$74,999 | 0.966 | 0.959–0.973 | 0.954 | 0.949–0.959 |
| ≥$75,000 | 0.978 | 0.972–0.985 | 0.968 | 0.963–0.972 |
| Urbanicity | ||||
| Non-metro | 0.952 | 0.939–0.966 | 0.947 | 0.937–0.957 |
| Metropolitan | 0.968 | 0.964–0.972 | 0.956 | 0.954–0.959 |
| Criminal Justice Subgroups (Past Year) | ||||
| Any Arrests/Booking | ||||
| No | 0.968 | 0.964–0.972 | 0.957 | 0.954–0.960 |
| Yes | 0.961 | 0.949–0.974 | 0.943 | 0.935–0.952 |
| Arrests/Booking for DUI | ||||
| No | 0.968 | 0.964–0.972 | 0.956 | 0.954–0.959 |
| Yes | 0.971 | 0.941–1.001 | 0.937 | 0.916–0.959 |
| Probation/Parole | ||||
| No | 0.968 | 0.964–0.972 | 0.957 | 0.954–0.959 |
| Yes | 0.959 | 0.945–0.974 | 0.938 | 0.928–0.948 |
Notes. The models were adjusted for sociodemographic factors including sex, age, race/ethnicity, employment status, marital status, educational attainment, annual household income, and urbanicity of residence. Odds ratios and 95% confidence intervals in bold are statistically significant at .05. Caution in interpretation of the supplemental tests is needed due to potential incomparability of DUI data between pre- and post-Year 2015.
Figure A.1.
Prevalence of Driving Under the Influence (DUI) of Alcohol and Number of Alcohol-Impaired Drivers Involved in Fatal Traffic Crashes, 2004–2017
Notes. Data on driving under the influence (DUI) of alcohol and alcohol-impaired drivers were derived from the National Survey on Drug Use and Health and National Highway Traffic Safety Administration’s Fatality Analysis Reporting System, respectively. According to Substance Abuse and Mental Health Services’ Center for Behavioral Health Statistics and Quality (2018), data for self-reported DUI of alcohol from 2015–2017 are not fully comparable to data prior to 2015 due to changes in survey design.
Footnotes
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Conflict of Interest
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