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An evidence-based review

Distracted driver

Llerena, Luis E. MD; Aronow, Kathy V. RN, MSN; Macleod, Jana MD; Bard, Michael MD; Salzman, Steven DO; Greene, Wendy MD; Haider, Adil MD; Schupper, Alex

Author Information
Journal of Trauma and Acute Care Surgery: January 2015 - Volume 78 - Issue 1 - p 147-152
doi: 10.1097/TA.0000000000000487
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Motor vehicle driving demands constant vigilance and the use of visual, auditory, and tactile senses for ultimate safety. These senses are routinely hampered by inherent vehicle constructs: the roof posts obstructing the field of view, soundproofing materials hampering auditory input, and stabilizing mechanisms mitigating road vibrations. As a driver advances in experience, these constructs are incorporated into the overall safe use of the vehicle. However today, two common driver-imposed distractions are posing serious threats to on-the-road safety: cell phone use and texting (which includes use of any type of tactile messaging system such as Twitter or Facebook messaging) while driving. The overarching problem is that the driver removes attention from the road, while the vehicle remains in motion during these distractions.

Cell phone use during driving necessitates temporary loss of attention and, if making a call, full control of the wheel. In 2008, this practice was estimated to account for up to 22% of vehicular crashes;1 in fact, 75% of adults and 52% of teens have admitted to talking on cell phones while driving.2–5

Texting is a related technology that further compromises the driver. The first text message was sent December 1992,6 and as technology advanced, total use steadily rose. However, not until the marriage of this technology and ubiquitous social adoption did a dramatic increase of overall texting occur. Pew Research Center studies reveal that the median number of teen texts per day is 50, and a third of teens text more than 100 times per day. In comparison with cell phone use while driving, 47% of adults and more than 50% of teens admit to texting while driving.3,5

According to the National Highway Traffic Safety Administration, motor vehicle crashes (MVCs) remain the Number 1 cause of death and disability for adolescents. Inexperience and distracted driving are common contributing factors for the teen driver involved in collisions, with statistics indicating that the highest incidence of collisions occurs within the first 6 months after licensure.7–10

Collisions caused by distracted driving have captured the attention of the US Government and professional medical organizations. In 2009 and 2010, Distracted Driving Summits took place in Washington, District of Columbia, and highlighted the dangers of distractions while behind the wheel. Although currently there are no federal laws regarding distracted vehicle operation, several states have implemented restrictions or bans on certain activities while driving. According to the Governors Highway Safety Association, 10 states and 3 territories prohibit all drivers from using cell phones while driving including California, Connecticut, Delaware, District of Columbia, Guam, Maryland, Nevada, New Jersey, New York, Oregon, Virgin Islands, Washington, West Virginia, while 32 states ban novice drivers from cell phone use, and 39 states, District of Columbia, Guam, and Virgin Islands ban text messaging for all drivers. The National Conference of State Legislatures reported in 2011 that legislators in 37 states considered 160 driver distraction bills. The importance of driver safety was also noted by the Oval Office when, on September 30, 2009, President Obama signed an executive order banning federal employees from texting while in government vehicles or while driving on official government business.10–14

Several organizations have also addressed distracted driving. The American College of Emergency Physicians advocates that teens should not text while driving, and the American Academy of Pediatrics recommended several physician actions to curb the increasing threats to teenage drivers, including discouraging distractions when driving. The Orthopaedic Trauma Association and American Academy of Orthopedic Surgery both endorse no texting while driving as well.15,16


MVCs remain the main source of morbidity and mortality in the United States, with distracted driving becoming an increasing source of injury in these circumstances. With the advent of certain technologies, namely cell phones and texting, this issue has been heightened. National attention has been focused on this new threat to public safety.

Questions to be Addressed

  1. What is the evidence that all distractions contribute to MVCs?
  2. What is the specific evidence that texting or cell phone use contributes to MVCs and affects vehicle control?
  3. Does driver experience mitigate MVCs caused by distractions?


A computerized search of the world’s literature was undertaken using PubMed, courtesy of the US National Library of Medicine. Key search words used were: texting and/or distraction + driving during the time frame 2000 to 2013. This time frame was used because there is strong evidence to suggest that during this period, the penetration of wireless devices exceeded 50% of the US population.17 State legislation that aimed at addressing the dangers of this technology was also introduced during this time frame.11–15,18

Initial computerized search identified 39 citations. The abstract for each citation was reviewed, and 33 candidate articles having possible applicability to the guideline topic were retrieved. Each article was further scrutinized to ensure topic focus by the authors of this evidence-based review (EBR). General reviews, letters to the editor, single-case reports, and retrospective reviews of poor quality were excluded, providing 19 articles with sufficient merit to form the basis for this EBR.

The articles were reviewed in detail by the authors, and the attached tables were then created (Tables 1– 3).

Distracted Driver Reviewed Articles—Distractions Contribute to MVCs
Distracted Driver Reviewed Articles—Cell Phone and Texting Contribute to MVCs
Distracted Driver Reviewed Articles—Younger Inexperienced Drivers’ Use of Cell Phones and Texting Contribute to MVCs


Level II

  • – All drivers should minimize all in-vehicle distractions while on the road.
  • – All drivers should not text or use any touch messaging system (such as Facebook or Twitter) while driving.
  • – Younger, inexperienced drivers should not use cell phones, text, or use any touch messaging system while driving because they are at increased risk for death and injury caused by distractions while driving.


The development of these guidelines greatly benefited from peer-reviewed published analyses of national databases. The three most uniformly used were the Fatality Analysis Reporting System (FARS), the National Automotive Sampling Systems General Estimate System (GES), and the National Motor Vehicle Crash Causation Survey. FARS is a census of all fatalities associated within 30 days of a crash; sources include police reports, death certificates, hospital medical records, and coroners’ reports. GES uses sampling techniques to extrapolate trends using police-reported crashes, and National Motor Vehicle Crash Causation Survey consists of on-the-scene investigation of more than 6,000 crashes.

The most comprehensive analysis of precrash behavior was undertaken in the 100-Car Naturalistic Driver Study by Dingus in 2006. Analysis of this robust database found that more than 23% of drivers experienced some form of distraction while driving. Drowsiness, tasks requiring greater than two glances away from the road, or greater than two button presses significantly increased crash/near-crash risk with odd ratios of 38.7, 26.4, and 2.3, respectively.19

Reviewed articles fell again into two categories: the first reviewed individual data, either in simulated environments or in surveys, and the second group considered database analysis. The findings of the former showed that distraction is prevalent in significant driving injuries and that level of distraction affects younger drivers more specifically.20–33 The second group correlated distraction and driver crashes as well as providing a near-linear relationship with fatalities and texting volume from 1999 to 2008.34–38 These articles were then subdivided into groups that addressed each of the three following questions posed in this EBR:

What Is the Evidence That All Distractions Contribute to MVCs?

In a study involving digital photography of New Jersey Turnpike drivers, 4% of nonspeeding and 3.4% of speeding drivers showed evidence of distraction.37 The most common distraction noted was cell phone use. Donmez et al.23 found visual distraction more detrimental than auditory distractions in their 2006 study of mitigation strategies, as well as a marginal increase in erratic steering and delayed braking. These results, however, only hint at the true danger of distracted driving. More than 30% of drivers admitted that distraction caused an accident severe enough to have them hospitalized.29 Driver distraction was found to contribute to more than 13% of all crashes29 and recently accounted for nearly 6,000 deaths per year.30,34 A recent electronic survey found distracted drivers to make up 72% of the population and distractions were causative in 9% of crashes.32 It was found that distracted drivers were less likely to pick up inherent dangers on the road, posing a potential increase to injury and death because of distractions.32

What Is the Specific Evidence That Texting or Cell Phone Use Contributes to MVCs and Affects Vehicle Control?

A recent survey found that 40% of adults used a cell phone at least a “few times per week” while driving.21 A similar study of high school drivers found that 79% had “ever” used a cell phone while driving and 48% had either placed or answered a call during their most recent trip. In the same study, 71% had “ever” texted while driving, and 60% had either placed or answered a text during their most recent trip.35 While these studies do not indicate the relationship between cell phone use and decline in driving ability, they set the foundation for the prevalence of this potential distraction. Surprisingly, perceived detrimental aspects of cell phone use is not readily apparent to the driver, although driver performance profile is significantly affected by cell phone and texting.22,26 In young drivers, texting caused more than 0.5 seconds off-road glance, 50% more swerving, a 140% increase in missed lane changes, and a sixfold increase in crashes during simulated driving.24,25 Cell phone use while driving has also been shown to cause lane change frequency, mean speed, and an increase in the chance of being behind a slower vehicle, mimicking traffic conditions of congested traffic.21 This behavior is indicative of distracted driving, and such road deviations have been associated with an increase in motor vehicle collision rates. In a crash culpability analysis comparing crashes with and without cell phones, it was found that the risk of a culpable crash was increased by 70% when a cell phone was present. To help put into context the degree of distraction cell phone use while driving can cause, it was noted that drunk drivers had similar performance profiles to cell phone users.36 While drivers using their cell phones had delayed braking times and increased accident rates, intoxicated drivers were found to drive more aggressively, which constituted driving closer to the car in front of the driver, and applying the brake more forcefully.36 Although showing different driving patterns, it was found that both displays yielded comparable impairments. While most research has looked at the effects of cell phone calls or texts on the impairment of driving, it was found that driving with cell phone merely ringing interfered with normal driver performance.31 Compared with control, driving with a cell phone ringing showed significant prevalence of road infractions, including a greater frequency of pedestrian collisions and speed exceedances,31 suggesting that drivers should keep their phones turned off while driving.

Does Driver Experience Mitigate MVCs Caused by Distractions?

A study of drivers younger than 20 years found that crashes were a result of lack of adherence to routine safe practices and failure to recognize clear dangerous situations.27 Perception is key to novice driver crashes. Atchley et al. underscored this in their work with students: 92% “ever texted” while driving, 70% believed that they could easily text without looking, and a majority felt texting was “more dangerous” than cell phone use while driving. These perceptions led to some dramatic outcomes: teen drivers were more likely to be involved in rear-end collisions, experience more severe injuries, and be responsible for severe injuries to passengers.28,38 Stravrinos et al.33 found that young or novice drivers were significantly affected by both cell phone calls or texting, compared with their baseline in simulated highway driving.

Study Limitations

This EBR was undertaken to answer the three questions generated; however, there are limitations. First, most published studies were retrospective, database analyses, and their results can be regarded as less than optimal. Second, some articles were based on self-reporting and/or questionnaires and therefore pose potential threats to their internal validity. Also noteworthy is that because of the nature of this research, many empirical studies were conducted using driving simulators. While the quality of simulation has improved, these results may not be indicative of real driving behavior, as driving in a simulator lacks generalizability compared with distracted driving on the road.


Competent driving involves dedicated attention to road conditions using all senses; dangerously, both the novice and the distracted drivers fail to appreciate their responsibility. Elimination of distraction is key to preventing further mortality. Data from this EBR suggest the following key points:

  • A. Driver distractions contribute significantly to MVCs across all age groups.
  • B. Cell phone use and texting cause significant distraction to motorists across the population. Their ubiquitous use in society has increased their role in MVCs.
  • C. Novice and teen drivers are less prepared to deal with the demands of driving; their use of cell phones while driving and subsequent morbidity and mortality are therefore higher than other groups of drivers.


Further investigation and emerging technologies will assist in our understanding of working models for injury prevention. These technologies will come in the form of hands-free vehicle communication technologies, early warning systems for drivers, improved vehicle parameters, and community education.

Prevention programs and legislation directed toward decreasing distracted driving will need to carefully scrutinized for overall impact. Ultimately, public awareness and emphasis from trauma organizations on distracted driving may prevent further harm.


L.E.L., K.A., J.B., M.B., S.S., and A.S. conducted the literature search. L.E.L., K.A., J.B., M.B., and S.S. collected the data. L.E.L., K.A., J.B., M.B., S.S., and W.G. performed the data analysis. L.E.L., K.A., J.B., M.B., S.S., and W.G. wrote the manuscript. L.E.L., A.H., and A.S. contributed to critical revision.


The authors declare no conflicts of interest.


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Distraction; driver; motor vehicle

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