INTRODUCTION Throughout the United States, innumerable individuals and organizations have worked to promote motor vehicle occupant protection for children, youth, and young adults, ages 16 to 20.* In spite of the great strides made, thousands of young people, from newborns through age 20, continue to die or experience serious injuries that could have been prevented had they been properly restrained in a child safety seat, booster seat, or safety belt. The National Highway Traffic Safety Administration (NHTSA) has developed this booklet to provide information supporting the ongoing need for legislative, enforcement, education, and public awareness activities promoting occupant protection for children, youth, and young adults ages 16 to 20. Collectively, this information illustrates the national imperative for addressing motor vehicle crashes as the leading cause of death and injury for children and youth in the United States. As a resource for occupant protection advocates, this booklet focuses on passenger vehicles. The majority of data in this fact book is from 2002, which was the latest year available when it went to press. This booklet also includes data from NHTSA"s 2003 Motor Vehicle Occupant Safety Survey (MVOSS). The National Scope of Motor Vehicle Crashes In 2002, police filed reports on an estimated 6.3 million traffic crashes. The police reports indicated that approximately 2.9 million people were injured, 42,815 people were killed, and property damage was sustained in an estimated 4.3 million of these crashes. The economic cost of motor vehicle crashes (police-reported and nonreported crashes) that occurred in 2000 totaled $230.6 billion. When vehicle occupants did not wear safety belts, the potential costs increased because unbelted crash victims sustained more severe injuries and more fatalities than belted crash victims. Belted crash victims average 60% to 80% lower hospital costs than unbelted crash victims. In 2002, a total of 17,651 (54%) of passenger vehicle occupants who were killed in a crash were reported not to have used a safety belt or child safety seat. How to use This Occupant Protection Booklet The facts contained in this booklet can be used to develop speeches and presentation materials, public information and education materials, backgrounders and news releases for the media, and to promote the use of occupant restraints in conjunction with law enforcement officials. Black-and-white duplicates of many of the charts are included in the back pocket of the original booklet for use as overheads or to support materials developed for local and State use. States and local communities have an important role to play in creating a national norm that makes it unacceptable to ride unrestrained in a motor vehicle. Our goal must be to make occupant restraint use a lifelong habit for all citizens. The booklet is divided into three main sections. The first section presents general information on the need for and importance of promoting occupant restraint use for children, youth, and young adults ages 16 to 20. Most of the data and discussion in the document refer to these groups according to the following ages: Children: newborns through 3 years of age and 4 through 7 years of age Youth: 8 through 15 years of age (15-year-olds, however, are sometimes included as young drivers.) Young adults: 16 through 20 years of age The next section provides occupant protection facts specific to children and youth, followed by facts for young adults. The last section includes survey findings from NHTSA"s 2003 Motor Vehicle Occupant Safety Survey on self-reported behavior, attitudes, and opinions about safety belt use and laws. This biennial telephone survey measures consumers" attitudes and opinions about occupant protection. Important Definitions As you review the data that follow, keep in mind the following definitions: Crash: An event that produces injury and/or property damage, involves a motor vehicle in transport, and occurs on a roadway or while the vehicle is still in motion after running off the roadway. Fatal Crash: A police-reported crash involving a motor vehicle in transport on a roadway in which at least one person dies within 30 days of the crash. (This includes the deaths of individuals who were not in a motor vehicle, such as pedestrians and bicyclists.) Injury Crash: A police-reported crash involving a motor vehicle in transport on a roadway in which no one died but at least one person was reported to have (1) an incapacitating injury, (2) a visible but not incapacitating injury, (3) a possible but not visible injury, or (4) an injury of unknown severity. Passenger Vehicles: Motor vehicles used for carrying passengers, including all passenger cars, SUVs, light trucks, and vans (including 15-passenger vans). Light trucks (under 10,000 lbs.) also include truck-based station wagons. Motorcyclists, buses, and large trucks are not included in this category. *Children, youth, and young adults within the age range of 0-20 years old are included in this booklet. When describing the age categories, the phrases "to" or "through" or the use of a dash (-) are used interchangeably and are equivalent in meaning. In all cases, both the lower and upper age are included in the category (i.e., 4 to 7, 4 through 7, and 4-7 all represent children of ages 4, 5, 6 and 7). THE NEED TO PROMOTE OCCUPANT RESTRAINT USE FOR CHILDREN, YOUTH, AND 16-20 YEAR OLDS The use of occupant restraints must be reinforced at an early age to reduce the disproportionately high rates of death and injury that young adults ages 16 to 20 experience in motor vehicle crashes. But parents cannot bear the burden by themselves. In communities across the country, health professionals, law enforcement officers, educators, elected officials, and every adult, not just parents, must develop the social and legal infrastructures necessary to make safety belt use a lifelong habit. Passenger vehicle occupant fatality and injury rates have declined slightly during the past 10 years. However, thousands of children through age 20 continue to be killed and injured in motor vehicle crashes. A total of 7,410 children and youth from birth to age 20 were killed and approximately 730,000 were injured in passenger vehicle crashes in 2002. Despite widespread public education campaigns promoting the use of proper occupant restraints, nearly 50% of children 4 to 7 years of age and 55 percent of children 8 to 15 years of age who were killed in passenger vehicle crashes in 2002 were unrestrained. Adult Safety Belt Use Makes a Difference Research conducted by NHTSA about national occupant protection use from 1991 to 2001 confirms that there is a strong positive correlation between the restraint use of an adult driver and that of young children in the vehicle. Among fatally injured children from birth to 15 years of age, the research revealed the following: The probability of being unrestrained was nearly four times greater for infants and toddlers when the child was with an unrestrained driver, versus being with a restrained driver. When drivers were unrestrained, 68% of children up to 3 years of age were also unrestrained; conversely, when a driver was wearing a safety belt, 28% of children up to 3 years of age were unrestrained. Among fatally injured passengers ages 4 to 7, 84% were unrestrained when the driver was unrestrained; conversely, when the driver was wearing a safety belt, 36% of children ages 4 to 7 were unrestrained. Among fatally injured child passengers 8 to 15 years old, 91% were unrestrained when the driver was unrestrained. Conversely, when the driver was wearing a safety belt, 46% of children 8 to 15 were unrestrained. This strong acknowledgment of the effect of parental influence on safety belt use speaks to the necessity of maintaining ongoing programs and outreach for children, youth, and parents to encourage the use of occupant restraints. NHTSA"s 2003 Motor Vehicle Occupant Safety Survey (MVOSS) further illustrates this need. In the 2003 MVOSS, researchers asked respondents their level of agreement with the statement, "I have a habit of wearing a seat belt because my parents insisted I wear them when I was a child." Among persons 16 to 24 years of age, 69% either strongly agreed or somewhat agreed with this statement. Occupant Restraints for All Age Groups Save Lives Most of the people who die in motor vehicle crashes are vehicle occupants (less than one-fourth of fatalities caused by crashes involve pedestrians, bicyclists, and motorcyclists). Safety belts and child safety seats have been designed to protect drivers and passengers from death and injury during a crash. But these restraints cannot save lives if they are not used. In 2002, among passenger vehicle occupants over 4 years old, safety belts saved an estimated 14,164 lives. Child restraints saved the lives of 376 children. From 1975 to 2002, safety belts prevented an estimated 164,753 fatalities. According to NHTSA"s The Economic Impact of Motor Vehicle Crashes 2000, the use of safety belts saved society $585 billion in medical care, lost productivity, and other injury-related economic costs (since 1975). Child safety seats are 71% effective in reducing fatalities among infants (younger than 1 year old) and 54% effective for toddlers (1 to 4 years old) in passenger cars. For infants and toddlers in light trucks, the effectiveness in reducing fatalities is 58% and 59%, respectively. Booster seat use substantially reduces the risk of injury for children 4 to 8 years old; however, most children in this age group are currently restrained by safety belts designed for adults. A recent study by Children's Hospital of Philadelphia found that the use of belt-positioning booster seats lowers the risk of injury to children in crashes by 59%, compared with the use of vehicle safety belts. When lap/shoulder safety belts are used properly, they reduce the risk of fatal injury to front-seat occupants riding in passenger vehicles by 45% and the risk of moderate-to-critical injury by 50%. For light-truck front-seat occupants, safety belts reduce the risk of fatal injury by 60% and the risk of moderate-to-critical injury by 65%. Ejection from the vehicle is one of the most harmful events that can happen to a person in a crash. In passenger vehicle crashes in which someone died in 2002, 73% of occupants who were completely ejected were killed. Safety belts are effective in preventing total ejections. In 2002, in crashes in which someone was killed, only 1% of the occupants reported to have been using restraints were totally ejected, compared with 30% of unrestrained occupants (in passenger vehicles). Nearly 30% of 16- to 20-year-old occupants were killed when they were ejected during a crash, compared with 22% of the general population. This increased percentage for 16- to 20-year-old occupants further illustrates the need to promote safety belt use in this age group. Closing the Gaps in Occupant Restraint Laws Can Save Young Lives All States (except New Hampshire) have adult safety belt laws and all States have child restraint laws requiring the driver to restrain children of specified ages in approved child restraint devices or safety belts. These laws, however, do not cover all occupants in all seating positions. In the majority of States, laws concerning the use of child restraint devices cover children only up to age 4, and laws concerning the use of adult safety belts cover only front-seat occupants, leaving large groups of children uncovered by any occupant protection law. For example, in some States, a 10-year-old can ride legally in the back seat without being secured because, at this age and in this seating position, the child is not covered by either the child restraint law or the safety belt law. Appendix C contains information on State child restraint laws. Primary Enforcement Laws Help Protect Children of All Ages Although child restraint laws are primary laws, which allow a law enforcement officer to stop a vehicle and issue a citation for an unrestrained driver or passenger, the safety belt laws in the majority of States are secondary enforcement laws. This means that a police officer cannot stop a driver for the sole purpose of enforcing the use of occupant restraints. Rather, a police officer can write a ticket for not using occupant restraints only if he or she stops the vehicle for another driving infraction. Booster Seat Use Saves Lives and Reduces the Risk of Injury: In 2002, only 33% of 4- to 7-year-old passenger vehicle occupants who were killed in crashes were restrained. Persuading parents to place their children in any kind of occupant restraint would undoubtedly reduce the number of children killed or seriously injured. In addition, children who have outgrown child safety seats, but are too small to ride safely in adult belts, should be properly restrained in booster seats until they are at least 8 years old, unless they are 4 feet 9 inches tall. If placed in adult safety belts prematurely, children can suffer serious internal injuries, slip out of the safety belt, or be ejected from the vehicle during a crash. Booster seat use substantially reduces the risk of injury for children 4 to 8 years old; however, most children in this age group are currently restrained by safety belts designed for adults. In the 2002 study by Children's Hospital of Philadelphia (CHOP), only 16% of 4-year-olds, 13% of 5-year-olds, and 4% of 6- and 7-year-olds were using booster seats. The CHOP study found that the use of belt-positioning booster seats lowers the risk of injury to children in crashes by 59% compared with the use of vehicle safety belts. The study also found that none of the 4- to 7-year-olds who were in belt-positioning booster seats had any injuries to the abdomen, neck, spine, or back. Yet, such injuries did occur in children who used safety belts alone. Children who are 4 feet 9 inches tall before their eighth birthday may be ready for adult belts. They can start using a safety belt when they can place their back firmly against the vehicle seat back cushion with their knees bent over the vehicle seat cushion. When this booklet was published, 26 States and the District of Columbia had enacted provisions in their child restraint laws mandating booster seat or appropriate restraint use for older children passengers. They are AR, CA, CO, DE, DC, GA, IA, IL, IN, LA, ME, MD, MT, NE, NH, NJ, NV, OK, OR, PA, RI, SC, TN, VA, VT, WA, and WY. A number of other States are considering legislation that would require similar upgrades for booster-age child passengers. FACTS ABOUT CHILDREN AND YOUTH Children and youth from birth to age 14 represented 21% of the U.S. population, according to the U.S. Census Bureau"s 2002 American Community Survey. Motor vehicle crashes are the leading cause of death for children 2 years of age, and for people of every age from 4 to 34 years old. Although the fatality rate has decreased, the total number of child occupant deaths is still high. This is due to population increases and a near doubling, over the past 20 years, of the number of miles Americans travel on our Nation"s highways. Facts About Restraint Use: In 2002, the use of child restraints saved an estimated 376 lives. Of the 459 occupant fatalities among children from birth through age 4 in 2002, nearly 40% were completely unrestrained. During 2002, a total of 1,785 children from birth through age 15 were killed in passenger vehicle crashes. Approximately 54% of passenger vehicle occupants in this age group were unrestrained. The breakdown by age group was as follows: 40.4% of children from birth through age 4 were unrestrained. 48.6% of children ages 5 through 9 were unrestrained. 62.3% of children ages 10 through 15 were unrestrained. If 100% of motor vehicle occupants younger than age 5 had been protected by child safety seats, an estimated 485 lives (an additional 109 lives) could have been saved in 2002. From 1975 through 2002, an estimated 6,567 lives were saved by the use of child restraints (child safety seats or adult belts). In most age groups (except the youngest and the oldest) a greater percentage of occupants who were killed, were not restrained. Unfortunately, being properly restrained cannot prevent all passengers from being fatally injured, especially in certain high impact crashes. However, a certain percentage of occupants in all age groups would not have been killed had they been properly restrained. There is a significant decrease in restraint use among the 5-9, 10-15, and 16-20 age groups (when compared to the 0-4 age group). This decrease in restraint use illustrates the critical need for public information and education about the importance of restraint use, along with the need for ongoing enforcement of existing laws.  (See the following chart for details.) Occupant Fatalities in 2002 Age Group Restrained % Restrained Unrestrained % Unrestrained Total Total % 0-4 274 59.6% 185 40.4% 459 100% 5-9 205 51.4% 195 48.6% 400 100% 10-15 350 37.7% 576 62.3% 926 100% 16-20 1,999 35.5% 3,626 64.5% 5,625 100% 21-24 1,199 32.6% 2,477 67.4% 3,676 100% 25-44 3,232 32.7% 6,656 67.3% 9,888 100% 45-64 2,947 46.8% 3,353 53.2% 6,300 100% 65-74 1,253 58.5% 887 41.5% 2,140 100% 75+ 1,983 63.9% 1,122 36.1% 3,105 100% Total 13,448 41.4% 19,071 58.6% 32,519 100% Keep in mind that even with the use of occupant restraints: Some crashes are so severe that occupants do not survive even when properly protected by a child safety seat, booster seat, or safety belt. There are instances in which the effectiveness of a child restraint or safety belt is compromised by incorrect use, e.g., improper installation or use of a child safety seat, placing a child in an adult belt. Occupants in the youngest age group, 0-4 and oldest age groups, 65-74 and 75+, are more fragile. Therefore, they are more vulnerable to death or a serious injury when in a crash. In many States, there is no law requiring the use of an appropriate occupant restraint (booster seat) for children who have outgrown their child safety seat. As a result, many young children are inappropriately placed in adult belts. Facts About Motor-Vehicle-Related Deaths and Injuries: Based on the 10-year period between 1993 and 2002, an average of 1,998 children from birth to 15 years of age died and 299,195 were injured in passenger vehicle crashes each year. In 2002, an average of 5 children from birth through age 15 were killed and 693 were injured every day in motor vehicle crashes. In 2002, a total of 1,785 children ages 15 and younger were killed and 253,000 were injured in passenger vehicle crashes. Eleven percent of the injured occupants had incapacitating injuries. In 2002, there were 459 passenger vehicle occupant fatalities and 59,000 occupants injured among children ages 4 and younger. In 2002, there were 1,326 passenger vehicle occupant fatalities and 195,000 occupants injured among children ages 5 through 15. In 2002, more than 80,000 children, youth, and young adults from birth to age 20 suffered incapacitating injuries in passenger vehicle crashes. Occupants killed or injured in 2002 Age Groups Killed Incapacitating* Non-incapacitating Possible Injury Injury Severity Unknown Total Injured Total 0-4 459 6,588 15,552 35,602 783 58,525 58,984 5-9 400 7,038 21,807 42,822 758 71,705 72,105 10-15 926 12,569 34,745 74,536 1,062 122,912 123,838 16-20 5,625 56,053 149,645 266,200 4,167 476,065 481,690 21-24 3,676 35,973 89,255 166,955 3,302 295,525 291,201 25-44 9,888 99,504 227,077 595,110 7,912 929,603 939,491 45-64 6,300 57,286 118,747 343,343 3,711 523,087 529,387 65-74 2,140 13,343 32,042 65,376 391 111,152 113,292 75+ 3,105 14,604 28,096 49,983 422 93,105 96,210 Total 32,519 302,957 716,246 1,639,968 22,507 2,681,678 2,714,197 *An incapacitating injury is any injury, other than a fatal injury, that prevents the injured person from walking, driving, or normally continuing the activities the person was capable of performing before the injury occurred. FACTS ABOUT YOUNG ADULTS AGED 16-20 YEARS OLD In 2002, young people ages 16 to 20 years old made up approximately 6.4% (12.5 million) of the 194.3 million licensed drivers in the United States. The estimated economic cost of police-reported crashes involving drivers between the ages of 15 and 20 was $40.8 billion in 2002. This cost represents approximately 18% of the $230 billion a year that police-reported traffic crashes cost our society. In short, young people represent less than 7% of the drivers but are responsible for 18% of the costs of traffic crashes. In addition to the disproportionate "harm" that 16- to 20-year-old drivers experience from motor vehicle crashes, consider the following additional "costs" for young drivers and passengers: Motor vehicle crashes are the leading cause of death for young adults ages 16 to 20. Young adults between the ages of 16 and 20 are more likely to be killed and injured in motor vehicle crashes than children and youth from birth to age 15. In 2002, of the 7,410 children, youth, and young adults from birth through age 20 who were killed in motor vehicle crashes, 76% were 16 to 20 years old; of the 729,207 injured from birth to age 20, 65% were 16- to 20-year-olds. Although young drivers made up approximately 7% of the total licensed driving population, in 2002, 15% (3,448) of all the drivers involved in fatal crashes were young drivers 15 to 20 years old, and 16% (310,000) of all the drivers injured in police-reported crashes were young drivers. During 2002, a young person died in a traffic crash an average of once every hour on weekends (weekends are defined as 6 p.m. on Friday through 5:59 a.m. on Monday) and nearly once every 2 hours during the week. Young adults who are 16 to 20 years old are most likely to be killed or injured when riding in passenger vehicles (as opposed to other motor vehicles). In 2002, a total of 1,915 16- to 20-year-olds were killed when totally or partially ejected from a passenger vehicle. In 2002, the fatality rate in motor vehicle crashes for 16- to 20-year-olds was approximately twice the rate for all ages. Facts About Safety Belt Use: More than 60% of the 5,625 young adults ages 16 to 20 who were killed when riding in passenger vehicles in 2002 were not wearing safety belts. In 2002, approximately 60% of the 3,448 drivers in the 16- to 20-year-old age group who were killed in passenger vehicle crashes were not wearing safety belts. Young drivers are less likely to use restraints if they have been drinking alcohol. In 2002, of the young drivers who had been drinking and were killed in crashes, 77% were unrestrained. Facts About Motor-Vehicle-Related Deaths and Injuries: In 2002, 16- to 20-year-old drivers had the highest fatality and injury rates per 100,000 licensed drivers. In fact, the fatality rate for young drivers was about three times the rate for drivers 25 to 64 years old. In 2002, an estimated 56,053 young adults experienced incapacitating injuries. This number represents approximately 18% of all (302,957) incapacitating injuries. In 2002, an estimated 149,645 young adults experienced nonincapacitating injuries. This number represents approximately 21% of all (716,246) people with nonincapacitating injuries. Despite a small improvement in safety belt use for 16- to 20-year-old drivers, the percentage of fatalities in which the driver was not wearing a safety belt has remained more than 60% for the past 10 years. Drivers ages 16 to 20 have the highest involvement rates for fatalities and injuries in passenger vehicle crashes. This is especially true for male drivers in this age group. Self-Reported Behavior, Attitudes, and Opinions on Safety Belt Use: The following information was reported in NHTSA"s 2003 Motor Vehicle Occupant Safety Survey. This telephone survey was administered to a randomly selected national sample of 6,000 persons ages 16 and older (with younger ages over sampled). Safety Belt Use Behavior: Most (79%) 16- to 20-year-olds reported that they wear their safety belts all of the time. An estimated% reported that they wear their safety belts most of the time. Most (87%) 16- to 19-year-olds reported that when they were not driving, they rode in the front seat of the vehicle. However, only 49% said that they always wore their safety belt when riding as a passenger in the back seat, while 14% said they never wore their safety belts when riding in the back seat. One-fourth (25%) of 16- to 20-year-olds reported that their use of safety belts when driving had increased in the past 12 months. (An estimated 2% indicated a decrease, while 73% indicated that use had stayed the same.) Attitudes Toward Safety Belt Use: Among persons 16 to 24 years of age, 69% either strongly (51%) or somewhat (18%) agreed with the statement, "I have a habit of wearing a seat belt because my parents insisted I wear them when I was a child." The number dropped to 44% among persons ages 25 to 34 and to 26% among persons ages 35 to 44, reflecting the lower usage rates during their childhood years. The vast majority of the public ages 16 and older either strongly agreed (88%) or somewhat agreed (7%) with the statement, "If I were in an accident, I would want to have my seat belt on." However, about one-half (47%) of 16- to 24-year-olds agreed with the statement, "Seat belts are as likely to harm as to help." About one in five persons (19%) either strongly (13%) or somewhat (6%) agreed with the statement, "I would feel self-conscious around my friends if I wore a seat belt and they did not." However, more than one in four (27%) of 16- to 24-year-olds strongly or somewhat agreed with this statement. Injury avoidance was the most frequent reason given for wearing a safety belt. The most common reasons given by drivers from the 16- to 20-year-old age group for not wearing safety belts were that they forgot or were driving a short distance. Thirty percent of 16- to 24-year-olds agreed with the statement that a crash close to home was usually not as serious, and 27% agreed that putting on a safety belt makes them worry more about being in a crash. Opinions About Safety Belt Use Laws: When asked whether they favor front safety belt laws, 66% of 16- to 20-year-olds said they favor them "a lot" and 26% said they favor them "some." Many (64%) 16- to 20-year-olds answered "yes" when asked whether police should be allowed to stop a vehicle if they observe a safety belt violation when no other traffic laws are being broken. Many (65%) 16- to 20-year-olds favored fines for drivers who do not wear safety belts. Almost half (42%) of 16- to 20-year-olds favored points against a license as a penalty for safety belt violations.