driving during alcohol hangover among dutch professional truck drivers
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Driving During Alcohol Hangover Among DutchProfessional Truck DriversJoris C. Verster a b , Martin A. Van Der Maarel a , Adele McKinney c , Berend Olivier a & LydiaDe Haan aa Division of Pharmacology , Utrecht Institute for Pharmaceutical Sciences, UtrechtUniversity , Utrecht , The Netherlandsb Centre for Human Psychopharmacology , Swinburne University , Melbourne , Victoria ,Australiac School of Psychology, Magee Campus , University of Ulster , Derry , Northern IrelandAccepted author version posted online: 16 Aug 2013.Published online: 28 Mar 2014.
To cite this article: Joris C. Verster , Martin A. Van Der Maarel , Adele McKinney , Berend Olivier & Lydia De Haan (2014)Driving During Alcohol Hangover Among Dutch Professional Truck Drivers, Traffic Injury Prevention, 15:5, 434-438, DOI:10.1080/15389588.2013.833329
To link to this article: http://dx.doi.org/10.1080/15389588.2013.833329
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Traffic Injury Prevention (2014) 15, 434–438Copyright C© Taylor & Francis Group, LLCISSN: 1538-9588 print / 1538-957X onlineDOI: 10.1080/15389588.2013.833329
Driving During Alcohol Hangover Among DutchProfessional Truck Drivers
JORIS C. VERSTER1,2, MARTIN A. VAN DER MAAREL1, ADELE MCKINNEY3, BEREND OLIVIER1,and LYDIA DE HAAN1
1Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands2Centre for Human Psychopharmacology, Swinburne University, Melbourne, Victoria, Australia3School of Psychology, Magee Campus, University of Ulster, Derry, Northern Ireland
Received 25 June 2013, Accepted 6 August 2013
Objectives: Alcohol hangover may impair potentially dangerous daily activities such as driving a car or operating heavy machinery.The purpose of the present study was to determine (1) whether driving during alcohol hangover is a problem of concern amongprofessional Dutch truck drivers and (2) to what extent they think their hangover state affects driving performance.
Methods: Three hundred forty-three professional truck drivers were interviewed at a Dutch trucker festival. In addition to demo-graphics, data were gathered on normal driving, alcohol consumption and hangover, and driving style during alcohol hangover.
Results: More than half of the professional drivers who consume alcohol and report occasionally having a hangover (56.4%)acknowledge that they have driven while having a hangover during the past year: 26.5 percent only when driving private, 2.6 percentonly when driving professionally, and 27.4 percent both private and professionally. Additionally, 45.3 percent reported driving whilehaving a hangover sometimes, whereas 7.7 percent and 1.7 percent reported doing so often or always, respectively. During alcoholhangover, professional drivers rated their driving style as significantly less relaxed, less safe, and less responsible (P < .001).
Conclusions: Driving with a hangover is a common phenomenon, and professional drivers acknowledge that their driving isimpaired. Therefore, future experimental research should examine the magnitude of impairment while driving with an alcoholhangover.
Keywords: driving, hangover, alcohol, professional drivers
Introduction
Alcohol hangover—that is, the general misery experienced theday after an evening of heavy drinking—is the most com-monly reported consequence of excessive alcohol consump-tion (Verster et al. 2009). There is no clear definition of thehangover state, which is characterized by several symptoms,including headache, tiredness, concentration problems, thirst,dizziness, nausea, cognitive impairment, and mood changes.A recent factor analysis (Penning et al. 2012) revealed that28 percent of overall hangover severity was explained by afactor called “drowsiness,” which included symptoms such asfatigue, sleepiness and weakness. The factor “cognitive prob-lems,” which included symptoms such as reduced alertness,memory, and concentration problems, explained 5.9 percentof the variance. Other symptoms/factors were less importantcontributors to hangover severity. Symptoms are most severe
Managing Editor David Viano oversaw the review of this articleAddress correspondence to Joris C. Verster, PhD, Utrecht Uni-versity, Utrecht Institute for Pharmaceutical Sciences, Divisionof Pharmacology, Universiteitsweg 99, 3584 CG Utrecht, TheNetherlands. E-mail: [email protected]
when the blood alcohol concentration (BAC) returns to zero,and the hangover state may last up to 20 h after alcohol con-sumption (Verster et al. 2010).
The causes of alcohol hangover are still unknown. Analy-ses of blood and urine samples revealed that concentrations ofvarious hormones, electrolytes, free fatty acids, triglycerides,lactate, ketone bodies, cortisol, glucose, and biomarkers of de-hydration such as vasopressin were not significantly related tohangover severity (Penning, van Nuland, et al. 2010). Whereassome findings suggest a role of acetaldehyde in developinga hangover, most convincing data suggest a relationship be-tween immune factors and hangover severity, because effectson cytokine production have shown to correlate with hang-over severity (Kim et al. 2003). More research is needed toexamine the pathology of alcohol hangover. Of interest, andstill unexplained, about one in 5 drinkers reports having nohangovers (Howland et al. 2008).
Given that the pathology of alcohol hangover is not yetelucidated, no effective treatments are available that preventor cure hangovers (Pittler et al. 2005; Verster and Penning2010). Many people experience next-day hangover symptomssuch as reduced alertness, apathy, and nausea, which may havea negative impact on performing daily activities. Given thelarge variety of reported symptoms (Penning et al. 2012), it
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Hangover and Driving 435
is understandable that during the hangover state people donot feel and function optimally. Hence, alcohol hangoverscontribute to absenteeism, impaired on-the-job performance,reduced productivity, and poor academic achievement. Al-though only rough estimates exist, the socioeconomic conse-quences of alcohol hangover are high. It is therefore surprisingthat relatively little scientific attention has been paid to the al-cohol hangover (Verster et al. 2010).
It is likely that alcohol hangover may impair potentiallydangerous daily activities such as driving a car or operatingheavy machinery. Recent reviews on hangover effects on cog-nitive and psychomotor functioning concluded that severalskills and abilities related to driving may be impaired dur-ing alcohol hangover (Ling et al. 2010; Stephens et al. 2008;Verster 2007). For example, tests measuring divided attention,reaction speed, eye–hand coordination, and working mem-ory all have shown impairment during alcohol hangover, aswell as more complex tasks such as next-day simulated shippower plant operation (Rohsenow et al. 2006) and academictest-taking performance (Howland et al. 2010). Direct com-parison of the cognitive effects of acute alcohol (BAC 0.08%)with the morning after a normal night’s drinking (BAC 0%)show that the magnitude of the impairment was compara-ble (McKinney et al. 2012), implying that although BAC iszero, the magnitude of impairment during hangover shouldbe regarded as clinically relevant.
Surprisingly, up to now only 2 experimental studies haveexamined driving during alcohol hangover (Laurell and Torn-ros 1983; Tornros and Laurell 1991). The first study wasperformed on a closed road (Laurell and Tornros 1983). Par-ticipants had to perform 10 difficult driving maneuvers, with-out hitting cones that were placed at each side of the car.During hangover, performance of the task was significantlyimpaired. In a subsequent driving simulator study (Tornrosand Laurell 1991), participants were instructed to drive as fastas possible, taking the risk of collision on a hilly and curved cir-cuit. The simulator test indicated a significant hangover effectjust after waking up; a test later on the same day did not show asignificant effect. Although both studies showed performanceimpairment during alcohol hangover, the methodology of thestudies has been criticized (Verster 2007), in that it can be ar-gued that the tasks have little relevance to everyday driving(e.g., driving as fast as possible).
Data on how many people drive during hangover is scarce,but given that driving is a daily activity it can be assumed thatthe numbers are high. A recent Norwegian study among 526employees, including 126 professional drivers, suggested thatpeople do drive while experiencing a hangover (Gjerde et al.2010), including 126 professional drivers. Almost a quarterof respondents (24.3%) reported inefficiency or hangover atwork due to alcohol during the past year, and 6.2 percentreported being absent the day after alcohol consumption. Un-fortunately, because no distinctions were made between thedifferent professions of the respondents, it can only be specu-lated whether professional drivers have the same prevalence ofinefficiency and absence during alcohol hangover than otherexamined employees.
Given the limited information available on driving duringalcohol hangover, 2 research needs can be posed. First, it
should be established whether driving during hangover is in-deed a significant issue of concern. Second, more high-qualityexperimental research is needed to examine the effects of al-cohol hangover on driving performance. The purpose of thepresent survey was to determine (1) whether driving duringalcohol hangover is a problem of concern among professionalDutch truck drivers and (2) to what extent they view the hang-over state as affecting their driving performance.
Methods
A survey was conducted August 28, 2012, at a yearly festivalvisited by Dutch professional truck drivers. Two trained surveyteams from Utrecht University approached potential partici-pants and asked them whether they were willing to completethe survey. Response rate was not recorded, but the majorityof approached truck drivers were willing to complete the shortinterview. Participants were eligible to complete the survey ifthey acknowledged being a professional truck driver and atleast 18 years old. The Institutional Review Board reviewedthe study protocol. No formal medical ethics approval wasneeded to conduct this survey.
Demographics and data on normal alcohol consumptionwere collected. Weekly alcohol consumption was scored in cat-egories (0, 1–6, 7–14, 15–21, 22–42, >42 alcoholic beverages).
The survey included questions about their driving behaviorand driving history, both private and as a professional driver. Itwas then assessed whether, and how often, during the past yearthey had driven a truck while having a hangover. If answeredaffirmative, participants had to estimate the average numberof alcoholic drinks they consumed on evenings preceding thehangover and rate the severity of their hangover from 0 (ab-sent) to 10 (extreme). A modified version of the Driving StyleQuestionnaire (McCormick et al. 1987) was completed fordriving while having a hangover as well as for a normal sober(alcohol-free) driving day. Participants rated 4 dimensions oftheir driving style as professional drivers on bipolar scales,dangerous–safe, tense–relaxed, unpredictable–predictable,and irresponsible–responsible. They also compared their owndriving performance with that of the average driver. Scores onall scales of the driving style questionnaire ranged from −3 to+3, around a neutral midpoint of 0.
Results
Three hundred forty-three professional drivers completed thesurvey. Surveys with missing data on essential questions werenot included in the statistical analysis (N = 20). Also excludedfrom the analyses were surveys of drivers who never consumealcohol (N = 77) and surveys of drivers who did not answerhow often they have hangovers (N = 17). Most professionaldrivers who drink (N = 225) consumed moderate amounts ofalcohol: 1–6 alcoholic drinks per week (60.4%), followed by7–14 alcoholic drinks (22.6%) or 15–21 alcoholic drinks (8%).A minority (8.9%) consumed more than 21 alcoholic beveragesper week. One hundred seventeen professional drivers (52.0%)reported having had at least one hangover during the past
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Table 1. Demographics of drivers with and without past yearhangovers
Overall(N = 225)
Nohangovers(N = 108)
Hangovers(N = 117) P-value
Age 33.8 (11.2) 36.3 (11.2) 31.5 (10.7) .001∗
Professional drivingexperience (years)
12.6 (9.5) 14.7 (9.3) 10.7 (9.3) .001∗
Kilometers/year drivenprofessionally
127,934(82,686)
135,397(107,407)
121,495(52,594)
.249
Kilometers/year drivenprivately
16,550(22,519)
19,859(28,964)
13,612(14,127)
.059
Mean and standard deviation are shown.∗Differences are significant if P < .05.
year. The vast majority of respondents were men (95.6%).Demographics are summarized in Table 1.
On average, professional drivers reported consuming 8.5(7.1) alcoholic beverages on occasions that resulted in a hang-over. The average hangover severity on a 0 to 10 scale was2.73 (2.37) and correlated significantly with the number of al-coholic drinks consumed (r = 0.447, P < .001). More thanhalf of the professional drivers who consume alcohol and re-port occasionally having a hangover (56.4%) acknowledge thatthey have driven while having a hangover during the past year:26.5 percent only when driving private, 2.6 percent only whendriving professionally, and 27.4 percent both private and pro-fessionally. Additionally, 45.3 percent reported driving some-times on occasions when they have a hangover, whereas 7.7percent and 1.7 percent often or always drive when having ahangover, respectively. Drivers rated several aspects of theirdriving style for an average driving day (control day, no al-cohol consumed the day before) and the same questions foroccasions on which they drove while having a hangover (seeFigure 1). Figure 1 shows the mean scores for each driving stylequestion for both conditions. Drivers rated their scores relativeto 2 extremes (e.g., safe versus dangerous) around a neutralmidpoint, which was considered normal driving. Paired com-parisons showed that during alcohol hangover, professionaldrivers rated their driving style as significantly less relaxed,less safe, and less responsible (P = .001). The difference in rat-ings on predictable–unpredictable did not reach significance(P = .07).
Interestingly, the vast majority of professional drivers whoconsume alcohol and occasionally have hangovers (75.7%)view their driving style (when not having a hangover) as sig-nificantly better than that of the average sober professionaldriver (P = .0001). Even when they have a hangover, 48.4 per-cent of professional drivers view their driving style as signifi-cantly better when they compare themselves to their colleagueswithout a hangover (P = .0001; see Figure 2).
Discussion
This survey shows that driving while having a hangover isa common phenomenon that should not be underestimated.About half of professional drivers acknowledged driving dur-ing hangover during the past year, and many of them do so
Fig. 1. Self-reported driving style during hangover and afterdrinking no alcohol (sober). Driving style was rated relativeto 2 extremes, around a neutral midpoint, which was consid-ered normal driving, for (a) predictable–unpredictable, (b) safe–dangerous), (c) relaxed–tensed, and (d) responsible–irresponsible.∗Differences are significant if P < .05.
both when driving privately and professionally. Participantsaffirmed their driving style to be worse during alcohol hang-over in that it is significantly less safe, more unpredictable, andless responsible when compared to driving without a hangover.The magnitude of the differences in driving style ratings be-tween hangover and control days is relevant because it is com-parable to that reported in experimental settings testing the ef-fects of simulated driving after administering alcohol to reacha BAC of 0.05 percent (Mets et al. 2011) and in on-road drivingresearch testing the difference between untreated and treatedpatients with attention deficit hyperactivity disorder (Versteret al. 2008). Nevertheless, they acknowledge driving a car dur-ing hangover. Of further concern, the majority rated theirown driving style significantly better compared to the average
Fig. 2. Self-reported driving style when compared to the averagesober professional truck driver. Note that both with a hangoverand without a hangover (sober), drivers rated themselves as bet-ter than the average sober professional driver. ∗Differences aresignificant if P < .05.
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Hangover and Driving 437
sober professional driver, and almost half of them still be-lieve that this is true despite having a hangover. This confirmsprevious findings that drivers overestimate their own drivingperformance and can poorly estimate their actual driving im-pairment (McCormick et al. 1987; Verster and Roth 2012a).
Given the nature of the current study, there are several lim-itations that should be mentioned. First of all, all data areself-reported. This may imply the risk of some inaccuracy bythe interviewed truck drivers and recall bias may have playeda role. Because all participants were anonymous and inter-viewed individually, there is no reason to assume that sociallydesirable answering had an impact on the results. Second, be-cause truck drivers were interviewed on the spot, in their freetime at a truck festival the duration of the interview had to beshort. Therefore, we did not include extensive questions on de-mographics, nor did we include standardized questionnaireson alcohol and drug use. For example, we included a one-itemhangover score and not more elaborate scales asking for spe-cific hangover symptoms (Penning et al. 2013; Rohsenow et al.2007). To prevent dropouts, data collection was kept limited tothe core questions needed to enable answering the main studyobjectives.
Regarding the generalizability of the collected data, thesample should be regarded as a reflection of Dutch profes-sional truck drivers, because they were sampled randomly atthe largest Dutch festival for truck drivers. The outcome ofthis study may, however, be different if performed in othercountries with other cultures with different views and beliefsabout drinking and driving and alcohol hangovers.
The self-reported driving impairment during alcohol hang-over combined with the high frequency of being engaged inthis dangerous activity advocate for further research into thistopic. It is essential that the methodology of future experi-mental studies is sound, following state-of-the-art guidelinesconcerning the setup and design of the study (Verster et al.2010), and includes objective outcome measures of drivingperformance with relevance to actual driving and crash risk(Verster and Roth 2011). The latter is essential because theoutcome of several cognitive and psychomotor tests measur-ing driving-related skills and abilities showed poor correlationwith actual driving performance (Ramaekers 2003; Versterand Roth 2012b).
If future research confirms the self-report of professionaldrivers, this should become an important issue for policy mak-ers and others whose jobs are concerned with increasing traf-fic safety. There is a wealth of information on the percentageof drivers who have driven after alcohol consumption andthe magnitude of corresponding driving impairment (Pen-ning, Veldstra, et al. 2010), and public health campaigns havewarned and informed the general public repeatedly about therisks of driving while under the influence of alcohol. Hence,the vast majority of people do not drive while intoxicated andthe percentage of people who drink and drive has declined overthe last 25 years (Centers for Disease Control and Prevention2012). Regarding alcohol hangover and driving, preventioncampaigns do not exist. Moreover, people may wrongly con-clude that because they are allowed to drive a car when theirBAC is zero, this can be considered as safe. The fact that in thecurrent study about half of professional drivers felt that their
driving is still significantly better than that of their averagecolleague who has not consumed alcohol the night before un-derlines the necessity of driver education and the developmentof effective prevention programs.
It is difficult to develop legislation concerning driving dur-ing a hangover that can be easily enforced. That is, becauseBAC is generally zero during hangover, breath analyzers willbe useless to demonstrate whether a driver has a hangover ornot. There is no quick and reliable method to demonstratethe presence and severity of alcohol hangover assessed in thecontext of traffic safety, with the exception of self-report bythe driver.
Taken together, this survey confirms that driving duringhangover is a common phenomenon with potential risks tothe driver and other road users. Creating awareness amongthe general public of the potential negative effects of alco-hol hangover on driving is vital. At the same time, future re-search should focus on developing easy screening instrumentsto enable assessing biomarkers that indicate that drivers havea hangover. First, researchers should examine driving per-formance during alcohol hangover in experimental research.Preferably, the results would be compared to driving perfor-mance observed during alcohol intoxication in order to com-pare the magnitude of impairment during hangover with well-established cutoff points for safe driving (e.g., a BAC of 0.05%,which is the legal limit for driving in many countries).
Second, effective biomarkers are needed to confirm thehangover state in drivers. Potential candidates of biomarkersthat are capable of showing recent alcohol use when BAC iszero are ethyl glucuronide (EtG) and ethyl sulfate (EtS). How-ever, the presence of these biomarkers is generally tested inurine and not in saliva or sweat, which makes them less usefulfor onsite road testing. Industry should focus on developingbiomarkers of the hangover state and its severity. Most impor-tant, however, is to conduct experimental studies to quantifythe magnitude of the effect of hangover on driving and how itmight compare to other impairments (e.g., fatigue).
Funding
This study was supported by Utrecht University. The authorshave no potential conflicts of interest to disclose. Joris Ver-ster received research support from Takeda Pharmaceuticals,Red Bull GmbH; has acted as consultant for Takeda, Sanofi-Aventis, Transcept, Sepracor, Red Bull GmbH, Canadian Bev-erage Association, Deenox, Trimbos Institute, and CentraalBureau Drogisterijbedrijven. Berend Olivier is a scientific advi-sor for Emotional Brain BV and has received research supportfrom Emotional Brain, PsychoGenics Inc., Sepracor, Servier,Abbott, and the Dutch Brain Research Organization.
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