C International Epidemiologica] Association 1998
Printed in Great Britain
International Journal of Epidemiology 1998,27:1038-1043
Water traffic accidents, drowning
and alcohol in Finland, 1969-1995
Philippe Lunetta, a Antti Penttila a and Seppo Sarna b
Objective
To examine age- and sex-specific mortality rates and trends in water traffic accidents
(WTA), and their association with alcohol, in Finland.
Materials
National mortality and population data from Finland, 1969-1995, are used to
and Methods analyse rates and trends. The mortality rates are calculated on the basis of population, per 100 000 inhabitants in each age group (<1, 1 ^ , 5-14, 15-24, 25^14,
45-64, 5*65), and analysed by sex and age. The Poisson regression model and
X2 test for trend (EGRET and StatXaa softwares) are used to analyse time trends.
Results
From 1969 through 1995 there were 3473 (2.7/100 000/year; M:F = 20.4:1)
WTA-related deaths among Finns of all ages. In 94.7% of the cases the cause of
death was drowning. Alcohol intoxication was a contributing cause of death in
63.0% of the fatalities. During the study period the overall WTA mortality rates
declined significantly (-4% per year; P < 0.001). This decline was observed in all
age groups except 5=65 year olds. The overall mortality rates in WTA associated
with alcohol intoxication (1987-1995) also declined significandy (-6%; P = 0.01).
Conclusions In Finland, mortality rates in WTA are exceptionally high. Despite a marked
decline in most age groups, the high mortality in WTA nevertheless remains a
preventable cause of death. Preventive countermeasures targeted specifically to
adult males, to the reduction of alcohol consumption in aquatic settings and to
the use of personal safety devices should receive priority.
Keywords
Water traffic accidents, drowning, alcohol, Finland
Accepted
24 March 1998
Finland (population 5.1 million) has 1100 km of coastline,
more than 188 000 lakes (33 551 km2; 9-10% of total land) and
9650 km of inland waterways, and is, despite its cold climate
(mean temperature in Southern Finland +5-6°C), a wateroriented society widi a high mortality in aquatic settings. During
the last three decades recreational and commercial water traffic
has increased markedly on the sea and on inland waters. 1 " 3 At
the beginning of the 1990s it was estimated that there were
-610 000 boats, of which 550 000 were rowing boats and small
motorboats, 50 000 registered motorboats and 10 000 sailing
boats. 3
In a recent study it has been shown that the overall drowning rates in Finland are the highest among the EU member
countries and that -30—40% of accidental drownings occur in
water traffic accidents (WTA).4 In previous studies more than
50% of WTA-related deaths in Finland were associated with
alcohol intoxication. 5 " 7
• Department of Forensic Medidne, PO Box 40, University of Helsinki, FIN00014. Finland.
h6
Department of PubUc Health, PO Box 41, University of Helsinki, FIN-00014,
Finland
This paper was presented in part at the 14th International Conference on
Alcohol Drugs and Traffic Safety, Annecy, 21-26 September 1997.
This study examines national age- and sex-specific rates and
trends in WTA-related fatalities from 1969 to 1995 among Finns
of all ages and their association with alcohol,
. .
,
,
,
Materials and Methods
Mortality and population data published by the Central
Statistical Office of Finland for 1969 Uirough 1995 were used to
determine fatal WTA rates. Mortality rates were determined on
the basis of population, per 100 000 inhabitants in each age
group (<1, \-4, 5-14, 15-24, 25-^4, 45-64, *65), and analysed by sex and age according to the most detailed classification
of death in use during the study period. From 1969 to 1986
WTA fatalities were classified according to the 8th International
Classification of Diseases (ICD-8) external cause of death codes:
E830 (Acddent to watercraft causing submersion), E831 (Accident to watercraft causing other injury), E832 (Other accidental
submersion or drowning in water transport), E833 (Fall on
stairs or ladders in water transport), E834 (Other fall from one
, e v e l t 0 a n o ^ , - ^ w a t e r transport), E835 (Other and unspecified
,„ .
„ „ ' ' ' ,.
fall in water transport), E836 (Machinery accident in water
,
,
,
transport), E837 (Explosion, fire, burning, in water transport),
^ d E838 (Other and unspecified water transport accident).
From 1987 to 1995 they were categorized according to a Finnish
1038
WATER TRAFFIC ACCIDENTS, DROWNING AND ALCOHOL IN FINLAND
classification of diseases and recorded with codes E810
(Submersion in water transport accident) and E819 (Other
and unspecified water transport accidents) and with a five-digit
classification (A: Occupant of small motorless boat; B: Occupant
of sailboat or motorboat; C: Occupant of other watercraft;
X: Other, unspecified person). Moreover during the period
1987-1995 a three-digit classification of fatal WTA (E810, E819)
in which alcohol intoxication (305) was a contributing cause of
death was also available. The %2 test for trend (StatXact software,
1995) and Poisson regression model (EGRET software, 1994)
were used to analyse time trends. The 95% confidence interval
(CI) was calculated assuming a Poisson distribution (EGRET)
and an exact binomial CI for proportion (CIA). In graphical
displays two-period moving averages were used to smooth
the variation in time series. Information on fatal leisure WTA
collected through semi-structured questionnaires 8 during the
period 1986-1988 by 12 provincial teams supervised by a
national team (Ministry of Interior, Finland; Department of
Forensic Medicine, Helsinki; National Public Health Institute,
Helsinki) included 291 leisure boat accidents with 510 people
on board and was used to study circumstances and risk factors
for fatal WTA.
1039
250
200
150
100
OWTA BDrown in WTA I
Figure 2 Water traffic accident-related deaths (E830-838, 810, 819)
and water traffic accident-related drowning (E810, 830, 832) in
Finland, 1969-1995 a
a
Trend line: two-period moving average
Results
Rates
During the study period (1969-1995) there were 68 669 fatal
accidents in Finland (average/year = 2543.3, SD = 280; 52.6/
100 000/year; M:F = 2.5:1). Of these 11.7% (n = 8020; average/
year = 297.0, SD = 81; 6.1/100 000/year; M:F = 9.4:1) were
drowning and 5.1 % (n = 3473; average/year = 128.6, SD = 28;
2.7/100 000/year; M:F = 20.4:1) were WTA (E830-E838; E810,
E819). In 94.7% (n = 3288; average/year = 121.8, SD = 28; 2.5/
100 000/year; M:F = 2 3.4:1) of the fatal WTA the cause of death
was drowning (E830, E832; E810) (Figures 1, 2). Drowning in
WTA was associated in 47.1 % of the cases with a motorless boat
and in 46.3% with a motorboat. In WTA, where the cause of
death was other than drowning (e.g. natural death), a motorboat
2
3
Ho 4
5to14
15 to 24
25 to 44
4Sto64
>65
-WTA - O - WTAaJc*
500
450
Figure 3 Age distribution of water traffic acadent-related deaths
(E830-838, 810, 819) in Finland, 1969-1995a
400
350
a
\
300
The dotted line indicates the age distribution of water traffic
accident-related deaths with alcohol intoxication (1987-1995).
n 250
200
150
100
50
8
OAII drown • Drown in WTA
Figure 1 All drowning (E8I0, 830, 832, 910) and water traffic
accident-related drowning (E810, 830, 832) in Finland, 1969-1995 a
a
Trend line: two-period moving average.
was involved in 54.2% and a motorless boat in 11.9% of the
cases.
The age distribution was unimodal with a single peak in
45_64 year olds (4.3/100 000/year). Of the victims, 97.3% were
5»15 years old and 41.5% were 25-44 years. The M:F rate ratio
(R_R) was 20.4:1 with the greatest difference between sexes in
those 3*65 years (32.6:1) (Figures 3, 4).
Association with alcohol
During the period 1987-1995, 63.0% (n = 583) of the fatal WTA
were associated with alcohol intoxication (average/year = 64.8,
1040
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
— * — M:F ratio - WTA — -O — M:F ratio - WTAalc+
Figure 4 Male:female rate ratio of water traffic acadent-related
deaths (E830-838, 810, 819) in Finland, 1969-1995a
a
The dotted line indicates the age distribution of water traffic
accident-related deaths with alcohol intoxication (1987-1995)
SD = 12; 1.3/100 000/year). In WTA-related drownings among
5»15 year olds, 66.0% were associated with alcohol intoxication. Only in one case was the victim (male) younger than 15.
The age distribution was unimodal with a single peak in 45-64
year olds (2.8/100 000/year) (Figure 3). The M:FRR was 26.7:1
with the greatest difference among 2"65 year olds (70.8:1)
(Figure 4). Fatal WTA associated with alcohol intoxication
accounted for 12.5% of all accidental deaths associated with
alcohol intoxication (M:F = 8.9:1).
Trends
Through the 27-year study period, the overall rates of fatal
accidents, drowning rates and WTA-related deaths declined
significantly (-0.4% per year, P = 0.002; -4.9% per year,
P < 0.001; - 4 % per year, P < 0.001, respectively; Poisson regression analysis). The decline in WTA-related deaths was significantly greater than the decline in all other accidental deaths
(1969-1986: E800-E827, E840-E947; ICD-8th revision.
1987-1995: E800-E804, E82O-E935; ICD-9th revision) (P <
0.001, x2 test for trend). Conversely, no pronounced difference
was observed between WTA-related drowning and all other
drowning (1969-1995: E910; ICD-8th and 9th revision) (P =
0.03, x2 test for trend). In WTA-related deaths a significant interaction between time trend and sex was observed (P < 0.001,
Poisson regression analysis) with a more pronounced decline in
males. Overall, WTA-related deaths declined significantly in all
age groups with the exception of >65 year olds (Table 1).
During the period 1987-1995 the overall rates of fatal accidents, drowning, and WTA associated with alcohol intoxication
have declined significantly (-2.5% per year, P < 0.001; -5.8%
per year, P < 0.001; -5.8% per year, P = 0.002, respectively;
Poisson regression analysis). The decline in fatal WTA associated
with alcohol intoxication was not significantly different to the
fall in all other accidents (P = 0.13, x2 test for trend); in addition
the decline in WTA-related drowning associated with alcohol
intoxication was not significantly different than the decline in
all other drowning associated with alcohol intoxication (P = 0.39,
X2 test for trend). The decline in WTA fatalities associated
with alcohol intoxication was more pronounced among males
(P = 0.002, Poisson regression analysis) and significant only
among 25-44 year olds (-8.3% per year, P < 0.001; Poisson
regression analysis) (Table 2).
During the study period two main legislative countermeasures
were introduced in Finland to decrease the consumption of
alcohol in water traffic. An Act of Parliement (960/1976) introduced a blood alcohol concentration (BAC) limit (1.5%o) for
boat operators and Act 655/1994 reduced further this limit
to 1.0%o. In 1992 a prevention campaign to increase the safety
of water traffic followed the publication of the results of the
analytical study on leisure boat fatalities (see paragraph below).
When comparing the decline in WTA-related drowning with
the decline in all other types of drowning before and after the
introduction of these countermeasures, a significant chronological interaction was observed only for Act 960/1976. Such
interaction was detected only in the 3-year period following the
introduction of Act 960/1976 (WTA-related drowning versus
all other types of drowning: P = 0.003, x2 test for trend). In a
longer period (6 years) all other drowning declined even more
than fatal WTA (P < 0.001, x 2 test for trend). No significant
Table 1I Time trends in water traffic accident mortality in Finland 1969-1995 a
Age
All ages
<1
1-4
5-14
15-24
25-44
45-64
»65
All
Death rates per 100 000 population
1969-1971
1993-1995
% variation/year
3.57
1.78
-4.0%
95%
confidence Interval (%)
P-valueb
(-5.2, -2.7)
<0.001
<0.001
0.004
<0.001
<0.001
<0.001
<0.001
-
0.82
0.68
3.32
6.09
4.65
2.21
0
0.05
0.53
1.76
3.55
2.29
-11.3%
-6.5%
-1.6%
-1.2%
-1.7%
-1.1%
-18.2,-3.8)
( 7 9.7.-3.1)
(-5.9, -3.3)
(-1.9, -3.6)
(-2.4,-1.0)
(-2.5, -0.0)
P-values. % variation per year and 95% CI art calculated on the basis of the Poisson regression model (EGRET software, 1994).
' NS = not significant {P > 0.05)
Interaction between time trend and sex
_
NS
<0.001
WATER TRAFFIC ACCIDENTS, DROWNING AND ALCOHOL IN FINLAND
1041
Table 2 Time trends in water traffic accident mortality associated with alcohol intoxication in Finland 1987-1995a
Age
All ages
15-24
25-44
45-64
>65
Death rates per 100 000 population
1987-1989
1993-1995
1.56
1.12
0.93
0.37
2.18
1.21
3.01
2.37
0.52
0.98
All age.sexc
a
b
c
% variation/year
-6.0%
-10.8%
-8.7%
-2.8%
+ 1.2%
_
95% confidence Interval (%)
P-value"
-10.0, -1.4)
(-21.7 , 1.6)
-12.8, -3.6)
-2.8)
(-1.6, 25.7)
0.01
_
NS
<0.001
NS
NS
0.002
P-values, % variation per year and 95% CI are calculated on the basis of the Poisson regression model (EGRET software, 1994).
NS = not significant (P > 0.05).
Interaction between time trend and sex.
Analytical study (1986-1988)8'9
Table 3 Summary of the most important findings of the national
investigation team on fatal leisure boat accidents (1986-1988)
95% CI(%)
Time
May-August
Friday-Sunday
3 p.m.-9 p.m.
Place and weather
Inland waters, good weather
42%
(69, 79)
(54, 65)
(36, 48)
57%
(50, 65)
Rowboat
Small boat, outboard motor
Person on board
Operator alone
33%
(28, 39)
(46, 58)
Operator alone alcohol-intoxicated
No life jacket on
Alcohol *1.5%
Rowers
Motorboat operators
69%
74%
60%
Boat
52%
50%
94%
50%
63%
(44, 56)
(61, 76)
(91, 96)
(40, 61)
(56, 70)
Cause of death
Drowning
Other non-natural cause
Disease
94%
5%
2%
(91, 96)
(3,8)
(0.3)
The analytical study on fatal leisure WTA was performed during
the period 1986-1988 by an ad hoc national investigation team
(Ministry of Interior, Finland; Department of Forensic Medicine,
University of Helsinki; National Public Health Institute,
Helsinki). This study covered all 291 leisure fatal boat accidents
in Finland with 510 people on board and 340 victims. Most
of the accidents occurred in inland waters (72.5%). The most
important findings of this study are summarized in Table 3. The
BAC was determined in 274 boat drivers and in 176 passengers
(Table 4). In 58.8% of the boat operators the BAC exceeded the
legal limit (1.5%o). This mandatory limit was exceeded by 50%
of the rowing boat and by 63.4% of the motorboat operators.
The presence of alcohol in blood (BAC >0%o) was found in a
significantly higher proportion in motorboat operators than in
rowers (P < 0.05, x 2 test). No significant differences were found
between boat drivers on the sea and on inland waters. Among
rowing boat and motorboat passengers the figures with BAC
3=1.5%o were 73.5% and 62.2%, respectively.
Among those on board who fell into the water, 72.1% (n = 298)
of the victims who drowned and 68.2% (n = 88) of the survivors had a BAC »1.0%o. The respective values for BAC s» 1.5%o
were 64.1% and 53.4%. Only 3.5% of those drowned were
using a buoyancy aid at the time of accident.
Death after accident
Immediately
In less than 10 min
80%
(22, 32)
(76, 85)
-
-
98%
27%
(93, 100)
(82, 92)
(13,45)
93%
-
27%
Hypothermia
No effect
No safety jacket
In rowing boats
In unregistered motorboats
In registered motorboats
87%
Survival possibility
If life jacket wom
Risk of being involved In water traffic accident
If BAC 1.0%.
IOX
-
If BAC 1.5%o
20x
-
effects were observed during the 3 years following the prevention campaign (WTA-related drowning versus all other types of
drowning: P = 0.25, x2 test for trend).
Discussion
In Finland, the high mortality from WTA (2.7/100 000/year)
has been a continuing problem in recent decades. The Finnish
mortality rates from WTA are well documented but difficult to
compare with those of other countries because although nationwide studies on drowning have been performed recently in
some countries few of them have focused on WTA or WTArelated drowning; moreover marked epidemiological differences
exist between different regions of the same countries.
The Finnish mortality rates from WTA are much higher than
those in the US where boat-related drownings declined from
0.6 to 0.4/100 000/year during the early 1980s. 10 The proportion of boat-related drownings compared to all drownings is
markedly higher in Finland than in the US (43.0% versus
< 2 0 % ) . n Although WTA-related drowning represents, in
Finland, 40-50% of all accidental drowning, the mortality rate
from WTA-related drowning (2.5/100 000/year) alone exceeds
the average EU mortality rate for all accidental drownings
(1.4/100 000/year). 4
1042
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Table 4 Blood alcohol concentration (BAC) in dnvers and passengers *15 years old involved in fatal water traffic accidents (n = 274)
BAC (%o)
0
(%)
0.1-0.4
0.5-0.9
1.0-1.4
1.5-1.9
2.0-2.4
*2.5
Total
(%)
(%)
(%)
(%)
(%)
(%)
(%)
Drivers
Motorboat (n = 180)
21.1
2.2
5.0
8.3
20.0
23.4
20 0
100
Rowing boat (n = 94)
34.0
43
5.3
6.4
170
19.2
13.8
100
Total (274)
25.5
29
5.1
7.7
19.0
21.9
17.9
100
Motorboat (n = 127)
16.5
24
8.7
10.2
22.8
18.9
20.5
100
Rowing boat (n = 49)
12.2
0
4.1
102
20.4
22.5
30.6
100
Total (176)
15.3
1.7
7.4
10.2
22.2
19.9
23 3
100
Passengers
In Finland, fatal WTA is an almost exclusively adult male
phenomena. More than 97.3% of the victims are ^ 1 5 years old.
The M:F relative risk (RR) (20.4:1)— which is higher than in the
US (<15:1) 12 —exceeds markedly the M:F RR in fatal accidents
(2.5:1) and drownings (9.4:1). In fact, exposure to aquatic settings, especially water traffic, is to a large extent confined to
adult males, who are devoted to leisure boating mainly during
the summer season and involved in professional activities all year.
Another factor which may explain the high rate of fatal WTA,
especially among adult males, is represented by the abuse of
alcohol in aquatic settings. Although alcohol use during boating
activities is an increasingly recognized hazard associated with
boating fatalities, a relative risk for accident and drowning
cannot be statistically determined without an exposure parameter (e.g. the number of boat operator h) and data on alcohol
consumption in aquatic settings. The question of drinking
behaviour in aquatic settings has recently been addressed in the
TJ<J13-17 k u t CO mparable information for Finland is limited. In a
pilot study on drunken driving performed in the late 1970s on
the southern Finnish seacoast it was found that 29.7% of 424
motorboat drivers tested positive for alcohol and among these
only 1.2% had a BAC higher than the legal limit (1.5%o).18 The
data on the cases of suspected drunken boat operators reported
to the police do not furnish valuable information on the
exposure to alcohol in water traffic. Nevertheless a considerable
proportion of the victims of WTA during the study period
had consumed alcohol near the time of death. The association
of fatal WTA with alcohol intoxication is much higher than the
respective values in all accidents and in all drowning (63%
versus 19% and 46.8%, respectively). Studies on the association between alcohol and drowning in some other countries
reviewed in the late 1980s indicate that alcohol may have been
a contributing cause of WTA-related drowning in 17-81% of
the cases, 19 but in most of these studies the association ranges
between 30 and 50%. In our study, the determination of alcohol
intoxication as a contributing cause of fatal WTA is based only
on the death certificate. No data on BAC levels, on the interval
* During the period 1991-1996 the Finnish police took 3870 blood samples
from suspected drunken operators In water traffic (97.2% males). In less
than 0 6% of the cases, the BAC was <0.5%o. During the period January
1991-August 1993 (legal BAC limit = 1.5%.) the BAC was 2>1 5%. in 78.7%
of these cases; during the period September 1994-Decembtr 1996 (legal
BAC limit = 1.0%.) the BAC was >1.5%o in 55.4% of the cases. (Source.
Alcohol Laboratory, National Public Health Institute, Helsinki. Courtesy
Dr R Undbohm )
between immersion and death and on the interval between
death and post-mortem BAC determination were considered. 20
However, in Finland, more than 97% of the death certificates in
instances involving violent death are based on a forensic autopsy,
and in almost all fatal traffic accidents an alcohol analysis is
performed. The relative significance of BAC in the few cases
with prolonged interval(s) between WTA and alcohol determination is generally taken into account by forensic pathologists when certifying the cause of death. Moreover the rate of
WTA fatalities associated with alcohol intoxication is comparable with the frequency observed in previous studies performed
in Finland 6 - 8 ' 9 in which BAC was analysed. The analytical study
performed during the period 1986-1988 provided evidence that
the risk of a fatal outcome was higher in people under the
effects of alcohol (lOx in individuals with BAC >1.0%o and 20x
in individuals with BAC >1.5%o). That study also demonstrated
that the lack of safety devices on board, e.g. buoyancy aids, was,
once the accident occurred, among the major risk factors for
the fatal outcome and that in 93% of the accidents wearing a
life jacket should have substantially increased the survival
possibilities. The insufficient use of safety devices in the fatal
outcomes of WTA has been underlined also in previous
studies. 12 ' 20
Despite a marked increase in both leisure and commercial
boating,1 mortality from WTA has decreased significantly during
the last three decades. This decline was more pronounced
than the decline in mortality in all other accidents, however
WTA-related drowning did not decline if compared with all
other causes of drowning. A significant interaction between
time trend, sex and age group was detected. The decline was
observed for all age groups, except >65 year olds, and was more
pronounced among men. Overall, WTA-related deaths associated with alcohol intoxication also showed a significant decline
during the period 1987-1995. The decline in WTA-related drownings was not significant when compared with the decline in
all other drownings associated with alcohol intoxication. This
decline concerned essentially males and was significant only
among 25—44 year olds.
The reasons for these time trends are not dear. The introduction in 1976 of a legal BAC limit for boat operators (1.5%o)
did not modify the long-term trend in fatal WTA. The subsequent reduction in 1994 of this BAC limit to 1.0%o is too
recent to be analysed. The prevention campaign alone did not
significantly modify the trend in fatal WTA. It is likely that a slow
increase in public awareness of the risks related to water activities
WATER TRAFFIC ACCIDENTS, DROWNING AND ALCOHOL IN FINLAND
and to the use of alcohol in aquatic settings, influenced by legislative countermeasures and prevention campaigns, has played
an important role in both the decline of WTA-related drowning
and that of drowning not related to WTA. In fact, the decline in
drowning not related to WTA was even more pronounced than
that of WTA-related drowning during the study period.
6
Pikkarainen J, Penttila A. VesUiikenne, hukkuminen ja alkoholi.
Duodeam 1984; 100:1277-84.
7
Pikkarainen J, Penttila A. Alcohol and fatal accidents in recreational
boating. A ten year study on drinking operating in Finland. In:
Procttdings of the I lth International Conference on Alcohol, Drugs & Traffic
Safety (T89). Chicago: National Safety CoundL 1989.
8
Pikkarainen J, PenttUa A, Piipponen S. Kuolemaan Johtaneet
Veneilyonnettomuudet Suomessa. Vuosina 1986-1988. Publications of
the National Public Health Institute A5I1992, Helsinki, 1992.
9
Penttila A, Pikkarainen J. Unfalle mit todlichem Ausgang im finnischen Wasserverkehr wahrend der Freizeit 1986-1988. Beitr gerich
Med 1990;48:185-91.
Conclusions
Despite a significant decline in most age groups, Finnish mortality
rates in WTA exceed markedly those of other countries with
reliable data. In Finland, the decline in mortality from WTA is
likely due to increasing public awareness of the risks related to
water activities and to the use of alcohol in aquatic settings as
demonstrated by the concomitant decline in drowning rates not
related to WTA. However, high WTA mortality remains a preventable cause of death. The reduction of the legal BAC limits
for boat operators alone is inadequate because a considerable
proportion of fatal WTA continues to be related to the behaviour of those on board rather than to impairment of the boat
operator. A long-term information and prevention campaign
directed at both drivers and passengers and specifically targeted
to adult males and to the reduction of alcohol abuse in aquatic
settings, together with the promotion (also through legislative
actions) of the use of buyancy aids on board, could contribute
to reducing risk-taking behaviour in water traffic and thus
further reduce WTA mortality.
1043
10
Anonymous. Progress toward achieving the national 1990 objectives
for injury prevention and control. MMWR 1988;37:138-40, 145-49.
11
Anonymous. Drownings—Georgia, 1981-1983. MMWR 1985;34:
281-83.
12
Orlowsld JP. Adolescent drownings: swimming, boating, diving, and
scuba accidents. Pediatric Annals 1988; 17:125-28, 131-32.
13
Anonymous. From the Centers for Disease Control. Alcohol use and
aquatic activities—Massachusetts. JAMA 1990;264:19-20.
14
Howland J, Mangione T, Hingson R, Levenson S, Winter M, Altwicker
A. A pilot survey of aquatic activities and related consumption of
alcohol with implication for drowning. Public Health Rep 1990,105:
415-19.
15
Glover ED, Lane S, Wang MQ. Relationship of alcohol consumption
and recreational boating in Beaufort County, North Carolina. J Drug
Educ 1995:25:149-57.
16
Anonymous. Alcohol use and aquatic activities—United States, 1991.
MMWR 1993;42:675, 6S1-83.
17
Howland J, Hingson R, Mangione TW, Bell N., Bak S. Why are most
drowning victims men? Sex differences in aquatic skills and
behaviors. Am J Public Health 1996:86:93-96.
Finnish Maritime Administration. Shipping between Finland and
Foreign Countries 1996. Merenkulkulaitoksen tilastoja 7/1997, Helsinki,
1997.
18
Penttila A, Piipponen S, Pikkarainen J. Drunken driving with motorboat in Finland. A pilot study on the southern seacoast in summer
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