Rural drivers at greater risk for impaired driving

by Martin LaSalle, University of Montreal

edited by Gaby Clark, reviewed by Andrew Zinin

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Drivers involved in serious accidents in rural areas have a higher prevalence of drunk driving, detectable cannabis and polysubstance use than urban drivers, according to a Canada-wide study published in the journal Traffic Injury Prevention.

The study was conducted by Floyd Besserer of the University of British Columbia and a research team including Dr. Raoul Daoust, a professor in the Department of Family Medicine and Emergency Medicine at Université de Montréal.

The researchers examined toxicology data from 13,792 drivers with moderate or severe injuries treated in 17 Canadian emergency departments between 2018 and 2024. A total of 2,078, or 15.1%, of the drivers were from rural areas.

Toxicological analyses were performed in a central laboratory, ensuring consistent results across sites.

Alcohol detected nearly twice as often in rural drivers

The team's first finding was that alcohol was present nearly twice as often in the blood of rural drivers. A blood alcohol concentration (BAC) above zero was found in 24.6% of rural drivers, compared with 14.8% of urban drivers. There was also a significant difference in BAC above the 0.08 legal limit, which was found in 18.5% of rural drivers and 11.3% of urban drivers.

Cannabis was also more prevalent in the blood of injured rural drivers: 17.2% had a tetrahydrocannabinol (THC) level above zero, compared with 14.6% of urban drivers. However, for high concentrations (5 ng/mL and above), the two groups were comparable. While cannabis was detected more frequently in rural areas, the degree of intoxication was not higher than in cities.

Opioids, depressants and central nervous system stimulants also had higher prevalence rates in rural areas, with probabilities ranging from 14% to 21% above urban thresholds.

Young drivers alone on the road

According to the study, the profile of injured rural drivers differs from that of urban drivers in several respects.

Rural youth ages 16 to 18 accounted for 6% of hospitalizations, compared with 3.4% in urban areas. Daoust believes the difference is due in part to the widespread use of off-road vehicles in rural areas. The 6% figure may even be an underestimate: The study did not cover drivers younger than 16, and it is not uncommon for rural teens under 16 to drive off-road vehicles.

"Accidents involving an all-terrain vehicle or similar vehicle, whether it is being used for recreational or practical purposes, are four times more common in rural than in urban areas—9.6% versus 2.2%—and it is mainly young people who drive them," Daoust said.

Accidents in which only one vehicle was involved were also more common in rural areas, at 56.2% compared with 39.4% in urban areas. The researchers attributed this to the combined effect of low traffic density, road conditions, the lack of alternative transportation and limited police presence.

The consequences of road accidents are more severe in rural areas. Rural drivers were hospitalized in 55.3% of cases, compared with 33.4% of urban drivers. Researchers attributed this significant difference to generally more serious injuries, compounded by the distance from trauma centers and longer lags in emergency response in rural areas.

Troubling use of multiple substances

Daoust was struck by the fact that 28.8% of injured rural drivers had two or more classes of substances in their blood, compared with 19.6% of urban drivers.

However, he does not consider this finding entirely surprising.

"If there is greater alcohol consumption, there is a higher risk that it will be combined with other drugs. The logic is simple: The more people use substances, the more likely they are to combine them."

The use of multiple substances can be particularly dangerous. A number of studies have shown that the alcohol-cannabis combination impairs driving ability more than each substance taken separately. Even levels of intoxication that seem to present a limited risk when substances are consumed in isolation can have a major effect on driving when they are combined.

"We know that alcohol above the 0.08 limit impairs driving ability," Daoust noted. "But even below that, any amount of alcohol has some effect, and when combined with THC or other substances, there can be a multiplier effect."

Here, too, the research team believes that the figures reported in their study are probably conservative. The longer lapse between the collision and the collection of a blood sample in rural areas—because of the time it takes for emergency responders to arrive and for the driver to be transported—means that substances are more likely to metabolize.

"If a driver has a BAC of 0.082 at the time of the accident, it may be 0.075 by the time they reach the hospital," Daoust pointed out. "This moves the driver to a different category in our classification. The actual prevalence of some substances at the time of the accident could therefore be higher than the data indicate."

Furthermore, cases in which it took more than six hours after the accident to collect a blood sample were excluded from the study, and this was more likely to occur in rural areas.

Targeting rural youth

According to the study's authors, their findings make a compelling case for more targeted public health interventions, particularly for rural youth ages 16 to 18, who are overrepresented in serious accidents, are more likely to drive off-road vehicles and live in an environment where alcohol consumption may be more culturally acceptable.

The researchers also point to structural factors—geographic isolation, lack of public transit, limited police presence and different social norms—that create an environment where risk factors accumulate.

They therefore advocate an approach that combines public health initiatives with increased law enforcement and community mobilization.

"Otherwise," Daoust warned, "prevention messages may not reach those who need them most."

More information

Floyd Besserer et al, A comparison of collision factors and toxicologic characteristics for rural and urban drivers presenting to the emergency department after a vehicular collision, Traffic Injury Prevention (2026). DOI: 10.1080/15389588.2026.2628945

Key medical concepts

AlcoholDronabinolAnalgesics, OpioidCentral Nervous System Stimulants

Clinical categories

Preventive medicineCommon illnesses & PreventionChildren's health Provided by University of Montreal Who's behind this story?

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