Drowning remains an important cause of fatal injury. Over the past decade there has been little change in the annual US drowning rate with an average of 3.56 recreational boating drowning deaths per 100,000 registered boats. In 2012, 459 people drowned in US recreational boating incidents; 85% of these were not wearing a life jacket.¹ In the Puget Sound area of Washington State, 22% of unintentional submersion deaths among adults between 1980–1995 were boating-related.² Nonfatal submersion rates are also high, thus it is important to identify the opportunities for improving prevention strategies.

Life jackets are United States Coast Guard (USCG) approved flotation devices, also known as personal flotation devices (PFDs). Life jackets are associated with a 50% reduction in drowning risk.³ All recreational boats in the USA are required to carry one USCG-approved wearable life jacket that fits for each person aboard.⁴ National and state surveys, however, suggest that most boaters do not regularly wear life jackets.⁵⁶ Efforts to increase life jacket use have targeted all boaters, with the strongest efforts directed towards children. Approaches include legislation mandating life jacket use, strengthened enforcement, life jacket loan programs, and educational efforts to increase awareness. Life jacket use is mandated for children in nearly every state in the USA, although age, boat size, and boat movement requirements vary widely.⁷ These steps have increased awareness among parents and life jacket use among children; however non-use remains high.^8–11

We sought to identify barriers to life jacket use among adult recreational boaters, with a focus on factors that might inform the design of effective interventions or improve public health messages.

Most interviews (86%) occurred on weekends, with an average temperature of 59 degrees Fahrenheit, and rain occurring during 31% of surveys (data not shown). Respondents were mostly male (85%) and owned the boat (86%), with a mean age of 46 years (range 18 – 81) (Table 1). A majority (77%) had completed at least some college. Approximately half (53%) were fishing, 25% were on a pleasure trip, 14% were participating in a watersport activity such as towing a water-skier or inner tube, and 8% reported other activities (e.g., boat maintenance or preparing the boat for storage). Most (72%) reported no life jacket use on the day of the survey. Consistent life jacket use was uncommon, with 14% of respondents stating they had worn a life jacket for the entire boating trip. One out of ten boaters reported that they always wear a life jacket when boating.

Our results are consistent with findings of some qualitative studies^20–22 and anecdotal information about life jacket use and behaviors: no/low life jacket use was associated with being on a larger boat, perception of life jackets as uncomfortable, and self-perceived ability as a capable swimmer. No/low life jacket use was associated with warmer weather. Higher lifejacket use was positively associated with higher prevalence of inflatable life jacket use and the presence of children on board.

The decreased life jacket use on longer boats may result from an increased sense of security among boaters on larger vessels. However, all the boats in the study were small, “trailer-able” vessels, in the size-range relevant to the majority of drowning-related boating deaths, indicating a need for efforts to increase life jacket use among these boaters specifically.

At least one previous study suggested that boaters dislike bulky life jackets that are uncomfortable and limit motion.²² Among life jacket ever-users in our study, inflatable life jackets were considered more comfortable than other models, although they are not suitable for all boaters. Inflatables are not appropriate for smaller children, and can be costly. The cheapest inflatables currently cost about $70 – $80, whereas traditional life vests may be < $20. Inflatables require periodic maintenance at additional expense; for example, a replacement cartridge costs approximately $20. Efforts to increase comfort of life jackets by engineering less bulky devices may promote more consistent use, especially in warmer conditions.

No/low life jacket use was associated with any level of alcohol use. Alcohol use is one of the most important risk factors for drowning, with estimates suggesting that alcohol contributes 10% – 30% of the attributable risk for all drowning deaths.²³ Even low levels of blood alcohol (10 mg/dL) appear to increase the risk for death among recreational boaters.²⁴ Alcohol-related drowning deaths in western Washington decreased by 81% between 1975 and 1995, potentially due to increased life jacket use and decreased alcohol use.²⁵ Since that time, Washington and many states have passed legislation prohibiting persons with a 0.08% or higher blood alcohol content (BAC) from boat operation. The US Coast Guard enforces the federal BAC level of 0.1% in waters it patrols.²⁶²⁷ Enforcement of laws prohibiting operation of a boat while intoxicated is important, but it is unclear what role this might have in increasing levels of life jacket use. It is possible that people who choose to drink while boating, even if they do not drink to intoxication, may also be those who choose not to wear life jackets. Given, however, that drinking increases the risk of capsizing, a collision or falling overboard,²⁸ increased life jacket use among drinking boaters and all passengers onboard with a drinking or sober pilot is likely to reduce fatalities.²⁹ In the absence of life jacket laws for all adult boaters, linking enforcement of “boating while intoxicated” laws to encouragement of life jacket use and inspections regarding presence of life jackets onboard may improve life jacket use.

Mandatory life jacket use among children and awareness efforts targeting parents appear effective at increasing life jacket use among children and adolescents.⁸⁹³⁰ Our results suggest that life jacket legislation and increased use among children (and possibly among preteens/adolescents) may increase use among adults on the same boat. Parents can role model safety behaviors by wearing life jackets when boating with children, a practice also associated with improved life jacket use.³⁰ Strengthening the legislative and enforcement climates are promising strategies for future efforts to prevent boating-related drowning.

In addition to legislation and enforcement efforts around life jacket use, some have suggested implementing measures similar to those effective at reducing impaired driving. These include encouraging a designated boat operator, sobriety checkpoints, and increasing public awareness of laws and enforcement campaigns.³¹³² Additional strategies may be needed to reduce drowning risk for impaired passengers.²⁹ Aggressive enforcement of life jacket laws has the added potential benefit of identifying other risky boating behaviors (e.g., alcohol use) and may increase compliance among higher risk boaters, who face greater risk of drowning. As noted with primary enforcement seat belt campaigns,³³ in a more aggressive enforcement climate, impaired boaters may be more willing to wear life jackets out of concern that a Coast Guard official may identify other illegal activity.

Perceived swimming expertise may contribute to the decision to not wear a life jacket. Previous research suggests many US adults overestimate their swimming ability, although this may vary by age, race/ethnicity, and gender.³⁴ Perceived swimming ability also likely depends on exposure to aquatic activities.³⁵ Our data also suggest a possible incongruity between one’s perceived swimming ability and self-reported swimming frequency. Public health campaigns to increase life jacket use may be more effective if they emphasize awareness of factors unrelated to swimming ability that contribute to boating fatalities, such as hypothermia and trauma from a capsize or collision, rather than swimming ability.

Our results suggest that individuals who had taken a piloting or boating safety class, or had obtained a Washington State Boater Education Card (BEC), were more likely to report life jacket use, although this finding was not statistically significant. If there is an association, it may be with the safety course (which emphasizes life vest use), or with the characteristics of individuals taking a safety course, but either way, the promotion of boater education courses that teach safety benefits and comfort options for life jackets may be beneficial. Previous studies examining the association of piloting/boat safety classes with life jacket use levels have had mixed results. One observed little difference in life jacket use levels between those with, and without formal boat safety training.³⁶ An early case-control study in Ohio compared boat operator characteristics of those involved in fatal boating incidents with characteristics of registered boaters without boating incidents in the previous four years. They observed that operators without formal boat safety training were slightly, but not statistically significantly more likely to be involved in fatal incidents (RR 1.27, 95% CI 0.63–2.57).³⁷ In Washington State, a BEC is required of boat operators with motorboats with ≥15 horsepower. At the time of our survey, only those who were < 20 years were required to have the BEC. Two of eight participants in this age group reportedly owned a BEC. By 2014, a BEC will be required for all boaters born in 1955 or later. As more boaters obtain safety training, there are increased opportunities to provide education about the risks, benefits, and legal requirements, as well as to emphasize that boating laws will be enforced.

There are limitations common to surveys such as ours. As with any observational study, the possibility of residual confounding exists. Although a majority of respondents reported no/low life jacket use, it is likely that some gave socially desirable answers, which may have underestimated the true level of no/low life jacket use. In our study, 27% of respondents reported some life jacket use on the day of the survey, 14% reported wearing one for the entire trip (100% use), and 10% reported that they always wear a life jacket when boating. Observational studies of adult boaters in the USA have slightly lower estimates of life jacket use (<10%), although these reflect one brief point of time onboard.⁶³⁸ Our reported life jacket use level was similar to observational studies in our region that have generally observed higher life jacket usage proportions (13%–17%) compared with rates of use in contemporaneous national studies.⁹³⁰³⁹ These higher rates in Washington State may be due to sustained local and statewide educational and legislative efforts to increase life jacket use over the past 20 years.⁸⁴⁰ It is also important to note that some of the associations we observed, although statistically significant, were modest. Our ability to examine some associations may have been hampered by small numbers for some variables. It is possible that there are other factors we did not explore that may better explain barriers to life jacket use.

In contrast to other safety behaviors such as helmet or seat belt use, fewer women reported always wearing a life jacket. This was unexpected and needs confirmation in future studies, given the observed higher levels of injury occurrence and risk-taking behaviors among males. It may also reflect uncontrolled confounding by boat size or passenger role (e.g., women may be less likely to waterski or fish).³⁰ One could speculate that women were more likely to report life jacket use levels accurately than males, but it is also possible that women were more likely to consider life jackets as uncomfortable or that they were less likely to have taken boater safety training classes, both of which were associated with life jacket use in our study.

Wearing a life jacket is a personal choice, and is not currently mandated for most adult recreational boaters and boating activities. Despite evidence that life jackets reduce the risk of drowning deaths,³ in the absence of a legal requirement, it is likely that many recreational boaters will choose not to wear them. Our results suggest this may be for many reasons, including personal comfort, lack of confidence in a life jacket’s life-saving ability, a possible perceived low risk onboard “larger” (16–25 foot) small recreational boats, and a perceived low risk of drowning due to a belief in one’s own swimming prowess. Based on this information, suggested strategies to increase life jacket use include engineering modifications to improve their comfort, and educational and marketing steps to increase accessibility to and awareness of inflatable life jackets. Efforts to alter risk perception are more complex. Although having had a boat safety class was not significantly associated with life jacket use, boating education classes present opportunities to increase awareness of life jacket effectiveness and to review state alcohol laws and penalties applicable to boaters.