<!DOCTYPE article
PUBLIC "-//NLM//DTD JATS (Z39.96) Journal Archiving and Interchange DTD with MathML3 v1.2 20190208//EN" "JATS-archivearticle1-mathml3.dtd">
<article xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:mml="http://www.w3.org/1998/Math/MathML" article-type="research-article"><?properties manuscript?><front><journal-meta><journal-id journal-id-type="nlm-journal-id">9510056</journal-id><journal-id journal-id-type="pubmed-jr-id">20569</journal-id><journal-id journal-id-type="nlm-ta">Inj Prev</journal-id><journal-id journal-id-type="iso-abbrev">Inj. Prev.</journal-id><journal-title-group><journal-title>Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention</journal-title></journal-title-group><issn pub-type="ppub">1353-8047</issn><issn pub-type="epub">1475-5785</issn></journal-meta><article-meta><article-id pub-id-type="pmid">30291154</article-id><article-id pub-id-type="pmc">6486438</article-id><article-id pub-id-type="doi">10.1136/injuryprev-2018-042931</article-id><article-id pub-id-type="manuscript">NIHMS1006754</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Challenges of enforcing cell phone use while driving laws among police: a qualitative study</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Rudisill</surname><given-names>Toni Marie</given-names></name><xref ref-type="aff" rid="A1">1</xref></contrib><contrib contrib-type="author"><name><surname>Baus</surname><given-names>Adam D</given-names></name><xref ref-type="aff" rid="A2">2</xref></contrib><contrib contrib-type="author"><name><surname>Jarrett</surname><given-names>Traci</given-names></name><xref ref-type="aff" rid="A2">2</xref></contrib></contrib-group><aff id="A1"><label>1</label>Department of Epidemiology, West Virginia University, Morgantown, West Virginia, USA</aff><aff id="A2"><label>2</label>Department of Social and Behavioral Sciences, West Virginia University, Morgantown, West Virginia, USA</aff><author-notes><fn fn-type="con" id="FN1"><p id="P1"><bold>Contributors</bold> TMR conceived the study. TMR and ADB and obtained the data. All authors processed the data, performed the analysis and drafted the manuscript. All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the manuscript preparation and approved the final version.</p></fn><corresp id="CR1"><bold>Correspondence to</bold> Dr Toni Marie Rudisill, Department of Epidemiology, West Virginia University, School of Public Health, Morgantown, WV 26506, USA; <email>trudisill@hsc.wvu.edu</email></corresp></author-notes><pub-date pub-type="nihms-submitted"><day>23</day><month>1</month><year>2019</year></pub-date><pub-date pub-type="epub"><day>05</day><month>10</month><year>2018</year></pub-date><pub-date pub-type="ppub"><month>12</month><year>2019</year></pub-date><pub-date pub-type="pmc-release"><day>01</day><month>12</month><year>2020</year></pub-date><volume>25</volume><issue>6</issue><fpage>494</fpage><lpage>500</lpage><!--elocation-id from pubmed: 10.1136/injuryprev-2018-042931--><abstract id="ABS1"><sec id="S1"><title>Background</title><p id="P2">Cell phone use while driving laws do not appear to be heavily enforced in the USA. This study seeks to gain law enforcements&#x02019; perspective and learn potential barriers to cell phone law enforcement.</p></sec><sec id="S2"><title>Methods</title><p id="P3">Qualitative interviews (ie, focus groups) were conducted with officers (N=19) from five West Virginia law enforcement agencies. The officers who participated were &#x0003e;18 years of age, sworn into their departments and employed in law enforcement for &#x0003e;1 year. Focus group sessions lasted 45&#x02013;60 min and followed a standardised, pilot-tested script. These sessions were audio recorded and transcribed. Qualitative content analysis was employed among three researchers to determine themes surrounding enforcement.</p></sec><sec id="S3"><title>Results</title><p id="P4">Four themes emerged including current culture, the legal system, the nature of police work and issues with prevention. Specific barriers to enforcement included cultural norms, lack of perceived support from courts/judges, different laws between states, the need for a general distracted driving law, unclear legislation, officers&#x02019; habits and perceived risk, wanting to maintain a positive relationship with the public, not being able to see the driver (impediments of vehicle design, time of day), phones having multiple functions and not knowing what drivers are actually doing, risk of crashing during traffic stops and lack of resources. Prevention activities were debated, and most felt that technological advancements implemented by cell phone manufacturers may deter use.</p></sec><sec id="S4"><title>Conclusions</title><p id="P5">Numerous barriers to cell phone law enforcement exist. Legislation could be amended to facilitate enforcement. Prevention opportunities exist to deter cell phone use while driving.</p></sec></abstract></article-meta></front><body><sec id="S5"><title>INTRODUCTION</title><p id="P6">Cell phone-related distracted driving has become a prevalent traffic safety threat in the USA as the vast majority of residents (&#x0003e;90%) own mobile devices<sup><xref rid="R1" ref-type="bibr">1</xref></sup> and many interact with them while driving.<sup><xref rid="R2" ref-type="bibr">2</xref></sup> A 2016 national survey of drivers found that in the 30 days prior to survey, 68% of respondents self-reported that they talked on a cell phone, 40% read a text message/email and 31% typed a text message/email while driving.<sup><xref rid="R2" ref-type="bibr">2</xref></sup></p><p id="P7">To discourage cell phone use among drivers, most states passed distracted driving legislation. As of March 2018, 49 states have at least one cell phone use while driving (CPWD) law.<sup><xref rid="R3" ref-type="bibr">3</xref></sup> Of these states, 47 ban all drivers from reading/sending text messages, while 15 states prohibit all drivers from engaging in hand-held cell phone conversations while driving.<sup><xref rid="R3" ref-type="bibr">3</xref></sup> Additionally, 38 states ban any cell phone use for young or novice drivers.<sup><xref rid="R3" ref-type="bibr">3</xref></sup> However, even if states pass such legislation, there is no guarantee that the public will abide by these laws or that these laws will be enforced by police.</p><p id="P8">Current research suggests that the enforcement of CPWD laws appear sparse.<sup><xref rid="R4" ref-type="bibr">4</xref>&#x02013;<xref rid="R8" ref-type="bibr">8</xref></sup> One study found that across nine states and the District of Columbia (DC), CPWD comprised 1% of all traffic citations written by police.<sup><xref rid="R4" ref-type="bibr">4</xref></sup> McCartt and Geary determined that hand-held cell phone violations characterised only 2% of all citations written by New York state police during the first 15 months after the handheld cell phone law was enacted.<sup><xref rid="R5" ref-type="bibr">5</xref></sup> McCartt and Hellinga reported that only 8% of DC&#x02019;s traffic citations were attributed to hand-held cell phone conversations in 2004&#x02013;2005.<sup><xref rid="R6" ref-type="bibr">6</xref></sup> Between 2006 and 2011, ~3% of all traffic violations issued in New Jersey were hand-held cell phone violations.<sup><xref rid="R7" ref-type="bibr">7</xref></sup> In Washington and North Carolina, citation rates for CPWD were very low compared with other traffic violations such as speeding and seat belt use.<sup><xref rid="R8" ref-type="bibr">8</xref></sup></p><p id="P9">It is unclear in the extant literature why law enforcement does not appear to write these citations often. Several studies suggested that it may be because this legislation is challenging for police to enforce. Researchers proposed that police may not be able to see if a driver is holding a cell phone while driving,<sup><xref rid="R6" ref-type="bibr">6</xref><xref rid="R9" ref-type="bibr">9</xref></sup> if a hands-free device is being used<sup><xref rid="R10" ref-type="bibr">10</xref></sup> or the age of the driver if the law has an age specification.<sup><xref rid="R10" ref-type="bibr">10</xref>&#x02013;<xref rid="R12" ref-type="bibr">12</xref></sup> Others suggested that officers may find the law discriminatory<sup><xref rid="R11" ref-type="bibr">11</xref></sup> or against cultural norms<sup><xref rid="R12" ref-type="bibr">12</xref></sup> and not write citations. Few have suggested that cell phone legislation is not written clearly and therefore hard to interpret and enforce.<sup><xref rid="R12" ref-type="bibr">12</xref>&#x02013;<xref rid="R14" ref-type="bibr">14</xref></sup> To the authors&#x02019; knowledge, no studies have actually consulted law enforcement to discern this information.</p><p id="P10">The purpose of this study was to gain a police officers&#x02019; perspective on enforcing CPWD legislation and potential barriers to enforcement through qualitative interviews (ie, focus groups). The study was conducted in West Virginia, which is one of the 15 states that has all three types of CPWD laws previously discussed; with the exception of the young driver all cell phone ban, these laws are primary enforced (ie, meaning drivers can be pulled over specifically for these offence).<sup><xref rid="R15" ref-type="bibr">15</xref><xref rid="R16" ref-type="bibr">16</xref></sup> West Virginia&#x02019;s laws are written broadly and prohibit drivers from engaging in text-based communication and require hands-free cell phone use. The law does permit drivers to use global positioning system (GPS) devices and to initiate/terminate hand-held phone conversations while driving. It also allows drivers to use cell phones in emergency situations. However, these exceptions are similar to other states&#x02019; legislation. Given the prevalence of CPWD, the findings could possibly inform or improve policy efforts to reduce motor vehicle injuries caused by cell phone-related distracted driving.</p></sec><sec id="S6"><title>METHODS</title><sec id="S7"><title>Study design and data collection</title><p id="P11">The researchers conducted five focus groups at police departments in West Virginia, USA. An average of four officers (total N=19) partook in each focus group, which lasted approximately 45&#x02013;60 min in duration. Focus groups were conducted in a private conference area at the participating police departments to ensure participant confidentiality and clear audio recording. Participation was voluntary. Informed consent and permission to audio record the session for transcription purposes was obtained from all study participants. Written permission to conduct the focus group at the police department was obtained from chief management of the agency. All focus groups were asked the same semi-structured, open-ended questions to allow for probing/follow-up questions, if needed.<sup><xref rid="R17" ref-type="bibr">17</xref></sup> The script used in the focus group sessions was pilot tested in an interview conducted with a former police officer; the script for the focus group sessions and remarks/rationale for the question are provided in the <xref rid="SD1" ref-type="supplementary-material">online supplementary appendix 1</xref>. Two researchers facilitated each focus group session; one researcher served as the facilitator and the other an observer for all focus groups. The observer audio recorded the session and documented any field notes/observations of the study participants. After the focus groups, the observer and facilitator discussed and summarised pertinent findings to aid with the analysis. To ensure validity, a member check was conducted at the end of each focus group.<sup><xref rid="R18" ref-type="bibr">18</xref></sup> The member check consisted of a summary of the focus group session/conversation that was written by the facilitator and sent via email to one member of the focus group for distribution to the other members generally within 3 days of the focus group. Any comments or discrepancies of the conversation were emailed back to the facilitator for clarification and incorporated into the analysis.</p></sec><sec id="S8"><title>Participant&#x02019;s eligibility and recruitment</title><p id="P12">Police departments and their respective officers were recruited via convenience sampling; the sampling frame consisted of any university, local, city, county or state police detachment. Chief management of the law enforcement agency (ie, Chief, Commander, Sherriff, etc) was initially contacted via phone and/or email and made aware of the study and its purpose. Permission was garnered from chief management of the police department to recruit and/or contact individual officers for participation in the study; the recruitment of officers most often occurred via email. To be eligible for inclusion, participants had to be: 18 years of age or older at time of recruitment, been employed and sworn into their department as an officer, was eligible at time of recruitment to write CPWD citations (ie, be a patrol officer or still go on active patrols) and have held their position for at least 1 year. All participants were male and had an average of 13 years (range: 2&#x02013;30 years) of experience in law enforcement. No other demographic information was collected to protect the identities of those who participated.</p></sec><sec id="S9"><title>Analysis</title><p id="P13">The audio tapes from focus group sessions were transcribed verbatim by a professional transcription service with all personally identifying information removed. To ensure accurate transcription, the audio recordings from focus group sessions were compared with the transcripts. NVivo V11 qualitative analysis software was used for all aspects of data management, including the searching, coding and categorisation of the data obtained from the focus group sessions. The data were analysed for themes surrounding CPWD and barriers to cell phone law enforcement using conventional content analysis. Conventional content analysis is often employed when little information or research exists on a particular phenomenon.<sup><xref rid="R19" ref-type="bibr">19</xref></sup> Three researchers were involved in the data analysis process. To minimise potential bias, one researcher who was not present during any focus group sessions was involved in the data analysis. The data analysis began with all three researchers thoroughly reading and re-reading the transcripts. Each researcher independently developed code words or phrases that labelled thoughts or concepts found in the transcripts. All researchers assembled and compared their initial coding schemes. A consensus was then reached on how thoughts or concepts found in the text should be coded.<sup><xref rid="R20" ref-type="bibr">20</xref></sup> These codes were then operationally defined and documented in a data dictionary.<sup><xref rid="R20" ref-type="bibr">20</xref><xref rid="R21" ref-type="bibr">21</xref></sup> After all transcripts were coded for these operationally defined codes, the research team reconvened. The operationally defined codes were sorted and collapsed into broader, more encompassing categories or subcategories of thoughts and concepts. A thematic map was drawn to help guide this process.<sup><xref rid="R22" ref-type="bibr">22</xref></sup> To ensure the reliability of the analysis, the researchers assessed the overall percentage of coding agreement between one another. This inter-rater reliability was evaluated using a Cohen&#x02019;s kappa statistic; reliability was considered adequate as the kappa statistic was between 0.8 and 1.0 (eg, &#x003ba;=0.96) which indicated excellent agreement between coders.<sup><xref rid="R23" ref-type="bibr">23</xref></sup> Once core themes were established, a final reading of the transcripts occurred to ensure that themes were adequately refined and accurately depicted the data.</p></sec></sec><sec id="S10"><title>RESULTS</title><p id="P14">Four overarching themes pertaining to the enforcement of CPWD laws emerged from the data collected (<xref rid="F1" ref-type="fig">figure 1</xref>). These overarching themes included: (1) current culture, (2) the legal system, (3) the nature of police work and (4) issues with prevention. Numerous primary and secondary subthemes materialised, which will be discussed along with the overarching themes.</p><sec id="S11"><title>Current culture</title><p id="P15">The current culture surrounding cell phones and CPWD appeared to be a challenge for many of the officers. Essentially, the officers are trying to enforce a law which restricts a behaviour that has become a social norm. Four subthemes pertaining to culture emerged during the focus groups and these were cell phone culture, prevalence of the behaviour, driver habits and driver risk perception. Most of the groups acknowledged that cell phones are part of American culture. Most people use them every day for a myriad of reasons, but mainly as a form of instant communication with their social networks. Thus, people are inherently dependent on their devices. To this effect, one officer stated:</p><disp-quote id="Q1"><p id="P16">People view this machine [cell phone] as an extension of themselves, really.</p></disp-quote><p id="P17">Another officer remarked:</p><disp-quote id="Q2"><p id="P18">...People are not very understanding of cell phone violations. Because like he said, I think we have moved to the point in our society where you, you just can&#x02019;t do without them.</p></disp-quote><p id="P19">Because cell phones are part of the culture, many people continue to use them even while driving. Thus, most officers acknowledged that CPWD is a prevalent and pervasive behaviour among drivers which complicates enforcement. As one officer commented:</p><disp-quote id="Q3"><p id="P20">If you&#x02019;re gonna enforce cell phone use, the way, the way it probably should be, you&#x02019;d never get a mile down the road. It would take you an hour. Because by the time you&#x02019;d stopped one car, you&#x02019;re ready to pull out, you&#x02019;d be stopping another one.</p></disp-quote><p id="P21">Because so many drivers interact with their phones, the officers remarked that certain behaviours have become almost habitual. For example, almost all groups acknowledged that many drivers routinely use their phones at traffic lights. The officers also noted that when they pull up beside other vehicles at traffic lights, many drivers will throw/drop their phones or try to conceal their cell phone use because many know they should not be engaging in the behaviour. Some officers revealed that a lot of drivers they pull over are just holding their phone, but not actually using it. One officer stated:</p><disp-quote id="Q4"><p id="P22">Some people just drive and hold their phones. Like, it is such a part of their body now they can&#x02019;t even let go.</p></disp-quote><p id="P23">Many of the officers indicated that CPWD is so commonplace that it may have altered drivers&#x02019; perception of risk. Several officers felt that drivers tend to underestimate the safety risk that it poses to themselves or others; many officers also felt that individuals tend to overestimate their ability to safely drive while using a cell phone. As two officers&#x02019; explained:</p><speech><speaker>Officer 1:</speaker><p id="P24">It&#x02019;s a danger nobody seems to accept as to how serious</p></speech><speech><speaker>Officer 2:</speaker><p id="P25">I agree. I think of it as a secondary thing, like, &#x02018;Aw, I know what I&#x02019;m doing,&#x02019; or &#x02018;I&#x02019;m not dangerous while I do it&#x02019;. And it&#x02019;s not the case. I can usually pick out a vehicle that&#x02019;s driving up the road in from of me and I say, &#x02018;I bet they&#x02019;re on their phone.&#x02019; When I get up to them, you see them [on their phone].</p></speech><p id="P26">Many officers felt that drivers&#x02019; perception of being apprehended for CPWD has also been skewed. Some of the officers commented that when they pull drivers over, many drivers appear defensive or annoyed. As one officer explained:</p><disp-quote id="Q5"><p id="P27">I think most people think it&#x02019;s like an issue of, &#x02018;This is my vehicle. I can do what I want in it.&#x02019; And that&#x02019;s the kind of the information that, without saying that, that&#x02019;s what their body language tells me.</p></disp-quote><p id="P28">The officer went on to say:</p><disp-quote id="Q6"><p id="P29">You guys correct me if I&#x02019;m wrong [speaking to the other officers in the group], the nonverbal [communication] I get back from people is that it&#x02019;s [CPWD], it&#x02019;s an unimportant thing. They think it is okay doing what they&#x02019;re doing.</p></disp-quote></sec><sec id="S12"><title>The legal system</title><p id="P30">The legal system was another overarching theme that heavily influenced how officers perceived the ability to enforce CPWD. Several subthemes emerged during the focus groups which included support from the court or judge, problems with how CPWD laws are enforced and written, different state laws and the need for a general distracted driving law.</p><p id="P31">An issue discussed in virtually all groups was the adjudication process. While officers write citations, it is ultimately up to a judge or court to decide if a driver should be convicted of the offence, if a fine is contested. Therefore, the officers must prove their case and the judge/court may or may not agree with the citation, which can be frustrating to the officers. One officer explained a recent encounter he had:</p><disp-quote id="Q7"><p id="P32">It&#x02019;s hard for us to enforce and the reason I say that...I can write all these people tickets for driving down the road on their phone, see them on their phone or have it up to their head or whatever, but, I&#x02019;ve seen in court, and I&#x02019;ve seen a judge throw it out because, it was actually my ticket at another department that I worked at, he said, &#x02018;Well, did you see his mouth moving?.&#x02019; No, I didn&#x02019;t see his mouth moving, but he had the phone up to his head, like, you know, like so. [The driver] tells me he&#x02019;s talking on the cell phone, but it got thrown out because I didn&#x02019;t see his mouth moving.</p></disp-quote><p id="P33">A second officer explained his frustration:</p><disp-quote id="Q8"><p id="P34">And what they&#x02019;re trying to do, or what they&#x02019;ve already done, is discourage a police officer from doing something which he feels is the right thing to do, and then the public or the system makes him feel like, &#x02018;Don&#x02019;t you have anything better to do?&#x02019; Well that&#x02019;s [enforcement is] what were supposed to do.</p></disp-quote><p id="P35">Another challenge discussed in all focus groups was problems with how CPWD laws are written. In most of the focus groups, officers discussed the issue with &#x02018;hands-free&#x02019; legislation. There are exceptions written into this law which allow drivers to perform certain activities such as dial phone numbers, input directions into GPS or make emergency calls. Drivers may know these exceptions and use this knowledge as an opportunity to mislead officers if they are at risk of receiving a hands-free ticket. Drivers may also legitimately be using their phone for one of the exceptions to the law, but officers and courts may have no way to discern the truth. GPS appears to be a major point of contention, especially if it involves a GPS application on a phone. One officer exemplified the problem with these exceptions and &#x02018;hands-free&#x02019; legislation:</p><disp-quote id="Q9"><p id="P36">You know, just because when you [make] exceptions it makes people go, &#x02018;Well, I mean I wasn&#x02019;t doing that. I was doing this [one of the exceptions] and I&#x02019;m allowed to do that.&#x02019;</p></disp-quote><p id="P37">Another officer quipped:</p><disp-quote id="Q10"><p id="P38">The exceptions need to go. Like I said, there&#x02019;s no difference inputting GPS and texting, zero difference.</p></disp-quote><p id="P39">Another officer explained what would help make this easier for enforcement:</p><disp-quote id="Q11"><p id="P40">If we get a true distracted driving, completely hands-free, no electronic devices in your hand whatsoever for anything.</p></disp-quote><p id="P41">The officers also all discussed how the current legislation is too narrowly focused. The laws do not permit drivers to send/read text-based messages or have hand-held phone conversations. The laws are somewhat vague and do not specify other phone activities, such as using phone applications, which could be equally distracting or dangerous. As one officer explained:</p><disp-quote id="Q12"><p id="P42">And a lot of time you&#x02019;ll find that state code&#x02019;s very vague, and what/how it says things. So, it&#x02019;s&#x02014;is scrolling through Facebook the same thing as texting, you know what I mean?</p></disp-quote><p id="P43">Law enforcement and first responders are exempt from the hands-free law and may use their phone while driving. This exception exists because these groups are often dispatched to emergencies by their cell phones or they use their cell phones to reduce congestion on the police radio. Focus group participants indicate that they perceive that the public, often unaware of this exception, will feel unfairly persecuted for the same behaviour. Officers, themselves, express varying opinions on this issue. In one exchange between two officers:</p><speech><speaker>Officer 1:</speaker><p id="P44">I don&#x02019;t feel guilty, but we should be held to the same standards as everyone else.</p></speech><speech><speaker>Officer 2:</speaker><p id="P45">Not in our nature of work. We just can&#x02019;t [not use cell phones]. There&#x02019;s, there&#x02019;s a lot of stuff you don&#x02019;t say over the radio. You just can&#x02019;t.</p></speech><p id="P46">The officers also mentioned that CPWD laws with age specifications may have limited utility. For example, young driver all cell phone bans do not permit drivers of certain ages (ie,&#x0003c;18) or licensure status (learner&#x02019;s permit or intermediate licenses) from using cell phones. Also, most officers explained that they rarely cite drivers under 18 years of age due to graduated drivers&#x02019; licensing laws which restrict their driving. As two officers explained the situation:</p><speech><speaker>Officer 1:</speaker><p id="P47">I mean, I don&#x02019;t know when he&#x02019;s driving down the road. I just see somebody driving a car. I stop them for distracted driving.</p></speech><speech><speaker>Officer 2:</speaker><p id="P48">Well, then he hands you the graduated driver license you know he&#x02019;s not supposed to do it.</p></speech><speech><speaker>Officer 1:</speaker><p id="P49">Oh okay, just like everybody else on the road, you&#x02019;re not supposed to be on your cell phone.</p></speech><p id="P50">Officers also expressed that drivers who travel across state borders are unaware of differences in state laws regarding CPWD. Thus, some behaviours, such as hand-held cell phone conversations, may or may not be permitted depending on the state. While states often erect signage at their borders indicating the idiosyncrasies of their traffic laws, this can be missed by drivers, which often results in traffic stops.</p><p id="P51">One officer explained:</p><disp-quote id="Q13"><p id="P52">And so, you know, you kinda gotta be a little lenient on that just because, hey, you know, they&#x02019;re not from here. Maybe it&#x02019;s not illegal there, you know what I mean...but, it&#x02019;s a judgement call, really.</p></disp-quote><p id="P53">The officers also discussed the need for a general distracted driving law. Many of them claimed that there are other distractions which are just as dangerous as cell phone use and the law should include these other behaviours. As one officer explicated:</p><disp-quote id="Q14"><p id="P54">I think the one thing that we [would] benefit from is an actual distraction driving law, because I mean, is it more distracting to have a cell phone than it is to have a dog right here [in your lap]. Or a hamburger or doing your makeup or reading the newspaper [while driving]?</p></disp-quote></sec><sec id="S13"><title>The nature of police work</title><p id="P55">The nature of a police officer&#x02019;s job can influence CPWD enforcement. The subthemes which arose during the focus groups were officers&#x02019; individual characteristics, physical/structural challenges and resources.</p><p id="P56">Policing is a multifaceted job. It involves numerous tasks such as responding to criminal complaints, performing investigations, reacting to emergency calls, completing paperwork and making court appearances. Consequently, officers often have to prioritise their responsibilities throughout their shift which can influence whether or not they are able to enforce traffic code, such as CPWD. As one officer stated:</p><disp-quote id="Q15"><p id="P57">The thing people don&#x02019;t realize is, that officer, sees that person talking on a phone or whatever, and they don&#x02019;t pull them over. Okay. They could be going to another call. Because, most of our calls, 90% of our calls, we don&#x02019;t run lights and siren to [respond to the situation].</p></disp-quote><p id="P58">Police often have some discretion in their work. Officers may enforce certain codes more or less than others. Some will write citations a certain way (ie, give warnings as opposed to tickets). These actions are based on numerous factors such as their personal habits, personal conviction or perceived risk that a behaviour poses to others in the community. One officer explained:</p><disp-quote id="Q16"><p id="P59">Some guys have a niche for different things. You know, I mean, some guys like to do that [enforce CPWD].</p></disp-quote><p id="P60">Another officer stated:</p><disp-quote id="Q17"><p id="P61">If I see them on their cell phone, they get a ticket [as opposed to a warning] because I consider it a serious traffic offense.</p></disp-quote><p id="P62">The perceived risk that a behaviour poses to others also influenced many officers. Interestingly, all groups stated the perception that drivers using cell phones are more dangerous than drunk drivers. As one officer explained:</p><disp-quote id="Q18"><p id="P63">I believe it&#x02019;s a good law. Um, I don&#x02019;t know if you&#x02019;ve ever experimented yourself and tried to look down at your cell phone while you&#x02019;re driving. But um, you know, your reaction time&#x02019;s one and a half seconds anyway. Then by the time you would do that, look at your phone, do that, look back up, you&#x02019;re talking three seconds. How far can you be down the road? You could be in a ditch, you could head-on with somebody, cause an accident...But, you know, probably we have a lot more accidents involving cell phone usage than what you do DUIs.</p></disp-quote><p id="P64">Another aspect that seemed to influence several officers was their relationship with the public. As one officer claimed:</p><disp-quote id="Q19"><p id="P65">Law enforcement can&#x02019;t have a worse public image in this country than it already does.</p></disp-quote><p id="P66">Therefore, this relationship with the public is something that some officers felt they must try to preserve. One officer explained one issue with enforcing CPWD because it is so commonplace.</p><disp-quote id="Q20"><p id="P67">I think it [enforcing CPWD], it engenders, my own opinion, is that it engenders ill will toward law enforcement because of what I&#x02019;ve just, we&#x02019;ve just explained. That these people feel as though they&#x02019;re being bothered. Like you&#x02019;re wronging them. If a guy&#x02019;s going 85 miles per hour in a 60, he knows he&#x02019;s going 85 in a 60. He understands that&#x02019;s probably way too fast. He understands that he&#x02019;s going way faster than everybody else. And when I see him do that and I stop him for that. ...Most people when they&#x02019;re doing something like that, they expect to get a ticket, okay? It&#x02019;s a risk reward for them. I want to get where I&#x02019;m going faster therefore, I&#x02019;m willing to do. And if I get caught, I get caught. So, but with this, that same guy that I stopped for doing this [CPWD], he&#x02019;s pissed. He has also passed those ten other people within the last two miles that were also doing this. But now he feels persecuted because I&#x02019;ve stopped him. Why didn&#x02019;t you stop them, right?</p></disp-quote><p id="P68">Besides individual characteristics, there were several physical/structural challenges that the officers identified which can make enforcing CPWD laws difficult. For example, the officers have to be able to see what the driver is doing. Therefore, numerous things can complicate this such as the time of day (ie, night), the design of the vehicle the officer is in or the driver is in, the way a driver&#x02019;s mirrors are positioned or even location/topography (ie, being in an elevated position). As one officer described the importance of being able to see a driver:</p><disp-quote id="Q21"><p id="P69">Imagine going to court and then being [on a] bench trial, them having you sit on the stand and testify that you know for 100% fact that they [the driver] were texting. Well, I can&#x02019;t prove that too much unless you&#x02019;re sitting beside them at the red light, but I can&#x02019;t prove without a doubt it was in his right hand [and] I saw it.</p></disp-quote><p id="P70">Cell phones are multifunctional. People can use their phones for a myriad of reasons such as to make calls, send texts, use applications, interact with the internet and email and music/song libraries. Sometimes it can be difficult or impossible for officers to see what drivers are actually doing on their phones. As one officer explained:</p><disp-quote id="Q22"><p id="P71">You know, even if I see someone going like this [rapid eye movements up and down as seen in the rearview mirror]. There is only two things that is&#x02014;it&#x02019;s Facebook or its Instagram. That&#x02019;s not GPS, that&#x02019;s not inputting a number, that&#x02019;s none of that. But I can&#x02019;t prove that they weren&#x02019;t inputting a number or making an emergency call.</p></disp-quote><p id="P72">An important issue that virtually all groups discussed was the ability to safely conduct a traffic stop. Sometimes they cannot pull someone over logistically because it could endanger themselves or other drivers. One officer described a common scenario:</p><disp-quote id="Q23"><p id="P73">Like, we just can&#x02019;t be pulling out in the, you know, traffic it&#x02019;s just unsafe. It&#x02019;s actually safer for them to be texting than for me to try and be weaving through cars and catching them.</p></disp-quote><p id="P74">Resources, such as officers&#x02019; time and staffing issues, can influence officers&#x02019; ability to enforce traffic laws such as CPWD. Virtually, all officers discussed federal highway safety grants that are given to states to enforce certain infractions such as CPWD. Most of the officers spoke positively about the grants because it gave them additional time, money and manpower (ie, man hours) to enforce CPWD. However, one group expressed some frustration with these grants because they perceived that the grant forces them to issue so many tickets within a specified time frame, which, they indicated felt like they were being asked to meet a quota; all the officers mentioned quotas are illegal. One officer explained why these grants are helpful:</p><disp-quote id="Q24"><p id="P75">So they&#x02019;re not you know as far as doing traffic enforcement 24&#x02013;7. No, they&#x02019;re patrol officers. They&#x02019;re mostly going to calls. And when the grants come out, these officers don&#x02019;t have to answer calls. Only thing you&#x02019;re doing is out there&#x02026;you&#x02019;re being paid by the federal government to watch for cell phone violations.</p></disp-quote></sec><sec id="S14"><title>Issues with prevention</title><p id="P76">Issues with prevention of CPWD was a theme across focus groups. Most of the officers were dubious that CPWD is something that could be completely eliminated or prevented. However, many officers acknowledged there were ways in which the behaviour could be reduced among drivers. The subthemes which emerged involved technological solutions, increasing penalties and driver education. There seemed to be a general agreeance among most groups that technology may be a more viable resolution to decrease CPWD than harsher penalties or driver education. One officer stated:</p><disp-quote id="Q25"><p id="P77">So, I don&#x02019;t think that through [higher] fines and, and laws you are going to be able to stop that [CPWD]. Hardware that [disables] the phone [so it] won&#x02019;t work is the only way people are going to curb that [CPWD].</p></disp-quote><p id="P78">Most groups suggested that cell phone manufacturers or carriers could design phones in such a way that certain features were disabled when a vehicle was in motion. As one officer shared:</p><disp-quote id="Q26"><p id="P79">...if all 50 states pass a law saying that cell phones cannot operate other than as a telephone in a moving vehicle, and Apple and Samsung are forced to make them. Then yes, that would prevent it [CPWD].</p></disp-quote><p id="P80">In almost all focus group sessions, increasing the penalties for CPWD citations was discussed. Most groups debated raising minimum fines, increasing points and possibly even licensure suspensions for CPWD citations. However, the officers were often ambivalent that harsher penalties would reduce CPWD as evident by an exchange between two officers:</p><speech><speaker>Officer 1:</speaker><p id="P81">I don&#x02019;t know, a $500 fine and 2 points on your license [for a cell phone violation]?</p></speech><speech><speaker>Officer 2:</speaker><p id="P82">People still commit murder and they know the penalty.</p></speech><p id="P83">When discussing penalties, most groups referenced driving under the influence (DUI) violations, which often result in exorbitantly high fines/penalties. As one officer stated:</p><disp-quote id="Q27"><p id="P84">You couldn&#x02019;t increase the fines or the penalties [for CPWD]. I mean the average DUI would cost someone roughly, what, eight or nine thousand dollars to go through the court process, all their fines, all their reinstatements, all that kind of stuff? Does it deter a lot of DUI&#x02019;s? No. Everybody still risks it.</p></disp-quote><p id="P85">Most officers seemed to agree that most drivers seem to know that they should not engage in CPWD. As one officer stated:</p><disp-quote id="Q28"><p id="P86">Uh, everybody knows at this point. I mean, it&#x02019;s just like drugs are bad. Everybody knows texting is bad. I mean, I don&#x02019;t think there is a kid out there that&#x02019;ll tell you texting and driving is a good thing, but [they will] make an excuse for why they did it.</p></disp-quote><p id="P87">Although, many officers believed there were some aspects of the law or even technologies to prevent CPWD in which the public could be more educated. For example, many officers mentioned how they do not believe the public knows that drivers are not permitted to be on a cell phone at a stop light or stop sign. One officer mentioned:</p><disp-quote id="Q29"><p id="P88">Sometimes I even wonder how many people actually know is illegal cause you can sit in traffic and there&#x02019;ll be four cars around you, like, where you can look right in their car and everybody&#x02019;s on their phones.</p></disp-quote><p id="P89">Additionally, the officers also mentioned how some drivers may not fully understand the term &#x02018;hands-free&#x02019; as many drivers they pull over think that they are permitted to hold a phone in their hand as long as it is on speaker. One officer recounted:</p><disp-quote id="Q30"><p id="P90">I&#x02019;ve actually had people say that, &#x02018;that I was, it was on speaker phone.&#x02019; I was like, &#x02018;Yeah, but it&#x02019;s still in your hands&#x02019;.</p></disp-quote><p id="P91">Officers expressed that drivers could be more educated about technologies which minimise hand-held cell phone use such as in-vehicle technology (ie, Bluetooth) or external hands-free devices or dashboard cell phone mounts. Several officers remarked that many drivers whom they pull over do not realise that their vehicles have hands-free technology or know how to use it. For example, one officer stated:</p><disp-quote id="Q31"><p id="P92">I&#x02019;ve asked people, &#x02018;This vehicle has Bluetooth, why didn&#x02019;t you use it?&#x02019; And they&#x02019;re like, &#x02018;I don&#x02019;t know what it is,&#x02019; or &#x02018;I don&#x02019;t know how to connect it.&#x02019;</p></disp-quote><p id="P93">Finally, related to the above discussion about first responder exemption, many of the groups discussed that the public may benefit from increased awareness that emergency services (ie, police, firemen, first responders) are permitted by law to engage in CPWD as it helps them communicate to dispatchers when responding to urgent calls.</p><disp-quote id="Q32"><p id="P94">This [the cell phone] is our lifeline to a lot of our dispatcher, to other units, and stuff like that. Our cars are completely Bluetooth now. So, most of us have a Bluetooth car or they&#x02019;ve purchased something for their selves to, to you know, to keep, combat people calling in, &#x02018;Hey, well why is that police officer on their on his phone?&#x02019; They don&#x02019;t know that there&#x02019;s an exemption for EMTs and stuff.</p></disp-quote></sec></sec><sec id="S15"><title>DISCUSSION</title><p id="P95">This analysis found that several challenges exist for officers when it comes to enforcing CPWD laws. Some of these challenges were previously postulated by researchers as the officers discussed physical/structural challenges, problems with current legislation and the current culture surrounding cell phones as barriers to enforcement.<sup><xref rid="R6" ref-type="bibr">6</xref><xref rid="R7" ref-type="bibr">7</xref><xref rid="R9" ref-type="bibr">9</xref>&#x02013;<xref rid="R14" ref-type="bibr">14</xref></sup> However, important barriers such as the nature of police work, including the responsibilities of the job, pulling drivers over in public, the relationship with the public, the functions of the phones or available resources were not previously identified. Also, the support from the courts/judge, different state laws, the need for a distracted driving law and specific problems with the legislation were also very important barriers to CPWD law enforcement. The literature regarding the relationship between police, citation issuance and traffic violations is extremely limited; thus, it is unknown if the identified barriers are unique just to CPWD or if they apply to other traffic safety violations as well (eg, seat belt or drunk driving violations). Previous studies have shown that police work is discretionary and officers often form habits in which they cite individuals based on their personal beliefs,<sup><xref rid="R24" ref-type="bibr">24</xref>&#x02013;<xref rid="R28" ref-type="bibr">28</xref></sup> which was seen in this study.</p><p id="P96">The findings of this analysis pose numerous policy implications. First, this study showed that improvements could likely be made to legislation. It was evident that some of the verbiage in the current CPWD laws could be amended to make enforcement easier for police. This could include enacting a general distracted driving law. It could also include removing the exceptions to the hands-free laws which permit activities such as dialling a phone number or inputting GPS. The laws could be made more encompassing to include all cell phone activities and not just be limited to prohibiting reading/sending text messages or hand-held cell phone conversations. Second, this analysis could help states that may be interested in passing or amending CPWD legislation. For example, most of the officers in this study felt young driver all cell phone bans had limited utility if there are already laws in place that prohibit these activities for all drivers. Additionally, laws which are restricted to a particular behaviour (such as texting only) may be fundamentally difficult for police to enforce. Also, states may want to consider neighbouring states&#x02019; legislation, especially if there is an abundance of interstate traffic. Third, it is evident that additional resources, such as more federal highway safety grants, benefit officers&#x02019; ability to enforce CPWD laws.</p><p id="P97">The findings of this analysis also had public health implications. As evident by the officers, CPWD is a pervasive and dangerous behaviour. It is evident that a culture change may be needed across the USA to dissuade this behaviour. However, effective interventions and best practices to reduce CPWD are lacking in the extant literature.<sup><xref rid="R29" ref-type="bibr">29</xref><xref rid="R30" ref-type="bibr">30</xref></sup> The findings of this study also showed that while prevention has its challenges, there are areas which could be examined as potential avenues to decrease CPWD. For example, technological solutions by cell phone carriers or vehicle manufacturers to reduce CPWD may be needed. Also, drivers could be more educated on certain aspects of the law. For example, campaigns to increase drivers&#x02019; knowledge of technology (ie, in-vehicle Bluetooth or the use of external hands-free devices such as cell phone mounts) could potentially lower CPWD. It may also be helpful to educate officers on what the law does and does not permit.</p></sec><sec id="S16"><title>LIMITATIONS</title><p id="P98">To the authors&#x02019; knowledge, this study is the first to gain law enforcements&#x02019; perspective on the enforceability of CPWD laws through qualitative interviews. However, there are several inherent limitations of this analysis. Because this was a convenience sample of officers from only one state, the views expressed may differ from officers in other areas or regions of the state or even other states. All participants were male; although, law enforcement is a male-dominated profession. Each states&#x02019; laws may have their unique nuances and are written differently. Those who chose to participate in the study may have differing views from those who did not participate. Nevertheless, the officers included in this analysis were from five different organisations, covered a wide geographic area and patrolled different types of areas (ie, rural and urban). Also, data saturation was reached after the third focus group and no new concepts/themes emerged.</p></sec><sec id="S17"><title>CONCLUSIONS</title><p id="P99">This study identified numerous barriers of cell phone law enforcement experienced by police. Four overarching themes emerged from the data, which included current culture, the legal system, the nature of police work and issues with prevention, along with numerous other sub-themes, which could inform the revision of laws. This study also offers substantive context which has been absent from the literature to date. Because drivers perception of enforcement can greatly alter their driving behaviour,<sup><xref rid="R31" ref-type="bibr">31</xref></sup> findings from this study could help to improve challenges in enforcement experienced by police and in effect create a safer environment for motorists.</p></sec><sec sec-type="supplementary-material" id="SM1"><title>Supplementary Material</title><supplementary-material content-type="local-data" id="SD1"><label>Data</label><media xlink:href="NIHMS1006754-supplement-Data.pdf" orientation="portrait" xlink:type="simple" id="d36e575" position="anchor"/></supplementary-material></sec></body><back><ack id="S18"><p id="P100"><bold>Funding</bold> TMR, AB and TJ all received support from the Centers of Disease Control and Prevention grant R49 CE002109. The funding agency had no role in the design of the study, collection, analysis or interpretation of the results or in the writing of this manuscript.</p></ack><fn-group><fn fn-type="COI-statement" id="FN2"><p id="P101"><bold>Competing interests</bold> None declared.</p></fn><fn id="FN3"><p id="P102"><bold>Patient consent</bold> Not required.</p></fn><fn id="FN4"><p id="P103"><bold>Ethics approval</bold> Institutional Review Board approval from West Virginia University, USA, was obtained for this project (protocol #1704562097).</p></fn><fn id="FN5"><p id="P104"><bold>Provenance and peer review</bold> Not commissioned; externally peer reviewed.</p></fn><fn id="FN6"><p id="P105"><bold>Data sharing statement</bold> No additional data available.</p></fn><fn id="FN7"><p id="P106">Additional material is published online only. To view please visit the journal online (<ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1136/injuryprev-2018&#x02013;042931">http://dx.doi.org/10.1136/injuryprev-2018-042931</ext-link>).</p></fn></fn-group><ref-list><title>REFERENCES</title><ref id="R1"><label>1</label><mixed-citation publication-type="web"><name><surname>Anderson</surname><given-names>M</given-names></name>, <year>2015</year>
<source>Technology device ownership 2015. Pew research center</source>. http://<comment><ext-link ext-link-type="uri" xlink:href="http://www.pewinternet.org/2015/10/29/technology-device-ownership-2015/">www.pewinternet.org/2015/10/29/technology-device-ownership-2015/</ext-link></comment> (<comment>accessed</comment> 12 Dec 2016).</mixed-citation></ref><ref id="R2"><label>2</label><mixed-citation publication-type="web"><collab>American Automobile Association Foundation for Traffic Safety</collab>, <year>2016</year>
<source>Traffic safety culture index</source>. <comment><ext-link ext-link-type="uri" xlink:href="https://aaafoundation.org/wp-content/uploads/2017/1&#x000bd;016TrafficSafetyCultureIndexReport.pdf">https://aaafoundation.org/wp-content/uploads/2017/1&#x000bd;016TrafficSafetyCultureIndexReport.pdf</ext-link></comment> (<comment>accessed</comment> 6 Mar 2018).</mixed-citation></ref><ref id="R3"><label>3</label><mixed-citation publication-type="web"><collab>Insurance Institute for Highway Safety</collab>, <year>2018</year>
<source>Distracted driving: cellphones and texting</source>. <comment><ext-link ext-link-type="uri" xlink:href="http://www.iihs.org/iihs/topics/laws/cellphonelaws?topicName=distracted-driving">http://www.iihs.org/iihs/topics/laws/cellphonelaws?topicName=distracted-driving</ext-link></comment> (<comment>accessed</comment> 4 Jan 2018).</mixed-citation></ref><ref id="R4"><label>4</label><mixed-citation publication-type="journal"><name><surname>Rudisill</surname><given-names>TM</given-names></name>, <name><surname>Zhu</surname><given-names>M</given-names></name>. <article-title>Who actually receives cell phone use while driving citations and how much are these laws enforced among states? A descriptive, cross-sectional study</article-title>. <source>BMJ Open</source>
<year>2016</year>;<volume>6</volume>:<fpage>e011381</fpage>.</mixed-citation></ref><ref id="R5"><label>5</label><mixed-citation publication-type="journal"><name><surname>McCartt</surname><given-names>AT</given-names></name>, <name><surname>Geary</surname><given-names>LL</given-names></name>. <article-title>Longer term effects of New York State&#x02019;s law on drivers&#x02019; handheld cell phone use</article-title>. <source>Inj Prev</source>
<year>2004</year>;<volume>10</volume>:<fpage>11</fpage>&#x02013;<lpage>15</lpage>.<pub-id pub-id-type="pmid">14760020</pub-id></mixed-citation></ref><ref id="R6"><label>6</label><mixed-citation publication-type="journal"><name><surname>McCartt</surname><given-names>AT</given-names></name>, <name><surname>Hellinga</surname><given-names>LA</given-names></name>. <article-title>Longer-term effects of Washington, DC, law on drivers&#x02019; handheld cell phone use</article-title>. <source>Traffic Inj Prev</source>
<year>2007</year>;<volume>8</volume>:<fpage>199</fpage>&#x02013;<lpage>204</lpage>.<pub-id pub-id-type="pmid">17497524</pub-id></mixed-citation></ref><ref id="R7"><label>7</label><mixed-citation publication-type="book"><name><surname>Maher</surname><given-names>A</given-names></name>, <name><surname>Ott</surname><given-names>P</given-names></name>. <source>Effects of New Jersey&#x02019;s cell phone/text ban</source>
<publisher-loc>Piscataway, NJ</publisher-loc>: <publisher-name>Rutgers University</publisher-name>, <year>2013</year>: <fpage>1</fpage>&#x02013;<lpage>39</lpage>.</mixed-citation></ref><ref id="R8"><label>8</label><mixed-citation publication-type="book"><collab>American Automobile Association Foundation for Traffic Safety</collab>. <source>Violations and enforcement of graduated driver licensing restrictions in North Carolina and Washington state</source>. <publisher-loc>Washington DC</publisher-loc>: <publisher-name>AAA Foundation for Traffic Safety</publisher-name>, <year>2014</year>: <fpage>1</fpage>&#x02013;<lpage>10</lpage>.</mixed-citation></ref><ref id="R9"><label>9</label><mixed-citation publication-type="journal"><name><surname>Abouk</surname><given-names>R</given-names></name>, <name><surname>Adams</surname><given-names>S</given-names></name>. <article-title>Texting bans and fatal accidents on roadways: do they work? Or do drivers just react to announcements of bans?</article-title>
<source>Am Econ J Appl Econ</source>
<year>2013</year>;<volume>5</volume>:<fpage>179</fpage>&#x02013;<lpage>99</lpage>.</mixed-citation></ref><ref id="R10"><label>10</label><mixed-citation publication-type="journal"><name><surname>Foss</surname><given-names>RD</given-names></name>, <name><surname>Goodwin</surname><given-names>AH</given-names></name>, <name><surname>McCartt</surname><given-names>AT</given-names></name>, <etal/>
<article-title>Short-term effects of a teenage driver cell phone restriction</article-title>. <source>Accid Anal Prev</source>
<year>2009</year>;<volume>41</volume>:<fpage>419</fpage>&#x02013;<lpage>24</lpage>.<pub-id pub-id-type="pmid">19393787</pub-id></mixed-citation></ref><ref id="R11"><label>11</label><mixed-citation publication-type="journal"><name><surname>Lim</surname><given-names>SH</given-names></name>, <name><surname>Chi</surname><given-names>J</given-names></name>. <article-title>Are cell phone laws in the U.S. effective in reducing fatal crashes involving young drivers?</article-title>
<source>Transport Policy</source>
<year>2013</year>;<volume>27</volume>:<fpage>158</fpage>&#x02013;<lpage>63</lpage>.</mixed-citation></ref><ref id="R12"><label>12</label><mixed-citation publication-type="journal"><name><surname>Rudisill</surname><given-names>TM</given-names></name>, <name><surname>Zhu</surname><given-names>M</given-names></name>. <article-title>The association between states&#x02019; texting regulations and the prevalence of texting while driving among U.S. high school students</article-title>. <source>Ann Epidemiol</source>
<year>2015</year>;<volume>25</volume>:<fpage>888</fpage>&#x02013;<lpage>93</lpage>.<pub-id pub-id-type="pmid">26688117</pub-id></mixed-citation></ref><ref id="R13"><label>13</label><mixed-citation publication-type="journal"><name><surname>Jamson</surname><given-names>SL</given-names></name>. <article-title>What impact does legislation have on drivers&#x02019; in-vehicle use of nomadic devices?</article-title>
<source>Transp Res Part F Traffic Psychol Behav</source>
<year>2013</year>;<volume>16</volume>:<fpage>138</fpage>&#x02013;<lpage>50</lpage>.</mixed-citation></ref><ref id="R14"><label>14</label><mixed-citation publication-type="journal"><name><surname>Jessop</surname><given-names>G</given-names></name>
<article-title>Who&#x02019;s on the line? Policing and enforcing laws relating to mobile phone use while driving</article-title>. <source>Int J Law Crime Justice</source>
<year>2008</year>;<volume>36</volume>:<fpage>135</fpage>&#x02013;<lpage>52</lpage>.</mixed-citation></ref><ref id="R15"><label>15</label><mixed-citation publication-type="web"><collab>West Virginia State Senate</collab>, <year>2012</year>
<source>Senate bill 211. West Virginia state legislature</source>. <comment><ext-link ext-link-type="uri" xlink:href="http://www.wvlegislature.gov/Bill_Text_HTML/2012_SESSIONS/RS/bills/SB211%20SUB2%20enr.pdf">http://www.wvlegislature.gov/Bill_Text_HTML/2012_SESSIONS/RS/bills/SB211%20SUB2%20enr.pdf</ext-link></comment> (<comment>accessed</comment> 18 Mar 2014).</mixed-citation></ref><ref id="R16"><label>16</label><mixed-citation publication-type="web"><collab>West Virginia State Senate</collab>, <year>2016</year>
<source>Senate bill 219. West Virginia state legislature</source>. <comment><ext-link ext-link-type="uri" xlink:href="http://www.wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=SB219%20SUB2%20enr.htm&#x00026;yr=2006&#x00026;sesstype=RS&#x00026;i=219">http://www.wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=SB219%20SUB2%20enr.htm&#x00026;yr=2006&#x00026;sesstype=RS&#x00026;i=219</ext-link></comment> (<comment>accessed</comment> 18 Mar 2014).</mixed-citation></ref><ref id="R17"><label>17</label><mixed-citation publication-type="web"><name><surname>Krueger</surname><given-names>R</given-names></name>, <year>2002</year>
<source>Designing and conducting focus group interviews</source>. <comment><ext-link ext-link-type="uri" xlink:href="http://www.eiu.edu/~ihec/Krueger-FocusGroupInterviews.pdf">http://www.eiu.edu/~ihec/Krueger-FocusGroupInterviews.pdf</ext-link></comment> (<comment>accessed</comment> 7 Jun 2016).</mixed-citation></ref><ref id="R18"><label>18</label><mixed-citation publication-type="journal"><name><surname>Birt</surname><given-names>L</given-names></name>, <name><surname>Scott</surname><given-names>S</given-names></name>, <name><surname>Cavers</surname><given-names>D</given-names></name>, <etal/>
<article-title>Member checking</article-title>. <source>Qualitative Health Research</source>
<year>2016</year>;<volume>26</volume>:<fpage>1802</fpage>&#x02013;<lpage>11</lpage>.<pub-id pub-id-type="pmid">27340178</pub-id></mixed-citation></ref><ref id="R19"><label>19</label><mixed-citation publication-type="journal"><name><surname>Hsieh</surname><given-names>HF</given-names></name>, <name><surname>Shannon</surname><given-names>SE</given-names></name>. <article-title>Three approaches to qualitative content analysis</article-title>. <source>Qual Health Res</source>
<year>2005</year>;<volume>15</volume>:<fpage>1277</fpage>&#x02013;<lpage>88</lpage>.<pub-id pub-id-type="pmid">16204405</pub-id></mixed-citation></ref><ref id="R20"><label>20</label><mixed-citation publication-type="web"><name><surname>Strauss</surname><given-names>A</given-names></name>, <name><surname>Corbin</surname><given-names>J</given-names></name>, <source>Grounded theory methodology, 1994. Handbook of qualitative research</source>. <comment><ext-link ext-link-type="uri" xlink:href="https://www.mheducation.co.uk/openup/chapters/9780335244492.pdf">https://www.mheducation.co.uk/openup/chapters/9780335244492.pdf</ext-link></comment> (<comment>accessed</comment> 4 Jan 2018).</mixed-citation></ref><ref id="R21"><label>21</label><mixed-citation publication-type="journal"><name><surname>Bradley</surname><given-names>EH</given-names></name>, <name><surname>Curry</surname><given-names>LA</given-names></name>, <name><surname>Devers</surname><given-names>KJ</given-names></name>. <article-title>Qualitative data analysis for health services research: developing taxonomy, themes, and theory</article-title>. <source>Health Serv Res</source>
<year>2007</year>;<volume>42</volume>:<fpage>1758</fpage>&#x02013;<lpage>72</lpage>.<pub-id pub-id-type="pmid">17286625</pub-id></mixed-citation></ref><ref id="R22"><label>22</label><mixed-citation publication-type="journal"><name><surname>Braun</surname><given-names>V</given-names></name>, <name><surname>Clarke</surname><given-names>V</given-names></name>. <article-title>Using thematic analysis in psychology</article-title>. <source>Qual Res Psychol</source>
<year>2006</year>;<volume>3</volume>:<fpage>77</fpage>&#x02013;<lpage>101</lpage>.</mixed-citation></ref><ref id="R23"><label>23</label><mixed-citation publication-type="journal"><name><surname>Cohen</surname><given-names>J</given-names></name>
<article-title>A coefficient of agreement for nominal scales</article-title>. <source>Educ Psychol Meas</source>
<year>1960</year>;<volume>20</volume>:<fpage>37</fpage>&#x02013;<lpage>46</lpage>.</mixed-citation></ref><ref id="R24"><label>24</label><mixed-citation publication-type="journal"><name><surname>Brown</surname><given-names>RA</given-names></name>, <name><surname>Frank</surname><given-names>J</given-names></name>. <article-title>Police-citizen encounters and field citations</article-title>. <source>Policing</source>
<year>2005</year>;<volume>28</volume>:<fpage>435</fpage>&#x02013;<lpage>54</lpage>.</mixed-citation></ref><ref id="R25"><label>25</label><mixed-citation publication-type="journal"><name><surname>Engel</surname><given-names>RS</given-names></name>, <name><surname>Calnon</surname><given-names>JM</given-names></name>. <article-title>Examining the influence of drivers&#x02019; characteristics during traffic stops with police: results from a national survey</article-title>. <source>Justice Quarterly</source>
<year>2004</year>;<volume>21</volume>:<fpage>49</fpage>&#x02013;<lpage>90</lpage>.</mixed-citation></ref><ref id="R26"><label>26</label><mixed-citation publication-type="journal"><name><surname>Johnson</surname><given-names>RR</given-names></name>. <article-title>Management influences on officer traffic enforcement productivity</article-title>. <source>International Journal of Police Service and Management</source>
<year>2005</year>;<volume>8</volume>:<fpage>205</fpage>&#x02013;<lpage>17</lpage>.</mixed-citation></ref><ref id="R27"><label>27</label><mixed-citation publication-type="journal"><name><surname>Mastrofski</surname><given-names>SD</given-names></name>, <name><surname>Ritti</surname><given-names>RR</given-names></name>, <name><surname>Hoffmaster</surname><given-names>D</given-names></name>. <article-title>Organizational determinants of police discretion: the case of drinking-driving</article-title>. <source>J Crim Justice</source>
<year>1987</year>;<volume>15</volume>:<fpage>387</fpage>&#x02013;<lpage>402</lpage>.</mixed-citation></ref><ref id="R28"><label>28</label><mixed-citation publication-type="journal"><name><surname>Schafer</surname><given-names>JA</given-names></name>, <name><surname>Mastrofski</surname><given-names>SD</given-names></name>. <article-title>Police leniency in traffic enforcement encounters: exploratory findings from observations and interviews</article-title>. <source>J Crim Justice</source>
<year>2005</year>;<volume>33</volume>:<fpage>225</fpage>&#x02013;<lpage>38</lpage>.</mixed-citation></ref><ref id="R29"><label>29</label><mixed-citation publication-type="journal"><name><surname>Coben</surname><given-names>JH</given-names></name>, <name><surname>Zhu</surname><given-names>M</given-names></name>. <article-title>Keeping an eye on distracted driving</article-title>. <source>JAMA</source>
<year>2013</year>;<volume>309</volume>:<fpage>877</fpage>&#x02013;<lpage>8</lpage>.<pub-id pub-id-type="pmid">23462782</pub-id></mixed-citation></ref><ref id="R30"><label>30</label><mixed-citation publication-type="journal"><name><surname>Buckley</surname><given-names>L</given-names></name>, <name><surname>Chapman</surname><given-names>RL</given-names></name>, <name><surname>Sheehan</surname><given-names>M</given-names></name>. <article-title>Young driver distraction: state of the evidence and directions for behavior change programs</article-title>. <source>J Adolesc Health</source>
<year>2014</year>;<volume>54</volume>(<issue>5 Suppl</issue>):<fpage>S16</fpage>&#x02013;<lpage>21</lpage>.<pub-id pub-id-type="pmid">24759436</pub-id></mixed-citation></ref><ref id="R31"><label>31</label><mixed-citation publication-type="journal"><name><surname>Stanojevl&#x00107;</surname><given-names>P</given-names></name>, <name><surname>Jovanovi&#x00107;</surname><given-names>D</given-names></name>, <name><surname>Lajunen</surname><given-names>T</given-names></name>. <article-title>Influence of traffic enforcement on the attitudes and behavior of drivers</article-title>. <source>Accid Anal Prev</source>
<year>2013</year>;<volume>52</volume>:<fpage>29</fpage>&#x02013;<lpage>38</lpage>.<pub-id pub-id-type="pmid">23298706</pub-id></mixed-citation></ref></ref-list></back><floats-group><fig id="F1" orientation="portrait" position="float"><label>Figure 1</label><caption><p id="P107">Overarching themes and subthemes which emerged during the focus group sessions. Bulleted items (&#x025cf;) are primary subthemes and (--) indicates secondary subthemes.</p></caption><graphic xlink:href="nihms-1006754-f0001"/></fig><boxed-text id="BX1" position="float" orientation="portrait"><sec id="S19"><title>What is already known on the subject</title><list list-type="bullet" id="L1"><list-item><p id="P108">Cell phone use while driving does not appear to be heavily enforced in the USA.</p></list-item><list-item><p id="P109">Researchers suggest that cell phone use while driving may be difficult for police to enforce.</p></list-item><list-item><p id="P110">No studies have sought law enforcements&#x02019; perspective on cell phone use while driving.</p></list-item></list></sec><sec id="S20"><title>What this study adds</title><list list-type="bullet" id="L2"><list-item><p id="P111">The officers revealed numerous barriers to enforcing cell phone use while driving.</p></list-item><list-item><p id="P112">Existing laws could be strengthened or a general distracted driving law enacted.</p></list-item><list-item><p id="P113">Technological advancements or even directed education on specific aspects of the law could be viable for prevention.</p></list-item></list></sec></boxed-text></floats-group></article>