There is extraordinary exposure in the United States to the risks of injury and death from motor vehicle accidents. More than 80 percent of all households own passenger cars or light trucks, and each of these is driven an average of more than 11,000 miles each year. Almost one-half of fatally injured drivers have a blood alcohol concentration (BAC) of 0.1 percent or higher. For the average adult, over five ounces of 80 proof spirits would have to be consumed over a short period of time to attain these levels. A third of drivers who have been drinking, but fewer than 4 percent of all drivers, demonstrate these levels. Although less than 1 percent of drivers with BACs of 0.1 percent or more are involved in fatal crashes, the probability of their involvement is 27 times higher than for those without alcohol in their blood. There are a number of different approaches to reducing injuries in which intoxication plays a role. Based on the observation that excessive consumption correlates with the total alcohol consumption of a country's population, it has been suggested that higher taxes on alcohol would reduce both. While the heaviest drinkers would be taxed the most, anyone who drinks at all would be penalized by this approach. To make drinking and driving a criminal offense is an approach directed only at intoxicated drivers. In some states, the law empowers police to request breath tests of drivers cited for any traffic offense and elevated BAC can be the basis for arrest. The National Highway Traffic Safety Administration estimates, however, that even with increased arrests, there are about 700 violations for every arrest. At this level there is little evidence that laws serve as deterrents to driving while intoxicated. In Britain, motor vehicle fatalities fell 25 percent immediately following implementation of the Road Safety Act in 1967. As Britishers increasingly recognized that they could drink and not be stopped, the effectiveness declined, although in the ensuing three years the fatality rate seldom reached that observed in the seven years prior to the Act. Whether penalties for driving with a high BAC or excessive taxation on consumption of alcoholic beverages will deter the excessive drinker responsible for most fatalities is unclear. In part, the answer depends on the extent to which those with high BACs involved in crashes are capable of controlling their intake in response to economic or penal threat. Therapeutic programs which range from individual and group counseling and psychotherapy to chemotherapy constitute another approach, but they have not diminished the proportion of accidents in which alcohol was a factor. In the few controlled trials that have been reported there is little evidence that rehabilitation programs for those repeatedly arrested for drunken behavior have reduced either the recidivism or crash rates. One thing is clear, however: unless we deal with automobile and highway safety and reduce accidents in which alcoholic intoxication plays a role, many will continue to die.