J. Sleep Res.

(2010) 19, 578584

doi: 10.1111/j.1365-2869.2009.00818.x

Sleep and driving

Sleepiness, near-misses and driving accidents among a representative population of French drivers
PATRICIA SAGASPE1,2, JACQUES TAILLARD2,3, VIRGINIE BAYON4, EMMANUEL LAGARDE5, NICHOLAS MOORE6, JACQUES BOUSSUGE7, G U I L L A U M E C H A U M E T 2 , B E R N A R D B I O U L A C 3 and P I E R R E P H I L I P 2 , 3
1 INRETS-LCPC, LEPSIS, Paris, 2GENPPHASS, CHU Bordeaux, Bordeaux, 3CNRS UMR-5227, Universite Bordeaux 2, Bordeaux, 4Hopital Hotel-Dieu, Paris, 5INSERM U897, ISPED, Universite Bordeaux 2, Bordeaux, 6INSERM U657, Universite Bordeaux 2, Bordeaux and 7ASFA, Paris, France

Accepted in revised form 28 October 2009; received 12 August 2009

SUMMARY

Study objectives were to determine the prevalence of sleepy driving accidents and to explore the factors associated with near-miss driving accidents and actual driving accidents in France. An epidemiological survey based on telephone interviews was conducted on a representative sample of French drivers. The questionnaire included sociodemographics, driving and sleep disorder items, and the Epworth sleepiness scale. Of 4774 drivers (response rate: 86%), 28% experienced at least one episode of severe sleepiness at the wheel (i.e. requiring to stop driving) in the previous year; 11% of drivers reported at least one near-miss accident in the previous year (46% sleep-related); 5.8% of drivers reported at least one accident, 5.2% of these being sleep related (an estimate of 90 000 sleep-related accidents per year in France). Sleepy driving accidents occurred more often in the city (53.8%), during short trips (84.6%) and during the day (84.6%). Using logistic regression, the best predictive factor for near-misses was the occurrence of at least one episode of severe sleepiness at the wheel in the past year [odds ratio (OR) 6.50, 95% condence interval (CI), 5.208.12, P < 0.001]. The best predictive factors for accidents were being young (1830 years; OR 2.13, 95% CI, 1.51 3.00, P < 0.001) and experiencing at least one episode of severe sleepiness at the wheel (OR 2.03, 95% CI, 1.572.64, P < 0.001). Sleepiness at the wheel is a risk factor as important as age for trac accidents. Near-misses are highly correlated to sleepiness at the wheel and should be considered as strong warning signals for future accidents. keywords accidents, age, epidemiology, french drivers, near-misses, sleepiness

INTRODUCTION Daytime sleepiness is widespread and has a negative impact on everyday life (Ohayon et al., 1997). Sleepiness can be dened as diculty in remaining awake even while carrying out activities (Dement and Carskadon, 1982). Epidemiological studies from the 1990s showed that fatigue and sleep-related accidents represent up to 20% of all trac accidents in industrial societies (Connor et al., 2002; Horne
Correspondence: Pierre Philip, MD, PhD, Universite Bordeaux 2, CNRS UMR-5227, GENPPHASS et Clinique du Sommeil (CHU Pellegrin), Place Amelie Raba-Leon, 33076 Bordeaux Cedex, France. Tel.: 33 5 57 82 01 73; fax: 33 5 57 82 00 38; e-mail: pr.philip@free.fr

and Reyner, 1995; Philip et al., 2001). Trac accidents at work or during the trip from work to home are a major cause of injury and death among workers (Barger et al., 2005; Harrison et al., 1993; Personick and Mushinski, 1997). Though drowsiness has been identied as the reason behind fatal road crashes and many industrial accidents (Connor et al., 2001b; Hakkanen and Summala, 2000, 2001; Mitler et al., 1988, 1997), many people drive when their alertness is at its lowest level and seem not to be concerned by public health campaigns alerting drivers about the risk of sleepiness at the wheel (Fletcher et al., 2005; Nabi et al., 2006). Experimental studies have been conducted to assess the impact of sleepiness at the wheel on driving performance. It has
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been demonstrated that healthy subjects driving in the middle of the night present major driving impairment related to circadian and homeostatic pressure (Philip et al., 2006), and that extended driving impairs nocturnal driving performances (Sagaspe et al., 2008). Many drivers are also patients aected by sleep disorders and have to manage deteriorated driving skills (Sagaspe et al., 2007). A recent 100-car naturalistic driving study using questionnaires about driver sleep habits and instrumented vehicles with video-recording for 1 year found that 12% of crashes (and 10% of near-crashes) were related to drowsiness (Dingus et al., 2006). Drowsy driving crashes tend to occur late at night when the circadian physiological sleep pressure is at its highest (Mitler et al., 1997). They also tend to occur on major highways at higher speeds leading to greater morbidity and they disproportionately involve young men (as do motor vehicle crashes in general; Horne and Reyner, 1995; Pack et al., 1995). In France, fatigue has been studied as a road trac crash risk factor (Philip et al., 2001), but data on the role of sleepiness in the burden of road accidents in this country are missing. France has decreased drastically its accidental rate from 8000 deaths per year in 2000 to 4800 in 2008 (Observatoire ` National Interministeriel de Securite Routiere (ONISR), 2008). Behavioral factors like sleepiness start being considered as future targets to reduce death and injuries on French roads. Following a national campaign directed by the French Ministry of Transport on the risk of sleep-related accidents, the French Highway Association (Association des Societes Francaise dAutoroute, ASFA), a not-for-prot foundation whose mission is to provide information about highway accidents and prevent them, commissioned our team to conduct a study on sleepiness at the wheel in order to inform and educate drivers via public campaigns. We investigated driving accidents and near-miss accidents using data extracted from a self-reported telephone-based survey of a representative sample of French drivers (n = 5000) in order to: (1) evaluate the prevalence of daytime sleepiness and prevalence of self-reported sleepy driving accidents; and (2) test the associations of demographic, driving, behaviors and sleep disorders variables with both self-reported near-miss accidents and actual driving accidents.

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MATERIALS AND METHODS Sample Association des Societes Francaise dAutoroute provided our research team with access to a telephone database of citizens representative of the population of French drivers. Out of 18 million telephone numbers (French homes base) of the society Pages Jaunes Marketing Service, 20 846 telephone numbers were randomly selected according to some dened quotas representative of the national statistics on French drivers of personal vehicles: department, age, gender, type of home and socio-professional status. From October to November 2007, 5000 interviews were obtained by telephone
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from this selected base (5555 drivers were contacted and 5000 accepted to be interviewed). We eliminated an extra 226 questionnaires with missing or inappropriate responses, and we ran our analyses on a sample of 4774 drivers (response rate: 86%). Our team prepared a specic telephone questionnaire designed to collect information from this large cohort of French drivers about the prevalence of daytime sleepiness and prevalence of self-reported sleepy driving accidents, and contribution of demographic, driving, behaviors and sleep disorders variables in near-misses and accidents. A near-miss driving accident was dened as an event that had not caused any harm and therefore had limited immediate impact (e.g. inappropriate line crossing). A driving accident was dened only if material damage or physical injury occurred. A questionnaire took a mean of 10 min to be completed. The questionnaires were completed by 30 interviewers operating for an independent company specializing in phone-based medical studies. To minimize potential bias, these interviewers were overseen by supervisors and a psychologist specially trained by a sleep specialist of our team working on sleepiness at the wheel. We, for instance, clearly explained to the interviewers the dierence between fatigue and sleepiness at the wheel. The rationale of the study and the proper strategy were particularly emphasized. Volunteers had to respond to the following. 1. Thirty-one questions covering information on gender, age, body mass index (BMI), marital status, profession and driving habits. 2. Two questions exploring the occurrence of near-misses and driving accidents. 3. A set of 10 questions previously used in an epidemiological survey (Philip et al., 1999) exploring frequency and conditions where sleepiness at the wheel aected drivers. Six questions explored the consumption of alcohol, coee and caeinated beverages. The potential eects on alertness of coee and taking a nap were also investigated to explore countermeasures to sleepiness. 4. Specic questions from the Basic Nordic Sleep Questionnaire (Partinen and Gislason, 1995) to explore the snoring frequency. 5. The Epworth Sleepiness Scale (ESS; Johns, 1991) to explore excessive daytime somnolence. The ESS is an eight-item questionnaire designed to evaluate the subjects likelihood of falling asleep in common situations. 6. Patients were also asked if they had ever been diagnosed and treated for sleep disorders [obstructive sleep apnoea syndrome (OSAS), restless legs syndrome (RLS), insomnia, narcolepsy hypersomnia] or psychiatric disorders (anxiety or depression). Statistical analyses Quantitative variables were expressed as mean and standard deviation (SD), and qualitative variables were expressed as relative frequency.

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Table 1 Demographic characteristics of the 4774 respondents Characteristics Age (years) (%) 1830 3150 5165 >65 Female (%) BMI (kg m)2) Marital status (%) Married Single Separated or divorced Missing Number of children Professional status (%) Farmers Artisans Senior executive Middle management Employees Working class Retired Non-worker With a job (%) Work (%) Diurnal work Nocturnal work Shift work Missing Time of work per week (h) Main reasons for driving on road (%) Homework Professional reason Hobbies Shopping Weekend Holidays None Licence (years) Frequency of driving a car (%) Once or more per day Once or more per week Once or more per month Once or more per year Missing Kilometers driven per year (%) 05000 500010 000 10 00015 000 15 00025 000 25 00040 000 >40 000 Missing Percentage of driving between 00:00 and 06:00 hours Self-considered as professional drivers (%) BMI, body mass index. Percent or Mean SD 12.7 43.8 27.7 15.8 54.3 24.4 4.2 72.1 14.6 11.9 1.4 1.8 1.3 1.9 3.1 8.5 15.0 19.5 16.4 26.0 9.6 59.5 87.4 2.8 9.8 0 37.5 10.6 52.3 7.4 30.6 7.9 0.6 0.4 0.8 26.2 14.0 70.0 27.9 1.2 0.3 0.6 15.1 20.5 21.7 24.5 11.8 5.6 0.8 11.8 7.6 11.5

For regression analyses, all variables associated with driving accidents and near-miss driving accidents were initially examined separately using univariate models. Time since drivers licence (years), gender, age, BMI (kg m)2), marital status, professional driver, ESS scores, pathologies, stimulant eect of coee, tea or cola, stimulant eect of nap, severe sleepiness at the wheel needing to stop and near-miss accidents during the previous year were submitted as independent variables. Years of detention of a driving licence were categorized by period of 10 years of driving; age was classied into 1830, 3150, 5165 and >65 years; BMI was analysed as a continuous variable; marital status was categorized as single, married, separated and divorced or widowed; professional driver was dichotomized into yes or no; ESS scores were classied into 010 or >11; pathologies were classied into OSAS, RLS, insomnia, anxietydepression, narcolepsy hypersomnia, multi-pathologies and without sleep pathology; stimulant eect of coee, tea or cola was dichotomized into yes or no; stimulant eect of nap was dichotomized into yes or no; severe sleepiness at the wheel requiring to stop was dichotomized into yes or no; and near-miss accident during the previous year was dichotomized into yes or no. Multivariate logistic regression analyses were performed for all variables that showed a signicant association in univariate models (P < 0.05) to control confounding factors and to determine the main correlates. The referent group for each factor was selected as drivers supposed to be at the lowest risk for near-misses or accidents. A signicant association was found between driving accidents and the following variables: licence, age, marital status, professional driver, ESS scores, pathologies, stimulant eect of coee, tea or cola, and severe sleepiness at the wheel needing to stop. As near-miss driving accidents is a well-known predictive variable for driving accidents (Powell et al., 2007) and in order to reduce co-linearity with severe sleepiness episodes at the wheel, we decided to not include in the model this specic variable. A signicant association was found between near-miss driving accidents and the following variables: licence, gender, age, BMI, marital status, professional driver, ESS scores, pathologies, stimulant eect of coee, tea or cola, stimulant eect of nap and severe sleepiness at the wheel needing to stop. Statistical tests of the regression estimates odds ratio (ORs) were based on Wald statistics. Odds ratio and their 95% condence intervals (CIs) are presented to show the association. All analyses were performed using spss statistical software package (SPSS, version12.0, Chicago, IL, USA).

RESULTS Sample Table 1 summarizes the demographic characteristics of the sample. Half of the responders were females (54.3%). The mean age was 48.5 15.5 years. The BMI ranged from 14 to 61 kg m)2. Most of the subjects were married (72.1%), 59.5% of the subjects declared to have a job and 11.5 self-considered themselves as a professional driver.
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Sleepiness, near-misses and driving accidents in France

Prevalence of sleep complaints The mean score for the ESS was 5.7 3.8. The prevalence of excessive daytime sleepiness in our population was 11.8% (ESS score 11), 1% reported an ESS score >16. Sleepiness at the wheel Over one-quarter of the respondents (28.2%) declared they experienced at least one episode of severe sleepiness at the wheel (i.e. requiring to stop driving) in the previous year (Table 2). Near-miss driving accidents One-tenth of the drivers (10.7%; 510 of 4774) reported at least one near-miss accident during the previous year, 46% of these being reportedly sleep-related (4.9% of drivers; 233 of 4774). Near-miss sleepy accidents principally occurred on a highway (77.6%), during a long trip (63.8%), and occurred more often during the night (40.9%) than the day (29.4%). Young drivers (1830 years) were the most exposed group to both all nearmisses (1830 years: 19.6%; 117 of 597; 3150 years old: 11.8%; 250 2115; 5165 years old: 7.8%; 102 of 1312; and >65 years old: 5.5%; 41 750) and to sleep-related near-misses (1830 years: 10.1%; 60 of 597; 3150 years old: 5.7%; 120 2115; 5165 years old: 3.4%; 45 of 1312; and >65 years old: 1.1%; 8 750). Driving accidents In the past year, 5.8% of drivers (278 of 4774) reported at least one driving accident, and 5.2% of these were sleep related (13 of 4774). Sleepy driving accidents occurred more often in the city (53.8%). They concerned more often short trips (84.6%), and most of them occurred during the day (84.6%). Young drivers were the most exposed group to accidents (1830 years: 12.9%; 77 of 597; 3150 years old: 6.1%; 130 2115; 5165 years old: 3.4%; 45 of 1312; and >65 years old: 3.5%; 26 750). Factors associated with near-miss driving accidents and actual driving accidents Table 3 describes the risk factors associated with near-miss accidents. Males had 1.51 (95% CI, 1.221.87, P < 0.001) more chances to be involved in a near-miss accident than females. Compared with our reference group (3150-year-old drivers), 5165-year-old drivers near-miss accidental risk was associated with a reduction to 0.75 (95% CI, 0.570.98, P < 0.05), whereas 1830-year-old drivers near-miss accidental risk was associated with an increase to 1.86 (95% CI, 1.412.44, P < 0.001). Being sleepy (ESS score 11) was associated with a risk of near-miss driving accidents (OR 1.67, 95% CI, 1.29 2.15, P < 0.001). Interestingly, we found that
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Table 2 Sleepiness at the wheel, near-misses and trac accidents Characteristics ESS Severe sleepiness at the wheel needing to stop (%) Never Less than once per month At least once per month At least once per week Sleepy during (%) Nocturnal driving Diurnal driving Both Near-miss driving accidents during previous year (at least once) (%) Near-miss sleepy driving accidents during previous year (at least once) (%) Number of near-miss sleepy driving accidents during previous year Location of near-miss sleepy driving accidents (%) City Road Highway All types of roads Type of trip for near-miss sleepy driving accidents (%) Short trip Long trip All type of trips Time of day for near-miss sleepy driving accidents (%) Day Night Day and night Driving accidents during previous year (at least once) (%) Sleepy driving accidents during previous year (at least once) (%) Number of sleepy driving accidents during previous year Location of sleepy driving accidents (%) City Road Highway Type of trip for sleepy driving accidents (%) Short trip Long trip Time of day for sleepy driving accidents (%) Day Night Anticipatory measures before departure (%) Type of preparation (%) Normal sleep duration Earlier departure in order to plan breaks Plan to sleep during breaks Take stimulant drinks Second rested driver Nothing ESS, Epworth Sleepiness Scale. Percent or Mean SD 5.7 3.8 71.8 24.4 3.1 0.7 46.8 39.4 13.8 10.7 4.9 4.4 14.5

2.2 35.1 59.3 3.4

40.3 57.6 2.1

44.6 45 10.4 5.8 0.3 1.1 0.3

53.8 38.5 7.7

84.6 15.4 84.6 15.4 55.6 68.6 12.7 5.5 3.7 6.8 2.7

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Table 3 Multivariate logistic regression results for prediction of near-miss driving accidents Near-miss driving accident Total (n) Gender Male 2178 Female 2596 Age (years) 3150 2115 1830 597 5165 1312 >65 750 ESS 010 4134 11 565 Pathologies Controls 3310 OSAS 105 RLS 93 Insomnia 424 Anxietydepression 348 Narcolepsy hypersomnia 7 Multi-pathologies 487 Stimulant eect of coee, tea or cola No 2964 Yes 1750 Severe sleepiness at the wheel needing to stop No 3363 Yes 1411 Yes (n) 288 222 250 117 102 41 384 117 316 13 14 46 54 1 66 277 230 147 363 % 13.2 8.6 11.8 19.6 7.8 5.5 9.3 20.7 9.5 12.4 15.1 10.8 15.5 14.3 13.6 9.3 13.1 4.4 25.7 OR (95% CI) 1.51 (1.221.87) Referent Referent 1.86 (1.412.44) 0.75 (0.570.98) P-value 0.001

0.001 0.05 NS 0.001

Referent 1.67 (1.292.15) Referent

1.82 (1.272.62)

NS NS NS 0.001 NS NS

Referent 1.20 (0.971.47) Referent 6.50 (5.208.12)

0.090

0.001

CI, condence intervals; ESS, Epworth Sleepiness Scale; OR, odds ratio; OSAS, obstructive sleep apnoea syndrome; RLS, restless legs syndrome.

anxietydepression was also predictive for accidental risk (OR 1.82, 95% CI, 1.272.62, P < 0.001). Subjectively, caeinesensitive drivers accidental risk was 1.20 (95% CI, 0.971.47, P = 0.09) compared with insensitive drivers. Finally, experiencing at least one episode of severe sleepiness at the wheel in the previous year was associated with a 6.50-fold increase (95% CI, 5.208.12, P < 0.001) in the near-miss accident rate. Table 4 contains information about the risk factors associated with driving accidents. Unmarried drivers had 1.40 (95% CI, 0.991.96, P < 0.05) more chances to be involved in an accident than married drivers. Compared with our reference group (3150-year-old drivers), 5165-year-old drivers accidental risk was associated with a reduction to 0.63 (95% CI, 0.440.90, P < 0.01), whereas 1830-year-old drivers accidental risk was associated with an increase to 2.13 (95% CI, 1.513.00, P < 0.001). Professional drivers were at higher risk of driving accidents than non-professionals (OR 1.52, 95% CI, 1.082.13, P < 0.05). Subjectively, caeine-sensitive drivers accidental risk was 1.43 (95% CI, 1.111.85, P < 0.01) compared with insensitive drivers. Finally, experiencing at least one episode of severe sleepiness at the wheel in the previous year was associated with a 2.03-fold increase (95% CI, 1.572.64, P < 0.001) in the accident rate.

DISCUSSION Our study is the rst one to focus on sleepiness, near-misses and accidental risk among a population of regular French drivers. Our sample matches the general population of drivers in France, and therefore our results should be applicable to the French population. Our data show that one-third of French drivers experienced at least one episode of severe sleepiness at the wheel (i.e. requiring to stop driving) in the previous year. This ratio matches with that of a French study (Nabi et al., 2006) investigating workers of the GAZEL cohort. This episode of sleepiness at the wheel is a major contributing factor to the occurrence of near-miss accidents or actual accidents. This result corroborates Connor et al.s study (Connor et al., 2002) showing that acute sleepiness in car drivers signicantly increases the risk of a crash. In our sample, 11.8% complained of excessive chronic daytime somnolence (ESS 11). We have shown an association between pathological ESS scores and near-miss driving accidents but, contrary to the Powell study (Powell et al., 2007), we did not found such an association between ESS scores and accidents. In the Powell study, near-miss accidents and accidents were reported over a 3-year period, increasing the statistical power and not only in the previous year like we did
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Table 4 Multivariate logistic regression results for prediction of driving accidents Driving accident Total (n) Age (years) 3150 1830 5165 >65 Marital status Married Single Separated or divorced or widowed Professional driver No Yes Stimulant eect of coee, tea or cola No Yes Severe sleepiness at the wheel needing to stop No Yes CI, condence intervals; OR, odds ratio. 2115 597 1312 750 3456 687 562 4146 535 2964 1750 3363 1411 Yes (n) 130 77 45 26 170 69 38 225 48 147 127 140 138 % 6.1 12.9 3.4 3.5 4.9 10 6.8 5.4 9.0 5.0 7.3 4.2 9.8 OR (95% CI) Referent 2.13 (1.513.00) 0.63 (0.440.90)

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P-value

0.001 0.01 NS

Referent 1.40 (0.991.96) 1.78 (1.212.61) Referent 1.52 (1.082.13) Referent 1.43 (1.111.85) Referent 2.03 (1.572.64)

0.05 0.01

0.05

0.01

0.001

in our study. Moreover, only 1% of our sample reports an ESS score over 16. This relatively low frequency (Baldwin et al., 2004) could be explained by the fact that our sample of drivers is active and healthy (Connor et al., 2001a). However, our result is in line with the one of Connor et al. (2002), indicating no increase of severe accidental risk (i.e. injured drivers) associated with measures of chronic sleepiness. Possibly falling asleep in common situations (up to a certain degree of severity, i.e. 11 < ESS score < 15) does not necessarily accurately predict an accident risk. Another possible explanation could be that sleepiness while driving has a major statistical weight compared with chronic daytime sleepiness (ESS score), and therefore we removed this variable from our model. We observed no relationship between snoring and sleep-related accidents. Our survey shows that sleepiness at the wheel is a risk factor as important as age for trac accidents. Young drivers (18 30 years old) are at particular risk for accidents because they present a high propensity to risk taking, alcohol or substance consumption (Calafat et al., 2009; Zakletskaia et al., 2009). We show that being subjectively sensitive to caeinated products (coee, tea or cola) is a risk factor for near-misses and trac accidents. Our results go in line with a study (Retey et al., 2006) demonstrating that subjects with the largest impairment from one night of sleep deprivation (i.e. vulnerable subjects) show the largest benet from caeine (i.e. caeinesensitive subjects). Caeine is an adenosine receptor antagonist, and adenosinergic mechanisms could therefore be a good candidate to explain inter-individual dierences to vulnerability to sleep loss. Near-miss accidents are more frequent than actual driving accidents. A study (Powell et al., 2007) has shown that driving near-miss sleepy accidents are dangerous precursors to actual driving accidents. Near-misses are known to be highly corre 2010 European Sleep Research Society, J. Sleep Res., 19, 578584

lated to sleepiness at the wheel and should be considered as strong warning signals for future accidents. Interestingly, in our study, sleep-related near-miss accidents occurred preferentially on the highway irrespective of duration or timing of the trip. Sleep-related accidents occurred preferentially in the city or on the open road, on a short trip and during the day. Driving in a city or on an open road during the day exposes the drivers to cross a higher number of vehicles or obstacles, which could explain the occurrence of these accidents. Our drivers report a higher rate of accidents (six accidents per 100 drivers) than the ocial police force statistics (three accidents per 1000 drivers; Observatoire National Interministe ` riel de Securite Routiere (ONISR), 2008). This high number is probably due to the lower severity of our accidents. Many of these probably did not result in trac disruption or physical injury, but simply in vehicle damage. Obviously we missed fatal accidents, and probably the severely injured that could not respond to a telephone survey. Even if the number of severely injured drivers is probably low in our sample, the very high number of total accidents represents a major cost for society. Another interesting point is the fact that sleep-related accidents represent a low proportion of total accidents in our sample compared with national highway data (30% of total accidents in the previous year; ASFA, 2008) or other epidemiological studies conducted in developed countries (Connor et al., 2002). Previous studies (National Transportation Safety Board, 1990, 1995) showed that sleep-related accidents are more severe than non-sleep-related accidents, and we suspect that hospitalized victims of accidents were underrepresented in our sample of responders. Even so, extrapolated to the French general population (30 million drivers), sleepiness could account for 90 000 accidents per year, a massive nancial burden for the French society.

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Some methodological issues have to be considered. Nearmiss driving accidents and driving accidents were self-reported, and we did not ask the nature, severity or circumstances of material damage and injury. Still our ndings are quite consistent with other studies (Connor et al., 2002; Powell et al., 2007) and we believe that they reect the reality. To conclude, our study shows that sleepiness plays a signicant role in urban and diurnal minor trac accidents in an active and healthy population (i.e. drivers). These ndings are quite new and extend signicantly the eld of accidental risk for sleepiness at the wheel for long distance or middle of the night travels to more classical and frequent urban trips. Our next step should be to conduct a study similar to Connor et al. (2002) in hospitalized French drivers to conrm the prevalence of sleep-related accidents in severely injured drivers. This new study should give us a full vision of accidental risk on French roads in relation to sleepiness at the wheel. ACKNOWLEDGEMENTS We thank Sandy Leproust for statistical support. DISCLOSURE STATEMENT No nancial conict of interest. REFERENCES
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2010 European Sleep Research Society, J. Sleep Res., 19, 578584