Three lessons for a better cycling future

Safe walking

It began in America, as so many trends do, but for years no one in Europe took any notice. American tourists wearing helmets around the streets of London first drew media attention. And although public response to walking helmets was initially amusement, the appeal of extra safety drew some pioneers to the habit, especially academics and competitive walkers.

The first case-control study of about 2000 injuries to pedestrians in Britain (180 of whom had worn helmets) concluded that the risk of serious head injury was reduced by 75% when a good walking helmet was worn. Safety campaigners used the slogan “walkers need helmets” to encourage parents to send their children to school in helmets. Several high profile accidents focused public attention on the dangers of walking. A well known television presenter was severely head injured by a police van answering an emergency call. Doctors concluded that her injuries would have been “substantially reduced” had she worn a helmet.

Walking helmets became widely available. The entire cabinet posed in their helmets outside Number 10, the beaming prime minister urging: “Let's go forward together into a new era of walking safety.” Most children now wore a helmet walking to school, although they were otherwise not seen on the streets. They played at home, where many injured themselves stunt walking in mountain boots. Safety campaigners praised the courage of the 25% of adults who wore a walking helmet.

Safety campaigner Jean Keystone read her Walkers' Helmet Bill before parliament: “As a society we are tired of the waste of lives in walking accidents. Every year, around a 1000 pedestrians are killed in walking accidents, and head injuries feature in 80% of these deaths. Since research has shown that 75% of head injuries are prevented if a good walking helmet is worn, legislation to compel wearing is justified by the saving of lives that will result.”

The bill wasn't passed, but time was on the campaigners' side. The pop group Toyzone promoted walking helmets in their video Take a Walk on the Mild Side. Safety campaigners founded the Helmet Youth. Only the most antediluvian public figure would appear bareheaded in the media. Compensation for injury was reduced if the pedestrian had not worn a helmet. Pressure was mounting against those who still valued the “dubious pleasure of walking with the wind in their hair.”

However, safety did have its consequences. Not only had walking declined, the aspiration to walk skilfully had disappeared. A generation was growing up incapable of crossing the road. Young walkers had become dependent on their helmets. Casualty rates were increasing. Many otherwise capable adults were afraid to walk, having been alarmed by the safety campaigns. As one chubby chap said from his car: “It's got nothing to do with helmets. Walking is dangerous—why take the risk.”

A new breed of walker had appeared, stern and serious about safety. They wore £100 helmets, lighthouse jackets, eye protection, and spent £1000 on footwear. But they were a rare breed. Gym clubs were expanding their car parks, and the traffic had never been so bad.

Risks of cycling

You think I am being facetious? Let us examine the facts. The inherent risks of road cycling are trivial.3 Of at least 3.5 million regular cyclists in Britain, only about 10 a year are killed in rider only accidents. This compares with about 350 people younger than 75 killed each year falling down steps or tripping.4 Six times as many pedestrians as cyclists are killed by motor traffic, yet travel surveys show annual mileage walked is only five times that cycled; a mile of walking must be more “dangerous” than a mile of cycling. In both cases, of course, the activity itself is harmless—but it's in the way. Although a mile of driving is ten times safer than a mile of cycling, a mile of urban driving is ten times more likely to kill a pedestrian than such a mile cycled.

Is driving safe?

One problem with comparing the safety of driving and cycling is that the population that cycles differs from that which drives. The average driver is trained, tested, will have about two decades of experience, and is to a degree regulated. The average cyclist is young, male, untutored, unregulated, not wealthy, riding a badly equipped machine on busy urban streets, and in the minority. Nearly half of all cyclists ride only occasionally, and most regular cyclists will do so for only a few years. Clearly there are potent risk factors here that confound comparisons based on averages. Adults aged 17-20 in the United Kingdom are probably less likely to be killed per hour cycled than hour driven,5 and the danger inflicted on others will be fractional. Experienced cyclists, like experienced drivers, have far better accident rates, suggesting that a given individual should not be at greater risk of death or serious injury per hour cycled than driven. There are not enough skilful, experienced cyclists on Britain's roads, however.

As the Cabinet donned walking helmets, the prime minister urged the nation to “go forward together into a new era of walking safety”

Notwithstanding the above, it still takes at least 8000 years of average cycling to produce one clinically severe head injury and 22 000 years for one death. A recent study in Glasgow estimated that 150 000 people are admitted to hospital annually with head injuries in the United Kingdom6; road cyclists account for only 1% of this total, yet 6% of the population are regular cyclists and a further 5% are occasional cyclists; 60% of admissions were alcohol related. Do we need revelling helmets?

Dangers of helmets

The statistical wrangle over the effectiveness of helmets is actually a side issue; what we need people in authority to understand is that cycle helmets inevitably damage public health. Even for cyclists on Britain's roads, the health benefits exceed the risks by a factor of 20.7 The health benefits of cycling are so great—and the health injuries from driving so great8—that not cycling is really dangerous. By telling people that they need helmets for an activity that for a century has been regarded as “safe”—and in fact has a fine safety record—you inevitably engender the impression that cycling must have become more dangerous than driving and walking. That deters cycling. That reduces cyclists' presence on the roads. That increases the risk of death. And if wild claims about helmets saving lives are published in the media,9 helmet users are bound to feel overly secure, thus compromising their one vital safety feature—a sense of caution. 10 11 In addition, over time most people— and especially parents—will come to believe that it is wearing a helmet that matters, not acquiring skilful technique.12 These effects have been noted in every country where helmets have come into general use, including the United Kingdom.13 Millions will die early because they did not cycle.

Do helmets protect the head?

Experience shows helmets give only limited head protection. Studies in Australia show some prevention of superficial injuries (such as scalp lacerations) but only marginal prevention of “mild” head injuries and no effect on severe head injuries or death.14 When helmets were made compulsory in Australia, admissions from head injury fell by 15-20%, but the level of cycling fell by 35%. 15 16 Ten years later, cycling levels in western Australia are still 5-20% below the level they were before the introduction of the law17 yet head injuries are only 11% lower than would be expected without helmets.18 Incidentally, 17 times more motorists than cyclists died of head injuries in Australia during 1988.19

The situation in New Zealand is poorly documented, but even sophisticated analysis reveals either no reduction in head injury with increased helmet use20 or a modest reduction (19%) when superficial injuries are included in the definition.21 Misreporting of the cause of injury among people cycling without helmets after the law made cycling compulsory must have influenced the figures. The United States and Canada have had similar experiences to Britain. 1 22

Many articles have been published claiming that a helmet will prevent 60-90% of serious head injuries while neglecting to evaluate the risks of cycling versus driving.23 But in 1988 the largest survey of cycling casualties ever undertaken concluded that helmets did not prevent injury; indeed, increased use correlated with increased risk of death.24 How could real world experience diverge so enormously from the savings promised by clinical research? The trouble was, researchers did not compare like with like. If you compare a helmeted minority who fell off in parks with an unhelmeted majority injured in collisions with motor vehicles, it is no surprise that people wearing helmets have much less severe injuries. Other studies did focus on road accidents but drew conclusions from a small group of helmeted cyclists, typically 10% of the sample. In the early days, those who wore helmets were cautious, mature, educated, life long cyclists. Researchers failed to consider that this group would be more likely to attend accident and emergency after receiving a head injury or that they would have better anticipation, thereby reducing the risk of an accident or the risk of serious injury in a given accident. In fact, the case-control studies confirm what experienced cyclists already know—that skill and a sense of caution cut the risk of serious injury by 80-90%.

Our tarmac world is stuck in the Dark Ages; if you get hurt, you're wrong. The assault on cycling has vandalised the appeal of the safest, cleanest, most efficient, healthy, and fun means of personal transport that exists—right at the time we most need it. Cyclists don't need helmets, they need priority.

Lesson one: cyclists get ahead when left alone

Cyclists gain more from improvements in road safety than other road users; hence the risk of death per mile cycled fell by 60% between 1971 and 1994 (fig 1). The number of reported accidents has not changed much in the past 40 years (see BMJ's website for details). The fall in the number of deaths is due to accidents getting less lethal rather than there being fewer accidents. The lethality of cycling accidents dropped faster than the average for all road users (fig 2). By 1994, the risk of death in a cycling accident was only 75% of what it would have been had the trend followed the average. This will surprise those who see cyclists as “vulnerable” and drivers as “safe.” However, cycling accidents got more lethal in the second half of the 1990s, when helmets became generally popular.

Fig 1.

Indices of cycling mileage and deaths (index year 1970)1

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Fig 2.

Index of lethality (number of deaths per number of accidents) of cycling accidents and all traffic accidents, 1970-98 (index year 1970)1

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Lesson two: cyclists fare best when they act and are treated as drivers of vehicles25

It is widely thought that cyclists should be segregated from the traffic for safety's sake. This appears logical, since most road cycling injuries are due to motor traffic. It is a naive conclusion. Segregation protects the cyclist from only a rare accident—being hit from behind—at the expense of increasing other risks and reducing convenience. International research shows that segregation multiplies the risks threefold to fivefold, 26 27 even in countries such as the Netherlands, where it is traditional. The promotion of danger has scared many cyclists out of the traffic, merely to put them at greater risk on pavements and “safe” cycle routes.

Experienced cyclists already know that the road system is by far the safest national cycle network that will ever exist. Cyclists and drivers are not enemies; each has something to offer the other in a civilised road environment. Cyclists should tackle the risks just as in a car, by acquiring a high standard of road craft.

Lesson three: promote cycling for a safer road environment

Increasing the number of cyclists is a straightforward way of making cycling much safer. It is a method we can be sure of, because it has already worked.

It is worth pausing here to consider the meaning of “road safety.” The roads can get more dangerous, yet total deaths still fall. Compulsion to wear a seatbelt cut deaths among drivers and front seat passengers by 25% in 1983. But in the subsequent years, the long established trend of declining deaths in car accidents reversed, and by 1989 death rates among car drivers were higher than they had been in 1983. Evidently the driving population “risk compensated” away the substantial benefits of seatbelts by taking extra risks, putting others in more danger. This period saw a jump in deaths of cyclists (fig 1). Although temporary, the jump can be explained fully only by cyclists having adapted to a more dangerous road environment through extra caution, retreat, or giving up. Is it coincidence that the long decline in cycling began in 1983?

Many drivers today surge about aggressively, accelerating and braking hard. They don't achieve a high average speed but touch peaks of 50-60 mph, at which pace the vehicle is a frightening menace to the most experienced cyclist. That kind of behaviour is the consequence of, among other things, compelling seatbelts, and it is a massive deterrent to cycling. Difficult though it may be, it is time that those who control road safety legislation faced the facts; reducing casualties is not the same as reducing danger. Give thought to the real cause of danger and how it can be reduced.

Between 1974 and 1982 cycling mileage in Britain increased 70%, but there was no increase in fatalities until the seatbelt law was introduced in 1983 (fig 1). The more cyclists there are, the more presence they have, the less individual danger there is. This truth is confirmed by experience in the Netherlands and Denmark, where cycling is far safer despite a tradition of segregation. All road users should gain. Pedestrians benefit because (skilful) cyclists are little threat to them and because a large increase in cycling should reduce traffic speeds and thus risks to all. Then there are the health benefits.

Cycling has slipped off the political agenda. The vital need to change attitudes is nowhere in sight. Doctors must press for recognition that in a civilised society, those who create danger will be held responsible for the consequences. Getting hurt doesn't make you wrong. Promote the positive aspects of cycling: speed, fitness, pride in learning a new skill. Focus on getting adults to cycle a few trips they currently drive—later they can teach their children. Promote cycling, not helmets. Get out there and enjoy the dubious pleasure of the wind in your hair.