Intended for healthcare professionals

Letters

Cyclists should wear helmets

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7073.69 (Published 04 January 1997) Cite this as: BMJ 1997;314:69

Increasing the number of cyclists is more important

  1. Adrian Davis, Research assistanta
  1. a Health and Transport Research Group, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA
  2. b Newcastle City Health NHS Trust, Arthur's Hill Clinic, Newcastle upon Tyne NE4 6BT
  3. c University of New England, Armidale, NSW 2351, Australia
  4. d Hedsor Idan, Llanfairpwll, Anglesey LL61 6HJ
  5. e Policy Studies Institute, London NW1 3SR
  6. f 5A Victoria Park Road, Exeter EX2 4NT

    Editor–Ronald M Davis and Barry Pless's letter about the value of cycle helmets once again illustrates the worrying reductionist tendency in research into health promotion and illness prevention, which often results in sight being lost of the ultimate goal of promoting health.1 Narrow sectoral approaches–in this case the view that wearing a helmet reduces head injuries among cyclists–address only part of the issue. Purely medically based prescriptions for change fail to consider behavioural responses to environmental changes. The case for all cyclists to wear helmets, as argued, fails to acknowledge the disbenefits that have resulted when such strategies have been enforced through legislation. Evidence from Australian states where laws have been enacted to require the use of helmets suggests that “the greatest effect of the helmet law was not to encourage cyclists to wear helmets, but to discourage cycling.”2

    We are familiar with the evidence of the benefits of regular physical activity and of the levels of inactivity in the population.3 Cycling has been viewed as an ideal form of aerobic physical activity: it is available to a large section of the population and can be incorporated into daily life without requiring additional time. In the past year or so several high level statements have been made about the value of moderate physical activity as part of the routines of daily living. These have come from the surgeon general and the National Institute for Health in the United States, the World Health Organisation and the International Federation of Sports Medicine, and, not least, the Department of Health in Britain.4

    The evidence is that the health benefits of cycling outweigh the dangers posed to cyclists.5 There is now a government led national cycling strategy, with a target to quadruple levels of cycling to a modest 8% of all trips by 2012 (from a 1996 baseline). This requires intersectoral action in the spirit of the Health for All strategy. Its achievement would promote health, including reductions in heart disease and strokes, and would encourage children (the potential habitual car drivers and coronary care unit patients of the future) to adopt physically active lifestyles.

    Health promotion requires researchers to break free from narrow sectoral paradigms and to collaborate if “benefits” gained through some advances are not to be outweighed by knock on effects in efforts to promote health and wellbeing.

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.

    Motorists are the cause of the problem

    1. Tony Waterston, Consultant paediatricianb
    1. a Health and Transport Research Group, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA
    2. b Newcastle City Health NHS Trust, Arthur's Hill Clinic, Newcastle upon Tyne NE4 6BT
    3. c University of New England, Armidale, NSW 2351, Australia
    4. d Hedsor Idan, Llanfairpwll, Anglesey LL61 6HJ
    5. e Policy Studies Institute, London NW1 3SR
    6. f 5A Victoria Park Road, Exeter EX2 4NT

      Editor–It is strange that two medical editors of health promotion journals should write about legislation in favour of wearing cycle helmets without mentioning measures directed at cars, the cause of the problem.1 This smacks of victim blaming and is akin to insisting that smokers use a filter tip rather than banning tobacco advertising. I agree that helmets are protective, and I always wear one. But no one in the Netherlands does, and the Dutch are famed for their high cycling rates.

      Many cyclists object to the continual advocacy for helmets without equal (preferably greater) emphasis on restrictions aimed at motorists–separating them from cyclists, reducing their speed, and stopping them from entering city centres. Has the United States Centers for Disease Control and Prevention, cited by Ronald M Davis and Barry Pless, issued an attack on the low prices of petrol in the United States, which feed the car addiction of Americans? I am less prepared to listen to its views on cycle helmets until it does.

      References

      1. 1.

      Australian laws making helmets compulsory deterred people from cycling

      1. Dorothy L Robinson, Statisticianc
      1. a Health and Transport Research Group, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA
      2. b Newcastle City Health NHS Trust, Arthur's Hill Clinic, Newcastle upon Tyne NE4 6BT
      3. c University of New England, Armidale, NSW 2351, Australia
      4. d Hedsor Idan, Llanfairpwll, Anglesey LL61 6HJ
      5. e Policy Studies Institute, London NW1 3SR
      6. f 5A Victoria Park Road, Exeter EX2 4NT

        Editor–Ronald M Davis and Barry Pless report that, after the implementation of a law requiring all cyclists to wear helmets, the number of cyclists admitted to hospitals in Victoria, Australia, was 40% below that expected.1 Figure 1 shows this effect, for subjects with and without head injury.2 Both head and non-head injuries showed a considerable decrease when the legislation was enacted, with non-head injuries outnumbering head injuries both before and afterwards by roughly 2:1. Changes in the relative proportions seem to have been a second order effect, hardly noticeable compared with the overall reduction, which was probably due to a reduction in cycling and safer roads.

        Fig 1
        Fig 1

        Number of cyclists admitted with head and other injuries to hospitals in Victoria before and after implementation of law making wearing of cycle helmets compulsory2

        The deterrent effect on cycling was substantial. In New South Wales identical surveys of children were carried out before and after the law was implemented. When possible the same observers were used, with the same sites, observation periods, and time of year; the weather was excellent for both surveys.3 Reductions in cycling in rural areas (35%) and Sydney (37%) were almost identical, with similar reductions at road intersections (32%), recreational areas (29%), and school gates (45%).3 Overall, the increase in the number of cyclists wearing helmets was only half the reduction in cyclists counted. An identical survey carried out a year later under generally sunny conditions found even fewer cyclists.3 This deterrent effect was confirmed by a survey of 1210 secondary school children two years after the law was enacted. Among those who had not ridden in the past week, having to wear a helmet and not owning a bicycle were the commonest reasons given (both 34%), whereas unsafe roads were cited by 12%.4

        In Victoria identical surveys found that cycling by children fell by 33% and 36% in the first and second years after the law was enacted.5 Cycling by adults was not measured, but counts of adult riders (which are highly correlated with use of cycles by adults) were 29% lower after the law was enacted.5 As in New South Wales, the increase in numbers wearing helmets was less than the overall reduction in numbers counted. A survey of 64 sites a year later5 showed (after one, atypical, site had been omitted) that counts two years after the law was enacted were 27% below counts before it was enacted, indicating a sustained decrease in cycling similar to that in New South Wales.

        Minerva is right: we do not want to deter people from healthy, pollution free transport. The data suggest, however, that the main effect of the helmet laws was precisely that.

        References

        1. 1.
        2. 2.
        3. 3.
        4. 4.
        5. 5.

        Better to control the demand for fast cars

        1. Richard Keatinge (richard{at}gwyha3.demon.co.uk), Consultant in public health medicined
        1. a Health and Transport Research Group, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA
        2. b Newcastle City Health NHS Trust, Arthur's Hill Clinic, Newcastle upon Tyne NE4 6BT
        3. c University of New England, Armidale, NSW 2351, Australia
        4. d Hedsor Idan, Llanfairpwll, Anglesey LL61 6HJ
        5. e Policy Studies Institute, London NW1 3SR
        6. f 5A Victoria Park Road, Exeter EX2 4NT

          Editor–I am disappointed to read that “the benefits of wearing helmets are so patently obvious” when in fact the evidence is thoroughly inadequate.1 Three phenomena combine to mislead Ronald M Davis and Barry Pless.1

          Firstly, cyclists who voluntarily wear helmets represent a group who take fewer risks than average. This can reasonably account for their lower accident rate in many observational studies. Davis and Pless's letter seems to confuse this phenomenon with the second–risk compensation.

          Secondly, cyclists who don helmets, voluntarily or otherwise, may obtain a false sense of security and so take greater risks than they would have done before. This effect, risk compensation, has prevented other forms of “safety” intervention on the roads from having their intended effect.2

          Thirdly, the authors refer to a study of admissions to hospital in Victoria, Australia, where helmets were made compulsory for cyclists in 1990.3 The study concluded that the law reduced the number and severity of head injuries to cyclists. Its statistical analysis tried to take into account the considerable reduction in the number of cyclists that followed implementation of the law, the coincidental local efforts against speeding and drink-driving, the changes in hospital funding arrangements, and the large changes in injury rates that form part of the economic cycle.2 It did not take into account any reluctance among cyclists (after the law was passed) to report honestly on head injuries that were associated with their breaking the law by failing to wear a helmet. It does not mention that the most dramatic fall in claims for head injury after the law was introduced came from pedestrians aged under 12.4 It also covered too short a period to generate robust predictions over an economic cycle. Neither the Victoria data nor their analysis are sufficient to justify any enthusiasm about helmet wearing, let alone compulsion. Retailers and manufacturers of helmets are the only people likely to benefit from compulsion, which may well discourage many people from obtaining the health benefits of cycling.5

          If we ever get good evidence that compulsion confers enough health benefits to be worth its expense, inconvenience, and infringement of civil liberties then I would support compulsory wearing of helmets. But we do not have that evidence, and it seems likely that we never will. Cycle helmets, after all, were not designed to give protection against impact with a motor vehicle. Any exhortation or compulsion should be directed to controlling the demand for fast motor vehicles, the main source of hazard on the roads.

          References

          1. 1.
          2. 2.
          3. 3.
          4. 4.
          5. 5.

          Health benefits of cycling greatly outweigh loss of life years from deaths

          1. Mayer Hillman, Senior fellow emerituse
          1. a Health and Transport Research Group, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA
          2. b Newcastle City Health NHS Trust, Arthur's Hill Clinic, Newcastle upon Tyne NE4 6BT
          3. c University of New England, Armidale, NSW 2351, Australia
          4. d Hedsor Idan, Llanfairpwll, Anglesey LL61 6HJ
          5. e Policy Studies Institute, London NW1 3SR
          6. f 5A Victoria Park Road, Exeter EX2 4NT

            Editor–Ronald M Davis and Barry Pless criticise Minerva for not wearing a helmet when she is riding a bicycle, pointing out that significant reductions in the number and severity of head injuries among cyclists have been achieved where wearing a helmet has been made mandatory.1 They also call for evidence to substantiate Minerva's claim that the health benefits of cycling outweigh the risk of serious injury if helmets are not worn.

            The great majority of serious head injuries among cyclists result from collision with a motor vehicle.2 Lowering the risk of collision in the first place is a far more effective way of preventing these injuries than is wearing a helmet. The risk can be lowered by reducing the volume and speed of traffic3; encouraging greater awareness among drivers of the vulnerability of cyclists (and pedestrians), and among cyclists of their vulnerability so that they maintain a high level of vigilance; and establishing safe and convenient networks for cyclists. In countries such as Denmark and the Netherlands where this has been done, and where few cyclists wear helmets, the injury rate is about a tenth of that in Britain.2

            It is important to bear in mind that the specification for helmets is restricted to providing protection for the head in the event of a fall,2 not after the cyclist has been run into by a car or lorry. While some people would argue “better some protection than no protection at all,” the danger stems from cyclists who wear a helmet feeling safer than they would without a helmet and then riding with an exaggerated sense of security. The law should be changed so that manufacturers are obliged to print on helmets the limited protection they afford.

            In Australia, where helmet wearing has been made mandatory, the greatest effect has been to discourage cycling. Although the proportion of cyclists treated for head injuries after collision with a motor vehicle has declined there, the reduction has been similar to that among pedestrians, which suggests that the major road safety initiatives on speeding and drink-driving that were introduced at the same time as the helmet law largely account for the reduction.5

            Finally, the health benefits of regular cycling, in terms of life years gained, have been shown greatly to outweigh the loss of life years from deaths of cyclists–even in Britain's traffic environment, which is hostile to cyclists.2 3 4

            Perhaps the reputation of advocates of helmet wearing is more at risk than the heads of cyclists who do not wear helmets.

            References

            1. 1.
            2. 2.
            3. 3.
            4. 4.
            5. 5.

            Do gooders' intolerance is counter productive to their aims

            1. G H Hall, Consultant physicianf
            1. a Health and Transport Research Group, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA
            2. b Newcastle City Health NHS Trust, Arthur's Hill Clinic, Newcastle upon Tyne NE4 6BT
            3. c University of New England, Armidale, NSW 2351, Australia
            4. d Hedsor Idan, Llanfairpwll, Anglesey LL61 6HJ
            5. e Policy Studies Institute, London NW1 3SR
            6. f 5A Victoria Park Road, Exeter EX2 4NT

              Editor–Ronald M Davis and Barry Pless assert that the only downside to wearing a cycle helmet is the “mussing of Minerva's hair.”1 Judging by their jobs (as editors of Tobacco Control and Injury Prevention), I assume that they are risk averse and wish to impose their views on those who are not. The message seems to be that when persuasion fails then there must be prohibition. This intolerance of the do gooders is objectionable and, indeed, counter productive to their aims.

              The tone of the authors' letter merely encourages me to continue both smoking my pipe and cycling without a helmet, which I do because I enjoy them. I hope that our legislators will continue to value personal freedom more than the mandarins of health promotion and disease prevention seem to do.

              References

              1. 1.
              View Abstract