Bicycle helmets: it's time to use them
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7268.1035 (Published 28 October 2000) Cite this as: BMJ 2000;321:1035
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The use of Cycle Helmets is recomended in the editorial from Rivara
et al. I use one and I think it may have saved me an occipital injury
during an episode of lost concentration leading to involuntary contact
with the road. However the gentleman who passes me regularly in his
Porsche at high speed frightens me far more. Please could the BMJ point
to the real problem - if we were to have speeds limited to perhaps 20 MPH
as suggested recently in New Scientist then road injuries would be reduced
and the benefits of cycling would then outway the slowness. What is more
the climate might benefit.
Competing interests: No competing interests
Editors: Peter Jacobsen's letter was well researched, well written,
and perhaps explained the data better than TRT themselves did. A widely-
respected publication such as the BMJ should not allow TRT to respond to
Peter's serious arguments by calling his response "unscientific and
vituperative". A serious intellectual discussion of this important public
health issue demands better than this and as editors you must tell your
readers that TRT failed in their obligation to seriously discuss the
issues raised in Peter's letter.
Competing interests: No competing interests
This non-issue will destroy road cycling unless you drop it.
My paper on cycling “Three lessons for a better cycling future” was
published in the Christmas edition of the BMJ - and I must extend my
gratitude to the Editor and Selection Board for having had the candour to
publish its unauthorised views. However, you in the medical profession
have largely cold-shouldered it and the media utterly ignored it. Now it
can be safely forgotten.
Just the other week I read a piece on cycle helmets by Tam Dalyell in
New Scientist magazine, which revealed all the normal ignorance of and
contempt towards cycling by the political class. To give Mr Dalyell his
due, he did change his opinions after I had sent him corrective material -
but he had been misinformed in the first place by precisely this editorial
by Dr Rivara, promoting misleading research by Cook and Sheikh.
The whole issue of risk when cycling is being left to politicians
badly advised by research programmes of extremely dubious quality. There
is no political protection of the cyclists’ case and there never has been.
A criminal is innocent until proven guilty - that basic right has never
been accorded to cycling, and efforts to place the risks of cycling in
perspective are being ignored by the safety establishment - as is the
uncomfortable fact that cyclist deaths increased by 25-30% after 1994
during years of continuous decline in mileage, a jump in fatalities not
seen for any other user group. Cycling in this country is going to get
further marginalised by bad research, political expediency and newspapers
ever-eager to have a go at cycling. By the time critics like myself have
inspected the research and found it wanting - even suspiciously selective
- the damage is done. The BMJ accepted my Rapid Response critical of the
Cook and Sheikh research (“Subsequences and consequences”) for publication
in the paper journal, and I thank the editorial staff for that, but a
letter published months after the event is not going to catch one shred of
media attention. The truth is nowhere in sight. Suggestion, selection and
misrepresentation are winning. Public health is the loser.
Unless something effective is done to halt this process, the
consequences for cycling over the next few years will be no different from
an actual helmet law. The appeal of cycling will fade, participation will
dwindle, risks will go up, public health will suffer. The National Cycling
Strategy will be bleated and the targets reset as they expire.
It is getting less and less bearable to walk or cycle even around the
suburbs. No one cares. The absolute servility to the motor vehicle is now
evidenced in children and pensioners being pressured to wear dayglo
jackets when walking. It is only a matter of time before some darling of
safety promotes walking helmets for schoolchildren. No one dares to
question the pre-eminence enjoyed by those who drive. I drive myself, but
I cannot grant that I should have such privileges over others merely
because I can hurt them if they get in my way. That is barbarism, but
there is no political criticism of it.
As I see it, the only measure likely to alter current trends is
strong editorial criticism by the medical journals - the kind of tough
stuff that not even the Daily Mail can ignore - and strong criticism by
GPs at the local level. The oppression of walking and cycling is harming
health. The amenity of our lives is being wasted serving juggernauts and
essential car use. Children have no freedom. The situation is allowed by a
particularly obnoxious, unmentioned public contract: you can kill my
child, but I can kill yours too. The politicians remain servile to the
status quo, behind their beaming smiles. This deplorable state of affairs
has to be attacked. The BMJ has carried several editorials over the last
year critical of the harm to life from excessive dependence on motor
transport, but the message just does not seem to be getting into the House
of Commons, let alone out to the wider public.
Well, I hope you doctors now understand the health consequences of
silence on this issue.
Competing interests: No competing interests
Rivara responds, explaining that they focus on helmets to protect
bicyclists from injuries, with "Other interventions ... have not been
subject to the kind of careful, rigorous research that has been done by a
number of investigators examining helmet effectiveness." [1]
That explanation reminds me of the man who lost his keys:
One night a fellow was intently looking around the on the ground
under a lamp post, obviously distraught. A passerby asked what was wrong
and if he needed assistance.
"Yes, I lost my keys."
"Where?"
"Over there," pointing down the street.
"Well, if you lost them over there why are you looking here?"
"The light's better here."
1 Frederick P Rivara www.bmj.com/cgi/eletters/321/7268/1035#EL17
Competing interests: No competing interests
Both the article and the response to critics fail to refer to the
proportion of serious and fatally injured cyclists who are subject to
emergency admission. Any casualty who is certified dead at the scene or
on arrival at hospital would be omitted from the figures analysed. These
casualties are the most important for considering the number/severity of
cyclist casualties, and the protection offered by helmets because they
represent the 'worst case'. If one considers only those who survive to
A&E, all subsequent analysis is of limited value. I agree with many
points made about the role of the cyclist in transport (indeed, why do
pedestrians not wear helmets?) but the critical point is whether the
review undertaken was worthwhile. I suggest the authors obtain figures on
numbers of fatally and seriously injured cyclist casualties as a whole,
then review their findings. In addition, Consumers' Association tests
show enormous variation in the resistance of helmets to impact,
irrespective of cost.
Perhaps the first step should be to ensure that accident statistics
collected locally by Police forces and collated nationally by DETR include
information on cycle helmet usage. Surprisingly, even seatbelt usage is
not routinely recorded in accident reports now. Without meaningful
information on usage rates in total, and among casualties, and the
differing levels of protection against impact, there seems little value in
in-depth analysis of only some of those seriously injured.
As an chartered engineer (a profession still viewed by the public as
oily-rag carriers and telephone fitters) I am rather frustrated to see
qualified medical professionals making fundamental omissions in a field
where much more research is needed. If nothing else, perhaps the debate
will encourage more people to consider wearing helmets, and to reduce the
number of fatal accidents I and my colleagues must investigate.
Competing interests: No competing interests
Would Frederick P Rivara, Diane C Thompson, and Robert S Thompson be
in favour of helmet wearing for pedestrians, train passengers, airplane
passengers and car passengers?
If yes then what have they done to promote this?
If not, why not?
aedan
Competing interests: No competing interests
Rivara and colleagues1 may care to reflect on the following plus two grim
news stories from either side of the atlantic. 2 and 3.
Our respective cultures are abnormally car-centric and heading for a
society where the elderly will only be allowed to cross roads if they are
wearing full fluorescent garb 2 and waving a red flag 3. Perhaps in a few
years time Rivara and colleagues will be debating the finer epidemiological points
of crash helmets, fluorescent garb, red flags and even curfews for
pedestrians.
I was at a conference run by the Glasgow Police last week looking at
how they can meet the latest Government target on halving Killed and
Seriously injured children in Britain by 2010 ( Labour could have done
this overnight at recent Roads review by reducing urban speed limits from
30 to 20 at a cost of only 3 minutes on the average commute but the government
bottled out for fear of losing the motorists' vote ) At this conference
someone from Mercededs safety research talked for 20 minutes on car
safety. The whole of his talk was about 'car occupant safety' and the
various electronic devices that serve to cosset and protect the driver and
passengers in the event of an accident ie him going too bloody fast( and
therefore , of course, encourage speeding by creating an unreal awareness
of speeding danger ). I asked why he had not mentioned anything on
pedestrian / cyclist survival in an accident and why had the car
manufacturers shelved car design research in '85 which showed that car
protection in accidents for the pedestrian / cyclist existed in the form
of softened bumpers and recessed engine blocks? He admitted that 'there
was no demand for this in their cars ' and 'it was sad that such safety
devices do not exist'. Sad? Surely a vile indictment of our car-obsessed
culture?.
Helmets are just an obfuscating diversion in a dead backwater of
transport safety visited by epidemiologists (who mostly don't know their
cogs from their bearings) for a bit of safe statistical sport and career
enhancement. The clear message from several recent response sites,
touching on cycle helmet usage, is that these waters are now very
dangerous areas in which to venture. We cyclists are thoroughly fed up
being used as epidemiological fodder in such an area of marginal risk
improvement. Back off. If public health / epidemiologists really want to
make a difference then do something useful and mine the far more
productive areas of speed restriction, urban design, child's play
restrictions and pedestrian -safe vehicle design. Or would this research
be dangerous for you? Would it bring you or your unit into conflict with
local / central politicians or even funding streams? Could there possibly
be public health departments out there funded by car manufacturers etc ?
Don't be so obsessed with YOUR evidence base. Reality is out there
staring in your face.
When you are being bombed you shouldn't have to hide in shelters,
you should be stopping the bombing.
Colin Guthrie
1 Frederick P Rivara
www.bmj.com/cgi/eletters/321/7268/1035#EL17
2 Headline:
" WEAR DAY-GLO OR DIE"
Police plea to OAPs as car deaths grow
The following story is on the front page of the weekly Birmingham
MetroNews - Thursday November 30 2000 Issue 491.
Story by Philip Jackson:
The city's OAPs are being urged to wear
fluorescent clothing to cut the number of pensioners hit by cars. Police
say there have been more serious and fatal traffic collisions in the Kings
Heath and Billesley area, and most involve elderly pedestrians.
Now local bobby Caroline Evans is advising senior citizens in Brum to be
smart and be seen - even if that means wearing bright or fluorescent
clothes.
She said that five of the seven road deaths in the area since June, and
most of the serious injuries, had been older people. She put the problem
down to elderly pedestrians crossing in the wrong place, and not being
seen until it was too late.
"There has recently been an increase in road traffic collisions where
unfortunately elderly people have died trying to cross the road" she said.
"To stop this from happening we advise the public - especially the elderly
-to wear a bright item of clothing or something fluorescent."
"We don't expect to see OAPs in those bright jackets that builders wear
even if it's just the bands cyclists wear on their arms, it's better than
nothing."
Jane Eason, from the Royal Society for the Prevention of Accidents agreed.
"It is always better to try and wear something bright so drivers can make
you out, like a brightly coloured or white coat."And the worsening winter
weather means, if pedestrians don't look out, the death toll in Brum will
rise.
"People should also bear in mind that the bad weather conditions will
affect the visibility of both the driver and the pedestrian," said PC
Evans. "The driver's ability to stop will also be drastically reduced if
the road
surface is wet or icy."
The Editor,
MetroNews,
28 Colmore Circus ,
Birmingham B4 6AX
3 From: Anthony Hinxman
Date: Thu, 7 Dec 2000 09:38:41 -0500
In Salt Lake City, Utah, clusters of orange flags will be placed at
the city's most dangerous crosswalks. Pedestrians can pick up a flag if
they like, wave it at oncoming traffic and then drop the flag off in a
container on the opposite side. The city has wide streets and rapid
drivers. "Salt Lake City is a place that loves its cars," says Edie
Trimmer, head of the city's transportation advisory board. "If you want to
get across, you've got
to be young and agile."
Competing interests: No competing interests
Our editorial on bicycle helmets and the Cook and Sheikh study has
engendered a great deal of discussion in the electronic pages of the BMJ.
The comments fall into a few major themes. First, factors other than
increased helmet use explained the decrease in bicycle-related head injury
admissions. Second, environmental measures are more important than
helmets in decreasing the risk of severe injuries. Third, mandating the
use of helmets can have an adverse effect by decreasing cycling as a form
of exercise, and thereby increasing the risk of cardio-vascular disease.
Fourth, helmets are not effective in motor vehicle-bicycle collisions, the
cause of most severe and fatal injuries. Finally, the protective effects
of helmets are markedly reduced by the increased risk-taking of helmeted
cyclists, "risk-compensation."
We agree with the comments by Nicholas Mann, PS Wootton and Colin
Reed. However, the tone of the other letters is vituperative and
distinctly unscientific. The letter writers counter scientific studies
published in prestigious peer-reviewed publications with opinion and with
unpublished studies, or with non-peer reviewed research reports. The
attitude is clearly anti-evidence based medicine and public health,
against the reliance on scientific literature strongly supported in the
pages of the BMJ.
The space limitations of the BMJ do not allow us to respond to the
multiple comments at length. Two well known cycling advocates, Bill
Curnow and Dorothy Robinson, have posited similar arguments to our
systematic review of helmet effectiveness published in the Cochrane
Library. (1) Their comments, and our responses, are fully published in
that forum and will not be duplicated here. We will be answering comments
from Richard Keatinge and Mayer Hillman in future issues of the Cochrane
Library. Interested readers can follow the debate at the Cochrane
Injuries Group website.
( www.cochrane-injuries.ich.ucl.ac.uk/HelmetComment.htm) .
Few injury control professional in the world believe that helmets are
the only answer for the prevention of serious disability and death to
bicyclists. Other interventions, such as separation of bicyclists from
traffic and bicycle rider training programs may also be important
measures. However, these and other proposed interventions have not been
subject to the kind of careful, rigorous research that has been done by a
number of investigators examining helmet effectiveness. Such studies are
welcome and clearly needed.
The purpose of publishing health research, and discourse about it, is
to improve the health of the public. We believe that the evidence
indicates that helmets have a net positive effect on the health of the
public. We look forward to the publication of future studies in the pages
of the BMJ and other peer-reviewed journals examining this question.
References
Thompson DC, Rivara FP, Thompson RS. Helmets for preventing head and
facial injuries in bicyclists (Cochrane Review) In: The Cochrane Library,
Issue 4, 1999. Oxford: Update Software.
Frederick P. Rivara, MD, MPH,
Diane C. Thompson, MS,
Robert S. Thompson, MD
Competing interests: No competing interests
Editor - Rivara et al correctly assert that the evidence that cycle
helmets prevent head injury is strong.1 Accident and Emergency physicians
are often frustrated at the lack of cycle helmet use, particularly in
children. In Leicester almost half of people involved in cycling
accidents presenting to the A&E department have some form of injury to
the head or face2. We performed a prospective structured questionnaire in
order to investigate the attitudes of parents to cycle helmets, and to
look at the reasons children gave for not wearing helmets when cycling.
Three hundred questionnaires were distributed to parents attending the
A&E department with their children. There were two parts to the
questionnaire, one for parents and one for the child. Children attending
with injuries related to cycling were excluded. Out of 241 adults that
completed the questionnaire (response rate 80%), 220 (91% of those who
responded) agreed that legislation should be introduced to make it
compulsory for cycle helmets to be worn. The most commonly cited reason
for parents (57% of respondents) not buying a helmet for their child was
that: "The child would not wear it anyway." Of the 207 children completing
the questionnaire, the most common reason (in 63, 30% of respondents)
given for not wearing a helmet was that it was not perceived as
fashionable. Comfort and the fact that friends did not wear a helmet were
other reasons cited (48, 23% for both).
In analysing the group of children who thought cycle helmets were
unfashionable, 24 (39%) said they would be more likely to wear the helmet
if a logo of their favourite pop-star or sports team was on the helmet.
Twenty-four (39%) in this group said that they would be more likely to
wear a helmet if their friends did. These factors do suggest possible
strategies for increasing cycle helmet use in the future. A helmet with
the logo of a pop star on would be easy to produce, and one would hope
that celebrities would help promote the use of cycle helmets.
Cook and Sheikh stress the importance of local publicity campaigns to
encourage cycle helmet use3 . We would add that measures to make helmets
more appealing to children also have a role.
1. Rivara FP, Thompson DC, Thompson RS. Bicycle helmets: it's time to
use them. BMJ 2000:321:1035-1036.
2. Ballham A. Absoud EM. Kotecha MB. Bodiwala GG, A study of bicycle
accidents. Injury 1985:16(6): 405-8.
3. Cook A, Sheikh A, Trends in serious head injuries among cyclists
in England: analysis of routinely collected data. BMJ 2000: 321:1035
Colin Read
Specialist Registrar
John McInerney
Specialist Registrar
Ravi Assomull
Senior House Officer
Gautam Bodiwala
Consultant
Accident and Emergency Department,
Leicester Royal Infirmary,
Leicester LE1 5WW
Competing interests: No competing interests
Re: Reply to critics of bicycle helmet editorial
Bad science
Would Thompson, Thompson, and Rivara please stop quoting the old,
well performed, but essentially flawed case control studies into bike
helmets please. Newer ecological studies have replaced them. The old
studies have never showed that bike helmets protect against head injury,
merely that people wearing bike helmets are less likely to present with a
head injury. It may sound like splitting hairs but it is for exactly this
reason that DBRCT were introduced.
I'm afraid that they are sounding like a tired old record and a little
annoying.
I wonder if they are actually interested in what has happened in the REAL
world since legislation or our so myopic that they have not looked past
there own flawed analysis.
Competing interests: No competing interests